Initial Questions - Healthy PA

Transcription

1 Initial Questions - Healthy PA October 17, 2013 Healthy PA Reform General Our Understanding - Is it Correct? The Commonwealth will be seeking an 1115 waiver from CMS to implement Healthy PA Questions and Concerns 1. What is the Commonwealth s timetable for submitting the waiver? 2. What is the Commonwealth s timetable for implementation of the waiver? 3. Are there segments of the waiver that will be implemented at different times (i.e. Long Term Care)? 4. What specific Medicaid and ACA regulations will DPW ask to be waived (benefits, eligibility, statewideness, copays, premiums, mental health parity, work requirement, participation in preventive care, etc)? 5. Does DPW plan to hold a public input process prior to waiver submission? 6. When does DPW expect to make details available about the Healthy PA plan? 7. What changes to the Public Welfare Code, other State law, and regulations will be necessary to implement Healthy PA? 8. What is DPW s expectation regarding CMS approval of all components of Healthy PA? 9. When will DPW make available details of the funding for Healthy PA? How will DPW demonstrate the cost neutrality required by an 1115 waiver? 10. How will Healthy PA affect Disproportionate Share payments? Will this plan change Pennsylvania s funding for Disproportionate Share? 11. How does Healthy PA affect the MCO Gross Receipts Tax? 12. Does DPW expect to collect Pharmacy Rebates on the new ACA eligibles to be served through HealthChoices? 13. Does DPW expect to collect Pharmacy Rebates on the new ACA eligibles to be served through the Healthy PA expanded Exchange? 1

2 Initial Questions - Healthy PA October 17, 2013 Healthy PA Reform Medicaid Delivery System Our Understanding - Is it Correct? Medicaid MCOs will continue to provide coverage to current Medicaid individuals through the HealthChoices model with the exception of Long Term Care services The new populations to HealthChoices will be Medically Frail adults who choose Medicaid/ HealthChoices Children ages 5 and above with incomes between 100% and 138% of the FPL (formerly CHIP-eligible) Questions and Concerns 1. Will any existing Medicaid enrollees be shifted to the Health Care Exchange? 2. Will these new eligibles be enrolled in HealthChoices? 3. What changes does DPW anticipate making to MCO rates to recognize a case mix with a much higher number of individuals with chronic and complex health care conditions? 4. What changes does DPW anticipate making to MCO rates to recognize increased utilization for the medically frail group due to pent up demand? 5. Will DPW be adding new rate cells for these new populations? 6. How many new enrollees does DPW expect who meet the existing Medicaid eligibility requirements (so-called woodwork eligibles)? 7. How many Medically Frail enrollees does DPW expect to enroll in Medicaid and HealthChoices? 8. How many CHIP children are expected to transfer to HealthChoices? 9. Does DPW anticipate an increase in medical service utilization when increasing access to services? How will such an increase be reflected in the capitation rates paid to insurers? 10. The increased access also includes currently uninsured medically frail individuals. How will cost estimates for this sub-population be developed? 11. In the absence of historical medical cost data for the medically frail individuals, will the DPW consider some type of risk sharing, before risk adjusted rates can be developed? 12. What adults does PA cover today who do NOT meet the definition of medically frail contained in the proposal? How many Medicaid adults would likely move to the Exchange under this proposal, if any? 13. Can we estimate the financial impact to Medicaid plans of serving only medically frail adults vs. a broader adult population? 14. It is unclear why the medically frail would have an option to remain with Medicaid or enroll in the exchange. What benefit would it be for these individuals to enroll in the exchange? 2

3 Initial Questions - Healthy PA October 17, 2013 Healthy PA Reform Expansion Delivery Model Our Understanding - Is it Correct? There is no specific or mandated role for the Medicaid MCOs in the expanded Exchange Medicaid MCOs which wish to provide coverage in the expanded Exchange would: Need to apply and become certified as QHPs (on 1/1/14 at the earliest) Need to offer silver and gold benefit package Would need to establish provider networks at the prevailing market reimbursement rates (i.e. commercial rates) Questions and Concerns 1. What is the Administration s financial and policy rationale for creating a duplicative structure for MCOs (and other insurers?) to serve low-income working adults? 2. Please explain how the Administration believes creating this new structure for people who currently have no insurance will prevent erosion of the private insurance market. 3. Does the Administration believe that CMS will commit to work with PA on a waiver that permits this new delivery system? 4. Will the 1115 waiver also waive non-medicaid ACA provisions relating to operation of QHPs in the Exchange? 5. How will DPW meet the cost neutrality provisions of an 1115 waiver? The plan contemplates that commercial insurers paying commercial provider rates will serve a significant number of the expansion population. 6. How many enrollees will receive coverage through this new mechanism? 7. How many QHPs does the Administration anticipate serving this population? 8. What consideration did the Administration give to ensuring that low-income families can receive benefits from the same insurer? Having children enrolled in a Medicaid MCO and their parents enrolled in an Exchange plan (possibly not a Medicaid MCO) will disrupt family treatment plans and continuity of care. 9. Why didn t the Administration alert Medicaid MCOs to the plan to serve the Medicaid expansion population through the Exchange? Prior notice would have permitted these insurers to gain certification as QHPs for Would the Administration consider seeking special QHP status for Medicaid MCOs from CMS? This could allow the Medicaid MCOs to participate in the Exchange without meeting an entire new set of requirements. 11. Would the Administration consider seeking Federal approval for these special status MCOs to serve as the only options for Medicaid expansion eligibles in the Exchange? Under this scenario, the MCOs would not have to offer all levels of benefit packages to a broader group of higher-income Exchange-eligibles. 12. Will the Administration run the Exchange in 2014 so that it will have flexibility to design a narrower, low-cost Exchange model geared to serve this population? 3

