New Update on Louisiana MLTSS

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April 10, 2016

2nd UPDATE on LOUISIANA MLTSS…

In my recent blog on the status of MLTSS in Louisiana, I noted HB 309 which sought to implement a number of “cost-saving” measures for the Medicaid program in Louisiana. Last week,  HB 309 was voluntarily deferred along with all other bills to implement copays and premiums on Medicaid recipients.  (You may recall HB 309 called for both copays/premiums and MLTSS).

However, when I wrote that blog, HB 790 hadn’t been filed yet and you guessed it… it calls for MLTSS implementation. To make matters worse, it includes a mandatory implementation date of October 1,2016.  While the bill addresses the elderly and adult-onset disability waivers, it specifically indicates that it is including them, BUT NOT LIMITING THE BILL TO THOSE WAIVERS.  The only other waivers there are are waivers for individuals with developmental disabilities.

A quick fix…. delete “included but not limited to.”  That’s what you need to tell your legislators and House Health and Welfare.

If you’ve read my blog, you know the only reason Louisiana was building a model for MLTSS on the developmental disability (“DD”) side was to create a better service delivery system with care coordination — not looking for cost savings. In fact, repeatedly, state officials indicated there would be cost increases at least the first year and the only cost savings would be realized through coordination of care and reduced duplication of services.  And, anyone reading my blog would know that even if we did go into MLTSS for DD services with this in mind, there would have to be significant (read MASSIVE) preparation of the managed care companies given universal lack of experience with DD populations.

Also not addressed are any of the recommendations of the Advisory Committee, inclusion of nursing homes, and the fact that there is absolutely no actuarially sound data anywhere in the United States that shows that managing services for individuals with developmental disabilities saves money.

So what does that mean?  It means that Bayou Health plans, who have little to no experience in providing health services to populations with DD and and less than zero experience in managing DD population long-term needs will be responsible for cutting life saving care our children and adults with DD will need.  That is the only way a savings could be realized under this bill.  That is going to kill people.

We don’t need to pay Bayou Health millions upon millions of dollars to just slash our services.  The state could do that tomorrow.  They know that. We know that. Is this a way to appease the Bayou Health Plans if their Per Person, Per Month rate is cut?  Who knows. But rest assured, this is a doomsday bill for individuals with developmental disabilities if it is not eliminated or amended correctly.

 

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SNAPSS Position on Upcoming Bills to Change Louisiana Medicaid and MLTSS

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Summary of Position on Medicaid-Related Bills 2016

Copays and Premiums for Medicaid Recipients – Opposed

Brand Name/Generic Drugs and Discontinuation of  OTC Medications — Opposed

Dedication of Copays/Premiums to NOW Fund – Opposed

Fees for Non-Emergent Care in ER Settings – Supported with Conditions

MLTSS for OCDD populations – Opposed at this time

Increased Premium on FOA Medicaid from $50 to $65 –Opposed

The following are the positions of Special Needs & Parent Support Services of LA, LLC to various bills in the Louisiana Legislature in 2016.  All positions are mine, Karen Scallan,  as owner of SNAPSS of LA, LLC.

Copays and Premiums for Medicaid Recipients – Opposed

Copays on medications, doctor visits and premiums in Medicaid might sound good on the surface but research has repeatedly proven they will cost more, not save money as people begin to ration critical and chronic care needs.  The National Health Law Program or NHELP’s paper on Medicaid Premiums and Cost Sharing, March 2014,  indicated cost sharing and premiums was heavily studied and the consistent and ever-expanding literature … repeatedly demonstrates that premiums and cost sharing pose barriers to care for low-income and vulnerable populations….” 

Since Medicaid recipients are mostly children, the poor, elderly, sick people and people with disabilities, that is who will be affected by these fees.  When individuals who are poor, sick, elderly and disabled have to pay $4-$8 per medication, a copay to the doctor and $50 a month premium, they are going to have to decide what they can do without…food or medication, heat in the winter or doctor visits.  They will ration critical care and that will push people to more expensive care when symptoms and conditions reach unbearable levels– strokes without blood pressure medications, heart attacks without blood thinners, greater numbers of seizures and brain damage without seizure meds and all will end up in the ER, intensive care, and other hospital settings in our state—care venues which cost the most and account for the largest portion of that 1/3 of our budget we’re complaining about.

NHELP’s paper cites a Canadian study that found that a recipient’s reduced use of essential drugs by 14% correlated to an 88% increase in hospitalizations and death and a 78% increase in emergency room visits.  Conversely, studies also show a reduction in cost sharing is linked to increase adherence and improved health outcomes. Increased health outcomes translate to lower costs.  Healthier people cost less.  And, NHelp cites studies focusing on nominal copays for Medicaid recipients in the range of $2 or $3 for individuals with schizophrenia that showed the individuals discontinued their medications at a significantly high rate when charged the copay.  Individuals on antipsychotics reduced their use by 12% and those on antidepressants by 20%.  In a Mississippi study, patients with schizophrenia were 5% less adherent to medications and 20% more likely to have a 90+ day gap without medications.  Now how would that affect our mental health care system?  Law enforcement? Are we really ready for that?

Individuals in group homes and institutional care are also at a huge disadvantage.  They already pay almost all of their income for their care except for a meager allowance.  Who will pay the copay for these individuals?  Who will pay their premium?  There’s nothing left.  House Health and Welfare Committee members heard testimony on March 22nd about how Home and Community Based (HCBS) providers are on the verge of collapse now with the roughly 22% cut they’ve taken since 2008.

