Special Health Care Needs Focused Study Update 12:45 p.m. – 1:15 p.m. Presenter: David Mabb, MS, CHCA Senior Director, Statistical Evaluation

Identification of Individuals with Special Health Care Needs Discussion of Proposed Standardized Methodology

Identification of Individuals with Special Health Care Needs The Balanced Budget Act of 1997 (BBA) requires that states implement mechanisms to identify persons with special health care needs (SHCN), as defined by the state, to managed care organizations (MCOs), and prepaid inpatient health plans (PIHPs).

Identification of Individuals with Special Health Care Needs Study Purpose: To determine how members with SHCNs are identified, and assessed. To determine if potential improvements and standardization can ensure more efficient, accurate identification, and assessment of people with SHCNs.

Identification of Individuals with Special Health Care Needs Study Methodology: Conduct an examination of AHCA’s enrollment/eligibility data. Collect information on how MCOs currently identify individuals with SHCNs. Examine member level data set of individuals identified by MCO as having SHCNs. Calculate current rate of occurrence of identification for each MCO.

Identification of Individuals with Special Health Care Needs Preliminary Findings: Considerable variation in the methods used to identify SHCNs across the MCOs. Percentage of identification ranged from <1% to 10%.

Identification of Individuals with Special Health Care Needs Current Methods Used: Provider referral Member self referral Health risk assessments Monthly enrollment (ACS) file Eligibility file assistance category codes Claims/encounter data

Identification of Individuals with Special Health Care Needs HSAG compiled the information collected and proposed a standardized methodology for AHCA review.

Identification of Individuals with Special Health Care Needs HSAG prioritized the methods considering which would provide the most complete and accurate results. HSAG also considered the MCO feasibility to implement the methods (resources, data availability).

Identification of Individuals with Special Health Care Needs Various methods may be effective in identifying potential individuals with special health care needs. To evaluate their effectiveness, HSAG will need MCO input and cooperation.

Identification of Individuals with Special Health Care Needs Proposed methods for discussion: Use of monthly enrollment (ACS) file recipient codes “01” through “20” indicate a member may have special health care needs.

Identification of Individuals with Special Health Care Needs Proposed methods for discussion: Use of pharmacy and/or lab results data help identify members with elevated blood lead levels (>10mg/DL), asthma, diabetes, HIV, and other diseases and conditions.

Identification of Individuals with Special Health Care Needs Proposed methods for discussion: Use of ICD-9 codes from claims/encounter data to trigger a need for an evaluation for special health care needs.

Identification of Individuals with Special Health Care Needs Next Steps: Discuss with AHCA which method(s) to use for MCO testing. Provide description of method(s), instructions, and a time frame for submissions to MCOs.

Identification of Individuals with Special Health Care Needs Next Steps: MCOs re-run data, create updated data file of newly identified members with SHCNs. Compare initial files with updated files using proposed methodology. Analyze results and make recommendations to AHCA.