Care Management Program Proposed Regulations 2020

Public Comments Received

Date FromPublic

Comments

DHCS Response to

Comments

01/02/2020 Interior AIDS Association

02/17/2020 Alaska Mental Health Board/Advisory Board on Alcoholism and Drug Abuse

02/25/2020 Division of Behavioral Health

02/25/2020 Alaska Mental Health Trust Authority

02/25/2020 Alaska State Hospital & Nursing Home Association

02/25/2020 Alaska Native Health Board

02/25/2020 Southcentral Foundation

02/25/2020 Alaska Primary Care Association

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Department of Health and Social Services

DIVISION OF HEALTH CARE SERVICES

Director’s Office

4501Business Park Blvd., Suite 24, Bldg L

Anchorage, Alaska 99503-7167

Main: 907.334.2400

Fax: 907.561.1684

Care Management Program Proposed Regulations: Response to Public Comments June 8, 2020

The Division of Health Care Services (DHCS) extends its appreciation to organizations that submitted comments and suggestions regarding proposed updates to 7AAC 105.600. Alaska’s Care Management Program (CMP) is designed to provide enhanced support to Medicaid eligible individuals who demonstrate a need for increased assistance with continuity of care.

Generally, commenters expressed concerns that changes to the CMP would restrict access to medically necessary services, restrict access to behavioral health services, and impose barriers to care, or penalize recipients. Others expressed concern that language was either too specific or not specific enough to protect recipients, would negatively impact availability of providers, or would be burdensome for the Department of Health and Social Services. The CMP is not a punitive program. Neither current regulations nor proposed changes penalize recipients; rather the CMP helps members establish positive relationships with health care providers and provides additional guidance and resources to individuals. At no time has, or will, participation in the CMP program resulted in the denial of medically necessary covered services, nor do proposed changes restrict or alter, in any way, a member’s right to appeal a decision by the department.

Alaska Medicaid values the relationships/partnerships with currently participating Primary Care Providers and Pharmacies, and the CMP Program looks forward to partnering with additional organizations under these new regulations in the very near future. Overall, CMP program enrollment accounts for 0.25% of the Medicaid eligible population. The expanded CMP program under these regulations is anticipated to impact up to 0.75% of the Medicaid eligible population. Based on this program data DHCS is confident that no single provider entity will be asked to take on more than their fair share of CMP members.

The CMP program will also continue a long-standing policy of assigning members to group/facility IDs where available. This will continue to allow groups of physicians, clinics, and other facilities such as Tribal Health Organizations (THOs) to serve in the primary care provider role without the need for internal referrals.

After operating under substantially similar regulations for more than 15 years, these proposed regulations will incorporate successful elements of other State Medicaid Agencies with similar goals as Alaska’s CMP. While the proposed regulations detail new data patterns for which CMP placement can occur, the review process and resulting decisions will continue to be reflective of the needs and circumstances of the individuals served by the program.

The inclusion of data patterns for prescription drugs, travel, no-shows, and other areas are intended assist members struggling in these areas. The CMP is intended to be complimentary to, and not a replacement for, other programs with shared desired outcomes that address substance abuse, mental health, and travel.

Lastly, DHCS experience, internal and external stakeholder engagement, and best practices of other states with similar programs were considered in the decision to allow for longer initial and subsequent placements. Research showed that extended periods of member support are more likely to result in the achievement of program goals for members, maximization of member support, and reduction in long term CMP recidivism rates.

Again, thank you for your participation in the regulatory process.

1

Dunkin, Susan M (HSS)

From: anna@interioraids.orgSent: Thursday, January 02, 2020 12:34 PMTo: Dunkin, Susan M (HSS)Subject: comments re: Medicaid Care Management Program Changes

7 AAC 105.600 (b)(2) the department identifies that the recipient (J) “…during a period of six consecutive months, failed to keep three or more appointments for services covered under 7 AAC 105- 7AAC 160; This seems particularly strict, especially as many of our clients have challenges that sometimes result in missed appointments – homelessness, no transportation, mental illness, etc. If the recipient calls in advance (24 hours?) and reschedules – it should not count against them. If referral to the Care Management Program results in increased support in order to make it to appointments, then I have no objection. Providers trying to NOT PROVIDE CARE will use this provision against “less desirable” patients. There must be more specific language about how “failure to keep appointments” is counted and, in my opinion, there should be required outreach to the patient to ensure engagement in care. …(d) The Department will assign a restricted recipient one primary care provider…and may assign.. one behavioral health provider.” Comment: someone with severe behavioral health issues will often have more than one provider - and they should if they are experiencing substance misuse disorders, mental health problems, and disability issues. If anything, you should require that behavioral health providers talk to each other – like a multi-disciplinary team. I see the word “may” – so perhaps my concern is misplaced. However, marginalized patients could see all of this as a barrier to care. Instead of “following the rules,” they will disengage and blame the providers and Medicaid. If the Care Management Program can provide support to the patients who have a chaotic approach to behavioral health care such that it is costing Medicaid a lot of money, then I have no objection. Perhaps identifying a “behavioral health home” for frequent users would help – to ensure that care is coordinated and provided efficiently and effectively. Anna Nelson Executive Director Interior AIDS Association (907)452-4222 ext. 115 Cell (907)590-7103

From: Schoonover, Bev K (HSS)To: Dunkin, Susan M (HSS)Cc: Tautfest, Charlene; Philip LichtSubject: LOC- Medicaid Care Management Program (7 AAC 105.600)Date: Monday, February 17, 2020 12:48:55 PMAttachments: Medicaid LOC AMHB.ABADA.2.2020.pdf

Ms. Dunkin;Please find comments attached from the Alaska Mental Health Board and Advisory Board onAlcoholism and Drug Abuse in regards to the proposed changes to regulations of the Medicaid CareManagement Program (7 AAC 105.600: Restriction of Recipient’s Choice of Providers). Beverly SchoonoverExecutive DirectorStatewide Suicide Prevention CouncilAlaska Mental Health Board/Advisory Board on Alcoholism and Drug Abuse Desk: 907-465-5114Business Cell: 907-419-7421

mailto:bev.schoonover@alaska.govmailto:susan.dunkin@alaska.govmailto:xyzcharlene@yahoo.commailto:philip@setfreealaska.org

Department of Health and Social Services

ALASKA MENTAL HEALTH BOARD

ADVISORY BOARD ON ALCOHOLISM AND DRUG ABUSE

431 North Franklin Street, Suite 200

Juneau, Alaska 99801

Main: 907.465.8920

Fax: 907.465.4410

February 17, 2020

Ms. Susan Miller Dunkin

Department of Health & Social Services

Division of Health Care Services

4501 Business Park Blvd., Building L

Anchorage, AK 99503

RE: Proposed Changes to Regulations: Medicaid Care Management Program (7 AAC 105.600: Restriction of

Recipient’s Choice of Providers

Dear Ms. Dunkin;

The Alaska Mental Health Board (AMHB) and the Advisory Board on Alcoholism and Drug Abuse (ABADA)

are the state agencies charged with planning and coordinating behavioral health services funded by the State of

Alaska. The joint mission of AMHB/ABADA is to advocate for programs and services that promote healthy,

independent, productive Alaskans.

