Community healthchoices overview - Dering



CHC OverviewTable of Contents TOC \o "1-3" \h \z \u Welcome PAGEREF _Toc16231528 \h 1Course Objectives PAGEREF _Toc16231529 \h 1What is Community HealthChoices? PAGEREF _Toc16231530 \h 1What are CHC’s goals? PAGEREF _Toc16231531 \h 1Who is included? PAGEREF _Toc16231532 \h 1Why make the change? PAGEREF _Toc16231533 \h 1How does this work? PAGEREF _Toc16231534 \h 2Who are the MCOs? PAGEREF _Toc16231535 \h 2What about the providers? PAGEREF _Toc16231536 \h 2Lesson 1 Knowledge Check PAGEREF _Toc16231537 \h 3Who enrolls in Community HealthChoices? PAGEREF _Toc16231538 \h 3Who enrolls in CHC? PAGEREF _Toc16231539 \h 3The LIFE Program PAGEREF _Toc16231540 \h 3Who is not eligible? PAGEREF _Toc16231541 \h 4What about Act 150 and OBRA? PAGEREF _Toc16231542 \h 4When is this happening? PAGEREF _Toc16231543 \h 4How will people enroll? PAGEREF _Toc16231544 \h 4What is an IEB? PAGEREF _Toc16231545 \h 4What if participants need more information? PAGEREF _Toc16231546 \h 5How do people apply? PAGEREF _Toc16231547 \h 5Lesson 2 Knowledge Check PAGEREF _Toc16231548 \h 5What about my current providers/services? PAGEREF _Toc16231549 \h 6What about my service coordinator? PAGEREF _Toc16231550 \h 6What if I hire and manage my LTSS DCWs? PAGEREF _Toc16231551 \h 6What if I live in a nursing facility? PAGEREF _Toc16231552 \h 6How about my current LTSS? PAGEREF _Toc16231553 \h 6What will be added? PAGEREF _Toc16231554 \h 7What about service coordination? PAGEREF _Toc16231555 \h 7What about a care plan? PAGEREF _Toc16231556 \h 8What does the planning team do? PAGEREF _Toc16231557 \h 8What else is added? PAGEREF _Toc16231558 \h 8Lesson 3 Knowledge Check PAGEREF _Toc16231559 \h 9FAQ PAGEREF _Toc16231560 \h 10Conclusion PAGEREF _Toc16231561 \h 12Register Completion PAGEREF _Toc16231562 \h 12WelcomeWelcome to an overview of Community HealthChoices.Course ObjectivesThe Department of Human Services (DHS) developed this online training to provide an overview of the Community HealthChoices program, the reasons for its implementation, how to enroll in the program, and how people benefit from Community HealthChoices.What is Community HealthChoices?So, what is Community HealthChoices?Community HealthChoices, known as CHC, is a new initiative that increases opportunities for older Pennsylvanians and people with disabilities to remain in their homes and increase their quality of life. CHC features the use of managed care organizations, or MCOs, to coordinate physical healthcare and long-term services and supports that people need to stay at home and be fully engaged in the community.What are CHC’s goals?The specific goals of the program are to:Enhance opportunities for community-based services,Strengthen healthcare and long-term service and support delivery systems,Allow for new innovations,Promote the health, safety, and well-being of enrolled participants, andEnsure transparency, accountability, effectiveness, and efficiency of the program.Who is included?The program enrolls adults who are:Eligible for both Medicare and Medicaid, orCurrently living in a nursing facility paid for by Medicaid, orNursing facility clinically eligible, known as NFCE, and receiving services through a Medicaid waiver program.Why make the change?Aren’t there already programs that provide healthcare and long-term care and support? Yes, but there are barriers and challenges. People may not know that services exist. Many people don’t plan. When a crisis happens, they seek information. Then, when they find assistance, there is an added challenge that multiple programs, services, and providers are necessary to meet their needs. Individuals must navigate a complex system to manage their healthcare, homecare and support needs.A person may need a regular doctor, specialist doctors, therapists, home care workers, home health worker, and other specialty service providers. Before managed care, the individual or their family had to manage all of these services with limited support. This can be challenging for individuals and families.In addition, to ensure quality, the Commonwealth must review and assess the performance of thousands of organizations that provide services. With the anticipated increase in this type of care, the situation will become too challenging to ensure the high level of quality that people deserve.With CHC, managed care organizations are responsible for coordinating all of these services. The MCOs are accountable for how well the services are delivered. The primary reason that CHC is being implemented is to provide better, more coordinated services so that individuals can live where they choose and be as engaged in their communities as they wish. MCOs are measured in terms of how well they meet the program’s goals and are expected to create better ways of serving Pennsylvanians.How does this work?How does managed care work?The Department of Human Services pays a per-member-per-month rate to the MCO. This is called a capitated rate. DHS then holds the MCO accountable for quality outcomes, efficiency, and effectiveness. The MCOs manage their members’ physical health and long-term care needs and coordinate with Medicare and with behavioral health organizations. Service providers, such as physicians, specialists, therapists, homecare and home healthcare, contract with, are managed by, and are paid by the MCOs.Who are the MCOs?There are three Community HealthChoices managed care organizations in Pennsylvania:AmeriHealth