4 Initial Questions - Healthy PA October 17, 2013 Healthy PA Reform Long Term Care Delivery System Our Understanding- Is it Correct? There is no commitment to adopt a Medicaid Managed Long Term Care model. The Governor will appoint a commission to study the rising costs of Medicaid Long Term care Questions and Concerns 1. Will the 1115 waiver include a Medicaid Managed Care model (Managed Long Term Care Services and Supports) for Long Term Care? 2. What will this Commission study? 3. How does this Commission differ in membership and scope from the long-term care task forces that DPW is scheduled to launch? 4. How will the Commission and Task Forces work align with the work already done on Managed Long Term Care by the State Innovations Model working groups? 5. Since MMLTSS has been studied extensively at the national level and in other state Medicaid programs, why has the Administration chosen to further study and delay implementation of a new Long Term Care approach? 6. What is the timeline for completion of the study and implementation of the new long-term care model? 7. What changes are expected in the redesign of services? To what extent is the number of individuals impacted expected to expand? 4

5 Initial Questions - Healthy PA October 17, 2013 Healthy PA Reform Changes to Existing Medicaid Benefits Our Understanding - Is it Correct? Three benefit packages One will be for children One will be for Federally-protected medically frail group One will be more like the Essential Benefits package in the Exchange Questions and Concerns 1. Will there be more than three Medicaid benefit packages? We are unclear about the high-risk/low-risk and commercial-like terminology used in explanations of Healthy PA. 2. What will be the criteria to assign members to each set of benefit packages? 3. What services will be eliminated or changed in the benefit package(s)? 4. Will any limits in services be eliminated (i.e. limits for current General Assistance population)? 5. Will changes be made to all Medicaid benefit packages? 6. When will DPW make available detailed information on these proposed commercial-like benefit packages? 7. Given the diversity and acuity of the Medicaid population, how does DPW propose to condense 14 benefit packages into three? How will DPW ensure that the benefit packages meet the needs of the populations to be served? 8. What will the impact of the benefit changes be on current enrollees? 9. Does DPW have a strong indication that CMS will allow alignment of Medicaid benefits with the national standards around essential health benefits, mental health parity, and preventive care? 10. Please clarify how DPW expects to achieve cost savings by cutting benefits that are not used? Please provide information about what those services are and the data being used to determine lack of use. 11. Will the MCOs be consulted about the scope of benefits that will remain? We are concerned about services such as dental that are critical to other health conditions (i.e. pregnancy outcomes, heart disease). 12. Please clarify how a reduced benefit package for Medicaid enrollees will enhance their access to commercial insurance. 13. Will DPW be redefining medical necessity? 14. Will DPW be interpreting EPSDT requirements in a more narrow fashion? 15. What provisions will be made for continuity of care for services that are being eliminated or capped at a lower level? 16. How will MCO rates be affected? We would like information on the expected changes to the rates/rate structure such as: the number of rate cells; elimination 5

6 Initial Questions - Healthy PA October 17, 2013 or reduction of benefits; medical expense shifts to other remaining services (i.e. elimination of chiropractic service may see increase in orthopedic specialty visits and procedures); changes in efficiency adjustments if certain services are curtailed; etc.? 17. Will DPW provide a detailed actuarial analysis of the cost projections and capitation rate development for the two commercial-like alternative adult benefit packages? Will potential insurers be given the opportunity to submit questions relating to the capitation rate development? Will capitation rates be riskadjusted? 6

7 Initial Questions - Healthy PA October 17, 2013 Healthy PA Reform Changes to Medicaid Premiums Our Understanding - Is it Correct? All adults with incomes at $5,745 per year (individual)/$7,755 per year (household) up to $15,282/$20,628 per year will be charged premiums on a sliding scale (not to exceed $25/$35 per month). Premiums can be reduced based on the individual s engagement in preventive health activities and work search Questions and Concerns 1. Will the new premiums apply to all adult Medicaid recipients whether existing categories of eligibility or new ACA categories of eligibility? 2. Will all adults, regardless of health status, be charged a premium (i.e. pregnant women, medically frail, people living in ICF-MRs, etc.)? 3. What is the age definition of adult? 4. Will the premium requirement apply to Dual Eligibles? 5. Will the premium requirement apply to people in Nursing Facilities? 6. Will the premium requirement apply to people in Waiver programs? 7. If a family has an adult in regular Medicaid and an adult in the expanded (Medicaid) Exchange, will the family be charged two premiums? 8. Can DPW provide specifics about the sliding premium anticipated for each income level? 9. What will happen if an individual cannot/does not pay the premium? Will that result in disenrollment from Medicaid? 10. How often will a premium be collected (Monthly, Quarterly, etc.)? 11. What entity will collect premiums (DPW, Enrollment Broker, MCO, Exchange)? 12. What entity will track the individual s participation in work search? 13. What entity will track the individual s participation in preventive health activities? 14. How will DPW define Work Search? 15. How will DPW define preventive health activities? Will there be a standard set of wellness activities? 16. Are those adults that are not physically or mentally able to work still required to use JobGateway? If not, will they have the opportunity for premium reduction? 17. Will those adults who are not physically or mentally able to engage in preventive health activities have the opportunity for premium reduction? 18. How often must an individual participate in work search to offset/reduce a premium? 19. How often must an individual participate in preventive health activities to offset/reduce a premium? 20. How will MCOs be compensated for systems changes, administrative activity, and other new functions for any new responsibilities required to implement these 7