In regard to the proposed changes to regulations regarding the Medicaid Care Management Program (7 AAC

105.600: Restriction of Recipient’s Choice of Providers), AMHB/ABADA offer the following comments:

1. The proposed regulations allow the Department broad authority to decide whether a recipient has used

Medicaid services at a frequency or amount that is not appropriate, which is a change from current

regulations that require the Department to conduct a clinical review to assess medical necessity of the

services (7 AAC 105.600.c). We caution the Department that relying on billing, payment and prescription

records alone to assess appropriate Medicaid use might ‘lock-out’ recipients who have compelling medical

reasons for their health care choices.

2. Under the proposed regulations, the Department may restrict a recipient’s choice of medical providers if

within a 12-month period the recipient seeks services at an emergency department more than three times

for a non-emergent condition. Although emergency rooms are not the most appropriate place for

behavioral health care, Alaskans who are severely mentally ill and/or who have advanced substance-use

disorders may not have the capacity or support to seek medical services outside the emergency department.

There is a statewide behavioral health workforce shortage and Medicaid recipients might seek non-

emergent medical care in emergency rooms due to waitlists at their regular providers. Other Medicaid

recipients may present at an emergency room because they have been turned away from their local

provider because they have outstanding bills they are unable to pay. There could be compelling factors

for why Alaskans with behavioral health disorders present at emergency rooms for non-emergent care and

in these cases a clinical review and referral from the Department to appropriate services would be

preferred.

3. We would like to caution the Department that studies show that people seeking Medication Assisted

Treatment might need several dosage adjustments in the first few months of treatment as well as tapering

of medications at the end of their treatment. We ask you consider these fluctuations in prescriptions in

your assessment process.

Thank you for the consideration of these comments on proposed regulation changes to 7 AAC 105.600.

Respectfully,

Beverly Schoonover

Executive Director

CC: Philip Licht ABADA Chair, Charlene Tautfest AMHB Chair

Department of Health and Social Services

ALASKA MENTAL HEALTH BOARD

ADVISORY BOARD ON ALCOHOLISM AND DRUG ABUSE

431 North Franklin Street, Suite 200

Juneau, Alaska 99801

Main: 907.465.8920

Fax: 907.465.4410

February 17, 2020

Ms. Susan Miller Dunkin

Department of Health & Social Services

Division of Health Care Services

4501 Business Park Blvd., Building L

Anchorage, AK 99503

RE: Proposed Changes to Regulations: Medicaid Care Management Program (7 AAC 105.600: Restriction of

Recipient’s Choice of Providers

Dear Ms. Dunkin;

The Alaska Mental Health Board (AMHB) and the Advisory Board on Alcoholism and Drug Abuse (ABADA)

are the state agencies charged with planning and coordinating behavioral health services funded by the State of

Alaska. The joint mission of AMHB/ABADA is to advocate for programs and services that promote healthy,

independent, productive Alaskans.

In regard to the proposed changes to regulations regarding the Medicaid Care Management Program (7 AAC

105.600: Restriction of Recipient’s Choice of Providers), AMHB/ABADA offer the following comments:

1. The proposed regulations allow the Department broad authority to decide whether a recipient has used

Medicaid services at a frequency or amount that is not appropriate, which is a change from current

regulations that require the Department to conduct a clinical review to assess medical necessity of the

services (7 AAC 105.600.c). We caution the Department that relying on billing, payment and prescription

records alone to assess appropriate Medicaid use might ‘lock-out’ recipients who have compelling medical

reasons for their health care choices.

2. Under the proposed regulations, the Department may restrict a recipient’s choice of medical providers if

within a 12-month period the recipient seeks services at an emergency department more than three times

for a non-emergent condition. Although emergency rooms are not the most appropriate place for

behavioral health care, Alaskans who are severely mentally ill and/or who have advanced substance-use

disorders may not have the capacity or support to seek medical services outside the emergency department.

There is a statewide behavioral health workforce shortage and Medicaid recipients might seek non-

emergent medical care in emergency rooms due to waitlists at their regular providers. Other Medicaid

recipients may present at an emergency room because they have been turned away from their local

provider because they have outstanding bills they are unable to pay. There could be compelling factors

for why Alaskans with behavioral health disorders present at emergency rooms for non-emergent care and

in these cases a clinical review and referral from the Department to appropriate services would be

preferred.

3. We would like to caution the Department that studies show that people seeking Medication Assisted

Treatment might need several dosage adjustments in the first few months of treatment as well as tapering

of medications at the end of their treatment. We ask you consider these fluctuations in prescriptions in

your assessment process.

Thank you for the consideration of these comments on proposed regulation changes to 7 AAC 105.600.

Respectfully,

Beverly Schoonover

Executive Director

CC: Philip Licht ABADA Chair, Charlene Tautfest AMHB Chair

From: Calcote, Rick M (HSS)To: Dunkin, Susan M (HSS)Cc: Moreau-Johnson, Gennifer L (HSS); Brown, Farina E (HSS); Chapman, Kathryn M (HSS); Roth, Terry A (HSS)Subject: Public Comment for Proposed RegulationsDate: Tuesday, February 25, 2020 10:14:23 AMAttachments: DBH Public Comment.Recipient Restriction.docxImportance: High

Susan,We have attached comments on the proposed Medicaid regulations under 7 AAC 105.600.Restriction of recipient’s choice of providers. You folks have done a great job on these. We believethat our comments provide additional ideas that will benefit the department in serving behavioralhealth recipients and providers. Best Regards, Rick M. Calcote, M.S.Policy, Regulations, and PlansState Behavioral Health3601 C. St., Suite 878Anchorage, AK. 99503907-269-3617907-269-3623 FAX

mailto:/O=EXCHANGELABS/OU=EXCHANGE ADMINISTRATIVE GROUP (FYDIBOHF23SPDLT)/CN=RECIPIENTS/CN=ECF882A5E8C749A49421AC5B560116DC-RMCALCOTEmailto:susan.dunkin@alaska.govmailto:gennifer.moreau-johnson@alaska.govmailto:farina.brown@alaska.govmailto:kathryn.chapman@alaska.govmailto:/o=ExchangeLabs/ou=Exchange Administrative Group (FYDIBOHF23SPDLT)/cn=Recipients/cn=edbe577fe07a44b58d3fda91c958dbe2-tahamm

DIVISION OF BEHAVIORAL HEALTH

Anchorage Regional Office

3601 C Street, Suite 878

Anchorage, Alaska 99503-5924

Main: 907.269.3600

Toll Free: 800.770.3930

Fax: 907.269.3623

2.24.2020

Public Comment on Proposed Changes to Regulations:

“Medicaid Care Management Program”

7 AAC 105.600 Restriction of recipient’s choice of providers.

The Division of Behavioral Health provides the following comments to the proposed regulations.

7 AAC 105.600(b)(2)(D)

As proposed, this criteria could penalize a person who is appropriately paying cash for a prescription on a temporary basis. It is not uncommon for recipients of Schedule II – V drugs to temporarily lose Medicaid coverage for various reasons. The division understands that these exceptions would be considered in a determination of restriction. However, it is still recommended that the department consider language that acknowledges a recipient could violate this condition temporarily for “good cause.”

