DSS: The Medical Care Administration Division

The Medical Care Administration Division
 


OVERVIEW:

The Medical Care Administration Division is responsible for overseeing the administration, policy, regulations and operations of the Medical Assistance Programs for the agency's clients.

 

MEDICAL CARE ADMINISTRATION - MEDICAL OPERATIONS

 

Medical Operations supports all activities relating to the processing, authorizing, reporting and monitoring of the medical assistance services the Department pays for as required by federal and state statutes.

 

The Department contracts with Electronic Data Systems Corporation (EDS) to perform as the fiscal agent responsible for designing, developing, implementing and maintaining a State-owned and federally certified Medicaid Management Information System (MMIS) for the services provided under Medicaid Fee-for-Service.  The MMIS also supports the Connecticut AIDS Drug Assistance Program (CADAP), Connecticut Pharmaceutical Assistance Contract to the Elderly and Disabled Program (ConnPACE), Katie Beckett Waiver Program, State Administered General Assistance Program (SAGA), Connecticut Home Care Program, and Connecticut Behavioral Health Partnership Program.  EDS provides full fiscal agent services including claims processing, provider relations and enrollment, ConnPACE participant relations and enrollment, Federal and State financial management reporting and surveillance, and utilization review reporting to the Department.

 

The Medical Care Operations Division is composed of four distinct functional areas - Medicaid Management Information Systems, Provider Relations, Pharmacy Programs, and Medical and Clinical Services.  The following is a brief description of each:

 

The Medicaid Management Information System (MMIS) Team oversees, directs and monitors EDS operations.  In addition, the MMIS Team coordinates and defines all system user requests, the oversight of system modifications and system maintenance and the monitoring of contractor and system performance.

 

The Provider Relations Team responds to inquiries from providers, clients and the general public concerning the medical assistance programs.  Provider Relations is responsible for directing and coordinating all areas of the Fee-for-Service provider enrollment process.  Provider Relations also has oversight responsibility for claim processing issues, the publication and updating of the provider specific fee schedules, provider billing manuals and provider bulletins.  Provider Relations triages multi-faceted issues related to the Connecticut Medical Assistance Program and aids clients and providers by resolving complex billing problems and by assisting clients in locating Fee-for-Service providers.

 

The Pharmacy Program Team directs the pharmacy benefits for the Connecticut AIDS Drug Assistance Program (CADAP), the Connecticut Pharmaceutical Assistance Contract to the Elderly and the Disabled Program (ConnPACE), and the Medicaid Fee-for-Service Program.  All CADAP application and eligibility determination processes and card issuance is performed within this unit.  The staff also oversees and directs EDS in the application and eligibility determination process for the ConnPACE program, as well as the Medicare Part D enrollments and monthly premium payments.  The Pharmacy staff coordinates the drug manufacturer rebate programs, monitors the contracts for the Retrospective Drug Utilization Review (DUR) Program, Prior Authorization, and participates on the Pharmaceutical and Therapeutics Committee, which maintains the Medicaid Preferred Drug List (PDL).  Pharmacy policy and regulations are also the responsibility of the Pharmacy staff.

 

The Medical and Clinical Services Team performs clinical and medical analysis, the authorization for specified medical services, and contract monitoring of the Connecticut Peer Review Organization.  The staff also performs medical case reviews for Employment Service Exemption requests in the Temporary Family Assistance Program.  The Medical and Clinical Services Team reviews and authorizes non-citizen emergency assistance and determines nursing home level of care as well as administers Connecticut's "Katie Becket" model waiver.

 

MEDICAL CARE ADMINISTRATION - ALTERNATE CARE UNIT

 

The Alternate Care Unit (ACU) is responsible for the development, operation and monitoring of the CT Home Care Program for Elders (CHCPE). The CHCPE is a state and federally funded comprehensive home care program. It is designed to enable elders who are at risk of institutionalization to receive the services they need to remain living in the community. CHCPE services include but are not limited to skilled nursing care, home health aide, homemaker services, emergency response system, home delivered meals and companion services. Currently, the CHCPE is piloting two (2) new home care services offering subsidized assisted living services under the Medicaid Waiver and personal care assistant services.

