presentation slides

PA's Community HealthChoices Proposal:
What Advocates Need to Know
Eric Carlson from Justice in Aging
October 7, 2015
Welcome to CARIE’s second ReadyTalk webinar. We will begin shortly.
We will be using the chat feature for questions and you may enter your
questions at any time. This webinar is being recorded and will be
archived. We will share a link to the archived presentation and slides
later this week. Please direct any questions to Kathy Cubit at
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Pennsylvania’s MLTSS proposal.
Two Penn Center
1500 JFK Blvd., Suite 1500
Philadelphia, PA 19102-1718
T: 215-545-5728
F: 215-545-5372
Eric Carlson, Directing Attorney
Eric has broad experience in many forms of long-term services and
supports (LTSS), including home and community-based services, nursing
facility care, and assisted living facilities. He led Justice in Aging’s
extensive research (funded through The Commonwealth Fund) on
Medicaid-funded assisted living and currently is leading a project to
assist consumer advocacy on Medicaid managed LTSS in Florida and
New Jersey. He counsels attorneys from across the country and cocounsels litigation on consumers’ behalf. Mr. Carlson serves as
President of the national Assisted Living Consumer Alliance and is
author of the legal treatise Long-Term Care Advocacy (Matthew Bender
and Co.).
Pennsylvania’s MLTSS Concept Paper:
Issues to Consider
Eric Carlson
October 7, 2015
The MLTSS Proposal:
Community HealthChoices Program
• In June 2015, Pennsylvania released a Discussion Document with a
broad outline of what it wants to achieve through a managed long-term
services and supports (MLTSS) program.
• State released Concept Paper on September 16, 2015.
• The proposed MLTSS Program is Community HealthChoices or CHC.
The Concept Paper
• The Concept Paper “describes the features of CHC and is intended to
gather feedback from stakeholders.”
• Comments are due on this concept paper by October 16, 5 p.m.
• The Request for Proposals is scheduled to be released in November.
• CHC is scheduled to begin in January of 2017 in Southwest Region.
• Phase 2 in January 2018 – Southeast Region
• Phase 3 in Jan. 2019 – Nothwest, Lehigh-Capital and N.E. Regions
(Still) Questioning Rationale for MLTSS
• Previous webinar discussed state assumptions about the rationale for
• Pennsylvania appears to have embraced the idea of MLTSS.
• Still, states should be expected to produce evidence for the effectiveness,
safety, and cost savings of MLTSS.
• The fact that states are moving to MLTSS, is not equivalent to a finding
that MLTSS is working as promised.
CHC Basic Structure
• 2-5 MCOs in each region
– Each MCO must offer companion D-SNP (dual-eligible special
needs plan)
• D-SNP requirement may be positive, if it increases competence
re: aging populations and Medicare-certified providers.
–State seeks input on coordinating Medicaid and Medicare.
• Replacing 6 current HCBS waivers
– Aging, Attendant Care, AIDS, CommCare, Independence, and
CHC Basic Structure (cont.)
• Covering most Medicaid-covered service
–Behavioral health services are excluded, and will
continue to be provided through BH-MCOs.
• Dual eligibles will have the option to have their
Medicaid and Medicare services coordinated by the
same MCO through the D-SNP.
CHC Basic Structure (cont.)
• Estimated 450,000 individuals, including 130,000 currently receiving
LTSS in the community and in nursing facilities.
• Most of the enrollees will be dual eligibles not receiving LTSS.
CHC Goals
• Enhance opportunities for community-based
• Strengthen care coordination, especially for
• Enhance quality and accountability.
• Advance program innovation.
• Increase efficiency and effectiveness.
Eligibility Determinations
• Financial eligibility administered by DHS and County
Assistance Offices.
• Level of care eligibility:
– State will develop standardized level of care tool
– Evaluations done by contracted entity that will not be
provider of services.
• Potentially positive, assuming that tool is appropriate,
process is transparent, and consumer has meaningful
appeal rights.
• “Regular needs screening” and “analysis of participant utilization.”
– Identification of needs, based on premise that enrollee is not asking for service(s) at issue.
• If need for LTSS identified, enrollee is “offered a comprehensive
needs assessment based on a standardized tool approved by the
– Tool used “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.”
Assessments (cont.)
• Good features in assessments:
–Assessments are standardized.
• Transparency, proprietary instruments otherwise are
troubling issues.
–Includes availability of unpaid caregivers, instead of
assuming that they always are available.
Person-Centered Planning for LTSS
• Positive features:
– Must address preferences in setting, schedule, and activities.
– Service coordinators must have “expertise with the conditions of
the target population.”
– Plan must “address needs of participants through support of their
unpaid caregivers.”
– Service coordinator monitors plan to ensure services are
– Plan shared with providers and caregivers with permission.
Service Coordination Outside of LTSS
• MCO “may” provide service coordination for others.
– Screen for, e.g., chronic conditions, use of multiple specialists, use
of ER, hospital admissions.