8 Initial Questions - Healthy PA October 17, 2013 premium requirements? 18. If these activities are new requirements, how will DPW add money to MCO rates? 19. How will DPW fund the MCO administrative costs for the required wellness tracking activities? 20. Will DPW design a standardized matrix that values and links wellness activity to a specific dollar amount of premium reduction? 21. How will the premiums otherwise affect the MCO rates? 22. What are the expected Commonwealth savings/ additional cost associated with implementation of cost sharing premiums for Medicaid recipients? 23. Has the Administration done a cost/benefit analysis to weigh the administrative and information systems cost of collecting premiums with the amount of premiums anticipated to be collected? 24. This aspect Healthy PA success depends, in part, on Medicaid recipients becoming more actively engaged in their health care delivery. What leads the Administration to believe that this approach will ensure success? How will success be measured? 8

9 Initial Questions - Healthy PA October 17, 2013 Healthy PA Reform Changes to Existing Medicaid Co-pays Our Understanding - Is it Correct? Copays for children will not change All copays for adults will be eliminated except for nonemergent use of an Emergency Room Questions and Concerns 1. Is our understanding correct about copays for children remaining the same? 2. Will all copays for adults be eliminated except for ER? The Healthy PA document says that all copays will be eliminated, but then refers more narrowly to physician copays. 3. Would DPW consider asking for a waiver for a higher copay for non-medically necessary ER visits? Even the higher amount of $10 does not appear to be a meaningful deterrent to inappropriate use of the ER. 4. How would the ER copay work? What would be criteria for applying the copay? 5. If all other copays are eliminated, especially Pharmacy copays, that may inhibit efforts to disincent the use of non-generic and non-formulary drugs. This could have cost implications. 6. Most MCOs do not currently require copays for PCP visits although the rates were reduced to account for the DPW requirement for copays for these services. How does DPW plan to adjust rates for eliminating PCP copays? 7. How will DPW adjust rates for other copay eliminations and additions? 8. What is the expected cost impact of the elimination of co-payments to insurers? Does DPW expect increased utilization of services as a result of copay reductions? 9. How, and by whom, will the inappropriate use of ER services be determined 9

10 Initial Questions - Healthy PA October 17, 2013 Healthy PA Reform Changes to Existing Medicaid CHIP Our Understanding - Is it Correct? Newly-eligible children ages 6-19 with incomes from 100% to 138% of the FPL will be enrolled in Medicaid/HealthChoices Current CHIP enrollees in that income range (children age 5 and above) will be transferred to Medicaid/HealthChoices Questions and Concerns 1. Will the newly eligible children be referred to the Enrollment Broker and follow the current HealthChoices MCO selection process? 2. Will the current CHIP children who will be transferred to HealthChoices be auto assigned to their current CHIP MCO s Medicaid product (with opt-out provisions to choose another MCO?)? How will parent company/medicaid MCO affiliations be treated? 3. How will the MCO selection process work for children who are enrolled in a CHIP provider without a Medicaid MCO product (i.e. Capital Blue Cross)? 4. Will CHIP MCOs be able to market to their members who are going to be moved to Medicaid (while still enrolled in CHIP) to help ensure continuity of care? Healthy PA Reform Newly eligible Medicaid expansion population; 0% - 138% of the FPL/Medicaid Our Understanding - Is it Correct? Medically Frail individuals may choose to enroll in the expanded Exchange or stay in HealthChoices Adults who are not Medically Frail can only receive coverage through the expanded Exchange Questions and Concerns 1. How will DPW define Medically Frail? 2. How will DPW determine if an individual is Medically Frail during the application process? 3. Can individuals who are not Medically Frail choose to enroll in HealthChoices rather than the expanded Exchange? 4. Does DPW plan to use new or different rate cells to cover this Medically Frail category? 5. How will DPW adjust rates to account for the greater percentage of high-risk individuals without the any corresponding influx of lower risk/healthy individuals into HealthChoices? 6. How will DPW adjust rates to account for pent up demand for this previously uninsured, Medically Frail category? 7. How does DPW expect to modify the MCO Pay for Performance program to recognize the significant shift in case mix for the MCOs? Will there be new P4P measures selected? Will the goals be lowered to better reflect the expected outcomes of a significantly Medically Frail population? 10