7 AAC 105.600(b)(2)(E)

There is a small percentage of recipients who legitimately receive both opioid and benzodiazepine prescriptions as medically indicated. Recipients who are concurrently receiving Care Coordination services and who have prescriptions for both types of drugs, regardless of prescriber, should not be penalized by this criteria.

7 AAC 105.600(b)(2)(F)

This criteria conflicts with the “Medication Assisted Treatment Guide” that the department recently published. On Pg. 45 of the Guide it states: “The length of time that a medication is prescribed for a use disorder is not defined by best practices other than to note that the longer one is treated with medication, the longer the person typically remains abstinent.” Further, on Pg. 48 of the Guide it states: “However, although objective withdrawal symptoms may be controlled at lower dosages of buprenorphine (4-8 mg), cravings may not be controlled until the patient reaches higher dosages (12-24 mg).” As well, research currently suggests that some individuals require long-term buprenorphine, and that the dosage may vary depending upon individual need. This will undoubtedly be an important factor to consider for recipients being treated for pain management.

7 AAC 105.600(b)(2)(J)

Recipients who experience mental health and/or substance use disorder conditions frequently miss appointments for many legitimate reasons. This criteria would create an unnecessary barrier for individuals to continue to access medically indicated care and services. “Three or more [missed] appointments” in a six month period is too restrictive for this population and would also cause undue disruption to provider operations.

7 AAC 105.600(b)(3)

The division is concerned that in certain circumstances, such as with seriously mentally ill adults, the Medicaid pharmacist, if not the Medical director, may need additional assistance or input to recommend restriction for a behavioral health recipient. Since Section .600 is clearly readopted to address behavioral health and specifically opioid use disorders, the division believes it may be important to include the division director in determinations involving behavioral health recipients.

7 AAC 105.600(d)

As proposed, this requirement would restrict a recipient to only one behavioral health provider. This ‘lock-in’ process is inappropriate for recipients receiving behavioral health services. It is common for behavioral health recipients to obtain various needed services from more than one provider. Many behavioral health providers do not have the capacity to deliver all the services a recipient may require. It is essential that a restricted behavioral health recipient is allowed access to more than one provider if medically indicated. This restriction, which may work for prescribing providers, does not fit well for the behavioral health services system.

DIVISION OF BEHAVIORAL HEALTH Anchorage Regional Office

3601 C Street, Suite 878

Anchorage, Alaska 99503-5924

Main: 907.269.3600

Toll Free: 800.770.3930

Fax: 907.269.3623

2.24.2020

Public Comment on Proposed Changes to Regulations: “Medicaid Care Management Program”

7 AAC 105.600 Restriction of recipient’s choice of providers.

The Division of Behavioral Health provides the following comments to the proposed regulations.

7 AAC 105.600(b)(2)(D)

As proposed, this criteria could penalize a person who is appropriately paying cash for a

prescription on a temporary basis. It is not uncommon for recipients of Schedule II – V drugs to

temporarily lose Medicaid coverage for various reasons. The division understands that these exceptions

would be considered in a determination of restriction. However, it is still recommended that the

department consider language that acknowledges a recipient could violate this condition temporarily for

“good cause.”

7 AAC 105.600(b)(2)(E)

There is a small percentage of recipients who legitimately receive both opioid and

benzodiazepine prescriptions as medically indicated. Recipients who are concurrently receiving Care

Coordination services and who have prescriptions for both types of drugs, regardless of prescriber, should

not be penalized by this criteria.

7 AAC 105.600(b)(2)(F)

This criteria conflicts with the “Medication Assisted Treatment Guide” that the department

recently published. On Pg. 45 of the Guide it states: “The length of time that a medication is prescribed

for a use disorder is not defined by best practices other than to note that the longer one is treated with

medication, the longer the person typically remains abstinent.” Further, on Pg. 48 of the Guide it states:

“However, although objective withdrawal symptoms may be controlled at lower dosages of

buprenorphine (4-8 mg), cravings may not be controlled until the patient reaches higher dosages (12-24

mg).” As well, research currently suggests that some individuals require long-term buprenorphine, and

that the dosage may vary depending upon individual need. This will undoubtedly be an important factor

to consider for recipients being treated for pain management.

7 AAC 105.600(b)(2)(J)

Recipients who experience mental health and/or substance use disorder conditions frequently

miss appointments for many legitimate reasons. This criteria would create an unnecessary barrier for

individuals to continue to access medically indicated care and services. “Three or more [missed]

appointments” in a six month period is too restrictive for this population and would also cause undue

disruption to provider operations.

7 AAC 105.600(b)(3)

The division is concerned that in certain circumstances, such as with seriously mentally ill adults,

the Medicaid pharmacist, if not the Medical director, may need additional assistance or input to

recommend restriction for a behavioral health recipient. Since Section .600 is clearly readopted to

address behavioral health and specifically opioid use disorders, the division believes it may be important

to include the division director in determinations involving behavioral health recipients.

DIVISION OF BEHAVIORAL HEALTH Anchorage Regional Office

3601 C Street, Suite 878

Anchorage, Alaska 99503-5924

Main: 907.269.3600

Toll Free: 800.770.3930

Fax: 907.269.3623

7 AAC 105.600(d)

As proposed, this requirement would restrict a recipient to only one behavioral health provider.

This ‘lock-in’ process is inappropriate for recipients receiving behavioral health services. It is common

for behavioral health recipients to obtain various needed services from more than one provider. Many

behavioral health providers do not have the capacity to deliver all the services a recipient may require. It

is essential that a restricted behavioral health recipient is allowed access to more than one provider if

medically indicated. This restriction, which may work for prescribing providers, does not fit well for the

behavioral health services system.

From: Baldwin, Michael R (DOR)To: Dunkin, Susan M (HSS)Cc: Abbott, Mike K (DOR); Moreau-Johnson, Gennifer L (HSS); Schoonover, Bev K (HSS); Vandagriff, Kristin L (HSS);

tom.abha@gmail.com; Williams, Stephen F (DOR); clchipp@anthc.org; Thompson, Lesley M (HSS); Biastock,Allison E (DOR); Baldwin-Johnson, Kathleen D (DOR); Vea, Autumn N (DOR); jared@ashnha.com

Subject: Public Comment re: Notice of Proposed Changes Project #2019200876 Medicaid Care Management ProgramDate: Tuesday, February 25, 2020 11:06:59 AMAttachments: AMHTA Public Comment #2019200876.pdf

Hello Ms. Dunkin, Please find attached written public comment regarding the Notice of Proposed Changes for theMedicaid Care Management Program submitted on behalf of Mike Abbott, CEO for the AlaskaMental Health Trust Authority. For reference: https://aws.state.ak.us/OnlinePublicNotices/Notices/View.aspx?id=196544 Thank you for your time and consideration. Respectfully, Michael Michael BaldwinSenior Evaluation & Planning OfficerAlaska Mental Health Trust Authority907-269-7969

mailto:michael.baldwin@alaska.govmailto:susan.dunkin@alaska.govmailto:mike.abbott@alaska.govmailto:gennifer.moreau-johnson@alaska.govmailto:bev.schoonover@alaska.govmailto:kristin.vandagriff@alaska.govmailto:tom.abha@gmail.commailto:steve.williams@alaska.govmailto:clchipp@anthc.orgmailto:lesley.thompson@alaska.govmailto:allison.biastock@alaska.govmailto:allison.biastock@alaska.govmailto:katie.johnson@alaska.govmailto:autumn.vea@alaska.govmailto:jared@ashnha.comhttps://aws.state.ak.us/OnlinePublicNotices/Notices/View.aspx?id=196544