Medicaid recipients are in the emergency room more often, and their care generally costs more, because they are more likely to be chronically ill and need emergency and high cost care.  And, as we begin to add administrative costs to collect these fees as more people ration critical care and move into emergency rooms, intensive care and other hospital settings we will see this sink our state even more in the hole.  This will cost more, not save money.

http://www.healthlaw.org/publications/browse-all-publications/Medicaid-Premiums-Cost-Sharing#.VwQUO6QrLcs

Brand Name v. Generic Drugs and Discontinuation of OTC Medications – Opposed

Moving all name brand drugs to non-preferred status would be detrimental to many individuals with special health care needs.  In very specific circumstances for individuals with complex medical needs, generic drugs simply do not work the same.  Individuals, particularly children with seizure disorders know this difficulty all too well.  A considered approach to any preferred drug list must be taken to protect medical necessity for our most vulnerable individuals.

Additionally, over the counter medications are costly for families of children with disabilities, the poor and elderly.  One bottle of Miralax for children is over $20.  Without providing for payment for this under Medicaid, children with special health care needs will not receive the care they need if the family cannot afford another $20 per month.

Dedication of Copays/Premiums to NOW Fund- Opposed

HB 173 includes a provision to dedicate the copays and premiums to the New Opportunities Waiver Fund. This provision proposes to pay for one of the needed developmental disability waivers on the backs of the poorest, sickest and most disabled individuals in our state while we protect corporate welfare.  Yes, Medicaid is expensive and yes we need a funding stream for the developmental disabilities waivers in Louisiana, but this is not the answer!

Fees for Non-Emergent Care in ER Settings – Supported with Conditions

Non-emergency care in emergency room settings continues to be a problem for the state by unnecessarily increasing the high cost of care to Medicaid recipients. But, if Medicaid recipients are to be charged a fee for non-emergency care administered in the ER, great care must be taken to protect individuals with significant and complex medical conditions or disabilities whose conditions are not readily evident to their caregivers due to such things as inability to communicate symptoms for example.  For individuals with developmental disabilities, a significant and dangerous medical condition may manifest itself in acting out behaviors and little else due to lack of communication.  Others with significant developmental and physical delays may simply “look bad” to the care giver and given their fragile state might need to be seen in an emergency room.  If it turns out ultimately that there was no emergency, these individuals must be exempt and protected from being charged for emergency room use.

MLTSS for OCDD populations – Opposed at this time

MLTSS for OCDD populations (individuals with intellectual and developmental disabilities or I/DD) MUST NOT be implemented at this time.  Not one component of an MLTSS program for individuals with I/DD is ready for implementation at this time, not DHH, OCDD, The Advisory Committee, the providers or the Managed Care Organizations (MCOs).  Additionally, the deadline which HB 790 imposes on implementation of MLTSS would mean that virtually none of the protections agreed upon by the state and the Advisory Committee would be implemented because there simply is not enough time.  And, finally, MLTSS as proposed in HB 790 and 309 are proposed for implementation as a cost saving measure.  There is absolutely zero actuarially sound data anywhere in the US that indicates that managed care for individuals with I/DD will save money.  That was never the purpose in DHH proposing it in the first place.  In fact such a program for OCDD recipients will cost more in the first year and be cost neutral thereafter.

Increased Premium on FOA Medicaid from $50 to $65 –Opposed

A $15 increase in the premium for Family Opportunity Act Medicaid families will most definitely not solve the budget crisis but will add yet another burden to families who already cannot afford their child’s care.  Families of children with disabilities pay significantly more just to care for their child on a daily basis as compared to a “typical” family.  Burdening them with a higher premium on top of the private insurance premium many have and the other costs they face is tantamount to punishing them for their child’s disability, especially since it will do nothing to alleviate our budget crisis.

Why Copaysand Premiums for Medicaid Recipients is a Bad Idea for Louisiana

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Why Copays and Premiums for Medicaid Recipients is a Bad Idea for Louisiana

By Karen Scallan

Louisiana has several bills in the Legislature right now proposing copays on medications, doctor visits and premiums for participation in Medicaid.  That might sound good on the surface, right? Charge Medicaid recipients for their care!  Nothing big–a $4 or $8 copay here and there, maybe institute a $50 premium, right? After all, we all know the state’s in the worst financial bind of our recent history.  Health care costs continue to rise.  Medicaid constitutes 1/3 of Louisiana’s budget.  And, people should be responsible for their care, right?  Well, we are in a bind and Medicaid is expensive, but the fact is, research has proven time and again copays and premiums will cost us more, not save us money as people begin to ration critical and chronic care needs.

The National Health Law Program or NHELP, issued a paper on Medicaid Premiums and Cost Sharing back in March of 2014.  That paper indicated cost sharing and premiums had been heavily studied and the consistent and ever-expanding literature on cost sharing repeatedly demonstrates that premiums and cost sharing pose barriers to care for low-income and vulnerable populations….”  So why are there so many bills in the Legislature right now seeking to impose just this very thing?  Because it feels like we’re doing something about the budget.  It’s quick.  It fits unsubstantiated rhetoric about our newly enrolled Medicaid recipients under 138% of federal poverty level that “THEY should pay” “THEY can pay” and “THEY are just lazy people.”

First, let’s be sure who “THEY” are.  People on Medicaid are predominantly poor, sick, disabled and children.  New enrollees under Medicaid Expansion are those under 138% of FPL, which is for a single individual is just over $16,000 a year GROSS.  For a family of 4, 138% of FPL is just over $33,500 a year GROSS.  These are the working poor.

“THEY” are also sick people.  There are higher numbers of very sick people on Medicaid because very sick people become poor really fast if they aren’t poor already.  Medicaid tends to have more people with disabilities, including those with intellectual and developmental disabilities, mental health disabilities and complex special health care needs.   So when we talk about making “THEM” pay, we are mostly talking about children, the poor, elderly, sick people and people with disabilities.

Okay, you may ask “but how could cost sharing or premiums cost us more?” Well, when individuals who are poor, sick, elderly and disabled on fixed incomes have to pay $4-$8 for each medication, a copay to the doctor and $50 a month premium, they are going to have to decide what they can do without…food or medication, heat in the winter or doctor visits.  Guess what’s going to go first.  That’s right, care for chronic conditions.  And that will push people to more expensive care when symptoms and conditions reach unbearable levels.  They will have strokes without blood pressure medications, heart attacks without blood thinners, greater numbers of seizures and brain damage without seizure medication and all will end up in the emergency room and the intensive care units in our state—care venues which cost the most and account for the largest portion of that 1/3 of our budget we’re complaining about.

