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Governor Accepts Recommendations for Improving LTSS System

On January 8, 2015, outgoing Governor Tom Corbett accepted the Pennsylvania Long-Term Care Commission’s December 2014 Final Report.  The report establishes a foundation for strengthening the state’s LTSS system, recommending strategies for improving care coordination; service delivery; quality outcomes; and fiscal sustainability.  Included in the report is a recommendation for the state to develop and implement a LTSS coordinated integrated demonstration program to pilot service delivery and financing models that provide coordinated, integrated, person-centered physical health, mental health, substance abuse, and LTSS services.  (Source:  State DHS LTSS website; PR Newswire, 1/8/2015)
Pennsylvania LTC Commission Final Report (December 2014)

Managed LTSS Program

Since 2009, Pennsylvania has provided Adult Community Autism Program to adults of age 21 or higher with diagnosis of Autism Spectrum Disorder under the authority of Medicaid §1915(a). Services included in the capitation rate are primary, behavioral, dental, ICF/MR, targeted case management, adult day, and occupational therapy/physical therapy/speech therapy (OT/PT/ST). The program is operating in four (out of 67) counties and enrollment is voluntary. (Source: CMS and Truven Health Analytics, The Growth of Managed Long-Term Services and Supports (MLTSS) Programs: A 2012 Update, July 2012) Program Website

On August 28, 2014, Pennsylvania became the 27th state to expand its Medicaid program under the Affordable Care Act.  The state and CMS agreed to the “Healthy Pennsylvania’ program – which will provide coverage to uninsured adults earning below 133 percent of the federal poverty line, or about $15,500.  Coverage will begin in January 2015 and will be offered by private health plans.  The state has authority to begin collecting premiums in year two of the waiver.  However, adults will be able to receive premium discounts for healthy behaviors; these healthy behaviors have yet to be defined under the waiver.  In conjunction with expanding Medicaid, the state plans to reform its existing Medicaid program by moving to a low-risk or high-risk benefit package, with “risk” referring to enrollee health status.  (Source: Washingtonpost.com; CSNBC Healthcare)

On June 1, 2015, Pennsylvania DHS and Pennsylvania DOA released a joint MLTSS Discussion Document detailing the state’s plan to move into MLTSS over a 3-year period. The proposed initiative aims to promote better access to care and improve service coordination, enabling more individuals to remain in their homes. The initiative will impact an estimated 130,000 Pennsylvania residents. Initial public comments are due by July 15, 2015. (Source: State DHS website, 6/1/2015)
MLTSS Discussion Document (6/2015)

On July 22, 2015, the PR Newswire reported on new steps that the Pennsylvania Departments of Human Services (DHS) and Aging (PDA) are taking to implement Governor Wolf’s Managed Long-Term Services and Supports (MLTSS) plan. Following substantial feedback and commentary regarding the plan, DHS and PDA will now: double the number of staff assigned to the Nursing Home Transition (NHT); establish an advisory committee with at least half the representatives being caregivers and beneficiaries that will also conduct monthly webinars; and restructure contracts to give participants in the program greater choice. (Source: PR Newswire, link no longer available 7/22/2015; Discussion Document)  

On September 16, 2015, the Pennsylvania Departments of Human Services (DHS) and Aging (PDA) disseminated a new concept paper on the state’s transition to managed long-term services and supports (MLTSS), and is seeking stakeholder feedback. The new paper was developed using public input and addresses the Community HealthChoices program, which looks to provide long-term services and supports for up to 450,000 enrollees, including dual eligibles. Public comments on the paper were due by October 16, 2015. PR Newswire 9/16/2015; Concept paper)

Pennsylvania’s Department of Health Services (DHS) released a draft request for proposals (RFP) for the state’s MLTSS program, Community HealthChoices (CHC), on November 16, 2015. Comments were due December 11, 2015. On December 14, DHS released a draft MLTSS contract, with comments due January 8, 2016. DHS is expected to release the final RFP for CHC in January 2016.  Pennsylvania will operate MLTSS under the joint authority of 1915(b) and 1915(c) waivers, approval of which is required by CMS. The program will operate in five geographic areas—Northwest, Southwest, Northeast, Lehigh/Capital, and Southeast. CHC-MCOs are expected to provide services to all of the counties in the geographic zone they are selected to operate in. (Source: Draft RFP 11/16/2015)

