Commonwealth of Pennsylvania s12

COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE

SUBJECT: Medical Assistance Advisory Committee Minutes

TO: Members and Interested Parties Medical Assistance Advisory Committee

FROM: Robert J. Gardner, Director Bureau of Policy, Analysis and Planning

Attached are the minutes of the Medical Assistance Advisory Committee (MAAC) meeting of June 27, 2013. The next MAAC meeting will be on Thursday, July 25, 2013, at 10:00 a.m. Lecture Hall 246/248, Temple University Harrisburg, 234 Strawberry Square, Harrisburg, PA.

The MAAC, as an advisory forum for the Medical Assistance Program, relies on the attendance of and input by its members. We strongly encourage your continued participation through attendance at the MAAC meetings and recommendations for future agenda items.

If you have any suggestions for agenda items, please contact my staff at (717) 772-6341.

Attachments cc: Secretary Mackereth Secretary Duke Mr. Harris Mr. Serafin Mr. Rosenstein Ms. Logan Ms. Padilla Mr. Kauffman Ms. Utz Ms. Minzenberg Ms. Deklinski Mr. Lokuta Mr. Marion Mr. Gordon Ms. Allen Ms. Rose Ms. Patterson Ms. Rock Ms. Calla Mr. Gardner Mr. Sorge File Control MEDICAL ASSISTANCE ADVISORY COMMITTEE MEETING

JUNE 27, 2013

Mr. Nick Watsula, Chair, called the June 27, 2013, meeting of the Medical Assistance Advisory Committee (MAAC) to order at 10:01 am. Members and guests were asked to introduce themselves.

Ms. Yvette Long made a motion, Ms. Minta Livengood second to approve the minutes from the May 23, 2013, meeting. The motion carried.

Mr. Vince Gordon, Deputy Secretary for the Office of Medical Assistance Programs, presented Mr. George Kimes with a letter and certificate of appreciation for his service to the MAAC. Mr. Kimes retired from his current position on June 30, 2013.

Subcommittee Reports Consumer Subcommittee

Mr. Laval Miller-Wilson gave the Consumer Subcommittee report which met on June 26, 2013.

The subcommittee had a discussion on the six prescription benefit limit. All medications count towards the six prescription benefit limit, including over-the- counter medications or prescriptions that are written by a doctor. Once the limit is reached, the consumer can only get additional medications if that medication is listed on the automatic exemption list from the six prescription limit. If they’re not on the auto exemption list, the doctor can request a Benefit Limit Exception (BLE). The subcommittee has been concerned about how the physical health managed-care plans have enacted this particular requirement. The subcommittee asked the Department of Public Welfare (Department) for data from the plans about how that was working. The committee received the data at the June 26, 2013 meeting.

The subcommittee is concerned that the data shows one of the managed- care organizations (MCO) has a medication denial rate that is significantly higher than other plans. According to the data, consumers who need a seventh medication should be automatically exempt; however, the data showed that members of one plan were denied at much higher rates than other MCOs. The subcommittee speculated, in looking at the data, that this MCO requires pharmacies to take additional actions when processing a BLE. The Department is evaluating the data to find out why this MCO has such a high denial rate.

Another issue is the high levels of denials for consumers when they go to the pharmacy contrasted against a very low rate of five day emergency supply issuance. The subcommittee feels the Department should reach out to the pharmacists to remind them of the opportunity to dispense a five-day emergency supply.

Regarding Medicaid expansion, the subcommittee reiterated their support to use the HealthChoices and traditional Medicaid model already in place, and they also discussed the children who will be transitioned from CHIP to Medicaid beginning in January 2014.

The subcommittee had a very vigorous discussion with the Department about monitoring the MCOs regarding consumers who want to get a face-to-face grievance and appeal when they receive a denial of services. When the consumer wants to present evidence that the services are medically necessary and they travel for the appointment, they are made to call the panel on the phone. The Department agreed to look into this matter and instruct the MCOs to make sure they are conducting in person grievance hearings.