NHELP’s paper says, “Cost sharing” is a “penny-wise and pound foolish” approach to saving money.  The report cites a Canadian study that found that a recipient’s reduced use of essential drugs by 14% correlated to an 88% increase in the occurrence of adverse events (hospitalizations and death) and a 78% increase in emergency room visits.  Conversely, studies also show a reduction in cost sharing is linked to increase adherence and improved health outcomes.

So what if health outcomes are increased or not?  Increased health outcomes translate to lower costs.  That is one of the purposes of managed care-to provide coordination and supports to increase health outcomes and therefore lower costs.  Healthier people cost less.  That is the reason the Affordable Care Act requires free preventative care and screenings.  Prevention is the new method for managing the high and ever-rising cost of health care.

The NHelp paper cites a study that showed this holds true for mental health care too.  Studies focusing on nominal copays for Medicaid recipients in the range of $2 or $3 for individuals with schizophrenia showed the individuals discontinued their medications at a significantly high rate.  And, individuals needing antipsychotics reduced their use by 12% and antidepressants by 20%.  In a Mississippi study, patients with schizophrenia were 5% less adherent to medications and 20% more likely to have a 90+ day gap without medications.  Now how would that result affect our mental health care system?  Law enforcement? Are we really ready for that?

And let’s take a look at our system for providing supports to people with developmental disabilities.  Individuals in group homes and institutional care already pay almost all of their income for their care except for a meager allowance.  For that, and the hourly rate that a provider gets for support services, the provider must provide a roof over the individual’s head, their place to sleep all of their food, clothing, uncovered medical costs, transportation and recreation.  Who will pay the copay for these individuals?  Who will pay their premium?  There’s nothing left.  House Health and Welfare Committee members heard testimony on March 22nd about how Home and Community Based (HCBS) providers are on the verge of collapse now with the roughly 22% cut they’ve taken since 2008.  You will drive the final stake in the heart of our system of supports and services for people with disabilities if you require copays and premiums for this population.

Yes, Medicaid is expensive.  And Medicaid recipients are in the emergency room more often, and their care costs more, but that is because they are more likely to be chronically ill and need emergency and high cost care.

The NHELP’s research review shows “sicker people with higher expenses are more likely to ration care when their costs go up and also more likely to suffer the consequences.”  And they ration all their care, including critical care.  That means more will move into emergency rooms, intensive care and hospitalization.  Combine that with higher costs to the state to administer the copays and premiums and you can see implementing these fees will sink our state even more in the hole.

So there are the facts.  We have to decide, do we just want to feel like we’re doing something about the cost of care and the state’s fiscal problems or do we want to really effect change.  Let’s find another way.

http://www.healthlaw.org/publications/browse-all-publications/Medicaid-Premiums-Cost-Sharing#.VwQUO6QrLcs

2016 Update-MLTSS: The Next Fight is Sooner Than You Think

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The idea of moving Medicaid waiver services into managed care has been dormant in Louisiana for a while now.  Nursing homes, which account for the greatest opportunity for cost savings lobbied to keep themselves exempt from any MLTSS process. Everything was placed on hold until the new Governor and Medicaid administration were in place.

Well, on March 1st, I got the first hint that MLTSS was coming back when questions were raised by Representative Dustin Miller (D, Opelousas), as representatives of the Louisiana Health Plan Association testified during  the Health and Welfare Committee meeting that day.  He asked about cost savings in MLTSS.  Of course the Health Plan Association representative indicated huge savings to the state in response to Representative Miller’s questions.

Anyone who has read my blog knows that the only savings that can come with MLTSS would be by including nursing homes.  The same nursing homes that lobbied to be excluded from MLTSS.  And, if you’ve read my blog, you know the only reason Louisiana was building a model for MLTSS on the developmental disability (“DD”) side was to create a better service delivery system with care coordination — not looking for cost savings. In fact, repeatedly, state officials indicated there would be cost increases at least the first year and the only cost savings would be realized through coordination of care and reduced duplication of services.  And, anyone reading my blog would know that even if we did go into MLTSS for DD services with this in mind, there would have to be significant (read MASSIVE) preparation of the managed care companies given universal lack of experience with DD populations.

NOW THE BOMBSHELL… On Friday, March 4th I came across HB 309, slated for the regular session coming up.  HB309, submitted by Reps.Tony Bacala (R,Prairieville)  and Valarie Hodges (R,Denham Springs) purports to stem the high cost of Louisiana’s Medicaid program through drastic cuts and cost sharing.

It starts with a provision to eliminate name brand drugs from the Medicaid formulary, and to implement co-pays and premiums for all Medicaid services possible for any non-exempt Medicaid recipients. As if that weren’t bad enough…then came the bombshell…

Reps Bacala and Hodges through HB 309, want “To establish an MLTSS system within Medicaid managed care program” including, but not limited to, elderly waiver populations.  That phrase including, but not limited to means people with developmental disabilities.

The bill tries to appease people on DD waivers by indicting all the “cost savings” achieved on our own backs through co-pays and premiums be included in the NOW Waiver fund (notably to the exclusion of protections for the other waivers).  But make no mistake that does not include savings from the MLTSS side.  That “savings” will go to the Bayou Health Plans.

Also not addressed are any of the recommendations of the Advisory Committee, inclusion of nursing homes, and the fact that there is absolutely no actuarially sound data anywhere in the United States that shows that managing services for individuals with developmental disabilities saves money.

So what does that mean?  It means that Bayou Health plans, who have little to no experience in providing health services to populations with DD and and less than zero experience in managing DD population long-term needs will be responsible for cutting life saving care our children and adults with DD will need.  That is the only way a savings could be realized under this bill.  That is going to kill people.

