Advisory Sub Committee
Archived Minutes
Meeting Minutes - June 6, 2003
Members Present: Dr. Mary Anne Guggenheim, Dr. Marian Kummer, Dr. John Johnson, Nancy Gass, Debbie Christian, Jo Ann Dotson, Cyndi Leaphart, Ellen Carey
CSHS Staff: Barbara Smith, Corliss Scott, Michele O'Donnell, Lois Tweten, Marylynn Donnelly, BJ Archambault, Mary Noel
Guests: Gwen Bergan, Paula Jane, MCHB Interns; Jackie Forba, CHIP; and Maggie Bullock, Administrator, Health Policy and Services Division.
Chair Mary Anne Guggenheim called meeting to order at 10:00. Member and staff introductions were made. Minutes of the October 25, 2002 meeting were reviewed. Dr. Kummer moved to approve the minutes, passed by unanimous vote.
New CSHS Program Manager (Section Supervisor) was introduced. Barbara Smith has been with the Department for nine years. Previously she managed community based long-term care services for Medicaid. She presented her management principles and her vision for CSHS. She asked for the committee to assist CSHS in making the necessary changes to be seen as the experts in children's health issues. The slide presentation is attached.
Jackie Forba gave an update on CHIP. Currently 9550 children are covered under the program. There is a waiting list of approximately 760 individuals. Current focus is to keep covered children covered. To do this the re-application process has been streamlined by using a pre-populated renewal application. In addition, the families receive post card reminders prior to receiving the application. The result has been a re-enrollment rate of approximately 92%, up from the mid 70 ranges. The down side is that the waiting list slows and gets longer. The current wait is from 4 to 6 months. Families should continue to apply to get on the list and to allow CHIP to plan for future coverage needs.
CHIP conducts a customer satisfaction survey on an annual basis. The results have led to increased communication with families in the area of benefit utilization, well childcare and application processes to satisfy their requests for more information. CHIP now also sends EOBs to beneficiaries to give them updates on where they are with their vision and dental benefits.
A question was asked regarding the dental provider network. There are 240 dentists in the network, the largest network in the state. A majority of them are open to taking CHIP kids. Paying at 85% of charges, processing claims quickly and keeping the process streamlined accomplished this. CHIP covers $350 per year. Beyond that level is the responsibility of the family. CHIP is currently experiencing a 50% utilization of dental benefits but is hopeful that increased communication about the benefit will raise the utilization numbers.
Dr. Kummer asked about the state-federal split with CHIP. 19% state funds, 81% federal funds.
Dr Guggenheim asked about contract negotiations and the changes of increased premiums. The contract is due for renewal on October 1, 2033. BC/BS has held the premium constant the last couple of years.
Ellen Carey asked how does the universal application get to CSHS when a family notes a special need. The application comes in, is processed for CHIP and is transferred to CSHS for follow-up. CHIP also has the responsibility to refer to Medicaid or the Caring Program for Children if the child is potentially eligible for those programs. A child can be on the CHIP wait list and receive financial assistance from CSHS.
Jo Ann Dotson requested statistics regarding the utilization of vision benefits. Jackie did not have it readily available but will get it for the committee. (Update: 13% of covered children have received frames &/or lenses. This does not include vision exams.)
Mary Noel provided the committee with an overview of the legislative session. CSHS is 100% federally funding, so there were no direct funding issues with this program. Jo Ann Dotson noted that we took a small hit from the feds for FFY03 which when asked the feds could not exactly explain why. From this CSHS lost approx. $2000.
CHIP: Authorized the program to search for non-state funds to expand the program. Follow up to the CI146 initiative to fund CHIP through the tobacco settlement, therefore in July, CHIP's general fund will be replaced by Tobacco settlement dollars.
MIAMI: Funding for the MIAMI project was touch and go but it eventually funded close to the current levels.
Child Support Enforcement: Granted funds to fill their deficit so they could continue to collect child support without charging a fee.
Child Care Assistance: Faces drastic reductions in state support over the biennium, 2005 will be worse than 2004. This issue has already affected many families of CSHCN as interim cuts were taken prior to the session.
Specific Bills:
HB 569 referred to as the Montana At Home Infant Act. This would pay parents of infants to stay at home in lieu of daycare assistance.
SJR21 a resolution urging the affordable and available daycare.
HB65 amended licensing requirements for dental students, hygienist and retired dental professional to practice in free clinics and/or underserved areas
HB150 provides state labor law waiver of minimum wage, workers compensation, unemployment insurance and overtime for companionship or respite services when the person providing the service is employed directly by a family member or legal guardian.
HB286 provided an additional $211,000 for the dental hygiene program at MSU in Great Falls.
HB384 allows insurance companies to provide a basic insurance package with few mandates, New West does have a product that they will be piloting.
Dr. Guggenheim commented that while it did provide some coverage it also eliminates some of the basic coverage we believe people should have. The short-term benefits of such a program are a philosophic change in insurance coverage.
Medicaid re-design was authorized through HJ13 is being handled by Peter Blouke, former director of SRS. This includes a review of all health programs administered by the Department.