From: Jeannie MonkTo: Dunkin, Susan M (HSS)Cc: Jared KosinSubject: ASHNHA comments on Medicaid Care Mgmt regulationsDate: Tuesday, February 25, 2020 1:04:18 PMAttachments: Medicaid care mgmt regulation comments 2-25-20.pdf

Hi SusanAttached are ASHNHA's comments on the proposed Medicaid care management regulations.Thanks for the opportunity to comment.Jeannie

-- Jeannie Monk, MPHSenior Vice PresidentAlaska State Hospital & Nursing Home Association426 Main St. Juneau, AK 99801907-586-1790 office907-723-9826 cell

This message is intended for the sole use of the addressee, and may contain information that is privileged, confidential and exempt fromdisclosure under applicable law. If you are not the addressee you are hereby notified that you may not use, copy, disclose, or distribute toanyone the message or any information contained in the message. If you have received this message in error, please immediately advisethe sender by reply email and delete this message.

mailto:jeannie@ashnha.commailto:susan.dunkin@alaska.govmailto:jared@ashnha.com

February 25, 2020

Submitted by email to: susan.dunkin@alaska.gov Dear Ms. Dunkin, The Alaska State Hospital and Nursing Home Association (ASHNHA) is submitting comments on the Department of Health and Social Services proposed changes to the Medicaid Care Management Program Restriction of recipient’s choice of providers. The Department proposes to adopt regulation changes in Title 7 of the Alaska Administrative Code, dealing with the Medicaid care management program. ASHNHA is supportive of the following changes:

• Expansion of the behavioral patterns the Department will use to identify a recipient as a candidate to restrict the choice of providers related to prescription drug use such as opioids, cash payments, etc.

• Addition of assigning a recipient a behavioral health provider and a dental provider along with a primary care and pharmacy provider.

• Ensure the recommendation for restriction is evaluated by the Medicaid medical director or pharmacy based on data from the clinical record.

• Maintain all recipient fair hearing rights. ASHNHA has concerns related to the designation of providers to Medicaid recipients who have their choice restricted. We want to be sure that the primary care providers and other designated providers are willing to take on these high needs, high risk Medicaid recipients and will be able to provide access to the care needed. If the “locked in” recipient is not able to easily access services through their designated provider, they are likely to go an emergency room to receive care. We also want to ensure there are adequate behavioral health providers to meet the needs of the “locked in” recipients. Many of the behaviors that will lead to the restriction of providers are related to substance abuse issues and require treatment beyond simple restriction of access to prescriptions or providers. We recommend the department consider an incentive or shared savings payment to primary care providers who are willing to take on the care of the high risk “locked in” recipients. These are patients that require more intensive care management and will take significant time on the part of primary care providers to meet the health care needs. Finally, ASHNHA has concerns about a potential issue of Medicaid recipients with restricted access to providers who choose to come to the emergency department. If a patient shows up at the emergency department, federal law (i.e. EMTALA) requires the facility to evaluate the

mailto:susan.dunkin@alaska.gov

2

patient, regardless of his or her status as a restricted Medicaid recipient. It is unclear how this situation will be handled. For example, if the emergency departmentclaims are retrospectively denied as not meeting the criteria of a true “emergency,” the result is simply a cost shift from the Medicaid program to the emergency department despite the emergency department following federal law as it relates to patients who present. If we want to reduce the use of the emergency department for non-emergent conditions, it is critical to do more then deny the claims for the visits. The process of restricting access to providers must ensure that the assigned providers have the resources and ability to meet the needs of the patients. This may involve providing after hours/weekend care, social workers or care coordinators, transportation, and other services.. The concepts related to restricting access to providers for certain Medicaid recipients makes sense, but the details related to how these recipients will be cared for are critical. Thank you for the opportunity to provide comments on the proposed regulations. Sincerely,

Jared Kosin JD, MBA President &CEO

February 25, 2020

Submitted by email to: susan.dunkin@alaska.gov Dear Ms. Dunkin, The Alaska State Hospital and Nursing Home Association (ASHNHA) is submitting comments on the Department of Health and Social Services proposed changes to the Medicaid Care Management Program Restriction of recipient’s choice of providers. The Department proposes to adopt regulation changes in Title 7 of the Alaska Administrative Code, dealing with the Medicaid care management program. ASHNHA is supportive of the following changes:

• Expansion of the behavioral patterns the Department will use to identify a recipient as a candidate to restrict the choice of providers related to prescription drug use such as opioids, cash payments, etc.

• Addition of assigning a recipient a behavioral health provider and a dental provider along with a primary care and pharmacy provider.

• Ensure the recommendation for restriction is evaluated by the Medicaid medical director or pharmacy based on data from the clinical record.

• Maintain all recipient fair hearing rights. ASHNHA has concerns related to the designation of providers to Medicaid recipients who have their choice restricted. We want to be sure that the primary care providers and other designated providers are willing to take on these high needs, high risk Medicaid recipients and will be able to provide access to the care needed. If the “locked in” recipient is not able to easily access services through their designated provider, they are likely to go an emergency room to receive care. We also want to ensure there are adequate behavioral health providers to meet the needs of the “locked in” recipients. Many of the behaviors that will lead to the restriction of providers are related to substance abuse issues and require treatment beyond simple restriction of access to prescriptions or providers. We recommend the department consider an incentive or shared savings payment to primary care providers who are willing to take on the care of the high risk “locked in” recipients. These are patients that require more intensive care management and will take significant time on the part of primary care providers to meet the health care needs. Finally, ASHNHA has concerns about a potential issue of Medicaid recipients with restricted access to providers who choose to come to the emergency department. If a patient shows up at the emergency department, federal law (i.e. EMTALA) requires the facility to evaluate the

mailto:susan.dunkin@alaska.gov

2

patient, regardless of his or her status as a restricted Medicaid recipient. It is unclear how this situation will be handled. For example, if the emergency departmentclaims are retrospectively denied as not meeting the criteria of a true “emergency,” the result is simply a cost shift from the Medicaid program to the emergency department despite the emergency department following federal law as it relates to patients who present. If we want to reduce the use of the emergency department for non-emergent conditions, it is critical to do more then deny the claims for the visits. The process of restricting access to providers must ensure that the assigned providers have the resources and ability to meet the needs of the patients. This may involve providing after hours/weekend care, social workers or care coordinators, transportation, and other services.. The concepts related to restricting access to providers for certain Medicaid recipients makes sense, but the details related to how these recipients will be cared for are critical. Thank you for the opportunity to provide comments on the proposed regulations. Sincerely,

Jared Kosin JD, MBA President &CEO

From: Davis, WinnTo: Dunkin, Susan M (HSS)Cc: _ANHBSubject: ANHB Comment on Proposed Regulation for Medicaid Care Management ProgramDate: Tuesday, February 25, 2020 4:37:08 PMAttachments: 20.02.25 ANHB to SoA re. Medicaid Care Management Program Proposed Regulation Final.pdf