We don’t need to pay Bayou Health millions upon millions of dollars to just slash our services.  The state could do that tomorrow.  They know that. We know that. Is this a way to appease the Bayou Health Plans if their Per Person, Per Month rate is cut?  Who knows. But rest assured, this is a doomsday bill for individuals with developmental disabilities if it is not eliminated or amended correctly.

 

 

 

Commentary and Questions re: the MLTSS Concept Paper for I/DD Services 9-2014

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On September 22, 2014, the MLTSS Advisory Group met to discuss the state’s concept paper outlining their managed care program for state services provided to individuals with intellectual and developmental disabilities.  The following is the text of my letter to Louisiana Department of Health and Hospitals with my comments on the concept paper and questions that arose after the presentations from that meeting.

September 30, 2014

Please accept this letter as commentary on the recently-released Concept Paper issued on September 22, 2014 for OCDD and other Medicaid services under MLTSS for individuals with intellectual and developmental disabilities (I/DDs).

My overarching comment for this paper and other materials around MLTSS is that all entities involved in the MLTSS process must bear in mind the complexity of the topic and significant stakes involved, along with individual and family need for simple, clear and concise information.  Clear information prevents misinterpretation and miscommunication.

The following are my commentary on specifics of the Concept Paper draft and questions.

 COMMENTS

1. The current draft contains headings that do not describe the content in the section that immediately follows. It may be useful to use the topics we discussed in MLTSS Advisory Group as the headings and add others such as Medicaid/Medicare dually eligible individuals, Superwaivers, Comprehensive Flexible Supports, Program Oversight.  Using these topics as categories will clarify specifics and provide continuity with other concept papers previously issued and discussed by the MLTSS Advisory Group.

2.  Of the 8 or 9 pages of text, about 4 pages are devoted to behavioral health and early intervention programs, but there is little discussion about other items such as LTSS. While Behavioral Health and Early Intervention are important and do require their place in the paper, there is no clear picture of the concept the state has for other services.

3. The section entitled “Medicare/Medicaid Dual Eligibles” does not mention or address the needs of individuals who are dually-eligible. It does not discuss the population and unique challenges in serving them or how the state plans to address these hurdles.

4. Care coordination should more clearly be described. It is mentioned in various places and the current system is described, but there is no clear picture of the state’s concept of care coordination. The flexibility in care coordination should be described in more detail.

5. Under the section entitled “Demonstration as the Solution,” the 2-phase approach is introduced but the section only describes Phase 1. Phase 2 is not addressed until the section “Medicare/Medicaid Dual Eligibles.”

6. My understanding is that Early Steps will be handled in an administrative capacity (i.e., no risk/no capitation) in both Year 1 and Year 2. The paper does not indicate this, but needs to do so if my understanding is correct.

7. Hospital Sitters should definitely be required when the hospital facility needs/requires someone to assist with communication due to the person’s disability.

8. Under “MLTSS for I/DD: Goals of Redesign,” please clarify “enhance the effectiveness of family caregivers.” 

9. Under “MLTSS for I/DD: Goals of Redesign,” please define “flexible authority” and “variety of support models.”

10. The Ombudsman Program should be presented and described in such a way as to communicate the state’s level of intent and commitment to this program beyond Year 1.

11. The paper does not indicate that a readiness assessment will be done. It is my understanding from the MTLSS Advisory Group meeting on 9-22-2014 that there will be a comprehensive readiness assessment that will include assessment of State, MCO and provider readiness before the system goes live. This needs to be included in the paper along with specifics about what will be assessed.

12. While CMS may consider an MCO sub-contracted provider a conflict-free entity to conduct needs assessments for individuals in the program, it is my concern that there will be behind-the-scenes influences by the MCO as the contractor of the assessing agency.  Truly conflict-free assessment should be discussed and more deeply considered.  Contracting separately with Human Service Authorities and Districts to do needs assessments should be considered before this is included in an MCO contract.

13. Page 5, Column 1, Item 6 states “address transition planning from acute medical and behavioral health settings from the point of admission.” Addressing transition from the point of admission is important for reduction in re-admissions and ensuring that individuals do not linger in mental health or hospital settings.  That said, Transition should be discussed within the content of appropriate care based on the needs of the individual and the ability of the family/natural supports in the community to continue supporting them once they are released.  Otherwise, the implication to families is that they would receive a “fast-food, drive through” approach to care.  This is important and an issue now in behavioral health in Louisiana.  Families currently have trouble accessing residential treatment and in-patient settings are not working on long-term underlying problems that need therapeutic resolution.  Instead they focus on medication management stays of 3-5 days. The problem is, when individuals return to the community, there are long waits for therapeutic appointments and appropriate therapy services are not available or easy to find (i.e., specialized trauma therapy services for a child with violence and anger issues).  The state’s concept of transition planning from date of admission needs further elaboration.

14. Consumer education is not really addressed in the paper, yet this is a population that will need extensive support and information. They need materials written for lower reading levels and detailed, meaningful information written for family caretakers of individuals with severe and complex medical issues. Bayou Health provided “marketing” materials only (Ex. Info on free gift cards for well-child visits, perks and other benefits).  This population will need much more and will need it provided in different ways.

15. Under “Opportunities for Improvements in Efficiency, “ Column 2, the paper states that a potential area for savings through improved coordination and payment systems includes “improved diversion and transitions management as compliments to continued MFP rebalancing efforts.” It provides an example:  “thirty seven percent (37%) of acute care costs of current I/DD waiver recipients are in pharmacy.”  The phrasing is not easily understood and the example does not clarify the statement.

16. On Page 3 under “Administrative Complexity,” the last sentence in the first paragraph in that section: Are you saying that combining the system will be confusing or the current fragmentation of the systems is confusing? Also, it is a long sentence that is hard to follow and not tied to the care coordination discussion in the paragraph.

QUESTIONS

Pharmacy-Related Questions

1. Will the MCOs use the same standard formulary that the Bayou Health plans are required to develop under their current contract? Will the MCOs develop their own common formulary?