11 Initial Questions - Healthy PA October 17, 2013 Healthy PA Reform Newly eligible Medicaid expansion population; 0% - 138% of the FPL/Exchange Our Understanding- Is it Correct? All ACA-eligible individuals who are not medically frail will be enrolled in the expanded Exchange and pay a premium for services. The Feds will pick up 100% of the cost for these individuals (less premium). In 2017 the State will begin to pick up its mandated share of that cost Questions and Concerns 1. Will these individuals be eligible for the full range of benefit options (bronze, silver, gold, platinum)? 2. Will these individuals be permitted to enroll in any QHP operating in the exchange? 3. Will these QHP s be required to adopt a separate premium structure for this group of Medicaid expansion enrollees? 4. If yes, will that premium structure mirror that for the people served in Medicaid? (See questions above relating to premiums.) 5. Will the newly eligible individuals served through the Exchange receive Behavioral Health services through their Qualified Health Plan or through a Behavioral Health MCO? 6. What State savings does the Administration anticipate in the Community Behavioral Health and Drug and Alcohol programs as a result of these services being funded 100% through the Federal government? 7. Healthy PA says that the private option would provide the opportunity for children and families to receive health care through the same QHP. Please clarify what children would be eligible for the private option. It appears to us that all children with incomes below 138% of poverty would be eligible for basic Medicaid. 8. Healthy PA speaks of churn between health care providers placing a hardship upon families seeking stability in their lives. Please clarify how splitting non- TANF adults into QHPs and their children into Medicaid reduces that churn. 9. Will Managed Care Plans be required to become QHPs on the exchange? 10. Can Medicaid Managed Care plans participating in the HealthChoices program be deemed a QHP on the federally run exchange? 11. Will Medicaid Managed Care Plans making application to be accepted to become a QHP on the exchange have to have a current contract with the Commonwealth through the HealthChoices program? 12. How will rates be paid to QHPs for Medicaid population? 13. What will the network requirements/accessibility standards with Managed Care Plans on the exchange need to meet? 14. Which PA state department will have regulatory oversight of Medicaid MCOs on 11

12 Initial Questions - Healthy PA October 17, 2013 the Exchange? 15. Will Medicaid MCOs on the exchange be required to pay hospitals and providers Medicaid rates? 16. Will Medicaid members on the exchange have the ability to change plans at any time like traditional Medicaid members? 17. Will continuity of care requirements remain consistent between traditional Medicaid and Medicaid on the exchange? 18. Will people eligible for Medicaid in the exchange be auto assigned if they fail to choose a plan? What would be the distribution criteria? 19. How many plans will PA Medicaid consumers have to select from on the exchange? 20. How does the adult Medicaid benefit package today compare to the essential health benefits required under the ACA and offered by Exchange plans? 21. Will a plan participating in the Medicaid program be required to participate in the exchange program or will it be optional? 22. If a plan participates in the exchange, will it have to accept all individuals eligible to obtain insurance through the exchange, or can the plan limit its exchange options to only those individuals covered by the Healthy PA initiative? 23. Will the plan be able to determine what counties it will participate or will it be required to participate in all counties? 24. Does the State anticipate establishing a fast track for review and approval of plan exchange applications and related plan materials? 25. Will the plan establish the benefits, premiums and other program requirements or will these be determined by the State? 26. Will the State establish the amount of the premium reduction for satisfaction of the work search requirement and the health and wellness requirement? Or, will this amount be established by the plan? 27. Will satisfaction of the work search requirement be determined by the State and then periodically communicated to the plan via a file? Or, will the plan be responsible for determining whether such requirement has been satisfied and if so, what is the mechanism for making such a determination? 28. What evidence does the Administration have that the existing commercial QHPs in the Exchange are interested in making the necessary financial and 12

13 Initial Questions - Healthy PA October 17, 2013 administrative adjustments necessary to serve this low-income population? 29. What Medicaid wrap-around services will remain a non-qhp responsibility? Will those services be provided by Medicaid Fee for Service? 30. What Federal/State reporting will QHPs be required to do relative to this Medicaid expansion population (i.e. pharmaceutical information for rebates, MCO assessment information, disproportionate share information, encounter data, DPW financial reporting, etc.) 13

14 Disability Rights Network of Pennsylvania 1414 N. Cameron Street, Second Floor Harrisburg, PA (800) (Voice) (877) (TDD) VIA October 18, 2013 Beverly Mackereth Secretary of Public Welfare Department of Public Welfare P.O. Box 2675 Harrisburg, Pennsylvania Re: Healthy Pennsylvania: Reforming Medicaid Proposal Dear Secretary Mackereth: The Disability Rights Network of PA (DRN) is the organization designated by the Commonwealth to protect the rights of and advocate for Pennsylvanians with disabilities. Access to the physical and behavioral health care services provided for under the federal Medicaid program, Title XIX of the Social Security Act, is critical for children and adults with disabilities. Accordingly, DRN offers the following comments on the main concepts of the Department of Public Welfare s Healthy Pennsylvania: Reforming Medicaid (Healthy PA) proposal. In general, as described below, DRN is concerned that specific pieces of the proposal will result in significant negative impacts for Pennsylvanians with disabilities. 1. Benefits Packages: Benefits for Medicaid beneficiaries must be broad enough to meet the needs of Pennsylvanians with disabilities and should at least be maintained at the current level. Any reduction in the benefits available through Pennsylvania s Medicaid program will potentially harm Protecting and advancing the rights of people with disabilities