Dear Ms. Dunkin, Please find attached the Alaska Native Health Board’s comment letter on the proposedchanges to 7 AAC 105.600. Medicaid Care Management Program. Please let us know if youhave any comments or questions regarding our comment letter. Sincerely, Winn DavisPolicy AnalystAlaska Native Health Board(907) 885-8337WDavis@anhb.org

mailto:wdavis@anhb.orgmailto:susan.dunkin@alaska.govmailto:anhb@anhb.orgmailto:WDavis@anhb.org

Alaska Native Health Board THE VOICE OF ALASKA TRIBAL HEALTH SINCE 1968 907.562.6006 907.563.2001 4000 Ambassador Drive, Suite 101 Anchorage, Alaska 99508 www.anhb.org

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ALASKA NATIVE TRIBAL HEALTH CONSORTIUM

ALEUTIAN PRIBILOF ISLANDS ASSOCIATION

ARCTIC SLOPE NATIVE ASSOCIATION

BRISTOL BAY AREA HEALTH CORPORATION

CHICKALOON VILLAGE TRADITIONAL COUNCIL

CHUGACHMIUT

COPPER RIVER NATIVE ASSOCIATION

COUNCIL OF ATHABASCAN TRIBAL GOVERNMENTS

EASTERN ALEUTIAN TRIBES

KARLUK IRA TRIBAL COUNCIL

KENAITZE INDIAN TRIBE

KETCHIKAN INDIAN COMMUNITY

KODIAK AREA NATIVE ASSOCIATION

MANllLAQ ASSOCIATION

METLAKATLA INDIAN COMMUNITY

MT. SANFORD TRIBAL CONSORTIUM

NATIVE VILLAGE OF EKLUTNA

NATIVE VILLAGE OF EYAK

NATIVE VILLAGE OF TYONEK

NINILCHIK TRADITIONAL COUNCIL

NORTON SOUND HEALTH CORPORATION

SELDOVIA VILLAGE TRIBE

SOUTHCENTRAL FOUNDATION

SOUTHEAST ALASKA REGIONAL HEALTH CONSORTIUM

TANANA CHIEFS CONFERENCE

YAKUTAT TLINGIT TRIBE

YUKON-KUSKOKWIM HEALTH CORPORATION

VALDEZ NATIVE TRIBE

February 25, 2020 Susan Dunkin, Regulations Coordinator Division of Health Care Services, Alaska Department of Health & Social Services, 4501 Business Park Blvd., Building L, Anchorage, AK 99503 Via Email: Susan.Dunkin@alaska.gov Re: Proposed Regulations for the Medicaid Care Management Program Dear Ms. Dunkin, The Alaska Native Health Board (ANHB) appreciates the opportunity to provide comments as part of the public comment process on the proposed Medicaid Care Management Program, as known as the Medicaid “Locked-In” Program. The ANHB was established in 1968 with the purpose of promoting the spiritual, physical, mental, social, and cultural well-being and pride of Alaska Native people. ANHB is the statewide voice on Alaska Native health issues and is the advocacy organization for the Alaska Tribal Health System (ATHS), which is comprised of tribal health programs that serve all of the 229 tribes and over 177,000 Alaska Natives and American Indians throughout the state. As the statewide tribal health advocacy organization, ANHB helps Alaska’s tribes and tribal programs achieve effective consultation and communication with state and federal agencies on matters of mutual concern. While the reforms of the Medicaid Care Management Program were approved as part of the cost containment measures in the FY2020 Operating Budget, the proposed regulations raise concerns about the way the Department of Health & Social Services (DHSS or “the Department”) seeks to implement, and achieve savings from, this regulatory change. Generally, the Department should consider seeking additional stakeholder engagement before finalizing this proposed regulation to avoid unintended consequences for Medicaid beneficiaries, providers, and the Department. Below, please find our comments and questions regarding the proposed changes to 7 AAC 105.600.

• We ask that when the Department restrict a beneficiary’s choice of provider under this regulation, that the Department allow for a Tribal Health Organization (THO) to be specifically specified as a beneficiary’s “locked-in” provider(s) for the duration of the “locked-in” period. THOs provide integrated health care services that include primary care, pharmacy, dental, behavioral health and related services. Integrated health care services can be beneficial to recipients for whom the State may seek restricting their choice under 7 AAC 105.600. For this reason, we

Page2of4

propose adding language to 7 AAC 105.600(d) to specifically include THOs as an option for assignment. Our recommendation is:

“(d) The department will assign a restricted recipient one primary care provider and one pharmacy, or Tribal Health Organization, within reasonable proximity to the recipient’s home, and may assign one dental provider and one behavioral health provider or Tribal Health Organization. The department will include the word “RESTRICTED” and will identify the designated providers on the recipient’s Medicaid identification card.”

• Proposed 7 AAC 105.600(a) and (b)(1) - a referral is made to the department indicating that the recipient has used a medical item or service at a frequency or amount that is not appropriate;

o This language is incredibly broad. The current regulation reads at 7 AAC 105.600(b)(1) “a referral is made to the department indicating that the recipient has used a medical item or service at a frequency or amount that is not medically necessary;”. The current text better reflects the intent of the Medicaid Care Management Policy. By changing this language to the proposed, it creates uncertainty of “appropriateness” and who determines that appropriateness. Under the current language, a medical professional, in completing a review, can reasonably assess medical necessity.

• Proposed 7 AAC 105.600(b)(2) – The State has listed several new factors to be considered in restricting a patient’s freedom of provider choice. Some of these new triggers have raised concerns. Can the Department explain where this new list of triggers under 7 AAC 105.600(b)(2) was sourced or how they were developed, specifically subsections (B), (C), (D), (E), (F), (H), (I), and (J)? Were these pulled from other states’ existing policies or were these items determined by DHSS?

• Proposed 7 AAC 105.600(b)(2)(C) – This proposed addition would restrict Medicaid beneficiaries who receive an opioid prescription from two or more providers within three consecutive months. It is conceivable that a patient who is being seen at a multi-physician practice or health care group might receive an opioid prescription from two providers within the same practice during a three-month period. Has the Department considered some form of leniency for Medicaid beneficiaries under this type of scenario? This could be provided in a case review process.

• Proposed 7 AAC 105.600(b)(2)(D) – This proposed addition would restrict Medicaid beneficiaries who paid in cash for DEA-designated Schedule II – V drugs two or more times within three consecutive months. It is conceivable that cash payments are still common in communities without extensive broadband services to run bank card readers.

• Proposed 7 AAC 105.600(b)(2)(H) – This proposed addition would restrict Medicaid beneficiaries who presented at emergency departments three or more times in a 12-month period for “non-emergent conditions”. How would this affect Medicaid beneficiaries who present at emergency departments with affiliated Urgent Care centers/tracks which are set

Page3of4

up to provide services for walk-in patients with “non-emergent conditions”. While Tribes and Tribal Health Organizations agree on reducing the use of EDs, it is important to note that there is still a cultural association with the ED and accessing health care that carries over from an earlier period in Indian health care in Alaska. While we continue to work to improve the use of primary care, we are concerned that beneficiaries might be restricted when they are processed through Urgent Care clinics affiliated with EDs.