Caritas, which goes by Keystone First in the Southeast,Pennsylvania Health & Wellness andUPMC Community HealthChoices.All eligible individuals are asked to select one of the three MCOs when they transition or enroll into CHC.What about the providers?Each MCO is accountable for having an adequate network of providers.In addition, during a 180-day transition period, MCOs must contract with all qualified and willing HCBS providers. This means that for the first 180 days, people can keep their current providers and service coordinators to give continuity of care during the transition.If you’d like to learn more about the individual MCOs, please check out the CHC Resources document. The Resource Document has contact information, emails, and websites for the MCOs.Lesson 1 Knowledge CheckNow check your understanding of Lesson One by answering these review questions.1. True or False? The main goal of the program is to contain costs.Please pause.The correct answer is False. The goals include providing and enabling:More community living opportunitiesBetter care managementMore innovationEnhanced sustainability2. True or False? During the transition period, individuals receiving waiver services at home and enrolled in CHC may keep their current service providers, if the providers have contracted with the MCO.Please pause.The correct answer is True. Direct service providers must contract with the MCOs to continue providing services to waiver participants.Who enrolls in Community HealthChoices?So, who can enroll in Community HealthChoices?Who enrolls in CHC?Individuals who are 21 years old or over, are enrolled in Community HealthChoices if they are receiving:Both Medicare and Medicaid. This is called dual eligible.Long-term services and supports, known as LTSS, through the Attendant Care, Independence, COMMCARE, or Aging waivers,Services through the OBRA Waiver and are nursing facility clinically eligible, orCare in a nursing home paid for by Medicaid.Eligible individuals age 55 and older may choose to enroll in CHC or they may choose to enroll or remain in a Living Independence for the Elderly (LIFE) program. The LIFE program features a managed care approach as well.The LIFE program is a capitated managed care model that fully integrates comprehensive long-term care services and supports, behavioral health, and physical health services to Medicare or Medicaid participants.The LIFE ProgramTo be eligible for LIFE you must:Be age 55 or older,Be nursing facility clinically eligible,Live in an area served by the LIFE program, andBe able to be safely served in the community.The program is based on a national program called the Program of All-Inclusive Care for the Elderly. The program focuses on individuals living independently in their home and communities for as long as possible. LIFE will continue to remain an option for eligible individuals alongside CHC.Who is not eligible?Individuals are NOT eligible for Community HealthChoices if they are:Receiving long-term services and supports in the OBRA waiver and are not nursing facility clinically eligible,A person with an intellectual or developmental disability who is receiving services beyond supports coordination through the Department of Human Services’ Office of Developmental Programs, orA resident in a state-operated nursing facility, including state veterans’ homes.What about Act 150 and OBRA?The Act 150 Program and OBRA Waiver continue to be available. Act 150 participants, who are dually eligible, receive their Medicaid physical health benefits from CHC and their long-term services through the Act 150 program.If you are not sure about the name of the program that you use, don’t worry. Everyone who is currently being served by an eligible program will be contacted and provided with guidance and assistance in making the transition.When is this happening?So, when is this happening?Pennsylvania is rolling out the program in stages. The Southwest zone was first with an implementation date of January 2018, followed by the Southeast zone in January 2019, and finally by the Northwest, Northeast, and Lehigh/Capital zones in January 2020. This allows for adequate time for individuals, families, nursing facilities, and service providers to prepare for the change. The Commonwealth’s priority is to ensure that there are no interruptions in services for participants.How will people enroll?As we noted earlier, people who are eligible and are currently served by other programs will receive guidance and assistance with enrolling in CHC and selecting a managed care organization. Enrollment in CHC is automatic for individuals currently enrolled in the programs that CHC replaces. The key consideration for people is how to select an MCO.Each person receives a letter from DHS prior to the implementation date. The letter outlines the first steps in the enrollment process, including reviewing the enrollment packet from the enrollment broker.What is an IEB?Pennsylvania has an Independent Enrollment Broker, known as an IEB, for its long-term service and support programs. The enrollment broker is an independent organization that walks people through enrolling in CHC and selecting a managed care organization. The enrollment broker follows-up with each person, provides options, and helps with the decision-making process by asking about current providers and preferences.For example, if Mrs. Smith really likes her current homecare provider, she would select an MCO that has that provider in its