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Testimony on Problems with Aging Waiver Applications and Pennsylvania's Shift to Managed Long Term Care

Aging and Disabilities

Testimony on Problems with Aging Waiver Applications and Pennsylvania's Shift to Managed Long Term Care

Date Posted: 

The following testimony was delivered by Pam Walz, Co-Director of CLS's Aging and Disabilities Unit, to the Pennsylvania Senate Aging and Youth Committee and the Pennsylvania House Aging and Older Adult Services Committee on October 18, 2016.

Good morning, Chairman Hennessey, Chairman Samuelson, Chairwoman Brooks, Chairman Haywood and other distinguished members of the committees.  Thank you for the opportunity to speak to the committees today on this important subject.  My name is Pamela Walz and I am the Co-Director of the Aging and Disabilities Unit at Community Legal Services.

Community Legal Services provides free legal services to address the legal needs of low‑income Philadelphia residents in civil matters affecting their families, their health, their jobs, their homes, and their incomes.  The unit that I work in, the Aging and Disabilities Unit, specializes in assisting older adults and people with disabilities facing barriers to health care coverage and difficulties in accessing specific health care services, including the Medicaid waiver cases that are the subject of the hearing this morning.  We advise clients and provide representation in appeals relating to financial and medical eligibility, enrollment, and access to services through Medicaid, including the waiver programs. We also represent residents of long term care facilities and have participated extensively in stakeholder groups including the Medical Assistance Advisory Committee’s Long Term Care Subcommittee. 

Our unit often receives requests for representation from older adults and people with disabilities who are having difficulty accessing waiver services.  Since April 1, 2016, when Maximus, as Independent Enrollment Broker (IEB), assumed responsibility for Aging waiver applications and the eligibility determination process was significantly changed, our clients have faced enormous new hurdles and lengthy delays in attempting to access waiver services. 

The first new hurdle is in simply getting an application filed.  Prior to April 1, individuals 60 and over called their AAA to apply for waiver services.  The AAA would schedule an in-home appointment to perform a level of care assessment, and at that appointment the AAA assisted the applicant in completing the PA 600, which is the Medicaid application.   In addition to answering all of the questions on the application, the applicant must submit a great deal of verification, including written proof of certain income sources, copies of as much as several years’ worth of bank statements, and proof of the current cash value of each life insurance policy.  This verification can be difficult for waiver applicants to gather, especially if they have severe physical or cognitive impairments, and the AAA workers would help hunt around the house or go through stacks of paper if necessary to help the older adult find what was needed.  The AAAs recognized that providing this assistance was the only way these frail individuals would be able to get through the application process.  For waiver applicants who were under 60 years of age, Maximus also provided assistance with completing the Medicaid application prior to April 1.

Starting April 1, however, Maximus began processing applications for individuals of all ages, and stopped providing this assistance.  Instead, the first step after the consumer’s initial call to Maximus is that Maximus mails an application packet to the applicant.  The application packet until recently consisted of 55 pages of documents, although we understand that it has been somewhat slimmed down, and some of these forms are written at a college reading level.  The onus is now on the applicant to read and complete these forms, and then return them to Maximus in order to start the application process.  If the forms are not returned, there is no follow-up by Maximus or the Department of Human Services, and the individual is left without services.  This is simply unworkable for waiver applicants, who by definition are likely to have difficulty with tasks like completing large packets of complicated financial paperwork due to cognitive impairments and/or physical impairments that may make it difficult to see or write.  Some applicants have limited English proficiency or lack the literacy level to understand the forms, and we think that many people would be overwhelmed by such a thick stack of papers to read and complete.   And in fact Department’s data shows that 76% of applications mailed out to callers by Maximus since April have not been returned;  80% of the individuals who did not return their applications were age 60 or over.  This represents over 8,600 people, 6,858 of whom are 60 or over, who called to apply for waiver services but have not succeeded in filing an application.

We are glad that the Department is planning to address this serious problem by having Maximus staff and person-centered counselors from the Aging and Disability Resource Centers (ADRCs) begin to offer assistance with applications.  However, we remain concerned about the details of how this will work.  It is essential that this assistance be proactively offered rather than requiring applicants to request it.  Before applicants see the paperwork, they may not realize how extensive and complicated the forms are and some may be reluctant to admit that they need assistance. We are also concerned that if applicants are required to call another agency to ask for assistance, some will not be able to do so or will get lost in the shuffle.  Applicants must already interact with at least five different entities in order to access waiver services (including Maximus, the Area Agency on Aging, the County Assistance Office, the service coordination agency, and either a home care agency for consumers using the agency model or the fiscal intermediary for those using the consumer directed model).  Each of these entities has a different function, and understanding their roles is extremely confusing for consumers, especially when they are first applying.  Instead of requiring applicants to contact yet another agency, we urge that applicants be seamlessly connected to application assisters, and the default assumption should be to schedule an appointment to assist with the application. 

