1. Is there any option to stop this proposal or get involved in its evolution?
2. Will family members be able to be paid as caregivers under managed long-term services and supports (MLTSS)?
3. What happens to participants who are already enrolled through the Office of Long-Term Living (OLTL)?  Will they have to re-apply for services under this new model?
4. Is there any plan for consumers to keep the services they currently receive or will everything get re-assessed?
5. What if the clients don’t have insurances to pay for services or any medication that they need?
6. Could PA stipulate that all qualified providers be permitted to be in a managed care organization’s (MCO’s) provider network?
7. Philadelphia County did a carve out when behavioral health went managed care under Community Behavioral Health (CBH).  Do you see this happening for this managed care transition?
8. Is there a quantitative outcome measure across all systems?

More questions were asked during the session, these are only the questions we were not able to get to during the presentation.


1. Is there any option to stop this proposal or get involved in its evolution?

This proposal is coming from the Governor himself (the general idea – not the details) so stopping it will be difficult.  Getting involved in its evolution is essential.  Information on the public forums is on the Department of Human Services website.  People are encouraged to submit comments in writing by July 15 to RA-MLTSS@pa.gov or April Leonhard, Department of Human Services Office of Long-Term Living, Bureau of Policy and Regulatory Management, P.O. Box 8025, Harrisburg, PA  17105-8025.

Deputy Secretary Burnett has stated that there will be opportunities for input even after July 15, although more aspects of the proposal will be set after that.  She has also been open to the idea of focus groups on select topics.  If there are specific areas that people are particularly concerned about, such as person directed services, people should include recommendations on the creation of focus groups on those topics.


2. Will family members be able to be paid as caregivers under managed long-term services and supports (MLTSS)?

    The Department of Human Services (DHS) has been silent on this question.  However, currently individuals in the consumer-directed model are permitted to pay family members other than spouses and guardians as caregivers under existing OLTL waivers. Most other states that have adopted MLTSS models have allowed family members other than spouses to be paid as caregivers. Arizona and Vermont do allow spouses to serve as paid caregivers, with certain restrictions, if the consumer is using participant-directed services.


3. What happens to participants who are already enrolled through the Office of Long-Term Living (OLTL)?  Will they have to re-apply for services under this new model?

    We need to distinguish re-applying for waiver versus re-applying for specific services currently being received under the waiver.
    If DHS keeps the existing waivers (as opposed to folding the waiver services into some global benefit package), there should be no need to “re-apply” for the waiver beyond the usual annual income re-determination.  As to “re-applying” for specific services or if the waivers are folded into some global benefit package, see the response to question 4.


4. Is there any plan for consumers to keep the services they currently receive or will everything get re-assessed?

The Discussion Document states that there will be “a standardized and validated assessment tool that reviews an individual’s physical, psychosocial, and functional needs and preferences”. So, at some point, the new health plan or its contractor would do an assessment of service needs for everyone and presumably, everything will get re-assessed. Following that assessment, a new service plan would be developed. That service plan might be different from the individual’s previous individual support plan (ISP). The Discussion Document does state that “Continuity of service protections [will] remain in place until the new service plan is developed and implemented”. Individuals whose services would be reduced under the new service plan would have the right to appeal and it appears that they would continue to receive their previous level of service if they appealed within 10 days. Nonetheless, the design of the “assessment tool” that will be used by health plans will be critical since it will drive what services the individual ultimately receives. Ensuring consumer involvement in its design is critical. Comments to DHS on this are important.


5. What if clients don’t have insurances to pay for services or any medication that they need?

    MLTSS would combine health insurance through Medicare and Medical Assistance, including prescription coverage, with coverage for home and community based services (HCBS) that are now covered under the OLTL waivers for people who are or would be eligible for those programs under current rules. This proposal does not affect eligibility for Medicare or Medical Assistance so it does not affect people who don’t have insurances. Medical Assistance eligibility was recently expanded by Governor Wolf to cover many people who previously did not have health insurance. Subsidized health insurance for many other people without insurance is also available through Healthcare.gov although the enrollment period for that coverage is over for this year.


6. Could PA stipulate that all qualified providers be permitted to be in a managed care organization’s (MCO’s) provider network?

    Yes, but that is unlikely, except for some specific types of providers. The HealthChoices physical health MCOs only have to allow all qualified providers to enroll in their network for a few types of providers. Allowing MCOs to decide which providers are in their network is a core component of managed care – for better or for worse. However, it is important to have a mechanism by which consumers can use an out-of-network provider while transitioning to MLTSS and in situations where specialized services are required and the MCO lacks network providers in the consumer’s area that have the expertise to provide that type of service. Again, comments on this point to DHS are encouraged.


7. Philadelphia County did a carve out when behavioral health went managed care under Community Behavioral Health (CBH). Do you see this happening for this managed care transition?

    Actually, behavioral health was carved out for most counties, not just Philadelphia. However, under the current MLTSS proposal, it would NOT be carved out. The health plans that get the MLTSS contracts would be responsible for covering behavioral health. That is the way most commercial health plans operate. However, existing Behavioral Health MCOs, like CBH, may be able to continue managing behavioral health for individuals enrolled in MLTSS if the health plans choose to contract with those behavioral health managed care organizations (BHMCOs). It may even be possible to maintain the currently behavioral health carve out in the new proposal if there is a strong advocacy effort to keep it.


8. Is there a quantitative outcome measure across all systems?

We don’t have that under our current systems. DHS argues that creating outcome measures across all systems will be possible with MLTSS because those systems will be combined. The Discussion Document states: “MLTSS will incorporate a comprehensive quality strategy that considers all aspects of acute and long term services and supports (LTSS) services and evaluates outcomes and quality of life.” See page 14 of the Discussion Document for more details. Outcome measures have not been adopted for MLTSS yet but DHS is looking to the National Quality Forum for guidance and is certainly open to comments on this issue.