The next meeting is July 24, 2013.

Ms. Long stated there will be a letter sent to the Department with some suggestions and ideas how this can be facilitated in person.

Mr. George Kimes asked if the data could be shared with the full MAAC. Mr. Miller-Wilson stated the subcommittee could share it.

Mr. Joe Glinka asked if the Department ascertained the degree of savings realized thus far with the six prescription limit. Mr. Glinka asked Mr. Miller-Wilson if the in-person grievance review would also be brought in front of the Managed-Care Delivery System Subcommittee.

Ms. Cindi Christ asked about the children transitioning from CHIP to Medicaid. Mr. Robert Gardner stated it is a federal law that regardless of Medicaid expansion, children between 100% and 133% federal poverty level transition from CHIP to Medicaid effective January 1, 2014. It is the Governor’s position that the Commonwealth maintain the current CHIP Program.

A member of the audience stated Medicaid expansion should be included on the MAAC agenda every month.

Fee-for-Service Delivery System Subcommittee (FFSDSS)

The FFSDSS did not meet. The next meeting is August 14, 2013.

Long Term Care Delivery System Subcommittee (LTCDSS)

Ms. Vicki Hoak gave the LTCDSS update. The LTCDSS met June 11, 2013.

The LTCDSS will be meeting from 10 AM to 1 PM instead of 10 AM to 12 noon.

Ms. Lynn Patrone from the Office of Mental Health and Substance Abuse Services (OMHSAS) gave an update on the mental health initiative.

Mr. Clint Eisenhower discussed the focus case reviews. 1,341 cases have been reviewed. 3% of those cases have been revised and the savings at this point is $2.1 million.

Ms. Hoak suggested the Department look at the cost savings included in the budget and see if the target was hit.

The LTCDSS received an update on the service coordination review group.

The LTCDSS was informed the Attendant Care and Aging Waiver renewals are with the Centers for Medicare and Medicaid Services (CMS).

The LTCDSS received an update on the PPL transition.

The next meeting is August 13, 2013.

A member of the audience asked if the Office of Long-Term Living waiting lists were discussed. Ms. Hoak stated there is a list that will be handed out at every LTCDSS meeting concerning the waiting lists.

Managed Care Delivery System Subcommittee (MCDSS)

Mr. Glinka gave the MCDSS update.

The MCDSS met on June 13, 2013.

The MCDSS received a behavioral health update. The final psych rehab regulations are complete as of May 11, 2013.

The Greene County Invitation to Qualify process attracted four bidders. They included CCBHO, CBH&P, Magellan, and Value Behavioral Health. All letters of interest from those behavioral health MCO’s have been received.

The MCDSS received an update on provider enrollment and credentialing. The Department is undertaking an initiative that they will be providing each physical health MCO with an individual work plan to help the plan identify areas of improvement in their processes.

The MCDSS received an update on the need to have behavioral health specialist licensed. As of June 13, 2013, 1,943 applications have been submitted. 310 behavioral health specialist licenses have been granted, 790 applications have been reviewed, and 843 applications are waiting to be reviewed.

The MCDSS received a presentation on the Pennsylvania LIFE Program. The Pennsylvania LIFE Program is known nationally as the PACE Program. 95% of the participants in the LIFE Program are dual eligibles. 100% of the dual eligibles are nursing facility certified eligible.

The MCDSS discussed the enhanced primary care physician (PCP) fee. This is the fee increase that was mandated in the affordable care act. The Department put together a statewide blended fee. If a provider negotiated a fee with an MCO that is in excess of what the blended fee is, that provider will not be penalized and reduced down to the blended fee. The MCO’s were provided with questions to give them a framework of how they could structure their summary to be presented at the meeting. Questions that were sent to the plans included: when will your systems be ready to implement the PCP enhanced fee; when do you anticipate approval of your compliance plan; when will providers receive details on how and when the conversion will occur; when will PCPs begin to receive payment for fee-for-service claims; how will EPSDT claims be handled; and, what provider education efforts will be provided for providers regarding the process of paying the enhanced fee.