• Proposed 7 AAC 105.600(b)(2)(I) – This proposed addition would restrict Medicaid beneficiaries “for a reason that was within the control of the recipient” who missed an appointment when traveling on department-authorized transportation. This language is incredibly broad. Can the Department explain how it will determine what reasons “that [are] within control of the recipient”? The current proposed regulation removes an automatic case review now in the current regulation. Without proper case review in the first instance, and only receiving relief through the fair hearing process at 7 AAC 49, this may inadvertently impact beneficiaries with legitimate reasons. There should be a proper case review process in the first instance.

• Proposed 7 AAC 105.600(c) – This clause reflects language from the current regulation at 7 AAC 105.600(d). While the language is largely the same, it would replace the existing 7 AAC 105.600(c), which provides for an individualized clinical case review based on an initial triggering event. As currently written, the proposed 7 AAC 105.600(c) would allow the Department to immediately restrict beneficiaries and force them to receive relief only through the fair hearing process described at 7 AAC 49. A change to the process as envisioned here may have unintended consequences on beneficiaries. The Department may also risk unintended budgetary impacts if beneficiaries are automatically enrolled into a “locked-in” provider without proper clinical review or if the Department failed to assign AN/AI Medicaid beneficiaries to THOs. Can the Department explain its current review process, and how it intends a review process to work under the proposed regulations?

• Proposed 7 AAC 105.600(e)(1) – This clause reflects language from the current regulation at 7 AAC 105.600(f)(1). Would the Department please explain how this particular rule works when retroactive referrals are used? We also recommend that the Department conduct provider engagement and education to help better support this part of the Care Management Policy.

• Proposed 7 AAC 105.600(f) – This clause largely reflects language from the current regulation at 7 AAC 105.600(g). The proposed language however changes the “lock-in” period from a period “not to exceed 12 months” to “not to exceed 24 months”. Can the Department explain the rationale behind this extension and the process used to determine that a two-year period was more appropriate for provider-choice restriction?

• Proposed 7 AAC 105.600(h) – This clause largely reflects language from the current regulation at 7 AAC 105.600(f). This proposed language however defines regulatory sections for the services to be reimbursed under the Care Management Program as “7 AAC 105 – 7 AAC 160”. Can the Department explain what services are covered under

Page4of4

the existing regulation when it uses the verbiage “medical services” which would not be covered under the proposed regulation?

• Proposed 7 AAC 105.600(i) – This proposed addition pulls the “emergency services” definition from 7 AAC 105.610(e) and adds a definition for “non-emergent conditions”. Can the Department please explain how it developed the definition of “non-emergent condition” for the purposes of proposed 7 AAC 105.600?

• Can the Department explain how the Care Management Program will be implemented to coordinate with the roll out of the 1115 Behavioral Health Waiver substance used disorder and mental health treatment services?

We again appreciate the opportunity to provide comment to the Department on these proposed regulatory changes. If the Department would like further dialogue or information on these comments, please do not hesitate to contact us. You may reach ANHB at (907) 562-6006 or at anhb@anhb.org. Sincerely,

Andrew Jimmie Chairman Alaska Native Health Board

Alaska Native Health Board THE VOICE OF ALASKA TRIBAL HEALTH SINCE 1968 907.562.6006 907.563.2001 4000 Ambassador Drive, Suite 101 Anchorage, Alaska 99508 www.anhb.org

Page1of4

ALASKA NATIVE TRIBAL HEALTH CONSORTIUM

ALEUTIAN PRIBILOF ISLANDS ASSOCIATION

ARCTIC SLOPE NATIVE ASSOCIATION

BRISTOL BAY AREA HEALTH CORPORATION

CHICKALOON VILLAGE TRADITIONAL COUNCIL

CHUGACHMIUT

COPPER RIVER NATIVE ASSOCIATION

COUNCIL OF ATHABASCAN TRIBAL GOVERNMENTS

EASTERN ALEUTIAN TRIBES

KARLUK IRA TRIBAL COUNCIL

KENAITZE INDIAN TRIBE

KETCHIKAN INDIAN COMMUNITY

KODIAK AREA NATIVE ASSOCIATION

MANllLAQ ASSOCIATION

METLAKATLA INDIAN COMMUNITY

MT. SANFORD TRIBAL CONSORTIUM

NATIVE VILLAGE OF EKLUTNA

NATIVE VILLAGE OF EYAK

NATIVE VILLAGE OF TYONEK

NINILCHIK TRADITIONAL COUNCIL

NORTON SOUND HEALTH CORPORATION

SELDOVIA VILLAGE TRIBE

SOUTHCENTRAL FOUNDATION

SOUTHEAST ALASKA REGIONAL HEALTH CONSORTIUM

TANANA CHIEFS CONFERENCE

YAKUTAT TLINGIT TRIBE

YUKON-KUSKOKWIM HEALTH CORPORATION

VALDEZ NATIVE TRIBE

February 25, 2020 Susan Dunkin, Regulations Coordinator Division of Health Care Services, Alaska Department of Health & Social Services, 4501 Business Park Blvd., Building L, Anchorage, AK 99503 Via Email: Susan.Dunkin@alaska.gov Re: Proposed Regulations for the Medicaid Care Management Program Dear Ms. Dunkin, The Alaska Native Health Board (ANHB) appreciates the opportunity to provide comments as part of the public comment process on the proposed Medicaid Care Management Program, as known as the Medicaid “Locked-In” Program. The ANHB was established in 1968 with the purpose of promoting the spiritual, physical, mental, social, and cultural well-being and pride of Alaska Native people. ANHB is the statewide voice on Alaska Native health issues and is the advocacy organization for the Alaska Tribal Health System (ATHS), which is comprised of tribal health programs that serve all of the 229 tribes and over 177,000 Alaska Natives and American Indians throughout the state. As the statewide tribal health advocacy organization, ANHB helps Alaska’s tribes and tribal programs achieve effective consultation and communication with state and federal agencies on matters of mutual concern. While the reforms of the Medicaid Care Management Program were approved as part of the cost containment measures in the FY2020 Operating Budget, the proposed regulations raise concerns about the way the Department of Health & Social Services (DHSS or “the Department”) seeks to implement, and achieve savings from, this regulatory change. Generally, the Department should consider seeking additional stakeholder engagement before finalizing this proposed regulation to avoid unintended consequences for Medicaid beneficiaries, providers, and the Department. Below, please find our comments and questions regarding the proposed changes to 7 AAC 105.600.

• We ask that when the Department restrict a beneficiary’s choice of provider under this regulation, that the Department allow for a Tribal Health Organization (THO) to be specifically specified as a beneficiary’s “locked-in” provider(s) for the duration of the “locked-in” period. THOs provide integrated health care services that include primary care, pharmacy, dental, behavioral health and related services. Integrated health care services can be beneficial to recipients for whom the State may seek restricting their choice under 7 AAC 105.600. For this reason, we

Page2of4

propose adding language to 7 AAC 105.600(d) to specifically include THOs as an option for assignment. Our recommendation is:

“(d) The department will assign a restricted recipient one primary care provider and one pharmacy, or Tribal Health Organization, within reasonable proximity to the recipient’s home, and may assign one dental provider and one behavioral health provider or Tribal Health Organization. The department will include the word “RESTRICTED” and will identify the designated providers on the recipient’s Medicaid identification card.”

