6. Pennsylvania’s MLTSS Concept Paper: Issues to Consider October 7, 2015 Eric Carlson 6

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8. The MLTSS Proposal: Community HealthChoices Program 8 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.

9. The Concept Paper 9 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

10. (Still) Questioning Rationale for MLTSS 10 Previous webinar discussed state assumptions about the rationale for MLTSS. 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.

11. 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 OBRA 11

12. 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. 12

13. 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. 13

14. CHC Goals Enhance opportunities for community-based living. Strengthen care coordination, especially for duals. Enhance quality and accountability. Advance program innovation. Increase efficiency and effectiveness. 14

15. 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. 15

16. Assessments “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 commonwealth.” – 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.” 16

17. 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. 17

18. 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 delivered. – Plan shared with providers and caregivers with permission. 18

19. 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. 19

20. 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 individuals.” – 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. 20

21. 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 consumer. 21

22. 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? 22

23. Service Coordination and Care Transitions Service coordinators will monitor consumer’s plan and services (p. 13). 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). 23

24. 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? 24

25. 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 – 4 th grade reading level. – “All materials and participant information must be made available as needed in alternative languages and formats.” 25

26. LTSS Benefits 26 Long list of benefits in Appendix A, including Community Integration, Personal Emergency Response System, TeleCare, and Vehicle Modifications. These evidently are benefits currently available in the six existing HCBS waivers.

27. “Extra” LTSS Benefits 27 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.

28. Transition Services 28 MCOs must offer Nursing Home Transition services. “CHC-MCOs will contract with NHT providers to identify NHT- appropriate 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”?

29. Self-Direction 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 29

30. Self-Direction Questions and Issues MCOs will have little experience with self-direction. Many of the concepts of self-direction seem foreign to “managed” care. Logistics may be difficult for consumers, but – State will contract with three financial management services vendors. – MCOs will be required to contract with these financial management services vendors. 30

31. Enrollment 31 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.

32. “Passive Enrollment” 32 “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.

33. Or Challenge “Passive Enrollment” Generally 33 Medicaid managed care enrollment for duals can be required through Section 1915(b) waivers or through Section 1115 demonstration waivers. 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).

34. Change from One MCO to Another 34 Consumers may switch to a different regional MCO at any time. Effective date is either 1 st or 15 th 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 only: For cause at any time. Annually. During initial 90 days of enrollment in initial MCO. Proposed 42 C.F.R. § 438.56(c).

35. Network Adequacy 35 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.

36. Network Adequacy (cont.) 36 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)

37. Network Questions or Issues 37 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.

38. Continuity of Care When Program Implemented 38 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?

39. Other Continuity Provisions 39 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 “replacement”?

40. Little Information on Appeals 40 “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.”

41. NY Integrates Medicaid and Medicare Appeals 41 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 appeals.

42. Emphasis on Home and Community-Based Services 42 “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?

43. Quality Management 43 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 Performance). Quality reporting to State.

44. Thinking About Quality 44 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.

45. “Comprehensive Approach to LTSS” 45 State seeks input on initiatives to meet three goals. Increased access to housing. Expanded access to integrated employment. Expanded LTSS workforce. Expanded use of technology.

46. Suggestions 46 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 language.

47. More Suggestions 47 Don’t rely too heavily on performance measures; question as to how they might have a real-world impact. 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.

48. Justice in Aging Would Be Happy to Help 48 On-going project to work with state advocates. Justice in Aging on-line resources: On-Line Library to MLTSS Contracts: http://www.justiceinaging.org/resources- for-advocates/publications/mltss-library-for-advocates/http://www.justiceinaging.org/resources- for-advocates/publications/mltss-library-for-advocates/ MLTSS Toolkit: http://www.justiceinaging.org/resources-for-advocates/mltss- in-managed-care-toolkit /http://www.justiceinaging.org/resources-for-advocates/mltss- in-managed-care-toolkit /

49. Thank you Eric Carlson, ecarlson@justiceinaging.orgecarlson@justiceinaging.org 49

50. 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: http://www.cdss.ca.gov/agedblinddisabled/res/CCI/chcs- uniform_assessment_mltss-9-12-13.pdf. 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: http://www.mnscha.org/WebManual/AbilityCare/PDFs/86_LTCC%20- %20single%20assessor%20DHS-3428.pdf. 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 for activities. http://www.cdss.ca.gov/agedblinddisabled/res/CCI/chcs- uniform_assessment_mltss-9-12-13.pdf http://www.mnscha.org/WebManual/AbilityCare/PDFs/86_LTCC%20- %20single%20assessor%20DHS-3428.pdf 50

51. 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, https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and- Medicaid-Coordination/Medicare-Medicaid-Coordination- Office/FinancialAlignmentInitiative/Downloads/OutreachDemonstrationEligibl eIndividuals021015.pdf. https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and- Medicaid-Coordination/Medicare-Medicaid-Coordination- Office/FinancialAlignmentInitiative/Downloads/OutreachDemonstrationEligibl eIndividuals021015.pdf Also, a duals letter states that a Medicare MCO can pitch current members on other Medicare products, including their Medicaid-Medicare integration plans. https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare- and-Medicaid-Coordination/Medicare-Medicaid-Coordination- Office/FinancialAlignmentInitiative/Downloads/OutreachDemonstrationEligibl eIndividuals021015.pdf. https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare- and-Medicaid-Coordination/Medicare-Medicaid-Coordination- Office/FinancialAlignmentInitiative/Downloads/OutreachDemonstrationEligibl eIndividuals021015.pdf 51