changes on the way: managed long term supports & services kyle fisher [email protected] october...
TRANSCRIPT
Session Topics
What is a “dual-eligible”?
What is a “waiver” program? Home & Community Based Services (HCBS) Current eligibility, enrollment & delivery system
What is Community Health Choices? Program design highlights Stakeholder engagement process Regions and timeline
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Delivery System Reform
“Community Health Choices is a significant shift from the commonwealth's current, fractured approach to providing these services and will enhance care for seniors and persons with disabilities through better coordination of care.
The result will be that more Pennsylvanians will be served in the community instead of in nursing homes or other facilities.”
- DHS Press Release 9/16/15
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Who’s Affected?
“Community Health Choices will serve an estimated 450,000 individuals, including 130,000 older persons and adults with physical disabilities who are currently receiving LTSS in the community and in nursing facilities.”
- DHS Press Release 9/16/15
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Dual-eligibles
What is a “dual eligible”?A person who is enrolled in both:
Medicaid Medicare
There are ~420,000 “dual eligible” adults in PA Medicaid is secondary coverage; Medicare is primary
Current delivery system (on Medicaid side) Medicaid Fee-for-Service
For physical health services / PA ACCESS card For behavioral health services, enrolled in BH
MCO
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HELPING CONSUMERS REMAIN IN THE COMMUNITY
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THE CURRENT FRAMEWORK
HCBS Waiver Programs6
Home & Community Based Services
What are “HCBS waiver programs”?
Alternatives to nursing facility care
Provide medical and non-medical services to allow older adults and people with disabilities to live independently in their homes and communities.
Multiple different waivers Based on age (60+), physical disability, or intellectual
disability
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Typical Waiver Services*
Home health Services HHA, RN, LPN,
therapiesPersonal care Attendant careRespiteAdult Day CareTransportationCounseling
Home modifications
Specialized medical equipment & supplies
Home delivered meals
Personal emergency response
*vary by waiver
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Waiver Services
Individualized Service Plan Describes type and amount of waiver services e.g., 20 hours per week of personal care assistance
Each waiver recipient has a “service coordinator” Through AAA or Service Coordination Agency
Waivers also confer full Medicaid coverage Waiver services not integrated with Medicaid or
Medicare Recipient either in FFS Medicaid or Medicaid MCO,
depending on whether dual-eligible
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Clinical Eligibility
How does someone qualify for a waiver program?
Each waiver has target criteria: Aging Waiver = Must be age 60 or older Attendant Care = Must be age 18-59, have a physical
impairment and be mentally alert
Also must be “Nursing Facility Clinically Eligible”
Level of Care Determination done by a local area agency on aging (AAA) Can be administered in the applicant’s home
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Clinical Eligibility
Nursing Facility Clinically Eligible (NFCE) legal term of art; requires a physician certification
Must require “care and services” that are either skilled nursing or rehabilitation services or
health-related care and services that may not be as inherently complex as skilled nursing or rehabilitation services but which are needed and provided on a regular basis ...
Key Q: need help with “activities of daily living”? Bathing, dressing, toileting, transferring, personal
hygiene
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Financial Eligibility
Adults age 19-64Special Income Limit
300% of Federal SSI Benefit Level Does not consider spouse’s income
Resource limit = $8,000
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Household of 1
Household of 2
Monthly (2015)
$2,199 N/A
How to Apply
Aging Waiver (age 60+): Apply through local Area Agency on Aging
http://www.aging.pa.gov/local-resources/ Clinical eligibility determined by AAA, reviewed by
DHS/OLTL Financial eligibility decided by CAO
Under 60/OLTL waivers: Apply through Independent Enrollment Broker
(Maximus) Phone: (877) 550-4227
Initial assessment by Maximus Clinical eligibility determined by AAA, reviewed by
DHS/OLTL Financial eligibility decided by CAO
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MANAGED LONG TERM SUPPORTS & SERVICES
(MLTSS)
Community HealthChoices14
Community HealthChoices
What is Community HealthChoices?
