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4. Pennsylvania’s MLTSS Proposal: Key Considerations for Advocates June 30, 2015 Eric Carlson 4

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6. A Rush Towards MLTSS 6 PA’s Discussion Document cites 22 states (including PA) that already have MLTSS. Number may be higher – NASUAD Integration Tracker lists 26 states.

7. Is the Move to MLTSS Evidence-Based? 6 Q. Where is the empirical evidence supporting MLTSS? Many of the arguments still are relatively theoretical, but CMS still seems to be strongly in favor of Medicaid managed care. Resisting the move to managed care is not necessarily impossible, but it likely would be difficult. One issue is the growing political influence of health plans. Systems frequently carve-out DD/ID populations, due to separate service system and/or political pressure.

8. Questioning the Rationale for Moving to MLTSS 6 Shouldn’t there be some real evidence at this point? The fact that states are moving to MLTSS, is not equivalent to a finding that MLTSS is working as promised. State should be expected to produce some data to support its proposal. Recent data has shown relatively poor performance by dual-integration programs.

9. In General, More Specificity Is Needed There’s obviously nothing wrong with rebalancing, person-centered services, etc. – But how can we be sure that the MLTSS system actually will produce the desired results? 7

10. Person-Centered Planning “Continuity of service protections that remain in place until the new service plan is developed and implemented.” – A relatively low bar to just require continuity until a service plan is in place. – Need continuity of care when service provider not in network, or when beneficiary is new to managed care. (This is addressed in the “Access to Qualified Providers” section.) 8

11. Person-Centered Planning (cont.) “The application of a person-centered service planning process.” – To really be person-centered, the consumer must be in charge, and this is where most MLTSS system fall short. “[S]tandardized and validated assessment tool that reviews … physical, psychosocial, and functional needs and preferences.” – What will this be used for? System should be transparent in how it allocates personal care hours. 8

12. Person-Centered Planning (cont.) “The maximization of self-direction in service including education on how to use these self-directed options.” – How much discretion will the consumer have? What does this mean in relation to provider networks? How can the consumer be sure that the budget is adequate? 8

13. Services and Supports Coordination “MLTSS vendors will be required to operate companion Medicare and Medicaid LTSS plans so that the full range of Medicaid and Medicare benefits are provided by the same health plan.” – Medicare managed care is optional – many dual-eligible plans have had high- opt-out rates. 8

14. Services and Supports Coordination (cont.) Financial incentives to discourage cost-shifting. – Such as? “Additional supportive services appropriate to the target population.” – These services need to be specified, and reasonably available. Use of service coordinators who will monitor consumer’s care and qualify of services that he or she is receiving. – But will this person be independent? 8

15. Access to Qualified Providers Access to providers, and network adequacy. – Difficult to measure and enforce this in a meaningful way. Inadequate networks are recognizable after the fact. “Qualifications and credentialing” – Some questions as to how this is applied to MLTSS services. Good to reference support for providers in transition to MLTSS. Good also to reference continuity of care during transition to MLTSS, and for possibility for staying with out-of-network provider when provider supply within network is insufficient. 8

16. Emphasis on Home and Community-Based Services 29 Very little detail provided. There’s one three-sentence paragraph, and the last two sentences make little sense. Should make sure that, at a minimum, services and slots from current waivers are retained. What would make HCBS meaningful? e.g., broad service package; ability to choose HCBS even if relatively more expensive; effective rebalancing provisions.

17. Performance-Based Payment Incentives 29 Payment structures should improve HCBS opportunities, incorporate person-centered service design, promote health, ensure efficiency, etc. These are admirable goals, but it’s unclear how to structure payment this way. As always, financial incentives are subject to gaming and unintended consequences.

18. Participant Education and Enrollment Supports 29 Conflict-free choice counseling, and “[e]nrollment and disenrollment independent of the vendors.” -- these are good. Advocacy and ombudsman services. Need funding and freedom – proposed federal regulations would prohibit ombudsman programs from representing in appeals.

19. Participant Education and Enrollment Supports (cont.) 29 Choice of plan,and “sufficient” advance notice of enrollment. Better consumer protections would be voluntary enrollment (very unlikely) or at least: Reasonable standards to excuse a consumer from managed care, and Increased ability to change plans for cause.

20. Preventive Services 29 Given that most enrollees will be dual-eligible, this seems to be mostly a matter of Medicare policy. “The existing Medicare preventive services will be intergrated or expanded into the Medicaid program and LTSS.” What does this mean?

21. Participant Protections 29 Almost no detail here – vague references to coordination with APS, and “a comprehensive grievance and appeals process.” One issue is the ability to appeal service plans.

22. Quality and Outcomes-Based Focus 29 Supposed to address five areas: Quality of life. Consumer experience and satisfaction (references person-level encounter data). Health/service outcome. Community integration. Rebalancing. Danger is that the data has no real-world impact.

23. Request for Stakeholder Input 29 Program Design Planning Phases Implementation Oversight Quality

24. Justice in Aging Would Be Happy to Help 29 On-going project to work with state advocates. Justice in Aging on-line resources: On-Line Library to MLTSS Contracts. MLTSS Toolkit.

25. Suggestions 29 Be as specific as possible – do the state’s work for it, as possible. Refer to existing models from proposed federal regulations and/or other states’ programs. Don’t be bought off by vague promises or flowery, unenforceable language. Also don’t rely too heavily on performance measures; question as to how they might have a real-world impact.

26. Thank you Eric Carlson, ecarlson@justiceinaging.orgecarlson@justiceinaging.org 26

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