• MCOs must implement care transition protocols when enrollees are
going in or out of hospitals, nursing facilities, or residential settings.
Person-Centered Planning
Questions and Issues
• Danger signs as well: “service coordinators will develop the
service plan during a face-to-face meeting with the
– Person-centered planning means the individual consumer
should be in charge.
– Mere presence at the planning meeting is not enough.
– Ideally, enrollee would have appeal rights.
Person-Centered Planning Regulations
• Important to compare to person-centered planning
regulations at 42 C.F.R. §441.301(c)(1)
– Process is led by the consumer when possible.
– Includes people chosen by the consumer.
– Provides necessary information and support for the
Person-Centered Planning
Questions and Issues (cont.)
• Will advocates have access to the assessment tool?
• Will assessments include caregiver assessments?
• Can consumers appeal an initial care plan?
• System should be transparent in how it allocates personal care hours.
• Will the process include sufficient notices of consumer rights?
• Service coordination through community partners “as long as
expertise can be demonstrated”
– What form would this demonstration take?
Service Coordination and Care Transitions
• Service coordinators will monitor consumer’s plan and services (p.
• Coordinators available during regular business hours and “system”
for after hours calls (p. 13).
• Must coordinate Medicare and Medicaid services (p. 14).
• Must implement care transition protocols for hospital, NF, or
residential settings (p. 14).
Coordination and Transitions
Questions or Issues
• Will the service coordinators be independent?
• Must have the flexibility and nimbleness to adapt to changes in
circumstances or conditions, including backup and emergency plans.
• Will transition protocols have consumer input?
Support for Enrollees
• Toll-Free Telephone Line
– If no one is available to speak in native language, translation services will be
made available.
• 24/7 nurse hotline.
• Enrollee Informational Materials
– 4th grade reading level.
– “All materials and participant information must be made available as needed
in alternative languages and formats.”
LTSS Benefits
• Long list of benefits in Appendix A, including
Community Integration, Personal Emergency
Response System, TeleCare, and Vehicle
• These evidently are benefits currently available
in the six existing HCBS waivers.
“Extra” LTSS Benefits
• MCO may choose to provide additional LTSS:
• LTSS to enrollees who don’t meet the level of care
requirements, and
• LTSS beyond those listed.
• Q: Are these “extra” benefits ever provided?
• Enrollees have no entitlement to them, and their cost is
not factored into capitation rate.
Transition Services
• MCOs must offer Nursing Home Transition services.
• “CHC-MCOs will contract with NHT providers to identify NHTappropriate participants and coordinate their NHT services.”
• Financial incentives here likely are important.
• Also, question as to whether and to what extent a consumer has
an entitlement to transition services.
• How can the consumer take the initiative, rather than waiting
to be “identified”?
• Three delivery models for Participant Directed Services
– Agency
– Participant-director employer authority
– “Services My Way” (budget authority model)
• Participant-direction allows consumer to employ own personal
assistance provider, including family caregiver
• Services My Way includes either agency or participant-direction at
the consumer’s choice
Self-Direction Questions and Issues
• MCOs will have little experience with self-direction. Many
of the concepts of self-direction seem foreign to “managed”
• Logistics may be difficult for consumers, but
– State will contract with three financial management services
– MCOs will be required to contract with these financial
management services vendors.
• Independent entity will advice consumers of their options and help
with the enrollment process.
• Staged notification is typical:
• Series of notices beginning approximately three months prior to
the proposed enrollment.
“Passive Enrollment”
• “Passive enrollment”: consumers who do not choose
an MCO will be “intelligently assigned” to an MCO that
“best meets their needs”
• D-SNP enrollees will be enrolled to the CHC plan
within the same MCO.
• State seeks input on factors in determining
“intelligent assignment”
• Recommended – “intelligent assignment” should
place heavy emphasis on allowing consumers to
retain providers.
Or Challenge “Passive Enrollment” Generally
• Medicaid managed care enrollment for duals can be required through
Section 1915(b) waivers or through Section 1115 demonstration
• But enrollment in Medicare managed care cannot be required.
• Proposed federal regulations call for at least 14 days of fee-for-service
Medicaid prior to passive enrollment in a Medicaid MCO:
• “A State must provide potential enrollees at least 14 calendar days
of FFS coverage to provide the potential enrollee the opportunity
to actively select their MCO … entity.”
• Proposed 42 C.F.R. § 438.54(d)(2).
Change from One MCO to Another
• Consumers may switch to a different regional MCO at any time.
• Effective date is either 1st or 15th of month, depending on when
transfer is requested.
• Compared to other states, this is very flexible.
• Proposed federal regulations would provide right to change MCO
• For cause at any time.
• Annually.
• During initial 90 days of enrollment in initial MCO.
• Proposed 42 C.F.R. § 438.56(c).
Network Adequacy
• MCO must demonstrate sufficient network.
• May be difficult to set meaningful standards for LTSS.