Governor Wolf’s proposal to reform the Medicaid long term care delivery system and integrate: Medicaid and Medicare coverage, and Physical health services and Long Term Care services
Community HealthChoices will enroll: Dual-Eligibles HCBS Waiver Recipients Nursing Facility Residents
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Community HealthChoices
Community HealthChoices will replace the six HCBS waiver programs managed by OLTL Aging Attendant Care AIDS CommCare (TBI) Independence OBRA
Concept Paper released Sept. 16, 2015 http://www.dhs.state.pa.us/foradults/communityhealthchoices/
index.htm
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Mandatory Managed Care
CHC reforms the delivery system
Expanded role for HealthChoices MCOs Would enroll all dual-eligibles (regardless of LTSS need) & Adults getting waiver services or nursing facility care
CHC MCOs required to have Medicare MCO too Called “D-SNP” (Dual Eligible Special Needs Plan) Offers potential to integrate Medicaid and Medicare care,
have instant claims data available on both sides DHS cannot require recipient enroll in D-SNP, however
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Goals
*From DHS Presentation (9/21/15)
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Physical health and LTSS needs coordinated by the CHC-MCO
Behavioral health services will continue to be covered by a separate BH MCO
2.3 Covered Benefits & 2.4 Coordination
Behavioral Health
Long-Term Care
Physical Health
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2.5 Provider Networks
CHC-MCO provider network standards will mirror those of existing HealthChoices program Beginning 2017, HealthChoices network adequacy
provisions will require MCOs to contract with any FQHC in its service area willing to accept the PPS rate
LTSS provider networks will be required to be sufficient to allow for participant choice New arena for MCOs: non-medical providers Minimum of 2 providers for each LTSS service?
Geography?
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2.6 Continuity of Care
Transition will include continuity of care provisions that mitigate service interruption risks
Continuity of care / 6 months Existing waiver participants will have access to
existing services and providers for 6 months After 6 months, CHC-MCO may cut any/all of a
participant’s services up to 25% of previously approved hours without state review
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Needs Assessments
CHC-MCOs will do (or contract) a “comprehensive needs assessments” to “identify the participants’ goals and preferences and
addresses physical, social, psychosocial, environmental, LTSS and other needs, as well as the availability and needs of participants through the support of unpaid caregivers.”
Individualized Service Plan (ISP) then developed by service coordinator
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Pennsylvania will issue a request for proposals (RFP) for CHC-MCOs in November 2015
Participant enrollment will begin with the first phase in the Southwest in January of 2017, Southeast in January of 2018
Statewide implementation complete in 2019
5. Regions and Timeline
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Preliminary Procurement and Implementation
Milestone Description Date
Deadline for submission of comments on concept paper October 16, 2015 (5:00 pm)
Release of RFP for CHC-MCOs November 16, 2015
Technical questions on RFP due to the commonwealth November 25, 2015 (5:00 pm)
Pre-proposal conference December 2, 2015
Answers to technical questions provided by the commonwealth December 11, 2015
Deadline for submission of proposals January 15, 2016 (5:00 pm)
Qualified Offerors respond to written questions and make oral presentations as requested by Commonwealth January-February 2016
CHC-MCOs notified of selection (all regions) March 2016
Agreement negotiations for Phase 1 CHC-MCOs March-June 2016
Readiness reviews for Phase 1 CHC-MCOs March-December 2016
Phase 1 CHC participants receive enrollment notices October 2016
Implementation of Phase 1 (Southwest region) January 2017
Implementation of Phase 2 (Southeast region) January 2018
Implementation of Phase 3 (Northwest, Lehigh-Capital and Northeast regions) January 2019
Advocate Questions
Questions & concerns:Why is the state selecting MCOs in 2016 for zones not
“live” until 2018 & 2019? How will MCOs meet the very different needs of older
adults vs members getting LTSS?Will MCOs be allowed to put limits on individual
expenditures? In the aggregate, or by service? E.g., could private duty nursing be limited to 16 hours per
day?Will MCO performance data be published? How will the ombudsman program work?
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Resources
Office of Long Term Living Waiver Programs http://www.longtermcare.state.pa.us/ http
://www.dhs.state.pa.us/fordisabilityservices/alternativestonursinghomes/index.htm
DHS Community HealthChoices (MLTSS) Website http://www.dhs.state.pa.us/foradults/communityhealthchoices/index.htm
PHLP manual: Home & Community Based Services http://
www.phlp.org/wp-content/uploads/2012/08/SW-Waiver-Manual-Formatted.pdf
PHLP Helpline: 1-800-274-3258
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