network. Remember, the MCO manages all services and supports by contracting with doctors, therapists, specialists, homecare and other healthcare providers. The enrollment broker helps Mrs. Smith select an MCO that best fits her needs and preferences in healthcare and homecare providers.What if participants need more information?In addition to the information provided by DHS and the enrollment broker, there are educational materials available and events scheduled throughout each area prior to the implementation. Individuals, agencies, facilities, and providers are encouraged to attend these events to learn more about the opportunities and processes.As people have questions throughout the process, they can call the Participant Hotline at 833-735-4416. The phone number is listed in the CHC Resources document.How do people apply?Individuals applying for CHC after implementation has begun in their county are enrolled in a similar manner to enrolling in current federal and State waiver programs. The independent enrollment broker coordinates the enrollment activities, which are:The physician diagnosis and certification,The functional ability and eligibility determination, andA financial eligibility assessment.For participants applying for long-term services and supports, like waiver services or nursing facility care, the MCO is selected during the enrollment process. The MCO starts covering participants the day after eligibility is determined. That way, they won’t have to wait for services.For participants not applying for long-term services and supports, the MCO is selected after CHC eligibility is determined. Participants are covered by the fee-for-service program until they are enrolled with their MCO.Lesson 2 Knowledge CheckNow check your understanding of Lesson Two by answering these review questions.1. Individuals currently eligible for CHC are contacted to enroll and select their MCO.Please pause.The correct answer is True. Eligible individuals are contacted by DHS and the enrollment broker. The broker will walk people through enrolling and selecting an MCO. Nursing facilities, service coordinators, and providers can also assist individuals in finding information about the program and their choices.2. People who are eligible for CHC will be assigned an MCO.Please pause.The correct answer is False. Eligible participants will be asked to select from three MCOs. Participants can change MCOs if they discover that another is a better fit for them.What about my current providers/services?So, what about my current providers and services?A common concern with any change is what happens to my current providers and my current services? Let’s first take a look at providers.People select the MCO that best fits their needs. That includes the desire to keep their current providers. Often, an MCO that has the network with their current providers is selected.Participants may keep their existing physical health providers for a 60-day continuity of care period.For long-term services and supports, there is a 180-day transition period. MCOs must contract with all willing and qualified HCBS providers for 180-days upon implementation in a zone. If the current nursing facility, service coordinators, and/or providers have contracts with the MCO of choice, people can keep them.What about my service coordinator?After the 180-day transition period, MCOs have the option of:Using existing service coordination entities,Hiring staff to perform service coordination orUsing existing entities and internal staff.What if I hire and manage my LTSS DCWs?What if I hire and manage my long-term service and support direct care workers?This is an approach called “participant-directed” or “employer authority model,” which continues under the CHC program. Participants can keep their direct care workers and continue to work with the financial management service as they do today.What if I live in a nursing facility?What if I live in a nursing facility?Participants may stay in the nursing facility they are in on the date CHC was implemented in their county unless they choose to move. Residents are strongly encouraged to select an MCO. If they do not, one will be assigned to them.How about my current LTSS?How about my current long-term services and supports?Service levels are also covered in the 180-day transition period. For 180 days, the services that people receive remain the same. During this time, MCOs will likely reach out and work with CHC participants to ensure that their current plans are meeting their needs.During the transition period, both the any willing provider requirement and service plan continuity requirement were put in place to lower the risk of service interruption. As long as the service providers have contracted with the MCO, people can keep their service coordinators and providers.What will be added?All CHC participants receive the physical health benefits in the Adult Benefit Package. These include services like doctor visits, laboratory tests, and hospital stays.For participants who are not receiving long-term services and supports, MCOs are required to do a health screen within 90 days to understand the needs of their participants. This provides a mechanism to determine if people require additional services to stay healthy and remain at home.For participants who qualify for Medicaid funded long-term services and supports (nursing facility residents and waiver participants), there are several services and activities that are added or