Answers to Clarifying Questions from HCFA, May 1998
Clarifications that are based in statute and are essential for approval of the plan
1. Please provide assurances that the Title XXI State Plan will be conducted in compliance with all civil rights requirements.
A. We will provide you with our Standard Form 424B (4-88) As prescribed by OMB Circular A-102. which includes assurance number 6:
"Will comply with all Federal statutes relating to nondiscrimination. These include but are not limited to: (a) Title VI of the Civil Rights Act of 1964 (P.L. 88-352) which prohibits discrimination on the basis of race, color or national origin; (b) Title IX of the Education Amendments of 1972, as amended (20U.S.C. 1681-1683, and 1685-1686), which prohibits discrimination on the basis of sex; (c) Section 504 of the Rehabilitation Act of 1973, as amended (29 U.S.C. 794), which prohibits discrimination on the basis of handicaps; (d) the Age Discrimination Act of 1975, as amended (42 U.S.C. 6101-6107), which prohibits discrimination on the basis of age; (e) the Drug Abuse Office and Treatment Act of 1972 (P.L. 92-255), as amended, relating to nondiscrimination on the basis of drug abuse; (f) the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (P.L. 91-616), as amended, relating to nondiscrimination on the basis of alcohol abuse or alcoholism; (g) 523 and 527 of the Public Health Service act of 1912 (42 U>S. 290 dd-3 and 290-ee-3) as amended, relating to confidentiality of alcohol and drug abuse patients records; (h) Title VIII of the Civil Rights At of 1968 (42 U.S.C. 3601 et seq.), as amended, relating to non-discrimination in the sale, rental or financing of housing; (I) any other nondiscrimination provisions in the specific statute(s) under which application for Federal assistance is being made; and (j) the requirements of any other nondiscrimination statute(s) which may apply to the application."
Section 3. General Contents of the State Child Health Plan
Section 3.1
2. HMOs currently participating in TSECMMP can opt out of CHIP participation if they are not willing to accept the CHIP premium contributions. Can other fee for service providers currently participating in TSECMMP opt out of CHIP also? If so, how is an adequate provider network guaranteed?
3. Who will be the providers of service for children with "special needs?"
A. Note: The State of North Carolina's Child Health Plan is designed as a fee-for-service indemnity plan. Managed Care Organizations may participate, but the basic program design is fee-for service.
Section 3.1 (Suggest rewriting as follows)
The State of North Carolina will provide health insurance benefits through a plan managed by the NCDHHS and administered by the TSECMMP, a program offering fee-for-service or some managed care options. Benefits and claims processing will be administered by the TSECMMP. Eligibility will be determined by local departments of Social Service, and upon receipt of any applicable enrollment fee the information entered into the statewide Eligibility Information System (EIS). Through the Division of Medical Assistance (DMA), NCDHHS, EIS will forward Title XXI eligibility information to the TSECMMP and will send notification of eligibility to families. The TSECMMP will send families information about the Plan of Benefits and will process claims. Optional Prepaid Health Plans (Health Maintenance Organizations) are available under TSECMMP but require additional premium contributions. If the contracting HMOs choose to participate without requiring additional premiums they will be made available as an option also. As part of an effort to encourage their participation, HMOs are being asked as part of their annual evaluation if they are willing to participate in the Title XXI program. Under the TSECMMP, all licensed health care providers will be able to provide services to eligible participants. This is a fee for service indemnity plan. Because the North Carolina Pediatric Society was instrumental in the development of this plan, the State feels confident that there will be an adequate provider network. Likewise the system for special needs children works as follows: any licensed or qualified provider may submit claims to the TSECMMP, claims will be paid according to the benefits handbook. Both Area Mental Health agencies and Public Health Departments will be included as qualified providers. Before any claim is denied the claim will be reviewed by the State's Title V Children With Special Health Care Needs Program. That program will assess the claim for special needs designation and will approve payment if the requested service is usually available under the Medicaid Program and if the service is deemed to be beneficial to the child.
Section 3.2
4. Please discuss the activities that will be in place for assessing under utilization. What role would the Medicaid agency play in oversight?
A. The Medicaid agency accepts its responsibility for utilization control. In the coming year the priority focus of the agency is improving oversight of both Title XIX and Title XXI. We are going to be developing a modified HEDIS measurement for fee-for-service and using a satisfaction survey pulling a sampling of cases through the Claims Processing Contractor. The Agency will also use performance utilization measures for routine infant and child care and Immunization to target non-compliance areas.
Section 4. Eligibility Standards and Methodology
Section 4.1.5
5. How does the State define "resident"? Would eligible immigrant and migrant children be eligible?
A. For purposes of eligibility, a state resident is anyone who is living in North Carolina and declares an intent to continue to reside in North Carolina. Eligible immigrant and migrant children would be eligible to the extent allowable under federal law currently and as that law changes. Under current federal law eligibles include:
Section 4.1.9
6. Is the state requiring a social security number as a condition of eligibility? We would like the State to be aware that although the social security number of the applicant may be required, the social security numbers of the parents/ guardians cannot be required.
A. No. We will request, not require Social Security numbers.
7. Could the State explain the requirement of "eligible under federal law?"
A. This was a repeat of the concept of residency as already outlined in the answer to Question 5.
Section 4.4.5
8. Is the State currently involved in administering the Caring Foundation Program? What will they do with the Caring Kids population once the program has ceased in September? Would these children be required to wait six months before they could enroll in the State's Title XXI program?
A. The State does not administer the Caring Program. It is administered by a not-for profit-board with no government oversight. The General Assembly allocates $2,055,000 annually to help support the program. As operated in North Carolina, the Caring Program for Children is a non-entitlement program which is strictly limited by the amount of funds in the budget. It does not provide for hospitalization, special therapies, dental, or durable medical equipment. Essentially it offers financial assistance to offset the cost of limited primary outpatient care. There is currently a draft legislative amendment designed to address this specific concern regarding the children under the Caring Program which is attached. It would allow children covered under the Caring Program to transition to the Title XXI program without a waiting period.
Section 6. Coverage Requirements for Children's Health Insurance
9. Kindly provide a complete copy of the benefits description, which includes limits on the amount or duration of services. The plan states that "immunizations are covered". Does this include all age-appropriate immunizations as recommended by ACIP?
A. We will provide a copy of the State Employees Benefits Handbook. The Title XXI plan for North Carolina is the equivalent of dependent's benefit coverage under that Plan. There is a $2 million lifetime maximum benefit. All medically necessary services will be covered. All age-appropriate immunizations as recommended by the ACIP are covered.
Because the benefits under the Title XXI plan will include dental, hearing, vision and special needs coverage, and because the Title XXI plan is for children only, a Title XXI booklet is in the process of being written in English and Spanish. It is not yet available, but will be provided to HCFA as soon as it is written.
Overarching all benefits limitations is the Special Needs portion of the program which may override other benefits restrictions in medically necessary situations.
All preventive health visits will be provided without copay.
Unless they are listed below or in the North Carolina's original submission, there are no further benefits restrictions:
Covered Benefits With Limitations:
Acupuncture -- Covered only when performed by a medical doctor (M.D.) or Doctor of Osteopathy (D.O.)
Cardiac rehabilitation programs -- limited to $650 each Plan year
Chiropractic services -- Limited to $2,000 each Plan year for covered services which are limited to alignment of the spine, release of pressure by manipulation and x-rays of the spine.
Continuous passive motion (CPM) machine -- Rental covered up to 17 days after surgery if treatment begins within 24 hours after one of the following covered procedures: total knee arathroplasty, reconstruction of anterior cruciate ligament of the knee, and synovectomy for rheumatoid arthritis (requires total prior approval).
Diabetic self-care program -- Limited to $300 each Plan year
Renal dialysis-- Benefits paid differently based on Medicare status. (The Plan is primary for the first 30 months after Medicare's effective date for active employees and eligible dependents, then Medicare becomes primary.)
Transplant -- Requires prior approval for the following covered transplants: bone marrow, corneal, heart, kidney, liver, lung and pancreas (Benefits are determined based on medical conditions and diagnoses; no benefits are provided for transplants determined by the Plan to be experimental or investigational.) If Medicare is the primary insurer, the covered transplant must take place in a Medicare-approved facility.
Temporomandibular Joint (TMJ) Dysfunction
The Plan provides limited benefits for the treatment of TMJ.
The following services are covered:
No charges will be covered for personal services such as barber services, guest meals, radio and TV rentals, etc.
No charges will be covered for cosmetic surgery or treatment except as required to repair damage resulting from accident or to correct congenital deformities or anomalies
Section 7. Quality And Appropriateness of Care
10. What would be the Agency's role in monitoring performance? What entity would be responsible for monitoring the performance measures identified in the application? Would performance measures be included in the contracts with health plans and providers?
