CLS Testimony on Community Health Choices
CLS Testimony on Community Health Choices
CLS Aging and Disabilities Unit Staff Attorney Testimony of Pamela Walz, Esq., delivered the following testimony on Community Health Choices before the Philadelphia City Council on October 22, 2018
Good morning. My name is Pamela Walz, and I am a supervising attorney in the Aging and Disabilities Unit at Community Legal Services. Community Legal Services (CLS) has provided free civil legal assistance to more than one million low-income Philadelphians during the past 50 years. CLS assists clients when they face the threat of losing their homes, incomes, health care, and even their families. CLS attorneys and other staff provide a full range of legal services, from individual representation to administrative advocacy to class action litigation, as well as community education and social work. CLS is nationally recognized as a model legal services program.
My unit, the Aging and Disabilities Unit, focuses on the legal needs of older adults and people with disabilities. One of our main areas of focus is access to long term services and supports (LTSS). We represent Philadelphia seniors and people with disabilities who have been denied LTSS through the Medicaid waiver programs in administrative appeals, helping them to establish or keep eligibility for the program or to be approved for particular waiver services they need. We also represent nursing home residents in Medicaid eligibility, quality of care, and residents’ rights issues. In addition to providing legal assistance to individual clients, we also engage in administrative advocacy with the Department of Human Services and other state agencies to remove barriers and improve these programs.
As you have heard in testimony earlier this morning, Community HealthChoices is coming to Philadelphia on January 1, 2019, which means that nearly 90,000 Philadelphia residents will have their Medicaid coverage changed from the fee-for-service model to managed care. Those to be enrolled in CHC include two groups: those who are eligible for both Medicaid and Medicare (often called “dual eligibles”) and those receiving LTSS. The dual eligible population are the lowest-income Medicare beneficiaries, and have higher than average rates of poor health, chronic disease and cognitive impairment. The population receiving LTSS have been assessed to need nursing home level care because of physical disability or dementia. These groups are therefore among the most vulnerable individuals in the City.
Pennsylvania has enrolled other populations of Medicaid recipients in managed care since the 1990s. What is different about Community HealthChoices is that this is first time that people receiving LTSS will be enrolled in managed care. Managed care organizations have a long history of providing medical services to Medicaid recipients, but LTSS are provided in a manner that is often referred to as a social model rather than a medical one. These are services which may include an attendant to help the consumer with activities of daily living like bathing and getting dressed and getting in and out of bed. The attendant may also prepare meals, do some cleaning and help the consumer get to appointments. In addition to taking care of daily living needs, LTSS are intended to make it possible for the individual to participate as fully as possible in their communities, including transportation to enable them to participate in social and community activities and supports to help those who want to pursue employment. A concern about Community HealthChoices is whether the CHC managed care plans will embrace and successfully implement this social model of services, rather than seeing their responsibility as providing mainly medical-based services based on narrow conceptions of medical necessity.
Another immediate concern is making sure that those who will be enrolled in CHC understand what is happening and how the program works. During September and October, Philadelphia residents have received pre-enrollment packets explaining that they will be enrolled in CHC and instructing them to contact the Independent Enrollment Broker, Maximus, to select one of the three CHC managed care plans. The Department and its subcontractors are to be applauded for the big effort they have put into holding approximately 60 community education sessions on CHC throughout Southeastern Pennsylvania. However, there are many individuals who will not have been able to attend those sessions and will need information about the program. We are especially concerned about individuals in the LTSS programs, many of whom are homebound and could not get out to one of these sessions. The Department’s plan is for their service coordinators to provide education to this population, and the Department created on-line training for service coordinators to prepare them for this task. However, so far only about 6% of the population who are receiving LTSS in the community has received an outreach from their service coordinators. We are very concerned that many of those who are the most dependent on these Medicaid services will not receive the information they need to choose a CHC plan and will not understand what is happening when this transition occurs.
We are also hearing a lot of concerns from recipients about whether they can keep their physicians who accept Medicare but may not join the CHC managed care plans’ networks. The answer to this question is yes, as long as the provider is treating them for a Medicare-covered service. On the other hand, for services covered only by Medicaid and for enrollees who do not have Medicare, they will need to make sure their providers are in their CHC managed care plan’s network. This interaction between Community HealthChoices and Medicare is complicated and confusing, which presents a huge challenge in preparing the dual eligible population for this transition.
There will be a continuity of care period during the first six months after the CHC roll-out, during which the CHC managed care plans are required to pay all of their enrollees’ providers, regardless whether or not they are in the plan’s network. The plans are also not allowed during this six month period to reduce the services provided under their members’ LTSS service plans. This is an important protection, to provide time for enrollees to learn about their plans, and for their providers to enroll in plans or for enrollees to consider switching providers or switching to a plan that includes their provider. It also provides time for the plans to assess the needs of their members who receive LTSS and avoids sudden cuts in the types or hours of services that those members receive. However, based on the experience in other states, we are concerned whether the CHC plans will inappropriately reduce the number of hours or the types of services participants are currently receiving after the continuity of care period ends on June 30, 2019. If this happens, it will threaten these individuals’ quality of life and their ability to avoid having to enter a nursing home. The Department has stated that it is not their intent to permit such reductions and that it will closely monitor the CHC plans, but we will all need to be watchful to ensure that this does not happen.
I’d like to finish by talking about an important need and an opportunity. First, there is a great need for supports, like an ombudsman program, to help people navigate the CHC program and to help them understand how CHC functions, how it interacts with their Medicare and other coverage, what their rights are, and how to file appeals if they are denied services they need. There will also be a need for legal representation for CHC enrollees in these appeals. The enrollee is entitled to a hearing if the CHC plan denies coverage for care or services, but this is a protection that is much more likely to be meaningful if the enrollee has legal representation, especially since the managed care plans will be represented by counsel at hearings. Based on experience with the existing Medicaid managed care plans, we know that appellants are much more likely to succeed if they have a lawyer because attorneys know the governing regulations, and how to frame the issues, present evidence and make effective arguments. These beneficiary support programs have not been fully developed yet by the Department and remain a big need to be addressed.
Finally, CHC represents an opportunity for many participants to access better behavioral health care. Until now, dual eligible and those in the Aging waiver, the LTSS program that serves people who are 60 and older, have not been eligible to receive behavioral health services from Community Behavioral Health (CBH). Instead, they could only access these services through the fee-for-service system, which has few providers enrolled. Nursing home residents have also had access only to limited behavioral services. With the roll-out of CHC, all of these populations will now be eligible to get behavioral health services from CBH, and the CHC managed care plans are required, under their contracts, to coordinate services with CBH. This is a great opportunity to fill a big need. In order to realize this opportunity, it will be crucial for CBH to become familiar with these populations and their needs, to develop and make appropriate services available, and to coordinate with the CHC plans, nursing homes and other providers.
Thank you for inviting me to speak today, and I would be happy to take any questions you may have.