• Proposed 7 AAC 105.600(a) and (b)(1) - a referral is made to the department indicating that the recipient has used a medical item or service at a frequency or amount that is not appropriate;

o This language is incredibly broad. The current regulation reads at 7 AAC 105.600(b)(1) “a referral is made to the department indicating that the recipient has used a medical item or service at a frequency or amount that is not medically necessary;”. The current text better reflects the intent of the Medicaid Care Management Policy. By changing this language to the proposed, it creates uncertainty of “appropriateness” and who determines that appropriateness. Under the current language, a medical professional, in completing a review, can reasonably assess medical necessity.

• Proposed 7 AAC 105.600(b)(2) – The State has listed several new factors to be considered in restricting a patient’s freedom of provider choice. Some of these new triggers have raised concerns. Can the Department explain where this new list of triggers under 7 AAC 105.600(b)(2) was sourced or how they were developed, specifically subsections (B), (C), (D), (E), (F), (H), (I), and (J)? Were these pulled from other states’ existing policies or were these items determined by DHSS?

• Proposed 7 AAC 105.600(b)(2)(C) – This proposed addition would restrict Medicaid beneficiaries who receive an opioid prescription from two or more providers within three consecutive months. It is conceivable that a patient who is being seen at a multi-physician practice or health care group might receive an opioid prescription from two providers within the same practice during a three-month period. Has the Department considered some form of leniency for Medicaid beneficiaries under this type of scenario? This could be provided in a case review process.

• Proposed 7 AAC 105.600(b)(2)(D) – This proposed addition would restrict Medicaid beneficiaries who paid in cash for DEA-designated Schedule II – V drugs two or more times within three consecutive months. It is conceivable that cash payments are still common in communities without extensive broadband services to run bank card readers.

• Proposed 7 AAC 105.600(b)(2)(H) – This proposed addition would restrict Medicaid beneficiaries who presented at emergency departments three or more times in a 12-month period for “non-emergent conditions”. How would this affect Medicaid beneficiaries who present at emergency departments with affiliated Urgent Care centers/tracks which are set

Page3of4

up to provide services for walk-in patients with “non-emergent conditions”. While Tribes and Tribal Health Organizations agree on reducing the use of EDs, it is important to note that there is still a cultural association with the ED and accessing health care that carries over from an earlier period in Indian health care in Alaska. While we continue to work to improve the use of primary care, we are concerned that beneficiaries might be restricted when they are processed through Urgent Care clinics affiliated with EDs.

• Proposed 7 AAC 105.600(b)(2)(I) – This proposed addition would restrict Medicaid beneficiaries “for a reason that was within the control of the recipient” who missed an appointment when traveling on department-authorized transportation. This language is incredibly broad. Can the Department explain how it will determine what reasons “that [are] within control of the recipient”? The current proposed regulation removes an automatic case review now in the current regulation. Without proper case review in the first instance, and only receiving relief through the fair hearing process at 7 AAC 49, this may inadvertently impact beneficiaries with legitimate reasons. There should be a proper case review process in the first instance.

• Proposed 7 AAC 105.600(c) – This clause reflects language from the current regulation at 7 AAC 105.600(d). While the language is largely the same, it would replace the existing 7 AAC 105.600(c), which provides for an individualized clinical case review based on an initial triggering event. As currently written, the proposed 7 AAC 105.600(c) would allow the Department to immediately restrict beneficiaries and force them to receive relief only through the fair hearing process described at 7 AAC 49. A change to the process as envisioned here may have unintended consequences on beneficiaries. The Department may also risk unintended budgetary impacts if beneficiaries are automatically enrolled into a “locked-in” provider without proper clinical review or if the Department failed to assign AN/AI Medicaid beneficiaries to THOs. Can the Department explain its current review process, and how it intends a review process to work under the proposed regulations?

• Proposed 7 AAC 105.600(e)(1) – This clause reflects language from the current regulation at 7 AAC 105.600(f)(1). Would the Department please explain how this particular rule works when retroactive referrals are used? We also recommend that the Department conduct provider engagement and education to help better support this part of the Care Management Policy.

• Proposed 7 AAC 105.600(f) – This clause largely reflects language from the current regulation at 7 AAC 105.600(g). The proposed language however changes the “lock-in” period from a period “not to exceed 12 months” to “not to exceed 24 months”. Can the Department explain the rationale behind this extension and the process used to determine that a two-year period was more appropriate for provider-choice restriction?

• Proposed 7 AAC 105.600(h) – This clause largely reflects language from the current regulation at 7 AAC 105.600(f). This proposed language however defines regulatory sections for the services to be reimbursed under the Care Management Program as “7 AAC 105 – 7 AAC 160”. Can the Department explain what services are covered under

Page4of4

the existing regulation when it uses the verbiage “medical services” which would not be covered under the proposed regulation?

• Proposed 7 AAC 105.600(i) – This proposed addition pulls the “emergency services” definition from 7 AAC 105.610(e) and adds a definition for “non-emergent conditions”. Can the Department please explain how it developed the definition of “non-emergent condition” for the purposes of proposed 7 AAC 105.600?

• Can the Department explain how the Care Management Program will be implemented to coordinate with the roll out of the 1115 Behavioral Health Waiver substance used disorder and mental health treatment services?

We again appreciate the opportunity to provide comment to the Department on these proposed regulatory changes. If the Department would like further dialogue or information on these comments, please do not hesitate to contact us. You may reach ANHB at (907) 562-6006 or at anhb@anhb.org. Sincerely,

Andrew Jimmie Chairman Alaska Native Health Board

From: Lamb, LisaTo: Dunkin, Susan M (HSS)Cc: Morris, Denise RSubject: Southcentral Foundation comments - Medicaid Care Management Program -Date: Tuesday, February 25, 2020 4:50:26 PMAttachments: Medicaid Care Management Program Comments 02.25.2020.pdf

Susan, Please find attached Southcentral Foundation’s comments regarding the proposed changes to 7 AACdealing with the Medicaid Care Management Program. Let me know if you have any questions. Lisa LambSenior Compliance Analyst

mailto:LLamb@SouthcentralFoundation.commailto:susan.dunkin@alaska.govmailto:DMorris@SouthcentralFoundation.com

From: Jon ZasadaTo: Dunkin, Susan M (HSS)Cc: Jessie Menkens; Nancy MerrimanSubject: APCA Comments on Medicaid Care Management Program RegulationsDate: Tuesday, February 25, 2020 5:18:59 PMAttachments: APCA Medicaid Care Management Program Reg Changes_Comments.pdf

Thank you for the opportunity to comment on this issue. Thanks - Jon Jon Zasada – Policy Integration DirectorAlaska Primary Care AssociationP 907-227-7913 E jonz@alaskapca.org W alaskapca.org

mailto:JonZ@alaskapca.orgmailto:susan.dunkin@alaska.govmailto:JessieM@alaskapca.orgmailto:Nancy@alaskapca.orgmailto:jonz@alaskapca.org

 

Helping to create healthy communities through the support of vibrant and effective Community Health Centers in Alaska 1231 Gambell Street, Suite 200     Anchorage, Alaska 99501  |  907‐272‐2722  |  www.alaskapca.org 

February 25, 2020 Submitted via email to susan.dunkin@alaska.gov Ms. Susan Miller Dunkin Division of Health Care Services Department of Health and Social Services 4501 Business Park Blvd, Building L Anchorage, AK 99503-7167 Dear Ms. Dunkin, Alaska Primary Care Association (APCA) appreciates this opportunity to comment on the proposed changes to the Medicaid Care Management Program Regulations. APCAencouragesDHSStopauseontheseproposedregulationchangesthatwouldbecounterproductive,andfurtherlimitaccesstohealthcareinAlaska’scommunities.

