Governor Wolf’s proposed 2015-16 budget commits to increasing opportunities for older Pennsylvanians and individuals with physical disabilities to remain in their homes. To do so, the governor has directed the Departments of Human Services (DHS) and Aging (PDA) to develop a plan to implement a Managed Long-Term Services and Supports (MLTSS) program for older Pennsylvanians and adults with physical disabilities called Community HealthChoices (CHC).
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What is MLTSS?
Managed Long Term Services and Supports is the delivery of long-term services and supports (LTSS) through capitated Medicaid managed care programs.
It refers to an arrangement between Pennsylvania's Medicaid programs and contractors. The contractors receive capitated payments for LTSS and are accountable for the health and welfare of participants through the delivery of services and supports that meet quality and other standards set in the contracts.
We are committed to creating a system that allows Pennsylvanians to receive services in the community, preserves consumer choice, and allows consumers to have an active voice in the services they receive. This initiative will result in a more strategic care delivery system and improve health outcomes for seniors and individuals with disabilities. CHC will create a capitated model that will improve care coordination and health outcomes while allowing more individuals to live in their community. CHC will expand home and community-based services, promote community inclusion, ensure quality and increase efficiency.
What is Community HealthChoices (CHC)?
Community HealthChoices is a new initiative that will use managed care organizations to coordinate physical health care and long-term services and supports (LTSS) for older persons, persons with physical disabilities, and Pennsylvanians who are dually eligible for Medicare and Medicaid (dual eligible).
What are the goals of CHC?
Am I eligible for CHC?
You are eligible for CHC if you are over 21 years old and:
You are not eligible for CHC if you:
If you are eligible for, and select, the LIFE program, we will not enroll you in CHC unless you specifically ask to be moved to CHC.
I receive services through the Department of Aging’s Options Program. Will I still be able to get services through them?
If you are a dual eligible, but do not qualify for Medicaid LTSS, you can continue to get your long-term services through the Options program. You will get your Medicaid health care services through CHC and your LTSS through Options. If you become clinically eligible for nursing facility level of care, you may apply to get your LTSS through CHC.
How do I apply for CHC?
We have created this application guide to help walk you through the process.
If you are eligible, our enrollment assister will talk to you about your CHC Managed Care Organization (CHC-MCO) options and enroll you in the program. You will have your choice of CHC-MCOs (or LIFE program, where available) and will receive counseling to help you to decide which CHC-MCO best meets your needs. If you do not choose a CHC-MCO, we will automatically assign you to a plan based on your needs.
What services will CHC cover?
CHC covers the same physical health benefits that are currently available through the Medicaid Adult Benefit Package.
If you are eligible for LTSS, all services currently available in the Office of Long-Term Living waivers will be included in CHC. The following additional services will also be available:
How will I get behavioral health services through CHC?
The way you access behavioral health services will not change. Behavioral health services will continue to be offered through the existing network of behavioral health managed care organizations (BH-MCOs)CHC-MCOs and BH-MCOs will work together to ensure everyone gets the coordinated services they need.
Will the current OLTL waiver programs continue to operate as separate waivers?
One CHC waiver will cover all participants who meet the eligibility for nursing facility level of care. As CHC rolls across the state, participants will transition from their waivers to CHC.
The OBRA waiver will continue to serve 18 through 20 year olds and those who are 21 years and older who meet the intermediate care facility/other related conditions level of care.
Will I have to change my provider?
If you do not live in a nursing facility, you can keep all of your current service authorizations and can stay with your current Medicaid providers for 180 days or until your new service plans are implemented, whichever is later. This includes your current service coordinators.
If you are a nursing facility resident at the time of CHC implementation, you can remain in that nursing facility for as long as you wish (if you remain eligible).
If you live in the community at the time of CHC implementation, and choose to remain in the community, the CHC-MCO will support your choice.
After the initial implementation, new enrollees and those that transfer to a different CHC-MCO will have a 60-day continuity of care period for existing services and providers. During this time participants will be helped by their service coordinator and CHC-MCO to choose providers who meet their needs.
Does CHC cover assisted living facilities?
CHC will not pay for room and board in assisted living facilities. However, it will be an allowable setting in which to receive certain home- and community-based services covered by CHC.
Will the CHC-MCOs offer contracts to all current MA providers?
All current MA providers in good standing that are willing to enter into an agreement with a CHC-MCO will be included in CHC-MCO’s provider network for a minimum of the first six months of implementation in the zone. Prior to implementation and during the six month period, CHC-MCOs will contract with willing and qualified providers of all types to make up their provider networks. CHC-MCOs are required to create a provider network that meet the needs of their participants and allows participants to have choose in providers. After the initial six month period, CHC-MCOs are not required to contract with all existing MA providers.
How will you guarantee that MCOs offer competitive rates?
The CHC-MCOs must provide all covered services and meet access to care standards. MCOs will not be able to meet network standards without offering competitive rates.
If a provider type must be included in the network, but there is a shortage of these types of providers, the MCOs will need to pay competitive rates to ensure access to these services.
Can the MCOs directly provide services like home health and home care?
The MCOs may have affiliated service providers. However, DHS requires that all providers that are related parties to a CHC-MCO must be willing to negotiate in good faith with other CHC-MCOs to ensure all CHC participants in any CHC-MCO have adequate provider choice within their network.
Who is responsible for service coordination in CHC?
The CHC-MCOs will be responsible for assuring that service coordination is provided. That will be done either through contracts with service coordination entities or through internal CHC-MCO service coordination staff.
How will the commonwealth ensure that service coordinators include all needed services in the service plan?
Service coordinators will work with participants and their supports to ensure the participant’s person-centered service plan meets their needs. Participants must be provided all needed, covered services. There are many ways that the commonwealth will monitor this requirement:
Who will perform the long-term services and supports clinical eligibility determinations?
The commonwealth will select a provider to perform clinical eligibility determinations.
What tool will be used for the level of care determination?
The commonwealth will develop a standardized level of care tool to replace what is currently used. The tool will comply with all federal and state laws and regulations. This tool is being developed with stakeholder input.
How can I stay involved in the process?
The commonwealth has had, and will continue to have, an extensive stakeholder engagement process throughout the implementation of CHC. Stakeholder input is key to the overall success of the program. The commonwealth is committed to drawing stakeholder input by: