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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

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Begun in 1994

1115 Waiver

Enroll TANF Families Into Their Choice of Four Health Plans

Incremental Strategy to Provide Coverage to the Uninsured

BACKGROUND - RITE CARE

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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

RHODE ISLAND’S COVERAGE OF THE UNINSURED

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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

RITE CARE ENROLLMENT

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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.)

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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

RHODE ISLAND’S GOALS UNDER RITE CARE

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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

RHODE ISLAND’S TITLE XXI PLANS

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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

RHODE ISLAND’S TITLE XXI PLANS (cont.)

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Transportation - RIPTA

Translation Services

Multilingual and Multicultural Provider Network and Member Services

RITE CARE IS MORE THAN A STANDARD COMMERCIAL PRODUCT

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Unlimited Mental Health and Substance Abuse Services

Early Intervention

School-Based Clinics

Consumer Advisory Council

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

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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

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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

RHODE ISLAND’S TITLE XXI PLANS (cont.)

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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

RITE BEGINNINGS

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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

RITE BEGINNINGS (cont.)

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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

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

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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

RITE CARE RESULTS

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

1993-1996

Vital Statistics Birth File-(n=51,365)Jan-Jun 1993 Jul-Dec 1993 Jan-Jun 1994 Jul-Dec 1994 Jan-Jun 1995 Jul-Dec 1995 Jan-Jun 1996 Jul-Dec 1996

0

5

10

15

20

25

30

35

40

45

50

Medicaid Private

31.5

26.4

30.32827.629.1 27.9

38.238.239.442.4

32 28.7 28.5

27.1 27.3

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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

RITE CARE RESULTS

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% Began Prenatal Care in 1st Trimester

By Insurance Status 1993 - 1996

Vital Statistics Birth File - (n=51,365)

75.7 77.6 78.8 79 78.5 82.2 80.3 80.9

96.1 95.6 95.3 94.6 94.2 94.1 94.4 94.5

Jan-Jun 1993Jul-Dec 1993Jan-Jun 1994Jul-Dec 1994Jan-Jun 1995Jul-Dec 1995Jan-Jun 1996Jul-Dec 19960

20

40

60

80

100

120Private Medicaid

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

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RITE CARE RESULTS

Improved Prenatal Care

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

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% OF WOMEN WHO RECEIVED ADEQUATE / ADEQUATE PLUS CARE

By Insurance Status 1993 to 1996

Vital Statistics Birth File - (n=51,365)

54.6 57 57.9 58.462.1 64.9 65.3

68.571.4 71.1 71.9 72.2 75 74.2 76.3 78.8

Jan-Jun '93Jul-Dec '93Jan-Jun '94Jul-Dec '94Jan-Jun '95Jul-Dec '95Jan-Jun '96Jul-Dec '960

20

40

60

80

100

Private

Medicaid

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

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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

RITE CARE RESULTS

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% OF PREGNANT WOMEN WHO REPORT SMOKE CIGARETTES BY

INSURANCE STATUS 1993-1996

Vital Statistics Birth File-(n=51,365)

11.312.5 11.7 11.6 10.7 11.1 10.8 10.9

32.731.4 32 31.6 30.5

28 27 27.2

Jan-Jun 1993Jul-Dec 1993Jan-Jun 1994Jul-Dec 1994Jan-Jun 1995Jul-Dec 1995Jan-Jun 1996Jul-Dec 19960

10

20

30

40

Medicaid Private

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

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RITE CARE RESULTS

Improved Infant Health Inner City Providence Infants Pre and Post RIte Care

1993 1995

First Visit Before Two Weeks 54% 70%

Up to Date Immunizations 88% 95%

Seen for Specialty Care Within Two Weeks of Referral

44% 75%

Low Birthweight 10.1% 5.1%

RITE CARE RESULTS

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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

EXCELLENT MEMBER SATISFACTION WITH RITE CARE

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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

EXCELLENT MEMBER SATISFACTION WITH RITE CARE (cont.)

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PERCENT OF ADULT RITE CARE MEMBERS WHO SELF REPORT

THAT THEIR PCP TALKED ABOUT PREVENTIVE CARE

Smoking Seat Belt Diet Exercise Stress Safe Sex Mental Health0

20

40

60

80

100Percent

Question 26 n=421

Alcohol orDrug Use

78.9%

60.6%

49.1%

59.3%63.5% 62.7%

67.0%

50.6%

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

PREVENTIVE CARE

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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

RITE CARE HEALTH PLAN CONTRACT OVERSIGHT AND MONITORING ACTIVITIES

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Provider Network Composition

Covered Services

Service Accessibility Standards

Member Services

Provider Services

Marketing

Grievance and Appeals

Encounter Data Reporting

Financial Performance

HEALTH PLAN MONITORING

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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

HEALTH PLAN MONITORING (cont.)

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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

CONCLUSION