# Presentation: 340034

## OUTLINE

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

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

- 1115 Waiver
- Enroll TANF Families Into Their Choice of Four Health Plans
- Incremental Strategy to Provide Coverage to the Uninsured

- BACKGROUND - RITE CARE

## 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

- 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

- RHODE ISLAND’S COVERAGE OF THE UNINSURED

## 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

- 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

- RITE CARE ENROLLMENT

## 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

- RITE CARE ENROLLMENT (cont.)

## 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

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

- RHODE ISLAND’S GOALS UNDER RITE CARE

## 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

- 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

- RHODE ISLAND’S TITLE XXI PLANS

## 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

- Uninsured Parents of RIte Care Children
- Uninsured Older Siblings
- Foster Parents

- RHODE ISLAND’S TITLE XXI PLANS (cont.)

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

- Translation Services
- Multilingual and Multicultural Provider Network and Member Services

- RITE CARE IS MORE THAN A STANDARD COMMERCIAL PRODUCT

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

- Early Intervention
- School-Based Clinics
- Consumer Advisory Council

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

## 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”

- 	“--‘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”

- MEDICAL NECESSITY

## 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

- 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

- RHODE ISLAND’S TITLE XXI PLANS (cont.)

## 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

- 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

- RITE BEGINNINGS

## 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

- 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

- RITE BEGINNINGS (cont.)

## 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

- 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

- RITE CARE’S IMPACT ON HEALTH CARE ACCESS, UTILIZATION AND HEALTH STATUS

## 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

- 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

- RITE CARE RESULTS

## % OF WOMEN WITH SHORT INTERVAL BETWEEN BIRTHS (<18 MONTHS) BY INSURANCE STATUS 1993-1996

## 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

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

- RITE CARE RESULTS

## % BEGAN PRENATAL CARE IN 1ST TRIMESTER BY INSURANCE STATUS 1993-1996

- % BEGAN PRENATAL CARE IN 1ST TRIMESTER BY INSURANCE STATUS 1993-1996

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

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

## % OF WOMEN WHO RECEIVED ADEQUATE/ADEQUATE PLUS CARE BY INSURANCE STATUS 1993-1996

- % OF WOMEN WHO RECEIVED ADEQUATE/ADEQUATE PLUS CARE BY INSURANCE STATUS 1993-1996

## 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

- The Percentage of Pregnant Women on Medicaid Who Smoked During Pregnancy Decreased Significantly From 33% in 1993 to 27% in 1996

- RITE CARE RESULTS

## % OF PREGNANT WOMEN WHO REPORT SMOKE CIGARETTES BY INSURANCE STATUS 1993-1996

## RITE CARE RESULTS

## 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

- 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

- EXCELLENT MEMBER SATISFACTION WITH RITE CARE

## 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

- 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

- EXCELLENT MEMBER SATISFACTION WITH RITE CARE (cont.)

## PERCENT OF ADULT RITE CARE MEMBERS WHO SELF REPORT THAT THEIR PCP TALKED ABOUT PREVENTIVE CARE

## 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

- 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

- RITE CARE HEALTH PLAN CONTRACT OVERSIGHT AND MONITORING ACTIVITIES

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

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

- HEALTH PLAN MONITORING

## 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

- 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

- HEALTH PLAN MONITORING (cont.)

## 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

- Broader Coverage Does Not Mean Greater Costs
- Partnership Between State and Health Plans is Critical to Success

- CONCLUSION