A Q-and-A on state's pending changes to Medicaid-funded long-term care

There are so many questions facing southwestern Pennsylvanians soon to be inducted into Pennsylvania’s new Community HealthChoices program for Medicaid recipients that it wasn’t possible to address them all in this recent story.

Nor is it possible to address them all with this one blog post. For one thing, I don’t yet know — if I ever will — all the right answers about this intersection of managed care and long-term care and Medicaid benefits and Medicare services that’s going to affect some 100,000 southwestern Pennsylvanians come Jan. 1.

It’s a rather complicated switch, and my own aging brain seems to slow down when it comes in contact with big government initiatives like this one. (God forbid if I were one of the people actually affected by it, maybe in some stage of cognitive decline, maybe relatively uneducated to begin with, maybe becoming aware of Community HealthChoices for the first time now as a result of some brief mailing instead of having written articles about it for the past year and a half.)

But limited as I am, I did have an interview last week with key Wolf administration officials running the new program, I’ve viewed some webinars in which good old CHC was discussed, and I’ve read some materials describing it. If I can’t take a stab at explaining it to whatever readers care about it, I’m pretty worthless as a journalist. So here’s a Q-and-A that may or may not be helpful:

Who is affected by Community HealthChoices on Jan. 1?

About 100,000 residents of Allegheny, Armstrong, Beaver, Bedford, Blair, Butler, Cambria, Fayette, Greene, Indiana, Lawrence, Somerset, Washington and Westmoreland counties whose combination of age, income and health criteria means they either: a) qualify for both Medicaid and Medicare b) are in what’s known as a Medicaid waiver program currently providing services for older adults and younger ones with physical disabilities c) reside in a nursing home in which Medicaid is funding their care. CHC expands within the following year to go statewide and cover an additional 300,000 such individuals.

How will it change their lives?

Instead of having Medicaid-funded services arranged for them currently by an Area Agency on Aging, Center for Independent Living or other government contractor, they will choose one of three state-approved managed care organizations to coordinate those services. The MCOs are UPMC Community HealthChoices, PA Health & Wellness or AmeriHealth Caritas.

Why does the state believe that will make things better?

The managed care organizations have financial incentives to do a better job of helping people avoid unnecessary, undesired and expensive use of hospitals and nursing homes. Their service coordinators are supposed to take a larger role in understanding their clients’ various health problems and linking them to a wider array of care options — especially at home and community settings — than they may have been aware of.

How will people figure out which managed care organization to select?

Each MCO is presently arranging its own network of providers of various long-term care and health services it will work with and connect its clients to. In many cases, these providers will be someone a consumer already uses and will want to retain, so they will likely select an MCO with that provider in its network. (Providers can partner with more than one managed care organization, however.) A mailing from the state in September will notify individuals how to use what are called independent enrollment brokers — unaffiliated with any of the three MCOs — to help them select an organization.

What if an individual doesn’t act to select a managed care organization?

An MCO will automatically be assigned, which state officials say they would rather avoid.

Does this mean everyone’s services change on Jan. 1?

No. People will have the option then to start making changes, but for those satisfied with services as they are, they are guaranteed a period of at least 180 days in which they can retain them.

How does this affect people who are already in nursing homes through Medicaid funding?

While also enrolled in Community HealthChoices, they will be allowed to remain in whatever nursing home they are in as long as they wish. State officials believe, however, that the program will create more opportunities for residents capable of returning to community living to receive assistance in doing so.

How are individuals with cognitive problems supposed to make a managed care decision?

State officials say they will be contacting nursing facilities and caregivers of people with cognitive problems to make them aware of Community HealthChoices and the need to assist such individuals in selecting an MCO.

What if consumers in the program don’t like the decisions the MCOs are making pertaining to their care?

There will be an appeals process, though I don’t pretend to understand that yet and will explain it later.

You haven’t even come close to answering my questions here. How can I get more information?

The Department of Human Services will be updating its website with information at www.healthchoicespa.com and consumers may also call 1-833-735-4416 during normal office hours, as the state has contracted with a service supposed to answer questions by phone. The state will also be sending out a mailing to affected individuals in September with more information.

Gary Rotstein: grotstein@post-gazette.com or 412-263-1255.


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