Understanding Pennsylvania's Long-Term Care Waiver Programs

CHC and Aging Waiver Update Pamela Walz, Community Legal Services of Philadelphia Rebecca May Cole, Pennsylvania Association of Area Agencies on Aging Fran Chervenak, Pennsylvania Health Law Project

Current Long Term Services and Supports Waiver Programs Medicaid-funded medical and non-medical services to allow older adults and people with disabilities to live independently in their homes and communities. Alternative to nursing facility Section 1915(c) of the Social Security Act permits certain Medicaid provisions to be waived to allow states to offer enhanced services to particular populations at risk of institutionalization

Current Waiver Programs (cont d) Must be NFCE Income limit for 2017 is $2,205/mo. Spouse s income does not count. Resource limit for single ($2,000 + $6,000 disregard) Married couples: spousal impoverishment rules apply

Current Waiver Programs (cont d) Eight waiver programs in PA, each targeting a specific population Must meet eligibility requirements of a specific waiver program In PA, the Office of Long Term Living administers most waiver programs (Office of Developmental Programs administers the rest).

LTSS Waivers in PA - Office of Long Term Living (OLTL) PDA (Aging) Waiver COMMCARE Waiver (for individuals with traumatic brain injury) Independence Waiver (for individuals 18-59 with physical disability but not intellectual disability or mental illness as primary diagnosis) Attendant Care (18-59 with physical disabilities capable of hiring and supervising attendant) OBRA Waiver (18-59 with severe developmental disability)

Office of Developmental Programs (ODP) Waivers Adult Autism Waiver Consolidated Waiver (age 3 or older with Intellectual Disability and recommended for ICF/MR level of care) Person Family Directed Support Waiver (age 3 or older with Intellectual Disability and recommended for ICF/MR level of care but do not need residential services)

Types of Waiver services (varies by waiver) Home health Personal care Attendant care Respite Adult Day Care Transportation Home modifications Counseling Specialized medical equipment, supplies Home delivered meals Personal emergency response Companion Service coordination

Models of managing services Agency model Consumer directed model Family member can be paid caregiver (except spouse) Role of fiscal intermediary (Public Partnerships Limited or PPL ) Services My Way (Cash & Counseling)

Living Independently for Elders (LIFE) Program of All-Inclusive Care for the Elderly (PACE) model Model of care focused around Adult Day Care attendance ALL services are coordinated and provided by LIFE LIFE is paid a capitated rate by Medicare, Medicaid, and/or the Participant (depending on the Participant s eligibility for Medicare and Medicaid) Must use LIFE providers

LIFE Eligibility Must be 55 or older NFCE level of care Must live in area served by a LIFE program (31 counties)

LIFE Services Adult day center, social activities, social services Home support, home health, personal care Respite Transportation Medical and nursing care Rehabilitation and restorative therapies Home modifications Hospital and nursing facility care if needed

LTSS Application Process since April 2016 Call Maximus (PA Independent Enrollment Broker or IEB) MA application (if not already on MA) Packet with PA600L mailed to applicant, must be returned to IEB to start application process and 60 day clock for eligibility decision Or can complete MA app on Compass PA Link (ADRC) person-centered counseling

Application process (contd) Physician Certification Form Robocalls and letter to consumer AAA performs functional eligibility determination (FED) Aging Well starting Jan. 2017 If physician form or FED not completed within 30 days, denial notice Application resumes being processed if physician form or FED received.

Application process (contd) Home visit from IEB Determine if meet criteria for a waiver Start creation of service plan Select service coordination agency and other providers CAO determines financial eligibility Decision is supposed to be within 60 days from date IEB receives PA 600L.

