SustiNet Board of DirectorsOctober 13, 2010Anya Rader WallackKatharine LondonLinda GreenStan Dorn

Recap of September 22 meeting

• Discussion of delivery system reform and payment reform

• Draft recommendations sent to all board members• Some comments and additions received, others are

welcomed (send to Anya: anya@arrowheadha.com)• Revised draft recommendations will be presented for

your action at a future board meeting

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Topic for today: governance and administration

• How should SustiNet relate to current state agencies? • What are the ongoing roles and responsibilities of the

SustiNet governing body? • To carry out these roles and responsibilities:

• What governance structure is most appropriate?• What powers and duties are necessary?• What administrative structures and capacities are necessary?

• Before 2014, should SustiNet be offered to small firms, municipalities, and non-profits? To individuals?

• Starting in 2014, should SustiNet be offered in the Exchange?

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BACKGROUNDPart I

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• SustiNet is a self-insured health plan • SustiNet Health Partnership Board of Directors "shall offer

recommendations to the General Assembly on the governance structure of the entity that is best suited to provide oversight and implementation of the SustiNet Plan"

• Recommendations may include establishing a public authority

• Long list of potential powers and duties that could be assigned to the authority, all associated with operating SustiNet

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SustiNet law: role and governance

Federal health reform• The exchange serves

Small firms Individuals without affordable access to

comprehensive employer-sponsored insurance (ESI)

• For eligible individuals and small firms, tax credits are available only through the Exchange

• Qualified health plans must be Offered by state licensed carriers Available at silver and gold actuarial value levels

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Wh

ere

do

es S

ust

iNet

fit

?

Health plans Health insurance coverage and group health plans

Not a “health plan”: Self-insured plans or MEWAs (any plan that is exempt from state insurance regulation under section 514 of ERISA) [Sec. 1301(b)]

Qualified health plans [Sec. 1301(a)]

Health plans that are (a) Certified by the Exchange (i.e. meet marketing

req’s, network adequacy, accreditation, uses uniform enrollment form, etc.); [Sec. 1311(c) and (e)]

(b) Provide essential health benefits; [Sec. 1302] and

(c) Offered by a health insurance issuer that is licensed, offers at least one silver and one gold-tiered product, charges the same premium inside and outside the Exchange, and complies with any regulations established by DHHS.

Also includes CO-OPs, multistate plans, and qualified direct primary care medical home plans.

Exc

han

ge-

elig

ible

p

lan

s

Health insurance carriers may offer:

OPTIONS FOR SUSTINET ROLE AND RELATIONSHIP TO STATE DEPARTMENTS AND THE EXCHANGE

Part II

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DSS Comptroller

A B C D

SustiNet Benefit Options

Medicaid SEHP9

SustiNet implements the country’s best thinking about how to slow cost growth while improving quality. Delivery and payment reforms include patient centered medical homes, HIT, realigned incentives, etc.

Note: The SustiNet agency could handle all administration of the SustiNet plan in-house or it could contract with one or more third party administrators (TPAs) to carry out particular functions.

DSS and Comptroller contract with SustiNet to provide coverage.

SustiNet governing body

What is SustiNet? Option A: SustiNet as health plan (Step 1 of 3)

SustiNet

DSS Comptroller

A B C D

Medicaid SEHP10

Individuals and small firms can buy SustiNet

directly (beg. 2012)

E F

SustiNet governing body

What is SustiNet? Option A: SustiNet as health plan (Step 2 of 3)

SustiNet Benefit Options

SustiNet governing body

DSS Comptroller

A B C D

Medicaid SEHP

What is SustiNet? Option A: SustiNet as health plan (Step 3 of 3)

11

Individuals and small firms can buy SustiNet through the exchange

(beginning 2014)

E F

Exchange

SustiNet Benefit Options

What is SustiNet? Option B: SustiNet as overseer and health plan (Step 1 of 3)

12

Subject to federal law and collective bargaining agreements, SustiNet has ultimate responsibility for all DSS & Comptroller rules, regulations and procedures for Medicaid, SEHP, and other programs relating to: •delivery system requirements•performance improvement •provider payment methods & incentives •covered benefits •etc.

A B C D

SustiNet Benefit Options

SustiNet governing body

DSS Comptroller

Medicaid SEHP

A B C D

SustiNet Benefit Options13

Individuals & Small

Businesses can purchase

SustiNet directly

(beg. 2012)

What is SustiNet? Option B: SustiNet as overseer and health plan (Step 2 of 3)

SustiNet governing body

DSS Comptroller

Medicaid SEHP

E F

A B C D

SustiNet Benefit Options14

Individuals & Small Firms

can buy SustiNet through

Exchange (beg. 2014)

Exchange

E F

SustiNet governing body

DSS Comptroller

Medicaid SEHP

What is SustiNet? Option B: SustiNet as overseer and health plan (Step 3 of 3)

What is SustiNet? Option C: SustiNet as consolidated agency and health plan (Step 1 of 3)

15

Authority for administering the Medicaid, SEHP and other programs is transferred from DSS and the Comptroller to a new entity, with a policy-setting governing body (consistent with federal law and collective bargaining agreements).