15 Secretary Mackereth RE: Healthy Pennsylvania: Reforming Medicaid Proposal October 18, 2013 Page 2 of 6 people with disabilities. DRN notes your commitment at the September 26th Medical Assistance Advisory Committee (MAAC) meeting that behavioral health services will be maintained and Heather Hallman s assertion at the October 8th MAAC Long-Term Care Delivery System (LTC) Subcommittee meeting that the current Medicaid benefits package will remain unchanged for those deemed as medically frail. DRN urges the Governor and Department to stand by the promise to maintain the current scope of behavioral and physical health services for Pennsylvanians with disabilities so that their complex health care needs can continue to be met. In order to fully meet the needs of Pennsylvanians with disabilities, it is also vital that no new limits be established on Medicaid services and that Pennsylvania maintain the current definition for medical necessity. Reducing the available Medicaid benefits in scope or duration, or otherwise limiting access to Medicaid services, will result in substantial negative consequences for Pennsylvanians with disabilities, such as deteriorating health and unnecessary institutionalization. DRN understands from your presentation at the September MAAC that the Department intends to establish two benefits packages, for people deemed as high-risk or low-risk. As per Ms. Hallman at the LTC Subcommittee meeting, the high-risk plan would be available for those determined to be medically frail and would include all services currently available through Pennsylvania s Medicaid program. DRN appreciates the Department s intent to maintain the current level of services for Medicaid beneficiaries. It is unclear, however, how the Department intends to define medically frail and how eligibility for these packages will be established. DRN recommends that Pennsylvania s definition for medically frail mirror the definition in federal regulations at 42 C.F.R Neither high risk nor low risk should be defined to reduce the current level of benefits under Pennsylvania s Medicaid program.

16 Secretary Mackereth RE: Healthy Pennsylvania: Reforming Medicaid Proposal October 18, 2013 Page 3 of 6 2. Premiums: The proposal to establish premiums for current Medicaid beneficiaries or for people eligible under an expansion of eligibility is troublesome. As individuals below, at, or near the federal poverty level, these low-income Pennsylvanians, including people with disabilities, will be unable to afford the proposed premiums. The imposition of premiums will thus serve as a barrier to health care. 3. Job Search Requirements: While DRN supports the promotion of independence, employment, and job search assistance for people with disabilities, the attachment of a job search and training requirement to health care services will serve as another barrier, especially given the potential negative impact on people with disabilities who are unable to work. Making job search or training a prerequisite to receipt of benefits, or tying a reduction in premiums to job search and training, will prevent many Pennsylvanians from accessing needed health care. The federal government appears to support this position, indicating in an April 6, 2012 response to Utah s proposed work requirements that the state may not impose an obligation on beneficiaries for access to health care coverage and services that is unrelated to the provision of health care coverage and services Health and Wellness Requirements: At the September MAAC, you requested ideas on healthy habits that could be used to incentivize overall health. Similar to the job search requirements, while DRN supports efforts to improve the health of Pennsylvanians, the establishment of such requirements as conditions of participation in Medicaid can again serve as barriers to accessing health care. Further, while the Department s intent is to utilize a private option under which Pennsylvanians would receive government assistance to purchase 1 Letter from Acting Administrator Marilyn Tavenner to Governor Gary Herbert, April 6, 2012.

17 Secretary Mackereth RE: Healthy Pennsylvania: Reforming Medicaid Proposal October 18, 2013 Page 4 of 6 health insurance through the federal health insurance marketplace, DRN instead supports a simple expansion of Medicaid as envisioned by Congress in the Affordable Care Act. The proposed private option adds complexity as well as additional time spent in negotiations with the federal government, which delays insurance coverage for Pennsylvanians in need, including individuals with disabilities. Because those eligible for Medicaid expansion have no other option for accessing health care, this additional negotiation time is unacceptable, especially when considering that newlyeligible Pennsylvanians would have had access to healthcare effective January 1, 2014 under Medicaid expansion. DRN therefore urges Pennsylvania to expeditiously pursue expansion of the Medicaid program under the Affordable Care Act, as numerous States have done already, to take full advantage of the higher federal match for this part of the Medicaid program. Medicaid expansion would maximize new federal dollars while affording beneficiaries the statutory protections of the Medicaid program. Years of history and economic studies have shown that commercial insurance is more costly than Medicaid. The Congressional Budget Office estimates that private insurance coverage costs 50 percent more per beneficiary than Medicaid. 2 A Milliman Healthcare Reform Briefing Paper similarly estimates that healthcare costs through the marketplace would be expected to be 40% to 65% greater than Medicaid in a competitive environment. 3 Additionally, to use the private option, Pennsylvania would need to expend resources to develop the administrative capacity to manage a private model. Medicaid expansion, on the other hand, could utilize Pennsylvania s existing administrative infrastructure to administer the expansion through Pennsylvania s Medicaid managed care system. 2 Updated Estimates for the Coverage Provisions of the Affordable Care Act, July 2012, p Considerations for Medicaid expansion through health insurance exchange coverage, April 2013, p. 2.