2. Will the contract include provisions to override private insurance as a primary insurance when the private provider requires use of an out-of-state mail-order pharmacy, thus blocking a Medicaid recipient’s access to Medicaid for prescription coverage?

Behavioral Health-Related Questions

3. What are EPSDT Mental Health services?

4. How will “specialized behavioral health services” be available to the 1,100 or so individuals with I/DD in Louisiana Behavioral Health Partnership in Phase 1, when that is when the specialized MLTSS Behavioral Health service array and provider network, resource allocation, development, validation and operational capacity building will be developed? It appears this will not be ready for these or other individuals.

5. Following up on Question 4, how will the MCOs be able to provide behavioral health services to others in the system in Phase 1/Year 1 given the plan development in Phase 1 listed above and when the state acknowledges the lack of understanding by the MCOs of the needs of individuals with I/DDs?

6. Why would we place additional pressure the new behavioral health system in Year 1 by also making those services at-risk/capitation services. The paper itself cites difficulties of the Louisiana Behavioral Health Partnership to provide the necessary services.  It is difficult to imagine how MCOs with no I/DD experience would be able to do anything different, especially in a capitated, at-risk environment.

7. The paper states that individuals with I/DD will be transitioned out of residential treatment facilities to “appropriate DD alternatives.”

a. Do you mean individuals with a Statement of Approval for OCDD Services?

b. What about those who are suspected to be eligible, but not yet confirmed to meet OCDD eligibility criteria?

c. What appropriate I/DD alternatives are you referring to?

d. Would people be forced to leave hospitals close to their home, family and supports to go to treatment in far reaches of the state for the sake of the plan, even if their current care is appropriate and working?

e. When would this transition take place? Phase 1? Phase 2?

f. If Phase 1, how will this be handled without endangering individual health given the lack of knowledge of MCOs and the fact that the behavioral health program will be in development at the same time.

Early Intervention-Related Questions

8. Please confirm that early intervention services will be handled in an administrative arrangement (non-risk/capitation) for Phase 1 and Phase 2. If this is correct, please include this in the paper as well.

9. Will there be a rate floor in Year 2/Phase 2 for early intervention providers? If so, please include this in the Paper.

10. How will the state ensure that Congressional intent of early intervention services as an educational program to mitigate costs for school systems is preserved using an educational model given the medical model that MCOs understand and use?

11. Will the MCOs have representation on the IFSP team? If so, how will the state ensure that federally-defined members of the IFSP team are the ones driving the services both directly and behind the scenes?

Questions regarding Concept Paper Wording

12. Under “Medicare/Medicaid Dual Eligibles” what does “implementation of a broader array of specialized LTSS options with joint coordination and care provision” mean

13. Under the same section, what does “implementation of conversion, diversification and repurposing supports” mean?

Transition and Readiness Assessment Questions

14. What will be assessed in the Readiness Assessment Process? Readiness of the MCOs, the providers, AND the state?  Training completion only or training and competency? Staff capacity –numbers and training?

15. At what point during Year 1 will the state begin transition? Will it be after the readiness assessment?  What if the readiness assessment indicates we are NOT ready?  Or not ready in certain areas?  Is the state prepared to delay Phase 2 in total or in part, if need be?

16. How will an administratively managed care program in Phase 1 inform through data what a risk-based program would be in Phase 2?

1115 Super Waiver Demonstration Questions

17. It was indicated that data collection would drive the development of the Super Waiver (1115) and services in Phase 2. If data has to be collected and analyzed, how much data from Phase 1/Year 1 does the state really think it will have in order to make decisions for Phase 2, given that transition will begin in Phase 1?  6 months?  Less? More?

18. What new services are you contemplating within the 1115 waiver?

19. On Page 8, Column 1, the paper states “In addition to the above, the consolidated 1115 waiver service package will offer LTSS from implementation of Phase 1.” Munderstanding of the 1115 waiver was that it would be implemented in Phase 2?  How will the 1115 waiver services package offer services in Phase 1?  When during Phase 1?  Is this referring to the transition?

20. Will the state include clearly stated criteria for MCOs changing and altering LTSS services and programs after the Super Waiver is implemented? Will MCOs be able to make changes to the program or services?

Placement Questions

21. Under the Medicaid/Medicare Dual Eligibles Section, the paper indicates that a “level of need assessment will determine ability to request long-term institutional stay.” Do you mean it will determine whether a long-term institutional stay is appropriate for the person?  Or will the assessment instrument itself determine whether a person can request a long-term institutional setting?

22. Will the need assessment take into consideration the length of time a person who is already in an institutional setting has been there, along with their desire to remain there as part of the consideration process of whether an individual may remain in the long-term setting? e., if they have lived in a setting like this for most of their lives, and do not want to leave will this be taken into consideration?

Populations Questions

23. Will Medicaid/Medicare dully-eligible individuals be included?

24. How will the program reconcile issues with these 2 federal programs and consolidate care coordination for dually-eligible individuals? And, for those with private insurance in addition to Medicaid and Medicare?

Transparency, Reporting and Accountability Questions

25. Regarding transparency, Will the MCOs provide data that will not otherwise be validated? What will the MCOs be allowed to self-report?  How will the state ensure numbers and information reported is correct and accurate?

26. What is the state’s plan for reporting to stakeholders? Will the state include stakeholders further in the process to determine what needs to be reported in order to have a transparent system?  Stakeholders must be able to evaluate how MCOs are making decisions.

27. Will requirements exist for cost savings reporting deadlines for the MCOs?

28. Will the state include in the process for moving from Phase 1 to Phase 2, a provision for distribution and dissemination of final reporting data to the public before Phase 2 goes live? If so, will the state secure public comment before changes and beginning of Phase 2?  It is of the utmost importance for the state to get feedback from the individuals affected by these changes, especially considering the state’s own acknowledgment thatthere is “relatively little experience nationally in I/DD commercial managed care.”  This feedback could be a significant indicator of whether the state is truly ready to move to Phase 2.

