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Community HealthChoices Summit: What Providers Need to Know

August 13, 2018
Reimbursement By Jennifer Matoushek, Senior Consultant

Pennsylvania Department of Human Services (DHS) held Community HealthChoices (CHC) Summits in the Southeast (SE) region of the state last month. The CHC Summits were held for providers and provided a detailed overview, leading into a deep dive into each subject area.

CHCSummit-2

According to 2016-2017 data, the SE region is the largest region in the state, with Philadelphia having the largest population and Chester county having the lowest. Per DHS, the SE region has more of a population of individuals receiving long term care.

During the overview session, DHS mentioned the following.

  • OBER waiver – individuals in this wavier will be able to stay in this waiver. If participate is considered nursing facility (NF) eligible, then they will go into CHC.
  • LIFE program – this program will continue and known as the PACS program. DHS is looking for this program to grow.
  • The Managed Care Organizations (MCOs) will oversee the operations of the NFs.

A Deep Dive into Community HealthChoices

So, let’s look at how CHC will work. Participants will choose one of three MCOs. Participants should consider the provider network and additional services offered by the MCOs. DHS will pay a per-member per-month rate (also called a capitated rate to MCOs). DHS will hold the MCOs accountable for quality outcomes, efficiency and effectiveness. MCOs will be responsible for coordinating healthcare and managing physical health.

During the overview session, DHS stated they have the following goals:

  1. Enhance opportunities for community-based living
  2. Strengthen coordinate of LTSS and other types of healthcare, including all Medicare and Medicaid services for dual eligible.
  3. Enhance quality and accountability.
  4. Advanced program innovation
  5. Increase efficiency and effectiveness.

DHS is always looking to enhance their programs. Areas of innovation that DHS is looking at are:

  1. Technology
  2. Information exchange
  3. Direct care workforce - Housing
  4. Employment

Several questions were asked and answered during the Summits. Some of which are listed below.

How does DHS expected MCOs to work on housing and employment when they are working on healthcare?

Per DHS, the MCOs already have experience doing these. There will be a housing director, which will work with housing resource. DHS is planning to add additional resources for employment. DHS is focused on keeping more individuals in the communities.

What plan are in place for the language barrios?

DHS will require MCOs to work with participates on these barrios. DHS already has five (5) languages on the state’s website.

Anything changing with the allocation per county with the behavioral health services?

No change with behavioral health organizations. Looking for opportunities to work with NFS.

How frequently can participants change their MCO?

Participants can change at any time. The effective date determines what time during the month.

Why is this process not automated for eligibility?

There are a lot of different types of providers and there no standard mode of communication.

Are provider able to bill weekly?

Yes

Other CHC Hot Topics

A hot topic discussed during the Summit was transportation. Per DHS, a big lesson was learned from the Southwest (SW) region. All CHC participants have access to emergency and non-ER medical transportation. Participants will continue to use the Medical Assistance Transportation Program (MATP) for non-ER medical transportation to and from medical appointments. Participants residing in a nursing facility (NF) are the exception. NFs will continue to coordinate transportation for their residents.

Another hot topic was the end of Continuity of Care, which was June 30, 2018 for SW region NFs. MCOs are required to contract with all willing and qualified existing Long Term Services and Supports (LTSS) Medicaid (MA) providers for 180 days after CHC implementation. For NF participants, they will be able to stay in their NF as long as this level of care is needed, or until they choose to move. As long as the NF stays enrolled in MA, then participants can stay as long as they need.

During the individual breakout session, the MCOs encouraged SE facilities to contact them if they haven’t received a reach out from their assigned MCO. The MCOs also encourage NFs to begin claims testing. Claims testing started in December 2017 for SW NFs. The MCOs stated that one of the lessons learned is that claims testing should have started a lot earlier than December; NFs could begin now. However, LW Consulting, Inc. has heard from several NF providers that the MCOs are now telling them the claims testing will begin in December 2018.

We will continue to provide monthly updates on CHC and hold 15-minute teleconferences on a monthly basis for NF providers.

 

Should you have any questions or need assistance with your CHC implementation, please contact Jennifer Matoushek at jmatoushek@lw-consult.com .