In February 2015, Pennsylvania Governor Wolf directed the Departments of Human Services (DHS) and Aging to develop a plan to shift Pennsylvania’s method of administering Medicaid Long Term Services and Supports (LTSS) to a managed care model. This means that the Pennsylvania will soon begin to hire private insurers (managed care organizations or “MCOs”) to administer the state’s Medicaid funded long term care services.
Medicaid is a federal and state funded benefit program which can pay for the cost of nursing home care and other long term care services if level of care and financial requirements are met. Medicaid is a primary source of public funding of nursing home and other long term care services for older adults.
On September 16th the Commonwealth issued a “Concept Paper” which describes the features of the new managed care approach – to be called “Community HealthChoices” (CHC). The plan represents a significant change that will impact an estimated 450,000 Pennsylvanians including 130,000 older persons and adults with physical disabilities who are currently receiving LTSS in the community and in nursing facilities. It is hoped that the managed care approach will result in reduced long term care costs while adding coordination to the current fragmented system and allowing more participants to receive services in more independent home and community based (HCBS) settings.
The new program will roll out in three phases over three years, beginning in January 2017.
The Concept Paper states the goals of CHC as follows:
- Enhance opportunities for community-based living. There will be improved person-centered service planning and, as more community-based living options become available, the ability to honor participant preferences to live and work in the community will expand. Performance incentives built into the program’s quality oversight and payment policies will stimulate a wider and deeper array of HCBS options.
- Strengthen coordination of LTSS and other types of health care, including all Medicare and Medicaid services for dual eligible individuals. Better coordination of Medicare and Medicaid health services and LTSS will make the system easier to use and will result in better quality of life, health, safety and well-being.
- Enhance quality and accountability. CHC-MCOs will be accountable for outcomes for the target population, responsible for the overall health and long-term support for the whole person. Quality of life and quality of care will be measured and published, giving participants the information they need to make informed decisions.
- Advance program innovation. Greater creativity and innovation afforded in the program will help to increase community housing options, enhance the LTSS direct care workforce, expand the use of technology, and expand employment among participants who have employment goals.
- Increase efficiency and effectiveness. The program will increase the efficiency of health care and LTSS by reducing preventable admissions to hospitals, emergency departments, nursing facilities and other high-cost services, and by increasing the use of health promotion, primary care and HCBS.
The CHC population will include the following:
- Adults age 21 or older who require Medicaid LTSS (whether in the community or in private or county nursing facilities) because they need the level of care provided by a nursing facility or an intermediate care facility for individuals with other related conditions (ICF/ORC);
- Current participants of DHS Office of Long Term Living (OLTL) waiver programs who are 18 to 21 years old; and
- Dual eligibles [qualified for both Medicare and Medicaid] age 21 or older whether or not they need or receive LTSS.
Persons included in the CHC population will be required to enroll in CHC. However, persons who are eligible for the LIFE program will not be enrolled into CHC unless they specifically ask to be enrolled.
CHC-MCOs will be accountable for most Medicaid-covered services, including preventive services, primary and acute care, LTSS (home and community-based services and nursing facilities), prescription drugs, and dental services.
Participants who have both Medicaid and Medicare coverage (dual eligible participants) will have the option to have their Medicaid and Medicare services coordinated by the same MCO.
The estimated total statewide enrollment of dual eligibles, older persons, and adults 21 and older with physical disabilities for CHC is 450,000. The CHC population will include individuals with Medicaid-only coverage who receive or need LTSS, and individuals with full Medicare and Medicaid coverage (dual eligible), including those with and without LTSS needs. The CHC population will not include Act 150 program participants, individuals receiving their services through the lottery-funded Options program, persons with intellectual/developmental disabilities (ID/DD) who receive services through the DHS Office of Developmental Programs, or residents of state-operated nursing facilities, including the State Veterans’ Homes.
This shift to managed care is a work in progress. The state is actively seeking comments from participants, advocacy organizations, providers, managed care organizations, care coordination agencies, legislators, family members, and other interested members of the public. Feedback received will be used to finalize the program design and issue a Request for Proposals (RFP) in November 2015.
Feedback is due by 5:00 p.m. on Friday, October 16, 2015.
Please submit your written feedback by mail or e-mail.
By mail, please address to:
April Leonhard Office of Long-Term Living Bureau of Policy and Regulatory Management P.O. Box 8025 Harrisburg, PA 17105-8025
By e-mail, please send your comments to:
RA-MLTSS@pa.gov and include “Community HealthChoices” in the subject line.