SB 190 expanded the practice of dental hygiene to establish criteria when a licensed dental hygienist may provide preventative dental hygiene services without prior authorization or presence of a dentist. (Will assist in getting hygienists into institutions)
SB 449 updates the fetal infant and child mortality prevention act.
SB 217 Updates child safety restraint laws, children under 6 years of age who weigh less than 60 pounds require child safety restraints in motor vehicles.
Health related bills that failed included the indoor air act, reversal of open container law, and graduated driver's licenses.
Barbara Smith added that HB573 passed to allow glucagons injections by school personnel when the family and that individual have worked together to develop a plan.
Dr. Guggenheim asked about Part C. Mary Noel provided the information that Part C at one time during the negotiation of HB 2 (state funding bill) was eliminated. However, Sylvia Danforth and Cris Volinkity activated the family support network and the program was restored.
Nancy Gass, Cyndi Leaphart, Marylynn Donnelly and Barbara Smith recently attended the Title V leadership conference in Baltimore. Each shared their view. Nancy noted areas where Montana could improve at involving families of CSHCN. Cyndi appreciated the status update of the performance measurements and how it related to her work at the clinic. Marylynn noted transition issues were once again at the forefront and how CSHS needs to get involved in improving transition for our adults. Barbara appreciated the big picture view of how the performance measures cover all service systems and where CSHCN programs should be taking the lead in this area.
Jo Ann Dotson provided an update for the block grant. Montana should receive approximately $2.67 million, of which 30% goes to CSHS. This is a slight increase over the current year, so long as we don't encounter any math errors. The block grant can be completed through an on-line process this year, but states are being required to send the MCH coordinator (Jo Ann) and the CSHCN Director (Barbara) to Denver to defend the grant. State staff will be connected via video link to participate.
CSHS rule revision. The advisory committee was thanked for their assistance with the rules. Barbara passed out the submitted version. Dr. Guggenheim noted that some of the changes were not made as discussed. Barbara noted those and will follow up with legal. Dr. Guggenheim asked Dr. Kummer, Dr. Johnson, Cyndi Leaphart and Ellen Carey to review the covered conditions section to insure that all body systems were noted. It should be noted that the pharmacy reimbursement methodology was changed to mirror Medicaid. Current CSHS practices reimburse at AWP (average wholesale price) plus $4 dispensing fee. This is currently way out of line, causing CSHS to pay more than what they should.
Dr. Guggenheim presented the Committee Charter for final review. A few changes were noted to the number of specialty and primary care providers, and the length of the terms. With these changes, Dr. Guggenheim motioned to accept the charter; Ellen Carey provided the second and the motion passed with unanimous vote. Updated charter is attached.
Dr. Guggenheim raised the discussion about the participation of members on the committee. A proposal was made to provide Barbara with a clean start by having all committee members resign, and be reappointed (or not) by Barbara. The new committee would have varying terms to allow turnover within the committee. Members present agreed to that process. Barbara will remind committee members to resign and the process of reappointment, (Update: this was done via e-mail on June 18).
Dr. Guggenheim respectfully requested the committee consider succession planning for the chair position. She is willing to serve for one more year, however a vice chair needs to be elected to assist with the process. The floor was opened for nominations for vice chair. A discussion ensued regarding the responsibility of the vice chair and options available to the committee. After much discussion, Dr. Kummer agreed to serve as vice chair for a period of one year. Barbara agreed to follow up with Dr. Laura Nicholson regarding her involvement with CSHS when she returns to Montana next summer.
Committee Composition was discussed and potential names were provided for Barbara to follow up. Per Charter:
A. Regional Nurse Coordinators:
a. Cyndi Leaphart
b. Ellen Carey
B. Parents or Family Members of CSHCN (Discussion of family members was suspended due to HIPAA privacy regulations. Potential family member names need to be submitted to Barbara after permission is granted from the family.) The following have agreed to submit their names.
a. Nancy Gass
b. Debbie Christian
c. Peggy Eggen
C. Representative of Part C.
a. Sylvia Danforth
b. Cris Volinkity
c. Sue Dowes
d. Audrey Pierce
e. Vicky Pfeifer
D. Specialty Providers
a. Mark Wilgus, DDS
b. Peggy Schlesinger, Rheumatoid Arthritis, Missoula
c. Jerry Eichner, Pulmonologist, Great Falls
d. Steve Hardy, Plastic Surgeon, Missoula
e. Anne Manketlow, Pediatric Surgeon, Missoula
f. Jim Wiggins, Pediatric Cardiologist, Billings
g. Suzanne Dixon, Developmental Pediatrician, Great Falls
h. Antonio Santin, Otolaryngology/Plastic Surgeon, Great Falls
i. Cary Mielke, Orthopedist, Missoula
j. Karl Buechsenschuetz, Orthopedist, Missoula
k. David Chavez, Pediatric Urologist, Billings
E. Montana Medical Genetics program
a. John Johnson
b. Genetic Counselor
F. Primary Care/Medical Home
a. Marian Kummer, Billings
b. Mary Ann Carlson, Columbia Falls
c. Ed Young, Miles City
d. Eric Mosqueda, Butte
e. Susan Sheperd, Community Clinic, Butte
f. Petra Messick-Laeven, Great Falls
g. Juilete Hansen, Butte
h. Blaise Favara, Hamilton
i. Lori Byron, Hardin
j. Mark Zilkoski, Wolf Point
k. Pat Sauer, Billings
l. Laura Bennett, Lewistown
Discussion ensued regarding additional member, such as representation from the primary care association, community health clinics, representative from the insurance industry, attorney with healthcare background, etc. Barbara will take names in these areas unit June 30, 2003. Pay particular attention to the NW and NE portions of the state to insure geographic representation. Barbara will draft a letter to these individuals soliciting interest in committee membership.