On March 1, 2016, the Pennsylvania Department of Human Services released a Request for Proposals (RFP) for managed care organizations (MCOs) to provide managed long term services and supports (MLTSS) through the state's Community Healthchoices (CHC) program. CHC will cover individuals 21 and older that require medical assistance (MA) and LTSS, whether they reside in a nursing facility or in the community, as well as dual eligible individuals who are are jointly eligible for Medicare and Medicaid. Operation fo the program will split the state's 67 counties into five regions or zones--Southwest, Southeast, Lehigh/Capital, Northwest, and Northeast. The goals of the CHC are to:

  • Increase opportunity for home and community-based services;
  • Enhance health and LTSS delivery systems;
  • Promote new innovations;
  • Strengthen the health, safety, and well-being of beneficiaries; and
  • Ensure transparency, accountability, and effectiveness of the program.

Responses to the RFP are due May 2, 2016. (Source: RFP 3/1/2016)

On March 16, 2016, Pennsylvania held a pre-proposal conference for its procurement of the Community HealthChoices program that will use managed care organizations to manage physical and LTSS services for eligible Medicaid beneficiaries. The potential bidders present were: United; Gateway Health; Molina; Health Partners; WellCare; AmeriHealth Caritas; Aetna; Magellan; UPMC; Atelier Health; Geisinger; and Accenda Health.  The Pennsylvania Department of Human Services released a Q&A following the conference, as well as Addendum #5 and a revised draft agreement. (Source: : HMA Roundup 3/16/2016; PA E Marketplace 4/12/2016)

On April 23, 2016, the Pennsylvania Department of Human Services (DHS) released draft Community HealthChoices (CHC) Section 1915(b) Managed Care and 1915(c) Home and Community-based Waivers for public comment. Pennsylvania intends to operate CHC, the state’s MLTSS program, concurrently under 1915(b) and 1915(c) waivers, which will allow delivery of HCBS services, and mandatory managed care enrollment. The comment period was open through May 23, 2016. (Source: PA DHS 4/28/2016)

On May 6, 2016, the Pennsylvania DHS announced that 14 MCOs have responded to the request for proposal (RFP) to implement the states Community Health Choices (CHC) program, which will manage physical health and LTSS for older adults, individuals with physical disabilities, and those jointly eligible for Medicare and Medicaid. DHS estimates that 420,000 individuals will be served by the program. The list of MCOs that submitted responses are as follows:

  • Accenda;
  • Aetna;
  • AmeriHealth Caritas;
  • Cedar Woods Care Management;
  • Cigna-Health;
  • Cateway Health Plan;
  • Geisinger Health Plan;
  • Health Partners Plus;
  • Molina Healthcare;
  • PA Health & Wellness;
  • Trusted Health Plan;
  • United Healthcare;
  • UPMC for You; and
  • WellCare. (Source:  PA DHS 5/6/2016)

The Pennsylvania Departments of Human Services and Aging recently announced that the first phase of implementation of Community HealthChoices, the state’s MLTSS program, will be pushed back from January 1, 2017, to July 1, 2017. The rest of the implementation timeline remains as is at this time. (Source: PA DHS, link no longer available 7/5/2016; HMA Weekly Roundup 6/15/2016) 

On August 30, 2016, Pennsylvania Department of Human Services (DHS) announced the three MCOs selected by the state to manage the state’s MLTSS program, Community HealthChoices: AmeriHealth Caritas, Centene Corp., and UPMC for You. The three MCOs will be responsible for managing and integrating care for 420,000 Pennsylvanians. (Philly.com 8/30/2016)

Pennsylvania’s Office of Long Term Living (OLTL) has received six protests from losing bidders in the Community HealthChoices procurement including Aetna (later withdrawn), United, WellCare, Gateway, Molina, and Geisinger. Negotiations between the state and the winning bidders have been placed on hold due to the protests, which may delay the start of the program that is set to launch July 1, 2017. (Source: Philly.com 9/19/2016 HMA Weekly Roundup 10/5/2016)

On October 28, 2016, the Pennsylvania Department of Human Services (DHS) released a draft request for proposal (RFP) for public comment in order to solicit interest in a new Independent Enrollment Broker (IEB) Program. The IEB Program aims to provide choice counseling and assistance with eligibility and enrollment for individuals seeking LTSS services, and will cover the following programs: Pennsylvania’s existing HCBS waiver programs, the Living Independently for the Elderly (LIFE) program (which is the name of Pennsylvania’s PACE program), and Community HealthChoices (CHC). Bidders are able to submit proposals for any combination of three geographic “Lots”, which coincide with the phases of CHC implementation. DHS will be accepting comments through November 21, 2016. (Source: PA.gov 10/28/2016)

