OUTLINE

1
OUTLINE

• Background - RIte Care
• Rhode Islands Title XXI Plans
• RIte Care Benefit Package Experience
• Impact on Health Care Access, Utilization, and
  Health Status
• Monitoring Strategies

2
BACKGROUND - RITE CARE

• Begun in 1994
• 1115 Waiver
• Enroll TANF Families Into Their Choice of Four
  Health Plans
• Incremental Strategy to Provide Coverage to the
  Uninsured

3
RHODE ISLANDS COVERAGE OF THE UNINSURED

• 1994 - Provided RIte Care Coverage to Children to
  Age 6 and Pregnant Women Up to 250 Percent of FPL
• 1996 - Expanded RIte Care Coverage to Children to
  Age 8 Up to 250 Percent of FPL
• 1997 - Expanded RIte Care Coverage to Children to
  Age 18 Up to 250 Percent of FPL
• 1998 - Bill to Expand RIte Care Coverage to
  Parents Up to 185 Percent of FPL

4
RITE CARE ENROLLMENT

• 75,000 are Enrolled
• 52,000 of Whom are Children Under 18
• Covers 1/3 (4,000) of the State's Births Annually
• 91 Percent of All RIte Care Enrollees Choose
  Their Own Health Plan
• Through RIte Care, Virtually all Rhode Island
  Children Have Access to Comprehensive Health
  Insurance

5
RITE CARE ENROLLMENT (cont.)

• New Streamlined Mail-In Application and
  Significant Investment in Outreach Will Help Us
  Enroll the Remaining 15,000 Uninsured Children
  Who Are Eligible But Not Yet Enrolled

6
RHODE ISLANDS GOALS UNDER RITE CARE

• Improve Access
• Assure Quality
• Results Improved Health Status
• Decrease LBW
• Increase Prenatal Care
• Improve Immunization Rates
• Decrease Lead Poisoning
• Lengthen Interpregnancy Interval
• Decrease Preventable Hospitalization

7
RHODE ISLANDS TITLE XXI PLANS

• Rhode Island has Already Covered the Title XXI
  Population
• Experience with Benefits, Program Evaluation, and
  Monitoring Strategies
• Rhode Island's CHIP Plan was Approved in May,
  Allowing Title XXI Coverage for Our Latest RIte
  Care Expansion Group Children ages 8 - 18 Up to
  250 Percent of FPL

8
RHODE ISLANDS TITLE XXI PLANS (cont.)

• Title XXI Public Process Has Resulted in a
  Recommendation to the Governor to Seek Approval
  Under Title XXI to Serve Families
• Uninsured Parents of RIte Care Children
• Uninsured Older Siblings
• Foster Parents

9
RITE CARE IS MORE THAN A STANDARD COMMERCIAL
PRODUCT

• Transportation - RIPTA
• Translation Services
• Multilingual and Multicultural Provider Network
  and Member Services

10
RITE CARE IS MORE THAN A STANDARD COMMERCIAL
PRODUCT (cont.)

• Unlimited Mental Health and Substance Abuse
  Services
• Early Intervention
• School-Based Clinics
• Consumer Advisory Council

11
MEDICAL NECESSITY

• New Definition
• --Medical Necessity or Medically Necessary
  Service means medical, surgical, or other
  services required for the prevention, diagnosis,
  cure, or treatment of a health related condition
  including services necessary to prevent a
  decremental change in either medical or mental
  health status. Medically necessary services must
  be provided in the most cost effective and
  appropriate setting and shall not be provided
  solely for the convenience of the member or
  service provider

12
RHODE ISLANDS TITLE XXI PLANS (cont.)

• Goal Break the Cycle of Lead Poisoning Through
  Education and Environmental Intervention
• Beginning July 1998
• Intensive Case Management, Including Assistance
  with Relocation or Finding Temporary Housing, as
  Needed
• Family Education on Establishing and Maintaining
  a Lead-Safe Environment
• Referrals to and Coordination with Other Health
  and Social Service Programs
• Replacement of Windows to Prevent Recurrence of
  Lead Poisoning

13
RITE BEGINNINGS

• Beginning January 1999
• Professional Nursing Case Management and Home
  Visitation
• Mother Will be Enrolled as Soon as Pregnancy is
  Identified Mother and Child Remain in Program
  Until the Child is Two, with Appropriate Linkages
  to Other Resources
• Home Visitations Will be Frequent, on the Order
  of Twice Per Month
• Intervention is Targeted to Low-Income,
  First-Time Teen Mothers, Based on Research by Dr.
  David Olds