We are also concerned about whether the ADRCs have sufficient capacity to provide the assistance needed.  We understand that some of the counselors are volunteers and have some concerns about the appropriateness of having volunteers handling these tasks.  It is also critically important that these services be implemented as quickly as possible. 

In addition to helping applicants complete the PA 600, assistance should be provided in gathering the verification documents needed, as the AAAs previously did.   One thing we are very pleased about is that we understand that the assistance to be provided will include following up with applicants’ physicians to urge them to complete the physician certification forms, as AAA workers formerly did.  This is very important, since doctors often don’t return these forms for many reasons.

The Department should also reach out to those who contacted Maximus but did not return their applications since April to provide assistance applying.  This is critically important since those individuals have been without services or help due to the flawed change in the application process.

A second issue I’d like to address is the lengthy wait time to access services that our clients who have managed to apply are experiencing.  In particular, disconnects of communication between the AAAs and Maximus have been a serious problem.  The story of a current CLS client illustrates the problem.  My client Elizabeth Detterline is a retired social worker from South Philadelphia who suffers from rheumatoid arthritis, diabetes, neuropathy and asthma.  She applied for Aging waiver services on April 1, 2016.  On April 29, her level of care determination was completed by the AAA and she was assessed as meeting the level of care requirements for waiver.   Spring and summer went by, and Ms. Detterline heard nothing further about her application.  She called Maximus repeatedly for five months to ask what was going on, and was told that Maximus had not yet received her level of care determination. She later learned – after coming to legal services for help - that the AAA had sent the level of care determination to Maximus on May 3, but apparently it was missing a supervisor’s signature.  However, instead of Maximus following up with the AAA to get the signature, her application fell into limbo.  Even after our office contacted officials at the Office of Long Term Living (OLTL) about the problem, it took nearly another month for Ms. Detterline to finally get to the next step of the process, her in-home visit from Maximus, and she is now going through the financial eligibility determination step with the County Assistance Office.  By the time she gets an eligibility decision, it will have taken seven months.

There also appears to be a problem with delays in starting services after applicants are found eligible.  My client Cynthia Rush applied for Aging waiver services on April 22, 2016 and received a determination that she was eligible for waiver on June 13, within the 60 day application time frame in the Maximus contract.  At the end of June, a person came out to see Ms. Rush from the service coordination agency she had selected and told her that services would start in a couple of weeks.  When several weeks went by and she did not hear from anyone, she called Maximus, which said to call the service coordination agency.  She called the service coordination agency repeatedly, and was told that they were awaiting approval of her service plan.  Eventually the service coordinator stopped calling her back.  After she had been waiting for two months, a health care provider referred her to legal services and we contacted OLTL.  Ms. Rush’s services finally started in early October, five and a half months after she applied and three and a half months after she was found eligible.   

I’d like to close by noting that the changes which we are discussing this morning are happening in the context of much bigger changes which are soon to come and carry the risk of further disruptions in access.  Most significantly, the Department’s Community Health Choices proposal will shift the entire Medicaid long term care population as well as several hundred thousand dually eligible individuals who receive both Medicaid and Medicare to private managed care plans beginning in the southwest in July 2017 and in the southeast in January 2018.  This is a massively complicated endeavor with many moving parts.   In addition, the Department will soon be releasing an RFP for the Independent Enrollment Broker function to do both what Maximus is currently doing and also to provide choice counseling to assist Community Health Choices participants in choosing managed care plans starting next spring.  The Department is also changing its level of care eligibility determination process, also next spring, to a new tool which will utilize an algorithm to determine whether applicants are functionally eligible.  This will require careful implementation to ensure that the algorithm works and that eligibility notices provide sufficient information about the specific reasons for eligibility decisions to meet due process requirements.  We are extremely concerned that with so many changes happening on a very aggressive timetable, there could be more roll-outs which cause disruption in access to waiver services.  We therefore strongly urge caution to ensure that sufficient planning and readiness review takes place so that frail older adults do not lose access to services they rely upon to meet essential daily needs.

Respectfully submitted


Pamela Walz

Co-Director, Aging and Disabilities Unit

Community Legal Services