Q1. Will each CHC-MCO have the same regulations for home based services?
A. According to the terms of the agreement, each CHC-MCO must comply with all applicable state and federal requirements. the CHC-MCOs can adopt additional requirements for network providers. Providers should discuss requirements with CHC-MCOs as part of the contracting process.
Q2. Will the Department of Health (DOH) have regulations on CHC-MCO?
A. According to the terms of the agreement, each CHC-MCO must comply with all applicable state and federal requirements. The CHC-MCOs can adopt additional requirements for network providers. Providers should discuss requirements with CHC-MCOs as part of the contracting process.
Q3. Will CHC-MCOs provide a list of all providers?
A. Yes, the CHC-MCSO must use a web-based provider directory. The CHC-MCO must notify its participants annually of their right to request and obtain a hard copy of the provider directory and where the online directory may be found. The Independent Enrollment Broker (IEB) will also have a master provider directory available on its website that lists all providers participating the CHC-MCOs networks.
Q4. What happens when a participant is reassigned to another provider when their provider is terminated?
A. CHC-MCOs have requirements to notify the Department of Human Services and impacted participants when a provider is terminated from their provider networks. The CHC-MCOs are required to assist participants with selecting new provides and participants have continuity-of-care protections.
Q5. How will participants requesting long-term services and supports (LTSS) be tracked?
A. A participant who has not been determined nursing facility clinically eligible (NFCE) and requests to be evaluated for LTSS will be referred to the IEB. The IEB will assist the participant with the LTSS application and eligibility process. The IEB will track the participant as he or she proceeds through the process. One the participant is determined eligible for LTSS, the CHC-MCOs will conduct a comprehensive assessment to determine the participants’s LTSS needs. If a participant is illegal for lTSS and chooses to receive service through the life program, the LIFE program will conduct the assessment to determine LTSS needs.
Q6. Will the CHC-MCOs be working with the IEB?
A. Yes, the CHC-MCOs are required to work with the IEB in many areas such as providing outreach materials, collaborating when a participant has unmeet needs, service gaps, or a need for service coordination, identifying and communicating with individuals with limited English proficiency, coordinating enrollment information, and exchanging provider and participant data.
Q7. Will there be changes to the compass website to support CHC?
A. COMPASS is continuously updated to improve the application process for state benefits. Most recently, the mobile application myCOMPASS PA was launch to allow access to benefits from anywhere, at any time. Particpants can review what they receive, check the status of submitted applications, upload documents, and report changes directly from a mobile phone.
Q8. Will the Department of Human Sservices be able to handle the additional work with the independent enrollment broker and other necessary tasks to support CHC while continuing to support the Fee-For-Service (FFS) Program?
A. The Governor and Secretaries of Human Services, Health and Aging are committed to the success of CHC and have looked to maximize the use of automation and leverage staff to support the implementation of CHC and the ongoing LTSS FFS operation.
Q9. Is January 1, 2018 remaining as the implementation date for the phase 1 of CHC while continuing to support the Fee-For Service (FFS) Program?
A. Yes, the southwest zone will be implementing January 2, 2018.
Q10. Will non-profit status be affected by working with and being paid by for profit CHC-MCOs?
A. Providers should consult with their legal counsel to discuss any contracting-related concerns including those related to impacts on non-profit status.
Q11. What are consistent, accessible ways for consumers to be involved beyond the SUB-MAAC on MLTSS?
A. The Department of Human Services (DHS) is committed to stakeholder engagement throughout the implementation and ongoing operation of CHC. DHS will continue the Third Thursday webinars and MLTSS sub-MAAC.
DHS is also committed to ensuring participants have involvement at the CHC-MCO level. The CHC-MCOs are required to establish and maintain several opportunities for participant input including a Participant Advisory Committee (PAC), Health Education Advisory (HEA) Committee, and a Pharmacy & Therapeutics (P&T) Committee.
