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Advocacy

December 11, 2015

Ms. April Leonard
Office of Long-Term Living
Bureau of Policy and Regulatory Management
P.O. Box 8025
Harrisburg, PA 17110-2675

SUBJECT: Pennsylvania’s Community HealthChoices Draft RFP

Dear Ms. Leonard:

On behalf of The Hospital & Healthsystem Association of Pennsylvania (HAP), which represents approximately 240 member hospitals and health systems across Pennsylvania, we appreciate the opportunity to provide comments about the draft Community HealthChoices (CHC) Request for Proposal (RFP) for managed long-term care services in Pennsylvania. We applaud the commonwealth’s efforts to integrate physical health and long-term Medicare and Medicaid services that support older adults and adults with physical disabilities.

As a pioneer in Medicaid managed care, we believe Pennsylvania is well-positioned to lead this ambitious project of transforming the delivery of long-term care services. To that end, HAP understands and supports the overall goals and objectives of the CHC initiative. However, HAP identified a number of areas of concern for our members. These concerns are as follows:

Dispute Resolution:

Currently, providers involved in payment disputes with the Department of Human Services (DHS) in the long-term care program have the right to an impartial administrative hearing before the DHS Bureau of Hearings and Appeals (BHA). CHC does not provide the same protection. Specifically, the draft RFP prohibits BHA from hearing disputes between providers and the managed care organizations (MCO) administering the CHC program. While the draft RFP does include an internal dispute resolution process, this process falls short of the protections currently available to providers through BHA.

Rates/Reimbursement:

HAP previously noted that DHS should ensure that the CHC program has sufficient funds to adequately compensate skilled nursing facilities and other long-term services and support providers. The final RFP and contract should, at a minimum, require that MCO pay providers existing Medicaid rates and provide for annual cost increases. In addition, the draft RFP’s payment methodology does not appear to require that MCOs consider the acuity of the patients when establishing reimbursement rates. A failure to properly incorporate these acuity levels could result in underpayments to providers and penalize providers treating consumers with complex medical conditions. The CHC program should do more to ensure providers are adequately compensated for treating complex patients.

Any Willing Provider:

Currently, the existing long-term care program allows any qualified provider willing to accept the terms and conditions to enroll in the program. This helps to ensure that consumers have a sufficient number of providers from which to select. It also helps to maintain continuity of care as consumers move throughout the long-term care system.

The draft RFP will allow consumers to keep their existing providers for six months. Nevertheless, due to the uniqueness of the CHC program and the often fragile medical state of consumers utilizing long-term care level services, six months is not enough. DHS should ensure that CHS allows any willing provider to enroll in the program. Alternatively, DHS should ensure that consumers are allowed to keep their existing providers for at least the first two years of the program.

Provider Protections:

DHS should require that MCOs’ 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 the program.

These comments are intended to supplement both the October 16 and July 15 letters submitted by HAP to DHS relating to the CHC program design.

We look forward to a continuing and productive dialogue about this very important issue. Again, thank you for the opportunity to comment about the RFP for Community HealthChoices. If you have any questions, contact me at (717) 561-5325, or Norris Benns, vice president, insurance and managed care, at (215) 575-3737.

Sincerely,

Jeffrey W. Bechtel

Senior Vice President, Health Economics and Policy

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