The next meeting of the MCDSS is July 11, 2013, on the DGS Annex Complex in the Clothes Tree Building.

Department Of Public Welfare Reports

OMAP Update

Mr. Gordon informed the MAAC that the Senate confirmed Beverly Mackereth as the Secretary of Public Welfare.

Mr. Gardner, Director, Bureau of Policy, Analysis, and Planning, gave the Office of Medical Assistance Programs (OMAP) update.

Regarding the PCP fee increase, the Department started paying the ACA rate on new claims May 31, 2013. The Department paid 86,164 claims. The Department started paying the retroactive fee increase on June 17, 2013 and paid 65,261 claims since then. There are a total of 287,660 claims to pay with 222,399 claims remaining.

The 2013 Healthcare Common Procedure Coding System (HCPCS) was implemented on June 24, 2013. The 2013 update included 93 procedure codes including several behavioral health related psychotherapy and psychiatry codes; all of which were covered in the published Medical Assistance (MA) Bulletin.

Mr. Bob Greenwood asked when old codes are removed is there always a replacement code added. Mr. Gardner stated there is not always a replacement code.

Mr. Gardner discussed the clinical laboratory improvement amendment (CLIA). On December 28, 2012, the Department issued MA Bulletin 01-12-67 that was called clinical laboratory improvement amendment requirements which was effective January 1, 2013. The primary purpose of the bulletin was to remind providers of lab services that their current CLIA certificate for each testing site was filed with the Department. Providers are to ensure that they are submitting claims for the laboratory service it provides with their CLIA certificate. The Department will deny laboratory claims for service locations not currently CLIA certified by the laboratory service bill or when the dates of service of laboratory tests are not within the providers CLIA certificate begin and end dates. Providers that received claim denials related to CLIA certification should contact OMAPs provider enrollment unit to ensure that their current CLIA certificate for their applicable service location is on file with the MA Program. Instructions for contacting the provider enrollment unit are included in the bulletin.

Dr. Eve Kimball stated some CLIA labs have oncologists in them that are not in private practice, whereas some of us in private practice have a CLIA certification but don’t get paid by Medicaid: is that correct?. Ms. Leesa Allen stated if the CLIA certification is such that you can perform those tests, then you can be paid for those tests.

Mr. Matt McGeorge gave an update on the health information technology (HIT).

Some activities include direct subscriptions, health share exchange of Southeast PA, and behavioral health and long-term care technical assistance.

Best practices include meetings held May 13 and June 24, and focus on effective ways to support meaningful use attestations when audited. Future meetings will discuss stage 2 preparation and health information exchange.

Ms. Hoak asked about the direct subscriptions and the 11 ordered. Mr. McGeorge stated different areas within OMAP have identified they could communicate effectively with the providers that have direct subscriptions if they also had a direct subscription.

Ms. Hoak asked what the health share exchange of Southeast PA is going to do. Mr. McGeorge stated it’s the mechanism to share information in the southeast.

OMHSAS Update

Ms. Lynn Patrone gave the OMHSAS update.

Ms. Patrone stated the 20 counties receiving block grant plans are currently under review.

Ms. Patrone gave an Olmstead update. Olmstead is for individuals that have some type of disability as it relates to Title II of the Americans with Disabilities Act. Counties have submitted plans last year on their update to the Olmstead planning. Internally OMHSAS has been revising the direction they would like to counties to work with OMHSAS for plans that meet the unique needs of populations as it pertains to behavioral health. Once the template is developed, OMHSAS will be sending that out as guidance to the counties in addition to technical assistance to help them develop a robust plan around Olmstead planning, as well as a diversion plan. In addition to the individual County plans, OMHSAS as well as internally in the Department, has started to meet to develop a unified plan with the Office of Developmental Programs and Office of Long-Term Living so there is a joint state plan inclusive of all program offices.

