Implementation of Community HealthChoices:What Providers Need to Know

Janice Meinert, MSW, ParalegalSeptember 28, 2016

This presentation is funded by a grant from the Pennsylvania Developmental Disabilities Council

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What is Community HealthChoices (CHC)?

• CHC is the state’s plan for the delivery of long term services and supports (LTSS) for adults in OLTL waivers and Medicaid coverage for the physical health services for dual eligibles.

• Current system of LTSS is separate from the delivery of physical health services.

• LTSS delivered now through the Office of Long Term Living (OLTL) by way of home and community based waiver services.

• Physical health services delivered through Medicaid FFS or HealthChoices (depending on whether or not person is a dual eligible).

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Community HealthChoices

Background on implementation:

State began exploring in 2015 - issued “Discussion document”, “Concept paper”, held many public meetings in 2015

Issued draft RFP and draft program requirements with public comment period – end of 2015

Issued RFP to interested health plans, Feb 2016 – 14 plans responded

State Office of Long Term Living (OLTL) holds third Thursday webinars

http://www.dhs.pa.gov/citizens/communityhealthchoices/

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What is LTSS?

Medicaid is the primary payer for long-term services and supports (LTSS) for those who experience difficulty living independently and completing daily self-care activities as a result of cognitive disabilities, physical impairments, and/or disabling chronic conditions

Delivered in institutional settings (e.g., nursing facilities) and in community-based settings (e.g.,

private homes)

Community-based services often called “waivers” or home and community based waiver services

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What is Community HealthChoices (CHC)?

The state paying health insurance plans a capitated fee to provide Medicaid coverage for dual eligibles (those on Medicare and Medicaid) and to provide LTSS for those determined eligible (also called Managed Long Term Services and Supports (MLTSS))

Enrollment is mandatory for those impacted (details on future slide)

Begins July 1, 2017 in 14 counties in Southwest PA **Date recently changed from January 2017**

Begins January 2018 in SE Zone Begins January 2019 in remainder of the state

67 Counties in five (5) Zones7

Who Will Be Impacted?

Adults (21 and older) who are dual eligibleswho are not receiving LTSS

Adults who are dual eligibles and receiving LTSS through OLTL waivers- Attendant Care, Independence, CommCare and Aging

Adults on Medicaid only who are receiving OLTL waivers

Adults in nursing homes on Medicaid

Adults in the OBRA waiver who are determined nursing facility clinically eligible (NFCE)

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Who Will Not Be Impacted?

Adults in the OBRA waiver who are NOT NFCE – they remain in the OBRA waiver

18-20 yr olds in an OLTL waiver – do not go into CHC until they turn 21

Those in Waivers operated by the Office of Developmental Programs (e.g., Consolidated, Person Family Directed Services)

Those in the Act 150 Program

Those in the Options Program

People who choose to enroll or remain in LIFE Programs

People in state-run nursing facilities and State Veteran Homes

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Changes to Current OLTL Waivers

Current OLTL waivers include: Independence, Attendant Care, OBRA, CommCare and Aging

Changes with CHC:

• People in CommCare waiver will be transferred to the Independence waiver and Independence will be amended to add residential habilitation and structured day habilitation to allow people now on CommCare to continue to receive those services

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Other Changes to Waivers with CHC

The CommCare waiver will be amended to become the global waiver for Community HealthChoices.

When CHC is implemented in each region it will subsume the current Independence, CommCare, Aging and Attendant Care Waivers.

The Aging, Independence and Attendant Care waivers will remain in place for Regions 1, 2 & 3 until Region 1 implementation of CHC in July 2017; Region 2 in January 2018; Region 3 in January 2019.

OBRA waiver will continue for people with developmental physical disabilities who are NOT nursing facility clinically eligible and those 18-20 yr olds before they move to CHC.

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Other Changes to Waivers with CHC

The CommCare global waiver (i.e. Community HealthChoices) will include all the services currently covered by the Attendant Care, Independence, CommCareand Aging waivers.

Additionally, Community HealthChoices will also add new employment services and pest eradication services.

This doesn’t mean all people in Community HealthChoicesdeemed Nursing Facility Clinically Eligible will get all these services – they will be available if determined needed and identified in their Service Plans.

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What’s Ahead with CHC?

Summer 2016: Plan Selection (Statewide)

Fall 2016: Readiness Review for SWPA

Early 2017: Notices sent to impacted individuals in SW Region, 90 day notices, 60 notices, 30 day notices with instructions to make a plan selection

July 2017: CHC begins in the Southwest Region 14 counties ** The state initially planned for January 2017

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How Dual Eligibles Currently Access Health Care

Primary Insurance is either 1) original Medicare or 2) Medicare Advantage

Secondary insurance is Medical Assistance (Medicaid) through FFS with ACCESS card for physical health services and HealthChoices for behavioral health services

Practice Note: Duals often must go to health care providers who take both their Medicare and Medical Assistance to avoid balance billing

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What Will Change for Dual Eligibles in Community HealthChoices?