 

The Alternate Care Unit (ACU) staff located both in central office and in five (5) field offices throughout the state. The unit staff determines financial and functional eligibility and approves care plans. Staff monitors service utilization and care plan cost limits. Contractor and subcontractor compliance with program policies and procedures are monitored by staff through required reports and on site record and administrative reviews. Client satisfaction surveys are also conducted as part of the ACUís quality assurance activities. Additionally, the ACU staff educates the general public and health care providers about program eligibility and services.

 

The ACU is also responsible for administering and performing a portion of the pre-admission screening required by the Omnibus Budget Reconciliation Act (OBRA) Nursing Home reform Act. Unit staff screen all individuals applying for admission to a Medicaid certified nursing facility for mental illness and mental retardation. The unit also screens individuals for level of care and approval of nursing home placement who are sixty-five (65) years and older, are Medicaid eligible or whose Medicaid application is pending and are seeking nursing home placement.

 

MEDICAL CARE ADMINISTRATION - MANAGED CARE DIVISION

 

The Managed Care Division has administrative and operational responsibilities for the Medicaid Managed Care program (HUSKY A); the State Childrenís Health Insurance Program (also known as SCHIP or HUSKY B); HUSKY Pus; Non-emergency Medical Transportation; Dental Initiatives; and the Connecticut Community HealthCare Initiative (CCHI).

Functions include program analysis; quality assurance; managed care capitation payments; FFS provider fee schedule updates; managed care enrollment; managed care regulations and policy development; reporting and program and contract monitoring.

 

The Managed Care division is composed of three teams, Program Analysis and Quality Assurance; Dental and CCHI and Managed Care. The following is a brief description of each:

 

The Program Analysis and Quality Assurance team performs four major functions. This team is responsible for the collection and analysis of data concerning utilization of services under the Medicaid managed care; SCHIP and HUSKY Plus programs as well as data analysis related to utilization of services under Medicaid FFS. Additional responsibilities include the updating of FFS provider fee schedules; oversight of quality assurance initiatives for the HUSKY programs and administration of Non-emergency Medical Transportation services. The Program Analysis unit works closely with other departments of state government, especially OPM, DCF, the State Department of Education, the Department of Mental Health and the Department of Public Health and Addiction Services. The data and analyses gathered and prepared by Program Analysis staff are critical components of major statewide and departmental programs.

 

The Managed Care Team has responsibility for the administration of the HUSKY A and B programs and HUSKY Plus. HUSKY A provides Medicaid coverage and services to families and children through contracts with four managed care organizations (MCOs). HUSKY B provides health insurance to uninsured children who do not qualify for HUSKY A. HUSKY Plus provides supplemental coverage for children with special health care needs enrolled in the HUSKY B program.

 

The Managed Care team provides monitoring and oversight of the contracted HUSKY managed care organizations, HealthNet/Healthy Options; Blue Care Family Plan; FirstChoice/Preferred One of CT and Community Health Network of CT. Responsibility for oversight of the HUSKY application and enrollment broker and HUSKY Plus contractors also rests with the managed care team.

 

The Dental and CCHI team oversees the Connecticut HealthCare Initiative. CCHI is made up of two components: HUSKY outreach and the Healthy Start program. The Healthy Start program provides supportive services to low-income pregnant women. This team is responsible for program management and contractor oversight of the 15 organizations with whom the Department contracts to provide HUSKY Outreach and Healthy Start services.

 

The Dental and CCHI team also has responsibility for management of Dental services, both in managed care and fee for service, and developing new initiatives that promote access to dental services.



Content Last Modified on 12/19/2011 1:47:52 PM