18 Secretary Mackereth RE: Healthy Pennsylvania: Reforming Medicaid Proposal October 18, 2013 Page 5 of 6 Medicaid expansion would therefore maximize taxpayers dollars in meeting the basic health care needs of uninsured Pennsylvanians, including children and adults with disabilities. Finally, the Healthy PA proposal is a concept paper with insufficient detail on key pieces of proposed changes. Critical elements, such as the definition of medically frail, services included in the benefits packages, and how people would move between packages based on need, must be fully described in order for there to be meaningful public input. DRN urges the Department to use a robust public input process in developing and implementing any changes to Pennsylvania s existing Medicaid program as well as plans to expand access to health care for those newly eligible under the Affordable Care Act. The disability community and others who would be impacted by changes must have ample opportunity to review and provide input into any proposals to expand health insurance or to modify the Medicaid program. Pennsylvania should at least meet the requirements in federal regulations 4 for public input of demonstration projects. DRN specifically requests that the Department make any Medicaid Waiver application or other potential proposed changes available in its entirety for public comment before being submitted to the Centers for Medicare and Medicaid Services (CMS). In addition, DRN urges the Department to provide various input opportunities, such as: use of the Healthy PA and Department websites to post detailed information in an accessible format on proposals or related materials; other distribution of accessible materials on the proposals and related information; meetings at various locations across Pennsylvania with people with disabilities and interested others to explain the core components of the proposals; webinars aimed at providing details and updates; and continued use of the MAAC and its Subcommittees for information sharing and obtaining input. Providing 4 42 C.F.R

19 Secretary Mackereth RE: Healthy Pennsylvania: Reforming Medicaid Proposal October 18, 2013 Page 6 of 6 expansive opportunities for input is in keeping with the Department s new core values of collaboration with stakeholders, communication, and accountability and is necessary to develop a final plan that will be effective for Pennsylvania, including persons with disabilities. Thank you for the opportunity to comment on the Healthy PA proposal and for consideration of our comments. Please contact DRN s Acting Chief Executive Officer, Judy Banks, at , x 305 with any questions. Respectfully, Kelly Darr Legal Director Judy Banks Acting Chief Executive Officer

20 123 Chestnut St., Suite 400 Philadelphia, PA Phone: (215) Fax: (215) Helpline: October 22, 2013 VIA Beverly Mackereth, Secretary Department of Public Welfare Harrisburg, PA Re: Comments on Healthy PA & Medicaid Reform Dear Secretary Mackereth, At your invitation, we write to provide our reactions to Governor Corbett s Healthy PA proposal. We share the Governor s belief that all of the Commonwealth s citizens should have access to quality, affordable health care, and we are encouraged by the Administration s proposal to expand coverage through Medicaid to half a million uninsured adults. As representatives of the Commonwealth s 2.2 million Medicaid consumers, the Consumer Subcommittee of the Medical Assistance Advisory Committee ( Consumers ) is the Department of Public Welfare s eyes and ears. We are part of communities whose health and well being very much depend on Medicaid, and our role is to advise on and monitor program changes and ensure that state Medicaid officials understand their human impact. Given this role, we deeply appreciate your continued commitment to work closely together in expanding and reforming the Medicaid program. Although Healthy PA is in concept form, we have a number of concerns (attached) about the legality and the policy merit of some of the proposed changes. As the Commonwealth crafts its proposal to the Secretary for the Department of Health and Human Services for permission to waive provisions of the Social Security Act governing Medicaid, we hope you will consider these comments. In advance of that submission (and thereafter), we will be available to provide additional information, clarification, and feedback. Philadelphia Harrisburg Pittsburgh Helping People In Need Get the Health Care They Deserve

21 These are extraordinarily busy times, and we appreciate the commitment and hard work of DPW staff to cover uninsured Pennsylvanians. We thank you for this opportunity to provide comments and for the Administration s commitment to sustaining and strengthening the Medicaid program. Sincerely, Consumer Subcommittee of the MAAC Yvette Long, Chair By Their Counsel: Pennsylvania Health Law Project Kyle Fisher Laval Miller-Wilson Cc: Vincent Gordon, Deputy Secretary Office of Medical Assistance Programs Leesa Allen, Executive Medicaid Director 2

22 COMMENTS OF THE CONSUMER SUBCOMMITTEE OF THE MEDICAL ASSISTANCE ADVISORY COMMITTEE ON HEALTHY PA AND MEDICAID REFORM October 22, Pennsylvania Must Ensure Demonstration Participants Receive the Benefits and Protections Required by the Medicaid Statute and Regulations a. Although Hundreds of Thousands Will Purchase Insurance in The Private Market, The Single State Medicaid Agency (DPW) Must Continue to Make Administrative and Policy Decisions for the Program Contingent on the federal government s approval, Healthy PA expands health access to individuals with incomes up to 133 percent of the Federal Poverty Level (FPL) by using Medicaid funds to purchase private health plan coverage through the Federal Health Insurance Marketplace. The federal government approved this approach in Arkansas, while maintaining a basic axiom of Medicaid law: the Medicaid state agency, which in Pennsylvania is the Department of Public Welfare (DPW), cannot delegate its Medicaid authority. The Consumers seek more information about how DPW will effectively monitor and oversee the provision of services by private health plans to private option participants. If, for example, a private health plan fails to provide a medically necessary essential health benefit (e.g., durable medical equipment, prescription drugs, mental health counseling), how will DPW ensure that the benefit is provided? Private health insurers in Pennsylvania s HealthChoices program are currently subject to extensive requirements regarding access to care, quality, collection of encounter data, beneficiary protection, and oversight. DPW, through its Bureau of Managed Care Operations, monitors the HealthChoices program aggressively compared to oversight of private health insurance plans in the Marketplace. Does Healthy PA contemplate a similar arrangement for the private health plans in the Marketplace? 1 What type of corrective action measures will the Commonwealth 1 DPW s Bureau of Managed Care Operations has several divisions: its Division of Financial Analysis develops appropriate rates to be paid to the managed care plans, and performs the financial monitoring; its Division of Monitoring and Compliance ensures that managed care plans are meeting program requirements, and that plans respond to consumer and provider concerns and develops corrective action plans as needed; and its Division of Quality Management and Special Needs Coordination collects and reports data to monitor the quality performance 1