• If MCO cannot provide necessary services must cover out-of-network.
• Must have culturally competent providers.
• Material changes in network must be approved in advance.
• “Material” means affecting ability to meet standards, and
changing “location” of services for > 5% of enrollees.
• Provider support/services/training available (including “provider
representative within MCO).
• Support may be particularly important for small LTSS providers.
Network Adequacy (cont.)
• Extensive requirements for “network management plan” that must be
submitted to the State for readiness review activities. It includes how
MCO will:
• Communicate with providers.
• Monitor provider compliance with rules and policies.
• Evaluate quality of services.
• Monitor network adequacy, including care to enrollees with limited
English proficiency.
• Credential and train providers.
• Ensure providers will return calls within 3 business days. (BTW, 3
business days seems like a weak standard)
Network Questions or Issues
• No specific sufficiency standards given.
• No access/travel/time standards set.
• Identifies “expertise in LTSS” as a requirement but no specifics on
how expertise is determined.
Continuity of Care When Program Implemented
• 6 months -- Must accept all willing and qualified LTSS providers.
• 180 days or new service plan -- Cannot reduce LTSS services but may
increase them.
• Any new service plan that reduces any one service by >25% must
be approved by State.
• May stay in nursing facility indefinitely.
• What about other settings? Any other change of provider that
would be similarly disruptive?
Other Continuity Provisions
• After transfer from one MCO to another, 60 days or until new
service plan.
• If LTSS provider drops out of network, enrollee can continue
to receive care from same provider until an in-network
“replacement” is found.
- Who determines the suitability/acceptability of the
Little Information on Appeals
• “All participants will have access to grievance and appeal processes
that provide the same protections afforded in HealthChoices. The
commonwealth is exploring ways to streamline Medicare and
Medicaid grievance and appeal processes for dual eligibles. The
participant handbook must provide clear information to participants
regarding the preparation and filing of grievances and appeals.”
NY Integrates Medicaid and Medicare Appeals
• Process:
• Internal plan level appeal.
• State integrated Administrative Hearing Unit (applies Medicare and
Medicaid law).
• Medicare Appeals Council (applies Medicare and Medicaid law).
• Federal District Court.
• So far, integrated Administrative Hearing Unit has heard only five
Emphasis on
Home and Community-Based Services
• “Value-based incentives to increase the use” of HCBS (p 1)
What does this entail
How will consumers and advocates know it is happening?
• What would make HCBS meaningful?
Broad service package?
Ability to choose HCBS even if relatively more expensive?
Effective rebalancing provisions?
Successful aging in place?
Quality Management
Participant surveys.
Focus groups.
Critical incident reporting.
Performance measure reporting.
Performance Improvement Projects (PIPs).
External Quality Review Organizations (EQROs).
Quality-related financial incentives, including Pay for
• Quality reporting to State.
Thinking About Quality
• Danger is that the data has no little real-world impact
• Lack of transparency in many states means consumers cannot use
performance measures to choose MCO
• Lack of transparency also makes it difficult for advocates to hold
State to rebalancing or HCBS focus guarantees.
• Important to get access to data.
“Comprehensive Approach to LTSS”
• State seeks input on initiatives to meet three
• Increased access to housing.
• Expanded access to integrated employment.
• Expanded LTSS workforce.
• Expanded use of technology.
• Be as specific as possible – do State’s work for it when possible by
writing out language.
• Refer to existing models from proposed federal regulations
and/or other states’ programs (see Justice in Aging’s MLTSS
toolkit and contract library for examples).
• The paper has some good ideas and practices, but
implementation is always the prime concern.
• Don’t be bought off by vague promises or flowery, unenforceable
More Suggestions
• Don’t rely too heavily on performance measures;
question as to how they might have a real-world
• Most macro-level interventions cannot have an
immediate impact for an individual enrollee.
• Take advantage of every opportunity to engage
with State in the development and oversight of
this process.
Justice in Aging Would Be Happy to Help
• On-going project to work with state advocates.
• Justice in Aging on-line resources:
• On-Line Library to MLTSS Contracts:
• MLTSS Toolkit:
Thank you
Eric Carlson,
Q&A Follow-Up from Eric
Eric shared the following information in response to questions asked
during the webinar:
Regarding assessments, here’s one study: This study preferred the MN
assessment tool, as did one of Justice in Aging’s attorneys, at least
compared to the alternatives. The MN tool is available here: Eric knows a NJ attorney who
thinks that the NJ tool is acceptable, mainly because there’s an
opportunity for the assessor to write on how the activity will take for that
particular person. She didn’t think much of the default time allotments for50
Q&A Follow-Up from Eric
Regarding MCO marketing to members for other products offered by the MCO,
Medicare MCOs generally may contact their members to pitch other products
offered by the MCO. See section 70.6 of the Medicare Marketing Guidelines,
Also, a duals letter states that a Medicare MCO can pitch current members on
other Medicare products, including their Medicaid-Medicare integration