A. The State Department of Health and Human Services is responsible for monitoring of performance standards. The State determines eligibility and has a contract with one health plan, the Teachers and State Employees Comprehensive Major Medical Plan which then subcontracts with North Carolina Blue Cross Blue Shield to handle its claims processing. Measures regarding the enrollment process (including demographics) would come from the eligibility information system that the Division of Medical Assistance administers and in which local social services participates. Measures regarding utilization, expenditures, and appropriateness of care would come from data sets received from the State Health Plan and its third-party administrator, Blue Cross, through a formal agreement with the Division of Medical Assistance.
This information will be analyzed and assessed by the Agency and will be reported by the agency to the Joint Legislative Health Care Oversight Committee for any needed action.
In addition, as the State agency develops HEDIS like measurements for fee-for-service through its ACCESS program, it will consider using these measurement criteria in the Title XXI program as well. A customer satisfaction survey will also be used with a random sampling to measure those criteria and to be added to feedback to providers when measuring performance compared to standards.
Section 8 Cost Sharing and Payment
11. Please provide further clarification of the copayment tracking procedures that will be put in place to assure that families will not spend more than 5 percent of their income on cost sharing. Are providers required to forgive further copayments once families have reached this limit?
A. At the point of eligibility determination, the 5% limit will be determined. The Division of Medical Assistance will provide the family income amount on its transmitssion of eligibility data to Blue Cross/Blue Shield for purposes of ensuring that the 5% limit will not be exceeded. BC/BS will generate a letter to the recipient's parent, guardian or other caretaker, when the limit is reached. Physicians will be required to honor the letter and not collect copayment. If a copayment is inadvertently collected, it will be reimbursed to the recipient. Information will be conveyed weekly regarding benefits eligibility and copayment requirements.
12. Is the State planning on charging copayments for dental services, such as exams, x-rays, prophylaxis and fluoride treatment? These are considered preventive services and as such, patient cost-sharing would be prohibited.
A. NO. We are not planning to charge copayments for preventive dental services.
Section 9. Strategic Objectives and Performance Goals for Plan Administration
13. Kindly clarify and elaborate upon the role of the Outreach Advisory Panel and the process that will be used by the State for ensuring ongoing public involvement in the implementation of the plan.
A. The Outreach Advisory Panel, which meets monthly, is envisioned as a two-way communications stream. On one direction of the stream, the Panel will disseminate information regarding the availability of children's health insurance through a statewide public awareness campaign (including a toll-free hot line), and through the development of Outreach Coalitions in each of North Carolina's 100 counties. The Panel is in the process of developing materials for these Coalitions. Training for the Coalitions will begin in July, 1998. In addition, the Panel has made application for three grants for additional funds to support outreach efforts.
On the other direction of the communications stream, the Outreach Advisory Panel will serve as the body to which citizens in the state can easily have direct access to express their concerns, desires and suggestions regarding the Plan. The panel is constructed as much as possible as a demographic representation of citizens and interest groups. In addition, the county coalitions will be asked to collect and funnel information to the Outreach Advisory Panel which can then both feed that information to the Division of Medical Assistance and the Joint Legislative Health Care Oversight Committee if appropriate.
The local Outreach Coalitions are anticipated to meet once every two weeks through December, 1998, and once a month following. Each local Outreach Coalition will be co-chaired by local health and social services directors. Suggested membership for local Outreach Coalitions include pediatricians, family physicians, community health centers, child care associations, schools, client representatives of community demographics, business human resources officials, and other groups/organizations unique to each county.
Information about both the local Outreach Coalitions and the State Outreach Advisory Panel will be included in information provided through the statewide public awareness campaign and toll-free hotline. All benefits booklets, brochures, and other publications will include in English and Spanish an invitation to provide consumer comments and concerns and will list the toll-free number as a source of information for local contacts.
Section 9.10
14. In Section 9.10, the State refers to an "attached fiscal note" to describe its source of the non-Federal share of expenditures. However, the fiscal note attachment only provides a dollar amount of the State's share of these expenditures through the year 2023. While Section 10 of the Senate Bill 2 states that funds will be appropriated from the General Fund, and we assume that this is the source(s) of the non-Federal share of the Title XXI expenditures, the source(s) need to be described in the body of the plan. Kindly provide this clarification.
A. The source of these dollars is the State's General Fund.
Recommend rewriting as follows: 9.10. Provide a budget for this program. Include details on the planned use of funds and sources of the non-Federal share of plan expenditures. (Section 2107(d)) See attached fiscal note for the description of funds to be appropriated from North Carolina's general fund.