SustiNetMedicaid SEHP

SustiNet Governing Body

16

Individuals & Small Businesses

can purchase SustiNet directly (beginning 2012)

SustiNetMedicaid SEHP

SustiNet Governing Body

Commercial-style

benefits

What is SustiNet? Option C: SustiNet as consolidated agency and health plan (Step 2 of 3)

17

Individuals & Small Businesses can buy SustiNet through the

Exchange(beginning 2014)

ExchangeSustiNet

Medicaid SEHP

SustiNet Governing Body

Commercial-style

benefits

What is SustiNet? Option C: SustiNet as consolidated agency and health plan (Step 3 of 3)

Discussion: some considerations for choosing among these options• Who has ultimate decision-making authority?• Who controls funding?• What are the administrative expenses associated with the model, for

the state, individuals, and firms?• Does the model facilitate efficient and effective program

management?• How would the model facilitate coordination across programs/conflict

resolution?• What approvals are necessary (e.g., Medicaid waiver)? Are there

other barriers to implementation?• What are the issues and costs related to program

alignment/realignment/transition?

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Other key issues: which entity has legal authority & responsibility for

• Serving as single state agency, for purposes of Medicaid and CHIP (including CMS relations, eligibility, enrollment, appeals, etc.)?

• Promulgating & enforcing rules and regulations?• Allocating funding across eligible populations &

programs?• Negotiating and enforcing collective bargaining

agreements with state employees?

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Why offer SustiNet outside the exchange in 2014 and beyond?• Firms with >100 full-time employees

Can’t use exchange till 2017 For firms large enough to be self-insured, may be easier to

prevent adverse selection outside the exchange

• Small firms For 2 years, firm tax credits limited to exchange Exchange requires list billing. Outside the exchange, firms

can group bill. Undocumented immigrants can’t buy individual coverage in

the exchange

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SUSTINET GOVERNANCEPart III

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Additional governance issues• What is the size and makeup of the governing

body?• How are individuals selected?• What disciplines should be represented?• What decision-making authority does the

governing body have?• What rules and procedures apply to their

decisions?• What advisory bodies will be established?

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Advisory Committee recommendations: Governance and Administration

SustiNet Board should:• Include at least 2 enrollees in the SustiNet plan

• Reflect the diversity of SustiNet plan members

• Include at least 2 individuals who have experience in reducing health disparities

SustiNet Board should establish formal relationships with:

• CT health agencies (e.g. DSS, DPH, DMHAS, DCF)

• Health Information Technology Exchange of Connecticut (HITECT)

• Related federal councils and task forces

Advisory Committee recommendations: Governance and Administration

Establish independent statewide councils• Patient Centered Medical Home• Obesity

Establish Board committees• Health care quality and payment• Health care safety• Preventive health care• Community advisory• Health disparities and equity

SUSTINET ADMINISTRATIVE NEEDS

Part IV

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Necessary administrative capacities for SustiNet, regardless of model chosen

• Eligibility determination and subsidy calculations• Enrollment into plans• Premium billing/collection• Marketing (if offered to new populations) • Provider contracting and payments• Customer relations• Quality and safety standards• Data exchange• Utilization management• System management to achieve measurable

objectives re disparities, chronic illness, etc. 04/19/23 26

Decision pointsOn governance:• Preferred model for SustiNet role and structure?• Nature and composition of governing entity?• Decision-making authority?

On administration:• Build versus buy?• Use existing state Medicaid or SEHP capacity?• How to achieve efficiencies?

On access to SustiNet:• Before 2014, offer SustiNet as an option to small firms, municipalities, non-profits? To individuals? If so, how

to prevent adverse selection?• Starting in 2014, offer SustiNet in the exchange?

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Work plan for the next two months

• November: costs and financing (includes implications of pursuing the federal Basic Health Program option)

• December: two meetings: wrap up deliberations, and review draft report

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SUSTINET INFORMATION TECHNOLOGY, DATA AND EVALUATION NEEDS

Appendix A

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SustiNet information technology needs

• Eligibility determinations• Enrollment process and maintaining records• Premium billing, collection and related accounting

functions• Payment for services • Annual reconciliations (e.g. performance

incentives, PCMH-specific annual payments)• Provider network management• Evaluation data• Consumer-facing website

Guidance from Advisory Committees and Task Forces about Data Needs

• Capture race and ethnicity data• Support care coordination across multiple provider

settings• Capture HEDIS measures• Baseline utilization measurement• PCMH evaluation should be broad (e.g. transition

planning) and deep (e.g. completeness of wellness visits). Should include qualitative measures as well.

• Data collection strategies should minimize administrative burden on providers

Potential recommendations regarding SustiNet information technology

• Plan for a multi-year phase in and consolidation• Identify capacity within existing state systems to add on Sustinet

enrollment, eligibility and premium handling functions• Assess current information exchanges between DSS and OCA and

health plans to identify options for Sustinet• Create Sustinet-specific finance and accounting structure, including

payment, contract reconciliation and rate setting capacity• Data and analytics should be driven by a set of reporting principles and

priorities. • Options for managing data and analytics include:

• Standardized reports provided by all carriers (including Medicaid fee for service)

• SustiNet plan-specific standardized reports provided by a TPA or MCO• Datasets provided by TPA or MCO and analyzed by SustiNet or an analytic

contractor

FOLLOW-UP ON POTENTIAL SUSTINET POPULATIONS

Appendix b

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Population estimates

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Medicaid 620,000

State Employees Health Plan  200,000 active employees  40,000 retirees  240,000 total   Local government1. Dept. of Labor Estimate (2010) 145,1002. Conference of Municipalities Survey Estimate (2008) 36,512 local govt  88,898 local education  125,410 total

Not-for-profitsCT Association of Non-profits estimate, based on Dept. of Labor data 177,000*

* note: this includes both small and large non-profits, including universities and large health care institutions