- The CHC-MCOs are required to establish and maintain a PAC for each zone in which it operates that include participants, network providers and direct care worker representatives. The PAV advises the MCOs and DHS on the experiences and needs of participants.
- The HEA committee includes participants and providers in the community to provide input on the health education needs of participants.
- The P&T Committee includes physicians and participants. The committee develops a list, which is approved by DHS, of outpatient drugs determined to have a significant, clinically meaningful therapeutic advantage over other outpatient drugs in the same class in terms of safety, effectiveness, and cost.
The CHC-MCO’s participant handbook will advise participants how they can participate in CHC-MCO advisory committees.
Q12. What is the Home and Community-Based Sservices (HCBS) loan program? What can the loans be used for?
A. The HCBS loan program is intended to support long-term care providers as they position themselves to successfully transition to CHC. The loans will support projects that help the commonwealth to improve the quality of care for seniors and people with disability by building infrastructure so individuals will have more choices available to them. More details on the program can be found at
http://www.dhs.pa.gov/cs/groups/webcontent/documents/form/c_261042.pdf
Q13. Do providers have the right to suspend or deny service to a consumer based on policies (ex. violent, illegal, seriously disruptive behavior) prior to due process of dismissing a participant?
A. The CHC-MCOs must develop provider policies, which the Department of Human Services must approve, including requests from providers to dismiss participants from the practice through an expedited process.
Q14. Can consumer submit verification of payment for covered service and receive reimbursement?
A. Network providers are required to submit claim for services provided to participants and not request reimbursement from the participants.
Q15. If a participant is Nursing Facility Ineligible (NFI) and not currently receiving long-term services and supports, does the CHC-MCO receive per person/per month capitated rate?
A. The CHC-MCOs receive a monthly capitated payment for both NFI and Nursing Facility Clinically Eligible (NFCE) individuals. The amount differ based on the age, dual Medicare and Medicaid eligibility, and NCFCE/NFI status.
Q16. Will MCOs be prohibited from being the CHC-MCO service coordinator and personal assistance provider to eliminate a conflict of interest? A few yeares ago it was determined to be a conflict of interest? A few years ago, It was determined to be a conflict of interest for a provider to also be the participant’s service provider. What will be put in place to ensure that CHC-MCOs don’t create a provider agency?
A. CHC-MCOs are required to provide service coordination (SC) as an administrative service and may provide SC with their staff or through a subcontract arrangement.
To avoid conflict concerns, the Department of Human Service (DHS) has established requirements for related parties. The CHC Agreement defines a related party as “An entity that is an Affiliate of the CHC-MCO or a CHC-MCO’s subcontractor and (1) performs some of the CHC-MCO or subcontracting CHC-MCO’s management functions under contract or delegation; or (2) furnishes services to Participants under a written agreement; or (3) leases real property or sells materials to the CHC-MCO or subcontracting CHC-MCO’s subcontractor at a cost of more than $2,500.00 during any year of this Agreement.”
CHC-MCOs that have a hospital, nursing Facility, or home health agency as a related party must negotiate with and make referrals in good faith to providers that are not related parties. The CHC-MCO must offer participants a choice of related-party and non-related party networks providers. A hospital, nursing facility, or home health agency that is a related party to a CHC-MCO must negotiate in good faith with ither CHC-MCOs regarding the provision of services to participants. DHS may terminate the agreement with the CHC-MCO if it determines that a provider related to the CHC-MCO has refused to negotiate in good faith with other CHC-MCOs.
Q17. Do the local County Assistance Office (CAO) and Are Agency on Aging (AAA) stay the same, just different names?
A. The department of Human Service’s CAOs do not have any change in their function or their name. The CAOs still determine financial eligibility for MA programs, including CHc. The IEB is playing a new role for nursing facility residents. Nursing facilities should contact the IEB to begin a Long-Term Care (LTC) application.
Aging Well (A subsidiary of the Pennsylvania Association of Area Agencies on Aging (P4A), which represents all AAAs may take on certain functions to support CHC. Some of these functions may have previously been performed by AAAs.