Maggie Bullock, Administrator of the Health Policy and Services Division joined the committee meeting. She provided the committee with an update on DPHHS reorganization. CSHS, CHIP, Acute and Primary Medicaid and Children's Mental Health Services will be combined to establish he Child and Adult Healthcare Resources Division. This will have a large budget and approx. 40 in staff. John Chappius DPHHS Deputy Director will be acting Division Administrator through at least December 2003. This division will increase CSHS collaboration with other children's programs such as EPSDT and mental health services.
The rest of the programs currently in HPSD will become the Public Health and Safety Division. CSHS will still be closely collaborating with public health programs to meet performance measurements and continue data sharing.
Dr. Kummer asked Maggie about the state's position on Medicaid block grants. The current block grant proposal is not advantageous to the state. The matching ratio is changed, but then leaves the state responsible. Under this arrangement it would be difficult to maintain the growth of the program.
Barbara provided a number of handouts to the committee regarding the case management, including definitions, history and a table of available sources of targeted case management (TCM). CSHS recently took over the management of the TCM for CSHCN program under Medicaid. The program was established in 1996, however little guidance has been given to these providers in the past few years. Originally designed as a public health visiting program, providers were encouraged to manage CSHCN through collaborative agreements within their local community. Since then, providers have dropped out leaving large geographic areas uncovered.
To understand Medicaid, Barbara explained the basic principles of Medicaid law affecting program management. Federal law in relation to Medicaid TCM for CSHCN allows states to provide case management services to a specified target group by willing providers who meet provider requirements. Federal Medicaid law also dictates that children receive case management from one source with some ability to provide care coordination from another entity on a limited basis. This is a difficult portion to manage of this program, as there is no centralized entity to track children in this program.
Barbara has met with three providers who have different approaches and level of interest in Medicaid TCM for CSHCN. There requests were simple, clarify their responsibilities and provide feedback to insure that services are being provided appropriately. A follow up meeting is scheduled for July 17 in Missoula to begin establishing provider criteria, standards of care, deal with documentation issues. Barbara suggested that the committee agree to support this approach of partnering with providers to develop an effective case management program.
The second issue to this service, is to define if and when CSHS should pay for case management services for non-Medicaid and non-financially eligible children. Historically, CSHS gave generic permission to providers to bill CSHS for such services, without any further guidance. To date, one county health department has taken advantage of this offer, CSHS has honored the agreement. Discussion ensued regarding the need for CSHS to reimburse for such services, to what degree and to what population. The committee determined that reimbursement for case management services to CSHCN with CSHS covered conditions, regardless of their financial eligibility status was appropriate. Guidelines for authorization and reimbursement will be developed within the framework of the rules and shared with the committee at a later date.
The complexity of this issue, led to the discussion of dissemination of information regarding services through CSHS or services for CSHCN. Dr. Kummer stated that her dream is a website where physicians, families and other interested parties can log in to find information regarding services, suppliers, etc. Barbara said that CSHS has a responsibility to develop a website that provides information to these parties. Michele O'Donnell will be heading up this effort. This issue will be on the next agenda for further discussion.
Further discussion regarding other forms of outreach ensued. CSHS needs to take a look at working with the Montana Chapter of the AAP, the Montana Association of Family Practice (MAFP) to further knowledge of services for CSHCN. Dr. Kummer will check the schedule for the AAP meeting. (Update: Barbara will speak at the MT AAP meeting in September to brief members on CSHS) Barbara was referred to the MMA to track down the MAFP chair. An outreach plan for CSHS will be developed when Corliss Scott's position description is finalized through personnel to allow her participation in this activity.
The final agenda item was a discussion regarding the support of in-state pediatric specialists in outreach clinics. Currently Drs. Schlesinger and Eichner are providing outreach clinic services away from their home base. CSHS supports only Dr. Schlesinger in this activity. Dr. Guggenheim suggested the committee develop guidelines of who CSHS will support and why. Traditionally it has been the pediatric sub specialist who is the sole sub specialist in the state. CSHS will retain this policy and will put it in writing for further reference. It was agreed that support would include mileage, transportation costs, per diem and lodging. In turn the sub-specialist will provide data on clinical activities.
A follow up meeting was set for Friday, October 17, 2003 in Helena. Topics for discussion will include CSHS web site development and defining the linkage with the disability determination bureau. Barbara will provide interim email updates on an as needed basis to the committee.
Respectfully Submitted,
Barbara Smith
CSHS Program Manager
