HAP Comment Letter to DHS on Managed Long-Term Services and Support
Department of Human Services
Health and Welfare Building
SUBJECT: Managed Long-Term Services and Support (MLTSS) Comments
you again for the opportunity to provide input on Community HealthChoices
(CHC), the commonwealth’s MLTSS Program. These comments are intended to
supplement the July 15, 2015, letter submitted by The Hospital &
Healthsystem Association of Pennsylvania (HAP) relating to the Department of
Human Services (DHS) Discussion Document.
the release of the Discussion Document during June of this year, DHS conducted
six listening sessions across the commonwealth to hear stakeholders and
consumers’ thoughts and concerns relative to its plan to implement MLTSS in
Pennsylvania for older Pennsylvanians and adults with disabilities.
September 16, 2015, DHS issued a Concept Paper which outlines its thoughts
relative to MLTSS in more detail. DHS is accepting comments on its Concept
Paper until October 16, 2015.
understands and supports the goals of the MLTSS, but has identified some areas
of concern for our members. These general areas are outlined below:
Opportunities: While we understand that DHS is not releasing
a draft request for proposal, we are pleased that you plan to share a draft
contract and accept comments from stakeholders. As you know, CHC seeks to
fundamentally alter the manner in which long-term care services are delivered
in Pennsylvania. This is an enormous undertaking on DHS’ part, and it is
important that consumers and others stakeholders have an opportunity to review
and comment on key aspects of the program, including rate setting, network
adequacy, and behavioral-physical health coordination requirements. We
anticipate providing more detailed comments after we have an opportunity to
review the draft contract language.
Program Release: DHS plans on implementing CHC in three
stages. The western part of the state will be rolled out during 2017, the
southeastern part of the state will be implemented during 2018, and the final
zone will be established during 2019. Despite this staggered implementation
timetable, DHS intends to award the RFP for all of the state’s zones at one
time. Instead, DHS should consider awarding the RFP in stages. This approach
would allow DHS to benefit from any “lessons learned” from the initial rollout.
Historically, with any significant program change or implementation, there are
always unforeseen consequences that require an ability to change course to
achieve a more positive outcome.
Network Adequacy: Much has been written about network adequacy
in the context of long-term service and support. This subject is currently
being debated by the National Association of Insurance Commissioners as it
seeks to update its network adequacy model law.
network adequacy has been monitored by the Department of Health (DOH) in
connection with commercial insurance plans. DOH also monitors network adequacy
in HealthChoices, along with DHS.
Since CHC will be a new program with provider
types for which existing protocols may not apply, it is important that DHS
share its proposed network adequacy model and provide enough time for consumers
and providers to understand and comment on the proposed standards. Network
adequacy standards also must be strictly enforced.
Any Willing Provider: Any willing provider provisions are generally
included to ensure that there is a sufficient number of providers for consumers
to select. We urge DHS to consider adopting this provision for the CHC program,
especially during the early years, so consumers have adequate access to care.
It is worth noting that this provision is not unprecedented, as it currently
exists in HealthChoices for the pharmacy benefit.
Provider Protections: DHS should require that managed care
organizations’ (MCO) policies are generally consistent. To the greatest extent
possible, critical components of the program such as credentialing, utilization
review, and payment should be aligned to prevent the imposition of unnecessary
administrative burdens on providers. If each MCO has its own approaches, it
will create a significant administrative burden for providers and add cost to
HAP also recommends that the program include stringent claims
processing timelines, and that the CHC MCO be required to establish robust provider
dispute resolution programs.
Rates/Reimbursement: It is critical that DHS ensures that there
are sufficient funds to adequately compensate skilled nursing facilities and
other long-term services and support providers. Among other things, the contract
should include provisions that reimbursement can be no lower than existing
rates and provide for annual cost increases.
There also should be an
opportunity for providers to negotiate value-based payment arrangements, to
award the provision of cost effective and high-quality care. The adequacy of
reimbursement rates also should be evaluated and monitored by the commonwealth
as the program is rolled out statewide.
Operational Issues: The implementation of CHC provides an
opportunity for DHS to improve and streamline aspects of the long-term care
program that have traditionally not worked well in Pennsylvania. Specifically,
the commonwealth should take steps to improve and automate the nursing facility
eligibility determination process, to facilitate timely, accurate, and
consistent eligibility determinations.
MCO Education: This program will be new to Pennsylvania. It’s
likely that many providers may be unfamiliar with managed care principles and
operations. As a result, DHS should put in place mandatory educational programs
and provide on-going technical assistance so that providers can quickly and
efficiently navigate the complexities associated with MLTSS.
Thank you for the opportunity to comment. We
look forward to the chance to review the draft contract, and provide more
detailed comments relating to the program design. We also are looking forward
to a continued partnership in launching this exciting new program for
Jeffrey W. Bechtel, JD
Senior Vice President, Health Economics and Policy