The Pennsylvania Department of Human Services (DHS) posted comment themes and state responses for feedback received on the proposed evaluation plan for Community HealthChoices (CHC), the state’s MLTSS program, which will be a multi-year effort in collaboration with the University of Pittsburgh. The evaluation will provide an independent assessment of the program over time, and will analyze administrative information, enrollment, utilization and cost data from both Medicaid and Medicare. (Source: PA.gov 11/2016)  

On December 15, DHS announced a six-month delay in implementing CHC.  The state cited ongoing bid protests and its impact on MCO payment, network development, readiness assessment and beneficiary education as the reason for the delay.   Implementation of CHC will now occur as follows:

  • Phase 1 (Southwest Region) begins January 1, 2018;
  • Phase 2 (Southeast Region) begins July 1, 2018; and
  • Phase 3 (rest of state) begins January 1, 2019.

On March 3, 2017, the Pennsylvania Department of Human Services (DHS) announced changes to the timeline for implementation of two major Medicaid programs: the Physical HealthChoices program, and the Community HealthChoices (CHC) program (the state’s new MLTSS initiative). The updated timelines for the two programs is as follows:

Region

Physical Health Start Date

CHC Start Date

Southwest

January 2018

January 2018

Northwest

January 2018

January 2019

Northeast

March 2018

January 2019

Southeast

July 2018

July 2018

Lehigh/Capital

January 2019

January 2019

On April 10, 2017, the Pennsylvania Department of Human Services (DHS) issued a request for proposals (RFP) seeking an Independent Enrollment Broker, or IEB, to serve the Community HealthChoices (CHC) MLTSS program and other LTSS programs. The IEB will provide choice counseling and enrollment services for consumers who enroll in Community HealthChoices – the state’s MLTSS program and Living Independent for the Elderly (LIFE) – the state’s PACE program.

The IEB will also serve the consumers in the following HCBS programs:

  • Aging Waiver;
  • Attendant Care Waiver;
  • Independence Waiver;
  • OBRA Waiver;
  • Act 150 Attendant Care Program. (Source: RFP 4/10/2017)

On April 19, 2017, the Rehabilitation & Community Providers Association (RCPA) noted that the Pennsylvania DHS has released an infographic for consumers and providers to assist with understanding the similarities and differences between HealthChoices, which is the state’s Medicaid managed care program for physical and behavioral health, and Community HealthChoices, the state’s MLTSS program. The infographic includes information on the three MCOs selected, and the timelines for implementation for both programs. (Source: Infographic 4/19/2017; HMA Weekly Roundup 4/26/2017)

On June 7, 2017, the Pennsylvania Departments of Aging and Human Services announced a new partnership with Aging Well—a subsidiary of the PA Association of Area Agencies on Aging (AAAs)—that pertains to the implementation of the state’s upcoming MLTSS program, Community HealthChoices (CHC). Under the agreement between the state and Aging Well, Aging Well will be responsible for:

  • Completing the Functional Eligibility Determinations (FEDs) for applicants for seeking LTSS, and re-determinations for individuals over 60;
  • Conducting Preadmission Screening Resident Review Evaluations (PASRR-EV Level II Tool);
  • Prior to CHC implementation, Aging Well will do annual in-person reassessments with service coordinating organizations for Aging Waiver participants. Once CHC is implemented, Aging Well will conduct desk reviews of MCO data for CHC waiver participants in order to confirm level of care determinations; and
  • Conduct CHC outreach and education activities statewide, including 20 public information sessions and training for service coordinators and nursing facility staff.

FEDs, PASRR screenings, and level of care determinations reviews will all be accomplished using subcontracts with AAAs. (Source: Email to stakeholders 6/7/2017) 

On June 21, 2017, the Pennsylvania Office of Long-term Living (OLTL) announced a home and community-based services (HCBS) loan program, with loan amounts between $50,000 – $200,000 dollars available for LTSS providers to assist with projects aimed at increasing opportunities for community-based LTSS. The initiative is aimed specifically at preparing LTSS providers and service coordinator organizations for a successful transition to Community HealthChoices (CHC), the state’s incipient MLTSS program. (Source: PA.gov 6/21/2017)