The ACCESS card will not be used; instead duals will be enrolled in a CHC managed care plan for their Medical Assistance There will be a choice of 2-5 health plans in every region

Primary insurance for duals will still be Medicare

Community HealthChoices plans must have a “companion” Medicare plan But consumers will not be required to join the

companion Medicare plan or any other Medicare health plan and can have just traditional Medicare

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How Those in OLTL Waivers Currently Access Services

LTSS/ Waiver services are paid for directly through the state. A developed and approved service plan determines the type and amount of those services.

Medical care - physical health & behavioral health –is accessed through individual’s insurance be it Medicare and Medicaid or just Medicaid.

Those in the Aging Waiver access their physical and behavioral health services through the Medicaid FFS system (not in HealthChoices) and Medicare if they also have it.

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What Will Change for Enrollees Getting LTSS?

Community HealthChoices managed care plans will be responsible for providing long term services and supports for those who had been in the following waiver programs:

Attendant Care

Independence

Aging

OBRA

COMMCARE

*Exception – those in OBRA who are not Nursing Facility Clinically Eligible – they remain in OBRA

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What Will Change for Enrollees Getting LTSS (continued)

Nursing home residents currently get their long term care needs in the Medicaid Fee-For-Service system; with Community HealthChoices MA nursing home residents will have to choose a CHC managed care plan.

Those currently in nursing homes when the change occurs must be permitted to stay where they are no matter what plan they enroll in.

New admissions to nursing homes will have to go to facilities that are in the network of their Community HealthChoices managed care plan (or change plans).

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Special Consideration for Enrollees Now in Waivers

• CHC plans will be responsible for determining the type and amount of services individuals receive (after 6 month transition period)

• All service providers will have to be in the network of the CHC plan unless otherwise approved by the plan

• CHC plan can choose whether to use Service Coordinators employed directly by the CHC plan or to contract with a provider agency

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What Won’t Change with Implementation of CHC?

• An Independent Enrollment Broker will still be used for determining eligibility for those requesting LTSS in the future

• Participant Directed Services will still be an option through: 1) Services My Way and 2) Consumer-directed services

• The LIFE Program will still be an option for individuals meeting nursing home level of care who are 55 and older (and have a LIFE Program available in their area)

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What About Behavioral Health Services with CHC?

• Behavioral health care with Medical Assistance will still be accessed through existing behavioral health managed care plans (i.e. Community Care Behavioral Health, Value Behavioral Health, Magellan, Community Behavioral Health and PerformCare).

• CHC plans are expected to coordinate the behavioral health needs of their members with the BH-MCOs.

• Those in the Aging waiver and Nursing Homes will now be in a BH-MCO – new population for BH-MCOs to serve!

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How Will People be Enrolled in Community HealthChoices?

The PA Enrollment Broker will notify participants 3 months before start date and provide information about the available health plans –pre-transition letters sent 90 days out, 60 days out, 30 days out

If participant does not choose a plan the state will choose one for him/her

Once enrolled in the health plan the plan can’t make changes to the person’s Individual Service Plan for the first 6 months –for those receiving long term services & supports

Plans also have to allow continuity of care with out-of-network providers for 6 months for those receiving LTSS

Participants will not be locked into a plan - can change at any time.

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Provider Issues

Providers of physical health services for duals and long term services and supports must be enrolled in network of CHC plans to be able to provide services.

There is no “any willing provider” requirement for plans so they can choose who they let in their networks and who they don’t –however, the plans do have to assure access to all covered services.

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Provider Issues

CHC means new members in BH-MCOs:

Those currently in Aging Waiver get all services in MA-FFS but will now be in CHC for physical health services and BH-MCOs for behavioral health services

Those in Nursing homes paid by Medicaid will now be in BH-MCOs.

Behavioral health providers will need to determine how to serve new populations, as Aging Waiver participants and NH residents move from FFS to BH-MCOs, as BH-MCOs are required to provide more services.

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Provider Issues

Aging Waiver participants will now be able to access mobile mental health treatment, peer specialists, psychiatric rehabilitation, non-hospital detox, non-hospital D&A treatment, crisis services and case management.

The above services are not available in MA –FFS.

Potential confusion between HealthChoices and Community HealthChoices, especially since there will be some insurance companies with both plans

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CHC Concerns

Consumers understanding the changes and how it impacts them

CHC plans responsible for LTSS – no experience in doing this

CHC plans can use their own staff as Service Coordinators for those receiving LTSS – conflict of interest

CHCs coordinating care across multiple systems –Medicare, Medicare Advantage plans, BH-MCOs

Consumers not being able to access current providers

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Questions/ Concerns?27

Resources

Questions contact Janice Meinert at 412-434-5637 or jmeinert@phlp.org

http://www.dhs.pa.gov/citizens/communityhealthchoices/

Third Thursday webinars with OLTL –register at above website

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