APCA and Alaska Federally Qualified Health Centers (FQHCs) look forward to ongoing stakeholder engagement opportunities related to Medicaid care management and other reform efforts moving forward. We appreciate your consideration of the following key questions and concerns: 1. Communication concerns – provider and patient outreach

APCA/FQHCs urge the Department to consider additional communication with providers and patients to seek additional input as it relates to these regulation changes. How were these proposed changes shared with relevant parties aside from posting them on the public notice website? What analysis has been done to assess projected patient outcomes and provider impact related to these proposed regulation changes?

2. Cost of providing care to these high need patients. FQHCs are adept at providing high quality care to complex patients. Given that FQHCs

may not turn away any patient, as opposed to other primary care provider, APCA is concerned that FQHCs are being asked to absorb the high costs associated with the noted restricted patients and this simply is not sustainable. How will DHSS ensure that FQHCs are adequately compensated for the level of care these patents warrant?

3. Assignment Criteria and Balance

FQHCs request additional information on how the Department will track and determine patient “problematic” behavior. As safety net providers, FQHCs encourage the department to evaluate policies and regulations that increase access to care, not the opposite. Furthermore, FQHCs want to know how the Department will balance patient

Proposed Changes to the Medicaid Care Management Program RegulationsAlaska Primary Care Association, Page 2 of 2 

Helping to create healthy communities through the support of vibrant and effective Community Health Centers in Alaska 1231 Gambell Street, Suite 200     Anchorage, Alaska 99501  |  907‐272‐2722  |  www.alaskapca.org 

assignments to FQHC and non-FQHC providers in each region, to ensure fair distribution while addressing patient needs.

4. Patient Rights and Grievances

Timely notification and patient outreach are critical. How will patients be notified of state decision making? If they have a grievance, what steps will the Department take to ensure patients are fully aware of their rights to a fair hearing under 7 AAC 49 Alaska?

5. Provider Designation Process and Challenges

APCA has additional concerns and questions regarding when provider designations may be changed within the proposed regulation changes. Per the notice designations may be changed if:

a - The provider requests the change – could an FQHC provider do so? b - The provider disenrolls in Medicaid – an FQHC provider is not permitted to disenroll in Medicaid. c - The recipient moves to a new geographic area – Medicaid patients can be very transient. How will this work smoothly and how will patients receive timely mail and guidance that is clear and plainly communicated? d - The department finds the patient doesn’t have adequate access to the services he/she needs, as assigned – what is the criteria to make this determination and how will it be assessed on an ongoing basis?  

As safety net providers, FQHCs are committed to reducing barriers to care while delivering quality, high value and low-cost healthcare to the patients they serve. APCA and Alaska FQHCs look forward to future opportunities to engage with DHSS on the topic of Medicaid care management in Alaska. Thank you. Sincerely, Nancy Merriman Executive Director

2020-02-25T17:02:03-0900

Nancy Merriman

 

Helping to create healthy communities through the support of vibrant and effective Community Health Centers in Alaska 1231 Gambell Street, Suite 200     Anchorage, Alaska 99501  |  907‐272‐2722  |  www.alaskapca.org 

February 25, 2020 Submitted via email to susan.dunkin@alaska.gov Ms. Susan Miller Dunkin Division of Health Care Services Department of Health and Social Services 4501 Business Park Blvd, Building L Anchorage, AK 99503-7167 Dear Ms. Dunkin, Alaska Primary Care Association (APCA) appreciates this opportunity to comment on the proposed changes to the Medicaid Care Management Program Regulations. APCAencouragesDHSStopauseontheseproposedregulationchangesthatwouldbecounterproductive,andfurtherlimitaccesstohealthcareinAlaska’scommunities.

APCA and Alaska Federally Qualified Health Centers (FQHCs) look forward to ongoing stakeholder engagement opportunities related to Medicaid care management and other reform efforts moving forward. We appreciate your consideration of the following key questions and concerns: 1. Communication concerns – provider and patient outreach

APCA/FQHCs urge the Department to consider additional communication with providers and patients to seek additional input as it relates to these regulation changes. How were these proposed changes shared with relevant parties aside from posting them on the public notice website? What analysis has been done to assess projected patient outcomes and provider impact related to these proposed regulation changes?

2. Cost of providing care to these high need patients. FQHCs are adept at providing high quality care to complex patients. Given that FQHCs

may not turn away any patient, as opposed to other primary care provider, APCA is concerned that FQHCs are being asked to absorb the high costs associated with the noted restricted patients and this simply is not sustainable. How will DHSS ensure that FQHCs are adequately compensated for the level of care these patents warrant?

3. Assignment Criteria and Balance

FQHCs request additional information on how the Department will track and determine patient “problematic” behavior. As safety net providers, FQHCs encourage the department to evaluate policies and regulations that increase access to care, not the opposite. Furthermore, FQHCs want to know how the Department will balance patient

Proposed Changes to the Medicaid Care Management Program RegulationsAlaska Primary Care Association, Page 2 of 2 

Helping to create healthy communities through the support of vibrant and effective Community Health Centers in Alaska 1231 Gambell Street, Suite 200     Anchorage, Alaska 99501  |  907‐272‐2722  |  www.alaskapca.org 

assignments to FQHC and non-FQHC providers in each region, to ensure fair distribution while addressing patient needs.

4. Patient Rights and Grievances

Timely notification and patient outreach are critical. How will patients be notified of state decision making? If they have a grievance, what steps will the Department take to ensure patients are fully aware of their rights to a fair hearing under 7 AAC 49 Alaska?

5. Provider Designation Process and Challenges

APCA has additional concerns and questions regarding when provider designations may be changed within the proposed regulation changes. Per the notice designations may be changed if:

a - The provider requests the change – could an FQHC provider do so? b - The provider disenrolls in Medicaid – an FQHC provider is not permitted to disenroll in Medicaid. c - The recipient moves to a new geographic area – Medicaid patients can be very transient. How will this work smoothly and how will patients receive timely mail and guidance that is clear and plainly communicated? d - The department finds the patient doesn’t have adequate access to the services he/she needs, as assigned – what is the criteria to make this determination and how will it be assessed on an ongoing basis?  

As safety net providers, FQHCs are committed to reducing barriers to care while delivering quality, high value and low-cost healthcare to the patients they serve. APCA and Alaska FQHCs look forward to future opportunities to engage with DHSS on the topic of Medicaid care management in Alaska. Thank you. Sincerely, Nancy Merriman Executive Director

Public Comments Summary - Care Mgt SvcsCMP Regulations - DHCS Response to Public Comments 2020.06.08CMP Response to Comments 2020.06.08

01-IAA102-AMHB-ABADA102-AMHB-ABADA203-DBH103-DBH204-AMHTA104-AMHTA205-ASHNHA105-ASHNHA206-ANHB106-ANHB207-SCF107-SCF208-APCA108-APCA2