expanded in the CHC program.Behavioral health services are provided through the existing HealthChoices behavioral health managed care organizations. This is new for people living in nursing facilities and Aging waiver participants.The CHC-MCO will work with the behavioral health MCO to ensure that all services are coordinated.What about service coordination?A notable addition for most people is how their services are planned and coordinated. MCOs use service coordinators to visit people in the program to review current services and assess their needs, strengths, goals, and preferences. The discussion includes healthcare, home care, community engagement, and housing.People no longer need to work with multiple organizations. One organization, the MCO, helps people to improve their health, maintain their independence, and enhance their quality of life while living in the setting of their choice.If a CHC participant currently lives in a nursing facility and wants to move back into the community, the MCO manages the process, which includes finding affordable, accessible housing and coordinating in-home services.If a CHC participant is, living at home and wants to start working again, their Service coordinator can assist them in finding and keeping a job.What about a care plan?An essential piece of the managed care approach is that CHC participants have a care management plan that focuses on coordinating their physical and behavioral health services including:Active chronic conditions,Health services,Veteran’s services,Medicare services, andOther services.Participants with long-term services and supports needs have a person-centered service plan. These plans include a care management plan focused on their physical and behavioral health needs with a long-term services and supports plan. Person-centered services plans are developed with the participant and their person-centered planning team.What does the planning team do?The team, representing all aspects of care and support, works together with the CHC participant to come up with the best approach to ALL needs and goals, not just the ones in their specialty. This is good for program participants because it saves time and energy…one plan with one team instead of multiple appointments and planning sessions with different organizations.Team planning ensures that “specialty areas” are well coordinated. It also helps everyone who supports the participant to understand the person and their situation so that they can provide better quality service.Finally, a managed care approach is good for families and caregivers. Instead of needing to work with multiple care managers, service coordinators, home care providers, doctors and specialists, families can work with one team to plan, coordinate, and monitor services. That one team is held accountable for how well the participant progresses. If things change with the person, there is one call to make. If things do not go as expected, there is one organization accountable to improve the situation.What else is added?In addition to a more integrated approach to planning, coordinating, and monitoring services, the MCOs have more flexibility in providing a broader range of services. MCOs are required to honor program participants’ wishes in terms of living in the least restrictive setting. People can choose to live in the community and it is the responsibility of the MCO to line up the services needed to do that.Affordable, accessible housing can be a barrier for people who do not choose to live in a nursing facility. MCO planning teams are responsible for working with individuals and housing services so that housing situations do not force a facility placement. MCOs also work with people to adapt housing to their needs and to deal with pest eradication and other housing support services.In some cases, behavioral health issues become a barrier to living in the community. People may need help with individual or social conflicts, family issues, or other communication and interpersonal issues to remain independent. In addition to services covered by the behavioral health MCOs, CHC provides counseling services, cognitive rehabilitation, and behavior therapy services. The managed care approach seeks to identify and address barriers to people living successfully in the community.Another added benefit of the managed care approach relates to changes in where people live and receive care. Currently, transitioning out of a nursing facility can involve nursing facility staff, a nursing home transition provider, the Independent Enrollment Broker and a service coordination provider. With this number of organizations (working under separate billing structures), there is a greater risk of gaps or interruptions in service. Moving forward with managed care, the MCO handles all aspects of an individual moving among settings and is accountable for the success of the move. Individuals and families work with one organization and one planning team.In summary, MCOs make it easier for program participants and their families to plan and receive services. A managed care approach also provides a central point of accountability for the services provided and funds invested.Lesson 3 Knowledge CheckNow check your understanding of Lesson Three by answering these review questions.1. True or False? CHC provides only the services that people currently receive under a waiver.Please pause.The correct answer is False. There are new services in CHC, which include housing