Medicaid LTSS System After April 1, 2016 ASSESSMENT / LEVEL OF CARE -ATION COUNSELING OTHER LTC SERVICES FINANCIAL DETERMIN SERVICE COORDIN- ATION ENROLLMENT & CHOICE Under 60 Other Other AAAs CAOs Maximus 60+ AAAs Other Maximus Other AAAs CAOs AAA Area Agencies on Aging LTC Long Term Care CAO County Assistance Offices 2/7/17 PA Association of Area Agencies on Aging

Medicaid LTSS System Before April 1, 2016 ASSESSMENT / LEVEL OF CARE -ATION MENT FINANCIAL DETERMIN ENROLLMENT CHOICE COUNSELING SERVICE COORDIN- ATION OTHER LTC SERVICES ENROLL- Under 60 Maximus Other Other Other AAAs CAOs 60+ AAAs CAOs AAAs AAAs Other AAAs Other AAA Area Agencies on Aging LTC Long Term Care CAO County Assistance Offices 2/7/17 PA Association of Area Agencies on Aging

Maximus problems barrier to filing applications No assistance with completing PA 600 or gathering verification Between April and November 2016, 8,621 application packets not returned out of 11,366 mailed. 6,858 of these or 80% of the total not returned were sent to older adults.

Maximus problems (contd) Communication problems/lost documents between AAAs and Maximus Poor customer service: incorrect and inconsistent information on application status Lack of follow up on physician certifications

More Maximus problems Difficult to escalate problem cases No ability to prioritize more urgent applications Post-eligibility delays Language access concerns

Aging waiver enrollment numbers Average 2015 monthly new enrollments: 584 2016 enrollments: Jan. 477 May 814 Feb. 681 June 857 March 946 July 285 April 856 Aug. 495 Sept. 538 Oct. 730 Nov. 867

Average processing time OLTL reported in December 2016 based on Maximus-reported numbers that average time to process waiver applications is: 41 days for Aging waiver 46 days for other OLTL waivers This does not match what consumers and advocates are experiencing.

Joint legislative hearing held October 18, 2016 by the PA Senate Aging and Youth and House Aging and Older Adults Committees New IEB RFP and contract PAELA/Advocates letter to CMS

Area Agencies on Aging Rebecca May-Cole rebecca@p4a.org 717-541-4214

Area Agencies on Aging 52 AAAs serve the Commonwealth: 33 are County and 19 are Non-Profit Established by Older Americans Act Manage multiple funding streams, contracted and volunteer services Are trusted entities within the local communities Provide support to keep older people independent and active in their communities Link for AAA contact information: http://www.p4a.org/about-us/aging-services- network/

Network of Area Agencies on Aging Planning and Service Area ERIE WARREN TIOGA SUSQUEHANNA BRADFORD McKEAN POTTER TIOGA WAYNE CRAWFORD FOREST WYOMING ELK CAMERON LACKAWANNA SULLIVAN VENANGO PIKE LYCOMING MERCER CLINTON CLARION LUZERNE JEFFERSON MONTOUR MONROE LAWRENCE CLEARFIELD COLUMBIA BUTLER CENTRE UNION CARBON NORTHAMPTON NORTHUMBERLAND ARMSTRONG SNYDER SCHUYLKILL INDIANA LEHIGH BEAVER MIFFLIN JUNIATA ALLEGHENY CAMBRIA DAUPHIN BERKS BUCKS PERRY BLAIR LEBANON HUNTINGDON MONTGOMERY WESTMORELAND WASHINGTON CUMBERLAND LANCASTER BEDFORD CHESTER PHILADELPIA FULTON DELAWARE FAYETTE GREENE SOMERSET FRANKLIN YORK ADAMS

Medicaid LTSS System Before April 1, 2016 ASSESSMENT / LEVEL OF CARE -ATION MENT FINANCIAL DETERMIN ENROLLMENT CHOICE COUNSELING SERVICE COORDIN- ATION OTHER LTC SERVICES ENROLL- Under 60 Maximus Other Other Other AAAs CAOs 60+ AAAs CAOs AAAs AAAs Other AAAs Other AAA Area Agencies on Aging LTC Long Term Care CAO County Assistance Offices 2/7/17 PA Association of Area Agencies on Aging

Medicaid LTSS System After April 1, 2016 ASSESSMENT / LEVEL OF CARE -ATION COUNSELING OTHER LTC SERVICES FINANCIAL DETERMIN SERVICE COORDIN- ATION ENROLLMENT & CHOICE Under 60 Other Other AAAs CAOs Maximus 60+ AAAs Other Maximus Other AAAs CAOs AAA Area Agencies on Aging LTC Long Term Care CAO County Assistance Offices 2/7/17 PA Association of Area Agencies on Aging