Mr. Miller-Wilson asked about the state plan and the County plans. Ms. Patrone stated the state plan is being revised and the Department is also offering direction to the counties. Mr. Miller-Wilson asked why the state plan is being revised. Ms. Patrone stated it’s an update.

Ms. Hoak asked if the Office of Long-Term Living was involved. Ms. Patrone stated they are involved.

Mr. Miller-Wilson asked if a draft plan will be circulated to the larger consumer community. Ms. Patrone stated it can be circulated.

Referring to the 90 bed Community Hospital Integration Projects Program (CHIPP), Ms. Jonna DiStefano asked if there’s been any decision on how the 90 beds will rollout that was included in the budget. Ms. Patrone stated not just yet.

Ms. Patrone discussed the physical health/behavioral health integration.

ODP Update

Ms. Elizabeth Campbell from the Office of Developmental Programs (ODP) gave the ODP update.

Ms. Campbell discussed the Autism Services, Education, Resources and Training (ASERT) collaborative. The ASERT collaborative is a partnership of medical centers, autism research and service centers, universities, community organizations, and other providers of services involved in the treatment and care of adults and children with autism. The mission of the collaborative is to improve access to quality services and information, provide support to individuals and caregivers, trained professionals and best practices and facilitate the connection between individuals, families, professionals and providers.

Mr. Miller-Wilson asked if the Bureau of Autism Services is directly under the Secretary’s Office. Ms. Campbell responded the Bureau is under ODP.

MEDICAL ASSISTANCE BULLETINS AND REGULATIONS

The list of MA Bulletins was published to the website on June 21, 2013.

There was one pharmacy feedback document published to the Listserv on June 19, 2013.

Old Business

Dr. Kimball stated she hopes the Department will increase the transparency of what the MCO’s are doing regarding the PCP fee increase.

New Business

Ms. Allen stated on May 17, 2013, CMS issued a State Medicaid Directors letter talking specifically about the facilitation of Medicaid enrollment coming up in 2014. In that document, CMS highlighted opportunities that states could take advantage of. One of those items related to the early adoption of the modified adjusted gross income. Pennsylvania is currently considering using the modified adjusted gross income prior to the January 1, 2014, mandated timeframe. In order to implement the early modified adjusted gross income rules; however, Pennsylvania must pursue an 1115 demonstration waiver with CMS. CMS provided some streamlined information and a streamlined application. The Department will be pursuing the 1115 demonstration waiver. The Department will also be publishing a notice in the Pennsylvania Bulletin announcing the Department’s intention to use the early modified adjusted gross income rules.

Mr. Glinka asked about the deadline for submitting comments. Ms. Allen stated comments could be submitted now, and when the notice is published there will be 30 days from that date.

Ms. Hoak asked when the notice would be published. Ms. Allen stated the Department hopes to have the notice published the second weekend in July. Ms. Hoak then asked why the Department decided to do it faster. Ms. Allen stated one of the things is the systems changes required. The timeframe between October 1 and January 1, the Department would be running two sets of eligibility systems, one for those who come in through the federally facilitated marketplace and the other for the traditional Medicaid population.

Mr. Greenwood asked if the Department has gotten guidance on that being the application or will there be additional information on the application for some of the other programs. Ms. Allen stated the Department has been asking questions but doesn’t have all the answers yet.

Mr. Miller-Wilson asked when talking about the application, is it the 1115 waiver application for the program and not a consumer application. Ms. Allen stated it is the 1115 waiver application.

A member of the audience asked if OMAP has given any consideration to any of the other four recommendations. Ms. Allen stated she does not have information regarding this.

Mr. Miller-Wilson asked if there would be a Pennsylvania specific application that will need to get adjusted. Ms. Allen stated there is a specific application that will have to be developed.

The next meeting of the MAAC will be Thursday, July 25, 2013, in Lecture Hall 246/248, Temple University Harrisburg, 234 Strawberry Square, Harrisburg, PA.

Adjournment

The meeting was adjourned at 11:43 am.