1. Changes on the Way: Managed Long Term Supports & Services Kyle Fisher Kfisher@phlp.org October 2015

2. 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 2

3. 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 3

4. 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 4

5. 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 5

6. HELPING CONSUMERS REMAIN IN THE COMMUNITY - THE CURRENT FRAMEWORK HCBS Waiver Programs 6

7. 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 7

8. Typical Waiver Services* Home health Services  HHA, RN, LPN, therapies Personal care Attendant care Respite Adult Day Care Transportation Counseling Home modifications Specialized medical equipment & supplies Home delivered meals Personal emergency response *vary by waiver 8

9. 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 9

10. 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 10

11. 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 11

12. Financial Eligibility Adults age 19-64 Special Income Limit  300% of Federal SSI Benefit Level  Does not consider spouse’s income Resource limit = $8,000 12 Household of 1Household of 2 Monthly (2015) $2,199N/A

13. 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 13

14. MANAGED LONG TERM SUPPORTS & SERVICES (MLTSS) Community HealthChoices 14

15. 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 15

16. 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 16

17. 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 17

18. Goals *From DHS Presentation (9/21/15) 18

19. 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 19

20. 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? 20

21. 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 21

22. 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 22

23. 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 23

24. Preliminary Procurement and Implementation Milestone DescriptionDate 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

25. 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? 25

26. Resources Office of Long Term Living Waiver Programs  http://www.longtermcare.state.pa.us/ http://www.longtermcare.state.pa.us/  http://www.dhs.state.pa.us/fordisabilityservices/alternativestonursinghomes/index.htm 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 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 http://www.phlp.org/wp-content/uploads/2012/08/SW-Waiver-Manual-Formatted.pdf PHLP Helpline: 1-800-274-3258 26