14
RITE BEGINNINGS (cont.)

• Focus on Parenting Skills, Child Development,
  Self-Sufficiency, Problems Solving Skills, Health
  Care Compliance, Enhancing Personal and Community
  Network
• Outcome Measures to Include
• Increased mother and child health care compliance
• Decreased maternal smoking, alcohol and substance
  abuse
• Increased interbirth intervals
• Reduction in child abuse and neglect
• Improved maternal education and employment status

15
RITE CARES IMPACT ON HEALTH CARE ACCESS,
UTILIZATION AND HEALTH STATUS

• Improved Access to Primary Care
• Doubled Primary Care Physician Participation
• Doubled Physician Visits From Two Per Year to
  Five Per Year
• Decreased Emergency Room Visits and Hospital
  Utilization by One Third

16
RITE CARE RESULTS

• Positive Impact on Maternal Health
• Decreased the Number of Women on Medicaid With
  Short Intervals (Less Than 18 Months) Between
  Births From 42 in 1993 to 28 Percent in 1996,
  Almost Completely Closing the Gap Between
  Medicaid and Commercially Insured Women

17
OF WOMEN WITH SHORT INTERVAL BETWEEN BIRTHS
(lt18 MONTHS) BY INSURANCE STATUS 1993-1996
18
RITE CARE RESULTS

• Improved Prenatal Care
• Increased the Number of Pregnant Women Entering
  Prenatal Care in the First Trimester
  Significantly From 76 in 1993 to 81 in 1996

19
BEGAN PRENATAL CARE IN 1ST TRIMESTER BY
INSURANCE STATUS 1993-1996
20
RITE CARE RESULTS

• Improved Prenatal Care
• Adequate Prenatal Care Also Increased
  Significantly From 55 in 1993 to 69 in 1996

21
OF WOMEN WHO RECEIVED ADEQUATE/ADEQUATE PLUS
CARE BY INSURANCE STATUS 1993-1996
22
RITE CARE RESULTS

• Positive Impact on Maternal Health
• The Percentage of Pregnant Women on Medicaid Who
  Smoked During Pregnancy Decreased Significantly
  From 33 in 1993 to 27 in 1996

23
OF PREGNANT WOMEN WHO REPORT SMOKE CIGARETTES
BY INSURANCE STATUS 1993-1996
24
RITE CARE RESULTS
25
EXCELLENT MEMBER SATISFACTION WITH RITE CARE

• Overall, 97 of the 1,344 Respondents (43
  Response Rate) to a December 1997 RIte Care
  Member Satisfaction Survey were "Very Satisfied"
  or "Satisfied" with RIte Care In 1996 it was
  95 of the 1,009 Respondents (30 Response Rate)
• 95 of Respondents were "Satisfied" or "Very
  Satisfied" with Their Primary Care Physician
• 95 of Respondents were "Satisfied" or "Very
  Satisfied" with the Amount of Time Primary Care
  Physician Spent with Them

26
EXCELLENT MEMBER SATISFACTION WITH RITE CARE
(cont.)

• The Provision of Anticipatory Guidance by Primary
  Care Physicians was Reported to be High by
  Respondents, For Example
• 79 of adults responded that their primary care
  physician talked to them about smoking
• Between 60 and 70 of adults responded that
  their primary care physician talked to them about
  alcohol/drug use, diet, exercise, stress, and
  safe sex
• 51 of adults responded that their primary care
  physician talked to them about mental health

27
PERCENT OF ADULT RITE CARE MEMBERS WHO SELF
REPORT THAT THEIR PCP TALKED ABOUT PREVENTIVE CARE
28
RITE CARE HEALTH PLAN CONTRACT OVERSIGHT AND
MONITORING ACTIVITIES

• Access Studies
• Four Focus Groups Each Year
• Annual Health Plan Comprehensive Site Visits
• Member Satisfaction Survey
• Utilization Data Analyses
• Focused Clinical Studies
• Financial Reviews
• Review and Analysis of Complaints and Grievance
  Data
• Special Studies

29
HEALTH PLAN MONITORING

• Provider Network Composition
• Covered Services
• Service Accessibility Standards
• Member Services
• Provider Services
• Marketing
• Grievance and Appeals
• Encounter Data Reporting
• Financial Performance

30
HEALTH PLAN MONITORING (cont.)

• Quality Assurance
• HCFA requirements
• Chart audits to support EQRO review
• Adherence to internal quality standards, e.g.
• first pre-natal visit
• baseline physical for new members
• annual physical
• routine care for newborns

31
CONCLUSION

• RIte Care Members Now Appropriately Access a Full
  Continuum of Quality Health Care and Support
  Services
• Broader Coverage Does Not Mean Greater Costs
• Partnership Between State and Health Plans is
  Critical to Success