Rhode Island overpaid Medicaid MCOs but hasn’t brought payments home

Rhode Island overpaid managed care organizations (MCOs) $208 million under the state’s Medicaid expansion program in fiscal year (FY) 2015. The overpayments resulted from the fact that the state overestimated the volume of services that the state’s 60,000 new Medicaid enrollees would use, according to a report from the Rhode Island Office of the Auditor General.

Capitation rates

In FY 2015, capitation rates designed to cover medical care costs for each new enrollee determined the payments that Rhode Island made to two MCOs, Neighborhood Health Plan of Rhode Island and UnitedHealthcare. When enrollees did not use the expected level of services, the insurers were left with $208 in overpayments. As a result of incentives clauses in the contracts between the state and the MCOs, the MCOs were able to retain some of the overpayments. The gain sharing provisions were intended to reward the MCOs for cost efficiencies attained through enhanced case management, preventive care, and enhanced coordination of services. However, the significant amount due to the state was a result of overestimated capitation rates, not efficiencies.


According to the Auditor General, as of June 20, 2015, approximately $133 million of the overpayment amount remained due to the state. State officials expect to collect most of the remaining overpayments by June and the rest by the end of 2016. Rhode Island’s slow attempts to recoup the payments raised concerns that it did not act fast enough. However, the state did take steps to cut rates. In 2014, it cut capitation rates 15 percent and, in 2015, by 17 percent. Additionally, when UnitedHealthcare resisted the state’s attempts to recoup payments, the MCO’s contract was revised to allow the state to recover overpayments mid-year if the payments exceeded claims by at least 30 percent.

Highlight on Rhode Island: Wave of health care innovations in Ocean State

The smallest state in America is working to improve its residents’ health through a number of new initiatives. From a pilot program that will provide children with access to behavioral health care in their schools to new programs to compile large-scale data on public health and insurance claims, these innovative projects will enable Rhode Island to track and improve health care.

School behavioral health initiative

Providence Public Schools, The Providence Center, and Behavioral Health Solutions are partnering in a program that will put behavioral health clinicians in two elementary and four middle schools. Rhode Island has a shortage of child behavioral health providers, and  most child psychologists in the state don’t accept insurance, leaving children in the state at risk. The public-private initiative will make it easier for public school children to receive necessary services.  The program will make care more accessible, with specialists on-site and available during school hours, and will allow teachers and principals to directly refer students for help quickly. Clinicians will not bill the school system, but rather will charge the students’ health insurance, including Medicaid and the Children’s Health Insurance Program, for services provided. Providence Mayor Jorge Elorza hopes this initiative will be the first step in providing behavioral health services to all area students in need. The program began with a pilot at West Elementary School, which has made counseling and referral services available to 44 students.

Pilot public health dashboard

Providence was chosen as one of four cities to participate in the Municipal Health Data for American Cities Initiative, launched by the National Resource Center and part of the White House Initiative on Strong Cities, Strong Communities. Providence residents face health challenges that include high chronic disease and related risk factor burdens. Low-income residents and communities of color are disproportionately affected. Providence will employ population-based strategies focusing on high-risk, vulnerable groups to expand the reach and health impact of improvements across sectors. Although it is not yet clear what data will be available through the dashboard, the initiative will frame federal and county data at the municipal level, extract key benchmarks that are embedded in existing city-level data, and create entirely new indicators through big data and social media activity. Elorza hopes to use the dashboard to see where Providence ranks among other cities in New England with regard to the city’s health levels, and then improve to be one of the fittest cities in the region. The other cities chosen to participate are Flint, Michigan; Waco, Texas; and Kansas City, Kansas.

All-payer claims database

Rhode Island recently launched the HealthFacts RI Database, an all-payer claims database that provides medical and pharmacy claims data from all private and public health insurers and administrators in the state, and the most comprehensive collection of health care claims data that the state has ever compiled. The database is intended to help state agencies and researchers learn where health care dollars are going, how effective various uses of dollars are, and track overall trends. It includes data from nearly 825,000 Rhode Islanders–using what the state calls “extensive precautions” to protect patient privacy –with claims totaling $18 billion between 2011 and 2014. Rhode Island is one of 18 states with such all-payer claims databases, though the Supreme Court’s recent decision in Gobeille v. Liberty Mutual Insurance Company makes it more difficult for states to require some plans to report data. The Gobeille Court found that the Employee Retirement Income Security Act (ERISA) preempts Vermont’s law requiring insurers to participate in that state’s all-payer claims database.


Connecticut Proposes Deaf Child Bill of Rights to Address Education Gap

Deaf and hard of hearing (HOH) children generally do not differ cognitively from their peers in a way that would prevent them from learning the same material just as well. So why is it that in Connecticut, as well as other locations, children with hearing disabilities appear to be falling behind hearing children in state tests? In 2011, approximately 71 to 81 percent of children with hearing disabilities failed to reach state standards in Connecticut Mastery Tests (CMTs) and Connecticut Academic Performance Tests (CAPTs). Comparatively, between 35 to 58 percent of hearing students failed to meet the goals.

The answer, according to advocates for deaf and HOH persons, is not the disability itself, but the manner in which the children are being taught.  According to Terry Bedard, president of Hear Here Hartford, a deaf advocacy group, “Their needs are not being addressed in the way they should be, and that’s resulting in this wide achievement gap.” Advocates believe that since there is a relatively “low incidence” of hearing disabilities, they are commonly overlooked. In Connecticut, approximately 700 children are registered with the education department as having a hearing disability; however, the number could be greater since such students are not tracked carefully.

Consequently, the Connecticut General Assembly’s education committee will be considering legislation this term to address the gap. “A Deaf Child Bill of Rights,” introduced by the Connecticut Council of Organizations Serving the Deaf, would focus on an individualized education program (IEP) centered around each student’s communication and language needs. Each student’s IEP would be connected to a formal “Language and Communication Plan” that would address that child’s specific needs. The measure would also require that the team implementing the IEP includes at least one educational professional who specializes in hearing disabilities. The bill would compel the state to execute a more specific tracking system in order to better identify hearing disabled children and chart their academic progress.

If the bill is passed, Connecticut will be the 12th state in the country to implement a deaf child bill of rights, joining California, Colorado, Delaware, Georgia, Louisiana, Montana, New Mexico, Pennsylvania, Rhode Island, South Dakota and Texas.