29. Will the state require the MCOs to have Advisory Boards that include individuals and family members? Will the MCOs be required to submit the minutes of their Advisory Boards to the State as part of their reporting?

General Questions regarding the Program:

30. If we have truly managed out all the savings we can from HCBS why put those services in a risk-based capitated group in Phase 2? What, if any, are the advantages the state seeks in including them in a risk-based package of services?

31. Same question as #27 regarding Early Steps, if it will be handled in a capitated, risk-based program in Year 2.

32. Will there be a requirement for allowing out-of-network care if the network does not have a provider that can provide the appropriate services, particularly in the case of individuals with complex needs? (Ex. They may have three urologists on the network, but none have experience treating individuals with complex urologic issues due to Spina Bifida.)

33. Will OCDD’s MLTSS system include an electronic verification system for the program? In whole or in part?

In closing, please accept these comments for consideration in the final version of this document.  If the questions cannot all be addressed within the context of the Concept Paper, please respond in another form regarding the answers.   The answers and the final Concept Paper will ultimately influence the Request for Proposals and subsequent contract for OCDD’s MLTSS program and are vitally important for family understanding as the process moves forward.

With thanks in advance for your consideration and assistance, I am

Sincerely,

Karen C. Scallan, CPSP

Update on August 29, 2014 MLTSS Advisory Group Meeting – OAAS Concept Paper/Research/Timelines

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UPDATE ON LOUISIANA’S MANAGED CARE AND LONG-TERM SUPPORTS

AND SERVICES (MLTSS) INITIATIVE IN LOUISIANA

August 29, 2014

 This update summarizes what occurred at the Medicaid Managed Care and Long-Term Supports and Services (MLTSS) Advisory Group meeting held on August 29, 2014. This document was prepared by Karen Scallan, member of the MLTSS Advisory Group representing parents of children and youth with developmental disabilities and complex needs.  Questions regarding this information should be directed to Kcscallan@gmail.com.

 This meeting consisted of three parts:

  1. Unveil of Office of Aging & Adult Services (OAAS) Plan for elderly and adult-disabled individuals;
  2. Review of draft timeline for both the OAAS and Office of Citizens with Developmental Disabilities (OCDD) conversion to MLTSS
  3. Review of research from other states utilizing managed care for long-term supports.

 OFFICE OF AGING & ADULT SERVICES PLAN AND CONCEPT PAPER OUTLINING SERVICES FOR ELDERLY AND ADULT-DISABLED INDIVIDUALS

 The state decided NOT to use Medicaid a Section 1115 Demonstration Waiver to implement managed care given risks involved.  Benefits would have included broader leeway to implement innovative services, payment and approaches to eligibility.  Risks included reimbursement to the Federal government if calculations were wrong and the program was not cost-neutral and the lack of time lines for Medicaid to approve the proposal.  Instead, Louisiana will implement the OAAS contract in two phases.

 1.   PHASE 1: They will transition all services AS THEY EXIST TODAY and merely have the managed care organization handle payments. The names of the programs will remain the same as will eligibility and services.

  2.   PHASE 2: They will use current data from PHASE 1 to change how services may be delivered including unbundling of services, tiered benefit structures, use of innovative behavioral health services and some expansion for at risk populations who do not currently meet Nursing facility level of care.

 OAAS feels this will provide stability in transition, provide a budget-neutral program, reduce risk to the state, and will provide real data on which to base decisions to change the program. 

 Additionally, they feel that the Managed Care Organizations (MCOs) taking over services will have other tools to provide new services not reimbursed by the State.  These are “value added” services.  Examples include preventative health screenings, dental, hearing or vision goods/services, nutritional counseling or incontinent supplies.  MCOs can also offer lower cost services to replace higher cost services.  These are “In lieu of” services such as paying for dental extractions (not usually covered by Medicaid) for an individual who is continually going to the Emergency room for tooth pain. 

 There will be three plans, all state wide.  Services will include doctors, hospitalizations, durable medical equipment (DME), hospice, nursing home services, the Long-Term Personal Care Services (LT-PCS) program, Community Choices Waivers (CCW), Adult Day Health Care Waiver (ADHC), behavioral health and pharmacy services.  The only exception will be for dentures.  This will be managed under a separate contract through Managed Care of North America.

 OAAS MLTSS and Medicare

 All members will continue to receive Medicare services and can remain in their current Medicare Advantage plan if they choose to.  One question asked was which care coordination — Medicaid or Medicare – would take precedence?  OAAS is still discussing how to get Medicaid and Medicare sides to talk to each other.  They are acutely aware of the need to facilitate that collaboration.  Another member noted frustrations of doctors who do not know who to call to get an answer the first time.  OAAS indicated they are building in requirements that primary care physician be identified even if they cannot control who the primary care physician is.

 Who is included?

 Estimates are the about 100,000 individuals will be covered through the OAAS contract for MLTSS.  Included will be all Medicaid recipients who acquire a disability at or after age 21 AND

                 Meet eligibility for Nursing Facility Level of Care, OR

                 Receive or are approved for Community Choices Waiver, OR

                 Receive or are approved for Adult Day Health Care Waiver OR

                 Receive or are approved for Long-term Personal Care Services, OR

                 Those NOT in Bayou Health AND who are approved for a long-term stay in a nursing facility funded by Medicaid, OR

                 Healthy individuals who have both Medicare and Medicaid.

 Who is NOT included?

 Medicaid recipients who

            Have intellectual and/or developmental disabilities,** OR

            Individuals participating in PACE, OR

            Individuals who ONLY have their Medicare premium paid by Medicaid.

 **Individuals with an intellectual and/or developmental disability (ID/DD) currently receiving services through OAAS programs (ex., LT-PCS) are still eligible but may only remain in the current program until the OCDD system for individuals with developmental disabilities launches.  OAAS did reiterate that NO ONE WILL LOSE SERVICES.  These individuals with ID/DD will be transferred over at some point.