support and coordination of physical health, behavioral health, and long-term services and supports.2. True or False? People lose their choice of providers under a managed care system..Please pause.The correct answer is False. Participants in CHC choose their direct service providers. Choice is a federally-mandated and state-supported function. Participants choose from providers who have contracted with MCOs in their region. MCOs must have an adequate network of providers.3. True or False? CHC participants living in a nursing facility and planning to stay, do not need to select an MCO.Please pause.The correct answer is False. The MCO provides additional support and services. Residents are strongly encouraged to select an MCO. If they do not, one will be assigned to them.FAQHopefully, we’ve helped you better understand what Community HealthChoices is and how it improves the quality of healthcare and homecare. You may still have some questions.Take some time to review the frequently asked questions about Community HealthChoices.Am I eligible for CHC?You are eligible for CHC if you are over 21 years old and:Are dually eligible for Medicare and Medicaid; ORQualify for Medicaid long-term services and supports because you need the level of care provided by a nursing facility.You are not eligible for CHC if you:Are a person with intellectual or developmental disabilities (ID/DD) who is receiving services beyond supports coordination through DHS’ Office of Developmental Programs; ORAre a resident in a state-operated nursing facility, including the state veterans’ homes.If you are eligible for, and select, the LIFE program, you are not enrolled in CHC unless you specifically ask to be moved to CHC.If eligible, the enrollment broker will talk to you about the Community HealthChoices Managed Care Organization (CHC-MCO) options and enroll you in the program. You will have a choice of available CHC-MCOs (or a LIFE program, where available) and will receive counseling to help make a decision about which CHC-MCO best meets your needs.How will I know if I need to enroll?Affected individuals will be notified before CHC begins in each geographic zone. This will help them be ready for the change.Will I have a choice of CHC-MCO?Yes. You are encouraged to choose your managed care organization. The MCOs to choose from are AmeriHealth Caritas, PA Health & Wellness, and UPMC for You.What if I don’t choose a CHC-MCO?If you do not choose a CHC-MCO, you will be automatically assigned 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 long-term services and supports, all services currently available in the Home and Community Based Service waivers will be included in CHC along with nursing facility care.How will I get behavioral health services through CHC?Behavioral health services will be offered through the existing network of behavioral health managed care organizations (BH-MCOs). For most participants, this is how you get your services today. For nursing facility resident and Aging Waiver participants, this will be new.CHC-MCOs and BH-MCOs will work together to ensure everyone gets the coordinated services they need.Will I have to change my provider?It depends.You can keep your current home and community based services and providers for 180 days or until your new service plans are implemented, whichever is later. This includes your current service coordinators. After that, you may need to choose providers who are in the MCO’s network.If you are a nursing facility resident at the time CHC is implemented, you can remain in that nursing facility for as long as you wish (if you remain eligible).After the initial implementation, new enrollees and participants 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 current OLTL waiver programs continue to operate as separate waivers?The OBRA waiver will continue to serve individuals 18 years old and older who meet the intermediate care facility/other related conditions level of care.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 long-term services and supports, you can continue to get long-term services and supports through the Options program. You will get your Medicaid healthcare services through CHC and your long-term services and supports through Options. If you become clinically eligible for nursing facility level of care, you may apply to get your long-term services and supports through CHC.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:Monitoring of reduction in service plan authorizations,Requiring service plan change reports from the CHC-MCOs,Review of all grievances and appeals from participants,Review of Fair Hearings decisions,Review of encounter data and plan comparisons,Monitoring how often participants leave a CHC-MCO, andConducting participant surveys.ConclusionThank you for taking the time to learn about Community HealthChoices and how it is providing choice, promoting independence and making it easier for Pennsylvanians to live in their communities.For more information about Community HealthChoices, and to keep current with events in your area, go to HealthChoices. or call the hotline. Register CompletionCongratulations! You have completed this module.If you have read the contents of the entire module, register your completion of this module by going to the appropriate webpage.If you are an enrolled provider, go to this webpage.If you are not an enrolled provider, go to this webpage. ................
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