On August 4, 2017, the Pittsburgh Post-Gazette reported that the Pennsylvania Department of Human Services has begun sending notifications to older adults and individuals with disabilities enrolled in Medicaid who will be impacted by the state’s launch of its MLTSS program—Community HealthChoices—which commences in 14 counties on January 1, 2018. Approximately 100,000 individuals will be affected by the initial shift. (Source: Pittsburgh Post-Gazette 8/4/2017)

On October 4, 2017, Philly.com reported that United Healthcare of Pennsylvania lost its appeal of the state's MLTSS awards. UnitedHealthcare had been seeking to re-compete for the state's incipient MLTSS program, Community HealthChoices (CHC), per a ruling from Pennsylvania Commonwealth Court. The state recently awarded management of the program to Centene, AmeriHealth Caritas, and UPMC Health Plan (owned by the University of Pittsburgh Medical Center). UnitedHealthcare came in fourth, but disputed the grading cirteria and process the state utilized. (Source: Philly.com 10/4/2017)

On November 6, 2017, the Pennsylvania Department of Human Services (DHS) announced the delay of Phase 2 and Phase 3 implementation for CHC. Phase 2 (southeastern PA) will now commence January 1, 2019 as opposed to July 1, 2018; Phase 3 (rest of state) will begin January 1, 2020, instead of January 1, 2019. DHS intends to use this additional to allow for the flexibility to make adjustments and examine lessons learned from Phase 1 implementation, which kicks off January 2018.  (Source: Philly.com 11/6/2017)

The State’s new MLTSS program, Community HealthChoices, began in 14 counties in the southwestern portion of the State (Pittsburgh area) on January 1, 2018.  Approximately 80,000 enrollees are being served by three statewide MCOs:  UPMC Community HealthChoices, AmeriHealth Caritas, and PA Health and Wellness (a subsidiary of Centene Corporation).  The three MCOs will be providing acute, primary, and long-term services and supports to dual eligible individuals and other consumers who need LTSS (Source: PA Department of Human Services).

On February 16, 2018, the Pittsburgh Post-Gazette provided an overview of the roll-out of Community HealthChoices, Pennsylvania’s new MLTSS program that officially launched January 1, 2018. Overall, state officials were pleased with the launch, noting they had received relatively minimal complaints, aside from a few billing issues with the MCOs. The state also noted that they hoped to do a better job of educating dual eligibles about their options moving forward as CHC expands statewide in 2019 and 2020. To date, 52 percent of CHC enrollees have chosen UPMC Community HealthChoices; 28 percent have selected PA Health & Wellness; and 20 percent selected AmeriHealth Caritas. (Source: Pittsburgh Post-Gazette 2/16/2018)

On February 16, 2018, the Pennsylvania Department of Human Services (DHS) announced that the governor, in his FY 2018-19 budget request, included an additional $69 million for continued implementation of the CHC program. The release also noted that 40 percent of CHC enrollees made an active selection of an MCO (rather than being auto-assigned to an MCO by the state); that percentage of ‘active choice’ exceeds the national average. (Source: Press Release 2/16/2018)

On April 23, 2018, Lancaster Online reported that Pennsylvania’s Department of Human Services (DHS) announced a delay to the implementation of Community HealthChoices (CHC) in Lancaster County. The delay will affect approximately 10,000 beneficiaries in Lancaster County. CHC will go live in Lancaster County beginning January 2020 as opposed to January 2019. (Source: Lancaster Online 4/23/2018) 

On June 30, 2018, the six-month “continuity of care” period ended for the first phase of Pennsylvania’s Community HealthChoices program – the state’s new MLTSS program. For the first six months of operation in the Southwest Region (Pittsburgh and 13 surrounding counties), the MCOs--UPMC Community HealthChoices, AmeriHealth Caritas, and PA Health and Wellness--were barred from reducing authorized services and were required to maintain existing provider-client relationships. Beginning July 1, the MCOs are able to revise service plans for individuals receiving HCBS based on the individual’s assessed need.The state will review each service reduction or denial. (Source: Pittsburgh Post-Gazette, 7-2-2018) 

Balancing Incentive Program

Pennsylvania submitted a BIP Application to CMS. Subsequently, CMS approved the state’s BIP Application. (Source: CMS BIP websiteKaiser BIP website, 6/2014)
BIP Application, link no longer available (4/18/2014)

As of January 2015, Pennsylvania has submitted to CMS a Structural Change Work Plan for the state’s Balancing Incentive Program.  (Source:  Medicaid Balancing Incentive Program website, 1/2015)
Structural Change Work Plan