 How will this affect providers?

 In year one, all LTSS providers will contract with the MCOs.  Individuals will not have to change their provider unless they want to.  MCOs must pay providers at least what the state pays currently.  Electronic Visit Verification (EVV) systems will be put in place before the system is converted to the MCOs.  A Request for Proposals (RFP) has been issued for the EVV system and the intent is to begin using the system in the spring of next year in advance of managed care implementation.  Standardized claim forms will be developed and the MCOs will have requirements to pay claims on time and on schedule. 

 Other aspects of the program

 Care coordination. MCOs will be required to provide specialized case management for high risk individuals (those with long-term supports and services, behavioral health needs and chronic health conditions).  Support coordination that exists now will be replaced with MCO Care coordination. 

 MCOs will not conduct eligibility determination.  The current assessment tools will remain in place to determine eligibility.  An Independent enrollment broker will be used a contract to assist individuals rather than the MCO (they will use Maximus, the same as the one for Bayou Health).  

 An independent Ombudsman contract will be issued.  Some states have the ombudsman program through the MCO themselves, but that is not independent.  The Advisory Group indicated that Ombudsman programs should be independent.  OAAS is now seeking info from other states inquiring about the items in their independent Ombudsman contracts for comparison. 

 The MCOs will be required to pay claims on time and on schedule.  There will be an appeal process outside the MCOs’ appeal processes.  A consumer satisfaction survey will also be conducted

 OAAS will also have the MCOs doing Performance Improvement Projects on things such as the effectiveness of the plans, systemic interventions, etc.  Examples include, Expanding self-direction in home and community based services or getting more diabetics tested properly or assistance with individuals suffering from chronic pain.

 The presentation by OAAS given at the meeting can be found at http://new.dhh.louisiana.gov/index.cfm/page/1684/n/379.

 2.   MATHEMATICA POLICY RESEARCH PRESENTATION

 Mathematica is the technical assistance contractor for Centers for Medicaid and Medicare (CMS).  They were asked to present to the Advisory Group on findings from other states that have adopted MLTSS.

 Their presentation included information on system rebalancing (moving individuals from institutional settings to home and community based settings), predicting costs and potential savings, care coordination and better outcomes.

 One overarching theme was that impact of MLTSS was difficult to compare from state to state given the variety of state programs and the nuances of the contract language in the state contracts.  Additionally, the effect of system change was influenced by the state oversight of the programs.  Oversight does matter and contract revisions along the way are needed to increase performance targets and incentives to reach their targets.

 During the Q&A session for this presentation, they mentioned that some states retain a percentage of the MCOs payments to be sure they meet the requirements for provider payments on time. This is used as incentive to be sure providers are paid appropriately.

 Another question was asked about how the MCO will help in rebalancing.  They discussed how states have built the rate structure to incentivize helping people stay in their homes and move people out of institutional care if they wanted to leave.  They also discussed Performance Improvement Projects can include rebalancing projects and that Louisiana already has experience with Money Follows the Person with My Place.

 The presentation provided by Mathematica at the meeting can be found at the state’s MLTSS page…http://new.dhh.louisiana.gov/index.cfm/page/1684/n/379

 3.   TIMELINES

 Two timelines were provided in draft.  Current relevant dates listed on both the time lines were the same and are as follows:

             Fall 2014 to Early 2015 – RFP Released

            August & Sept. 2014 – Concept Paper Updates to CMS

            Fall 2014 to Early 2015 – Waivers Submitted to CMS

            60 Days from RFP Release – Deadline for Proposals

            30 Days from Deadline for Proposals –Proposal Evaluation Begins

            7 Days from Evaluation End – Announcements of Anticipated Contract Awards

            7 Days from Announcement – Deadline for Signed Contracts from Awardees

            Early 2016 – Go live date for OCDD contract

 The time lines provided at the meeting can be found at the state’s MLTSS page…

http://new.dhh.louisiana.gov/index.cfm/page/1684/n/379

 NEXT MEETINGS AND OPPORTUNITIES TO GIVE COMMENT

 HOW TO COMMENT ON MLTSS IN LOUISIANA

YOUR VOICE IS IMPORTANT. THESE CHANGES WILL CHANGE HOW YOU OR YOUR LOVED ONE RECEIVES WAIVER SERVICES.  See the note at the end of this update regarding future meetings and public forums.  In the meantime, learn more and send your comments by visiting the following links:

Find out More, Visit:  http://new.dhh.louisiana.gov/index.cfm/page/1684/n/379

Send Comments to:  dhh.louisiana.gov/index.cfm/page 1684/n/379.

 NEXT MEETING

The next meeting of the MLTSS Advisory Group will be Monday, September 22, 2014, 11:00am to 2:00pm. The group will receive the OCDD plan for individuals with developmental disabilities at this meeting. 

.For questions regarding this update contact:

Karen Scallan

kcscallan@gmail.com

 

 

 

SHOULD EARLY INTERVENTION SERVICES BE INCLUDED IN LA’S MLTSS PROGRAM?

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An important discussion is brewing around MLTSS and early intervention in Louisiana.  Should we include it in the MLTSS contract or not?  Or, is there another answer?  The decision could have a life-long effect on children. The program is not widely known or understood among Managed Care entities and there are important differences between this program and its services versus other developmental disability services in the state. 

What is Early Steps and Early Intervention?