23 demand of private health insurance plans in the Marketplace that do not meet program requirements? We have observed that the waiver the Department of Health and Human Services (HHS) recently authorized for Arkansas requires that state s Medicaid agency and Department of Insurance to both enter detailed memorandums of understanding with each private health plan that enrolls demonstration participants about membership pathways, payment of premiums and cost-sharing reductions, reporting and data requirements necessary to evaluate private option benefits, and noticing requirements. See Section VI page 12, paragraph 28, Approval of AR Health Care Independence Program. The Consumers expect Pennsylvania s application to HHS will be just as, if not more, detailed about its regulatory arrangements in order to ensure that services for demonstration participants are delivered in a manner that do not discriminate against Medicaid beneficiaries, gives participants a choice of (at least two) health insurance plans, and meets quality and network adequacy standards. b. Demonstration Participants Should Be Able to Access the Medicaid Appeals System for All Medicaid Covered Services When a demonstration participant challenges a private insurer s denial, reduction or termination of prescribed medical benefits or services, the Consumers have grave reservations if private insurance companies, rather than DPW, make the final decision on a consumer s appeal. Medicaid applicants and recipients have rights to notice and administrative fair hearings when their claims for assistance are denied or not acted on with reasonable promptness. These rights are found in the Medicaid statute and regulations, and also are guaranteed by the Due Process Clause of the United States Constitution. In Goldberg v. Kelly, the U.S. Supreme Court found that the brutal need of low-income children and adults conferred due process protections in their receipt of public assistance. 397 U.S. 254, 261 (1970). In Arkansas s recently approved waiver, appeal rights (including fair hearings) must be provided by the state in compliance with all federal and state requirements. No waiver was granted relating to appeals. See Section IX page 14, Approval of AR Health Care Independence Program. Arkansas must inform of managed care plans to ensure compliance with contract standards and coordination of services for all recipients. What will be the role of these agencies in evaluating private health plans? 2

24 applicants and beneficiaries of the right to request a hearing, the method to obtain a hearing, and the ability to be represented by an attorney or other representative. The Consumers expect Pennsylvania s waiver application to HHS will describe the content of notices and the circumstances under which private plan benefits and services will continue pending appeal. Healthy PA must ensure that demonstration participants who challenge private plans are given both the right to an internal grievance process and the ability to be heard through testimony and witnesses by an impartial decision-maker. The Consumers welcome a discussion with the Department staff in the near future about these particular processes and the resources that should be available to help consumers challenge plans denials of medically necessary services. 2 c. Current Law Governing Prior Authorizations for Prescription Drugs Should Not Differ for Demonstration Participants Section 1927 of the Social Security Act requires that prior authorization requests for prescription drugs be handled within 24 hours in Medicaid and that beneficiaries receive a 72 hour supply of a drug in emergency situations. The Commonwealth s policy is to provide a five-day emergency supply. These are protections that should not be waived under a private option delivery system. d. Healthy PA Must Allow Demonstration Participants To Change Marketplace Insurers In the Same Manner and Frequency As Current HealthChoices Enrollees Currently, the HealthChoices program allows consumers to change Physical Managed Care Organizations (MCOs) monthly. An independent Enrollment Broker (Maximus) contracted by DPW facilitates consumers choice of MCO. This protection is not used frequently. Each month, less than one percent of consumers exercise this right to change plans. There are approximately 82,000 voluntary plan changes annually. Despite its infrequent use, the Consumers believe their ability to promptly disenroll is a powerful tool for Medicaid program management. Healthy PA does not suggest this protection will change, and the Consumers expect demonstration participants will have the same ability to change Marketplace insurance plans i.e., monthly. 2 Pennsylvania might consider establishing and adequately funding independent ombudsmen and advocates with extensive knowledge of consumers rights to help individual consumers and to feed information about systemic problems to state officials and advisory committees. 3