Medicaid LTSS System Under CHC FINANCIAL DETERMIN -ATION COUNSELING DETERMINATION FUNCTIONAL ELIGIBILITY ENROLLMENT & CHOICE MCOs Under 60 CAOs Aging Well (AAAs) IEB LTC Service Administrative Service Coordination NF Adult Day Cognitive Rehab Home Health Personal Care Other Billing Payments Contracts MCO Aging Well (AAAs) 60+ CAOs IEB Contract Out AAAs Other AAA Area Agencies on Aging CAO County Assistance Offices LTC Long Term Care IEE Independent Enrollment Entity MCO Managed Care Organization CHC Community HealthChoices 2/7/17 PA Association of Area Agencies on Aging

Community HealthChoices Fran Chervenak Director of Client Representation PA Health Law Project

What is Community Healthchoices? Community HealthChoices is what PA is calling its new Managed Long Term Services & Supports delivery system New program for providing Medicaid coverage and Long Term Care services and supports (LTSS) to dual eligibles (those on Medicare & Medicaid); those in OLTL waivers and those in nursing homes. Individuals affected must enroll into one of 3 CHC managed care plans and receive Medicaid and LTSS through the plan

Community HealthChoices Goals 32

CHC Phased Roll-out Phase - Date 1 2 3 3 January 2018 3 July 2018 1 2 3 January 2019 33

CHC Population Phase Health Choice Zone Age Group Zone total Totals Age < 60 42,057 Southwest 99,369 1 99,369 Age >= 60 57,312 Age < 60 51,477 Southeast 143,332 2 143,332 Age >= 60 91,855 Age < 60 33,277 Lehigh/Capital 79,467 Age >= 60 46,190 Age < 60 24,680 North East 177,913 3 62,737 Age >= 60 38,057 Age < 60 16,018 North West 35,709 Age >= 60 19,691 420,614 420,614 34

Phase 1-Southwestern PA Starting 1/1/2018 OLTL Programs Available Erie Susquehanna Warren McKean Bradford Tioga Potter Crawford Wayne Aging Wyoming Forest Sullivan Attendant Care Independence Cameron Lackawanna Elk Venango Pike Lycoming Mercer Clinton Jefferson Luzerne Clarion Columbia OBRA Monroe Clearfield Montour Lawrence Union Butler Centre Carbon Northumberland LIFE (where available) Armstrong Northampton Snyder Schuylkill Beaver Indiana Lehigh Mifflin Cambria Juniata Blair Allegheny Dauphin Nursing Facility Care Berks Perry Bucks Lebanon Westmoreland Huntingdon Montgomery Washington Cumberland Lancaster Philadelphia Bedford Chester Act 150 Somerset Fulton Fayette York Franklin Delaware Greene Adams OLTL Programs Available CHC OBRA (for small number of folks) Pennsylvani a Health & Wellness (Centene) UPMC LIFE (where available) Act 150 (non- Medicaid funded Program) AmeriHealth Caritas 35

CHC Target Populations and How Things Will Change 36

CHC Target Populations Enrollment into CHC will be mandatory for: Dual eligibles (most but not all) People receiving services through OLTL Waivers: Aging Attendant Care COMMCARE Independence OBRA (most but not all) Medicaid beneficiaries in nursing home Except for residents in state-operated nursing facilities, including state veterans homes 37

Duals-Whos Out? Certain Duals Full Duals who are: Under age 21; or In Intellectual Disability Waivers (Consolidated or Person/Family Directed Supports); or In Developmental Disability Waivers (Adult Autism or Adult Community Autism Program) Partial Duals (QMB, SLMB, QI-1) Medicare and Medicaid coverage for these duals will not change 38

Duals-Whos Out? LIFE Program Participants LIFE provides long-term services and supports to people age 55+ who are otherwise eligible Must be LIFE program in area LIFE provides coverage for all healthcare and LTSS (becomes someone s Medicare and Medicaid) LIFE will exist alongside CHC Individuals 55 & older who are NFCE can choose between the two; if choose LIFE, not in CHC 39

Whos In? Duals with and without LTSS Duals who are not getting LTSS Individuals who have Medicare and who also qualify for Medicaid insurance coverage based on age, disability, and income/resources. This includes: Healthy Horizons MAWD Medicare coverage and choices will not change Original Medicare + Prescription Drug Plan Medicare Advantage 40