25 . 2. The Process And Criteria for Determining Medical Frailty Should Be Clarified The final federal regulations defining alternative benefit plans for people in the new adult eligibility category provide that individuals who are medically frail as defined in the regulations must be given a choice of the traditional Medicaid benefit package and the alternative benefit plan (ABP) that would otherwise be available to that individual. Consumers who are medically frail must also be allowed to choose the traditional Medicaid delivery system. Thus, Healthy PA appears to be consistent with this portion of the regulations, but lacks detail about the ABP that would be offered as an alternative to the standard Medicaid benefit package. The Consumers support providing medically frail individuals with traditional Medicaid coverage to ensure that they receive the full scope of Medicaid benefits. We assume that most individuals who are medically frail will choose to receive traditional Medicaid benefits and the traditional Medicaid delivery system (the HealthChoices program). 3 Given this expected increase, does the Commonwealth contemplate making additional arrangements with HealthChoices plans to insure care for this group vulnerable group? 4 Moreover, the Healthy PA proposal does not provide sufficient information regarding the process and criteria that will be used to determine whether an individual is medically frail. It is not clear whether the approach proposed by the state will actually identify those who are medically frail within the definition set forth in Medicaid regulations at 42 CFR (f). The Consumers urge state officials to share as soon as possible the screening tools they are considering to determine whether an individual may be medically frail/have exceptional needs. 3 Although, Pennsylvania s approach of giving medically frail individuals a choice is required by federal regulations, Pennsylvania s approach might undermine the expected rationale and cost effectiveness of the demonstration. If the hypothesis of state officials is that those enrolled in the demonstration will have lower rates of preventable hospital admission than those in traditional Medicaid, can the hypothesis be truly tested if those who are the sickest remain in traditional Medicaid? 4 This calendar year, the Department announced Keystone Mercy Health Plan (now Keystone First), the Southeast region s largest Medicaid managed-care plan, would no longer take new members, in part because of overenrollment by medically frail individuals. The Consumers seek greater understanding about health plan enrollment and provider access if more medically frail individuals are placed in HealthChoices. 4

26 3. Cost-Effectiveness of Premium Assistance in Medicaid All premium assistance options that will be approved by HHS require states to establish that the cost of covering an individual through premium assistance in the private Marketplace must be the same or less than providing comparable coverage to the individual in the traditional Medicaid program. Centers for Medicare and Medicaid Services and the Affordable Care Act: Premium Assistance (March 29, 2013). Under this standard, a state must include the cost of providing wraparound benefits that are required for an Approved Benefit Plan but not covered by private insurance on the Marketplace. One of the most significant wraparound benefits is non-emergency medical transportation. As noted above, the consumers seek to learn more about the arrangements for accessing transportation to medical services for consumers who do not have other transportation available to them. Counties have typically provided these services at relatively low cost. How will private health insurers deliver these services, and will their costs be at amounts comparable to the current Medical Assistance Transportation Program? Healthy PA assumes the use of expansion funds to buy private coverage for Medicaid beneficiaries through the new health insurance exchange will be more cost effective than a traditional Medicaid expansion. The Consumers seek more information about this assumption. Will Pennsylvania s demonstration application compare costs under the private option demonstration to costs that would have happened under expansion through HealthChoices or Medicaid fee-for-service? The Congressional Budget Office estimated the per capita cost to provide Medicaid coverage to the expansion population to be $6,000 per year, whereas the cost to purchase comparable insurance through a health insurance marketplace is predicted to be $9,000 per year. 5 In Massachusetts, which has a long established health insurance marketplace, the yearly cost of Medicaid in 2009 was $2,965 whereas the cost of a comparable exchange plan was $5,143. Whether Medicaid premium assistance programs can deliver on comparable costs remains an open and critical issue. The Consumers urge the Commonwealth to be open and transparent with all stakeholders about this matter. 5 Congressional Budget Office, Estimates for the Insurance Coverage Provisions of the Affordable Care Act Updated for the Recent Supreme Court Decision (July 2012) 5

27 4. Healthy PA's Proposed Benefit Redesign is Unlikely to Achieve Significant Cost- Savings Healthy PA proposes to reform the existing Medicaid system by simplifying the existing 14 adult benefits packages into two commercial-like alternative benefit packages: one will be for federally-protected medically frail group, and one will be more like the required essential health benefits (EHB) in the Marketplace. Adult consumers would receive a high risk or low risk benefit package based on their level of care needs. The Consumers would like to learn more about this aspect of the proposal, specifically: By what standard and process will DPW assess "high risk" and "low risk"? What will be the criteria to assign members to each set of benefit packages? How would the types of services differ between the high risk package, the low risk package, and the current benefit package for categorically-needy adults (e.g., HCB02)? How would limitations on services differ between the high risk package, the low risk package, and the current benefit package for categorically-needy adults? The Consumers are skeptical that Healthy PA s proposed benefit redesign will achieve significant cost-savings. Long-term care costs are the primary cost driver in Pennsylvania s Medicaid program. The Commonwealth spends over $21,000 per aged enrollee, which is well above the national average of $13, In contrast, its spending on children, parents, and individuals with disabilities is near or below national averages. Further, our spending on aged Medicaid beneficiaries, who also have Medicare, is disproportionately skewed towards long-term care services, as opposed to acute care. 7 Altering the benefit package available to adult consumers will do little to change these realities or control costs. 5. Experience Shows Premiums Will Result in Significant Disenrollment Healthy PA proposes to overhaul the current Medicaid cost-sharing arrangement by eliminating copays and imposing a sliding scale premium structure for adults with income between 50 and 133 percent FPL. Premiums would be capped at $25 for an individual and $35 for a two-adult household. Consumers could have their premiums reduced by participating in wellness activities or job search and training programs. 6 Kaiser Family Foundation, Medicaid Payments per Enrollee (FY 2009), available at: 7 In Pennsylvania, 84 percent of spending on dual-eligibles goes towards long-term care. Kaiser Family Foundation, Distribution of Medidaid Spending for Dual-Eligibles (FY 2009), available at: 6