Duals Not Getting LTSS in CHC Medicaid coverage for these dual eligibles will change under CHC Medicaid Current CHC Physical Health Coverage ACCESS (fee-for-service) CHC Plan Behavioral Health Coverage HealthChoices-BH plan in county HealthChoices-BH plan in county Relationship to Medicare Secondary Secondary Benefits Adult Benefit Package CHC Benefit package 41

Duals Getting LTSS Dual eligibles who get long-term services and supports (LTSS). This includes: Aging Waiver Attendant Care Waiver Administered by the Office of Long-Term Living (OLTL) COMMCare Waiver Independence Waiver OBRA Waiver (most) Nursing Home Residents 42

Duals with LTSS in CHC Medicare coverage and choices for these duals will not change Original Medicare + Prescription Drug Plan Medicare Advantage Medicaid coverage will change in the same way as duals without LTSS (slide 22) Except: People in Aging Waiver and NH now get their behavioral health coverage through ACCESS; the move to HealthChoices for BH will be new to them LTSS coverage will change (next slides) 43

Duals with LTSS at home in CHC Current OLTL Waiver System: Each Waiver program covers unique set of LTSS Person must use service providers (i.e., service coordination; personal care assistance) enrolled in specific Waiver OLTL approves service plan LTSS under CHC Each CHC plan will cover whole array of LTSS (and can decide to cover extra services) Person must use providers in CHC plan s network CHC plan approves the service plan 44

Duals in Nursing Homes in CHC Current NH system: NH responsible for providing or arranging all care NH bills the patient the patient pay amount Consumer must be in NH that accepts Medicaid and Medicaid pays the nursing home NH under CHC: NH responsible for providing or arranging all care NH bills the patient the patient pay amount Consumer in NH that is in network with CHC plan* and CHC plan pays the nursing home * Exception for those in a NH when CHC starts in region 45

Who Else is in CHC? Anyone who is in Medicaid only & getting LTSS in nursing home or through OLTL Waiver Their Medicaid + LTSS coverage will change Medicaid coverage Aging Waiver for LTSS Adult Benefit Package Attendant Care, COMMCare, Independence and OBRA* Adult Benefit Package Nursing Home ACCESS card for all coverage Medicaid covers NH care Adult Benefit Package eligibility Current ACCESS card for all CHC CHC plan-physical+LTSS HealthChoices-BH plan CHC Benefit Package Aging Waiver HealthChoices plans (PH; BH) Waiver for LTSS CHC plan-PH+LTSS HealthChoices-BH plan CHC Benefit Package CHC Plan-PH+LTSS/NH HealthChoices-BH plan CHC Benefit Package * OBRA current population will be split between CHC and non-CHC depending upon clinical 46

Role of the Independent Enrollment Broker (IEB) DHS soon to issue an RFP for a statewide Community HealthChoices IEB IEB to have 3 main functions: Educating consumers and others in region on CHC prior to and during implementation Enrolling people into CHC plans and helping people to change plans if they want to switch Assisting CHC consumers and others apply for LTSS at home or in NH once CHC starts in region

CHC Managed Care Contracts DHS chose 3 plans to participate in CHC across the state- Amerihealth Caritas, UPMC for You and PA Health & Wellness (Centene) 4 plans protested the state s decision and lost, 3 appealed to Commonwealth Court Court denied Requests for a Stay by Molina and United Healthcare Protests delayed DHS s timeline but now going forward with contract negotiations and readiness review

Potential Advantages of CHC Dual eligibles struggling to find providers who accept ACCESS card will now have a plan provider network CHC plan is responsible for coordinating care with member s Medicare and/or behavioral health coverage Medicaid benefit package for those in CHC expanded to include eyeglass coverage Common package of services to anyone determined eligible for LTSS that include home modifications, employment-related services, home delivered meals Plans could choose to provide additional services to those not yet NFCE-i.e. housing supports, personal care services to keep members healthy and at home

Concerns/Questions Re: CHC CHC plans ability to deliver Plans chosen will be new to some or all regions of the state Plans have no experience delivering LTSS in PA LTSS provider networks State s imposing bare minimum network requirements Plans willingness to contract with existing LTC providers