 Early Steps is Louisiana’s early intervention program for children ages 0-3 funded through the US Department of Education and Louisiana.  The program provides occupational, physical and speech therapy, special instruction (early educational service), nutrition and other services to infants and toddlers up to age three with developmental delays.  Early intervention programs exist across the country and are governed by the Individuals with Disabilities Education Act, (IDEA) 2004 under Part C

 There are specific requirements under IDEA regarding how each state’s program must operate.  Things like timelines for completion of plans, implementation of services, and transition of the child are spelled out in IDEA.  The program also provides case management and support, evaluations for children and an Individualized Family Service Plan (“IFSP”).  This IFSP governs what services and frequency of services are needed.  The plan may also include services for the family and is developed by an IFSP team.  IDEA also governs who is on the team creating the IFSP.  Included are Parents/Guardians, other family members, family service coordinator, anyone conducting the evaluation or assessment, and service providers.  The plan is based on an evaluation and assessment of the child and family’s concerns and priorities for the child.  It must be developed in a meeting and reviewed every 6 months, revised annually, and address transition of the child at age 3.

 Early intervention services are provided via a developmental and educational model to remediate as much developmental delay before the child attends school.  This is not just a suggestion; it is part of the Congressional intent of the law.

 “Congress finds that there is an urgent and substantial need–…

(2) to reduce the educational costs to our society, including our

Nation’s schools, by minimizing the need for special education

and related services after infants and toddlers reach school age;”

 IDEA 2004, Part C, Infants and Toddlers with Disabilities, 20 U.S.C. Section 1431(a) Findings, (emphasis added).  Congress also stated in IDEA that services have to include “an educational component that promotes school readiness and incorporates preliteracy, language and numeracy skills.”  IDEA 2004, Part C 20 U.S.C. Section 1435(c )(2)(B) (emphasis added).

“All Inclusive–” Early Steps in MLTSS …Yes or No?

 Two bodies have discussed Early Steps in the context of MLTSS in Louisiana.  The LA Office of Citizens with Developmental Disabilities’ (OCDD) System Transformation stakeholder work group discussed “all inclusive” MLTSS services. But they only discussed this in the context of whether MLTSS should be a “cradle to grave” system.  A “cradle to grave” system allows families to access services that they cannot access now.  (Ex. Right now, families in Early Steps cannot access Individual and Family Support assistance because applicants must have a current statement of approval of eligible for services.  Eligibility determination is not done until the child turns 3 as they age out of Early Steps.) 

 The MLTSS Advisory Group also discussed an “all inclusive“ MLTSS system, but, again, in the context of accessing services.  That was the intent of the MLTSS Advisory Group recommendation.   Neither of these groups (and I am a member of both) discussed the implications or complications of including Early Steps in the MLTSS program. 

What Do Other States Do for Early Intervention and Managed Care?

 Since those meetings, Early Steps providers raised some legitimate concerns.  A group of independent Early Steps providers have joined together to form a group called Provider Alliance Network (PAN) and conducted their own research.  They discovered the following:

 ● Only four other states included early intervention services under a managed care organization (MCO).  Of the four, 3 continued most of their services outside of an MCO.   Georgia, Florida and Mississippi only require services such as speech, occupational and physical therapy to go through the MCO.  All other services (evaluation, nutritional, IFSP development and case management) remained carved out of the MCO system.

 ●Despite only including these services, these 3 states are experiencing what PAN describes as “significant problems” in maintaining an adequate provider network and quality of services, this due at least in part to MCO rate reductions.

Why Not Include Early Intervention in MLTSS?

 I share in PAN’s very valid concerns about fully including Early Steps in the MLTSS process, including:

 ●Differences between how MCOs and how Early Steps must operate make it nearly impossible to adhere to state and federal mandates.  MCOs would have to adhere to strict time lines for transition, IFSP development and implementation of services.  Decisions about level of services cannot be driven by funding or dictated by an MCO.  Under IDEA, only the IFSP team decides amount and type of services.  Under an MCO medical model, care coordinators make level and type of care decisions to minimize the cost to the MCO.  Reconciling these two approaches will be almost impossible.

●Already low provider rates may be further reduced under MLTSS, causing providers to leave, creating deficits in the provider network and gaps in services.  Even though OCDD has stabilized the budget of the program, when an MCO takes over, managed care practices are applied to all sectors of care across the board. 

 ●Delay in authorization of services will cause compliance issues and reduction in services.  Despite what anyone says, delays will defer costs.  The longer it takes for someone to pay, the greater the chance they will not pay.  But in early intervention, this will cause health and well-being issues and potentially violate IDEA.

●Early intervention programs use an educational/developmental model, not a medical model (which MCOs use).  How exactly will an MCO manage educationally-based services?  Care coordinators under MCOs are usually medical professionals (doctors/nurses), not teachers or early childhood specialists.  They have no experience in this area.

● How will the different funding streams be reconciled?  Funding for the program comes from the US Department of Education.  The only payments made by Medicaid for Early Steps services are payments for Medicaid services to Medicaid recipients in the early intervention program.

●  Another danger is MCOs, unfamiliar with mandates and Congressional intent of the program may seek out anyone with a license for the network, without understanding the specialization of early intervention services.  Providing speech services to an infant with feeding issues is exceedingly different than providing them to an adult stroke or accident victim.

 And if that wasn’t enough…What happens after “Any Willing Provider” Expires?

 The MLTSS Advisory Group has recommended that “any willing provider” provisions be included in the MLTSS contracts for at least 1 year.  “Any willing provider” means the MCO must pay any willing provider you choose to provide your services for a period of time.  This enables you to keep current providers while the hiccups are worked out of the system.  After year 1 when “any willing provider” expires, MCOs begin negotiating lower rates with providers for their year 2 contracts.  Physicians, having gone through iterations of managed care, are more familiar with this.  That is why you see more large practice groups and fewer independent physicians.  They have formed groups to share costs and lessen the impact of lower rates on their practices.   Most other types of providers are not familiar with this and that could mean smaller, independent providers of all types will be unable to meet expenses under lower rate contracts.  Early Steps providers tend to be independent providers, and work part time.  This could spell disaster for the program and the children it serves. 

 According to PAN’s research, Early Steps has met objectives of managed care in that the program is “balanced,” (i.e., all services are provided in the home or community) and the budget is controlled through eligibility requirement changes and family cost participation.  The provider network is generally sound and outcome data shows improvements.  So there’s no hugely compelling fiscal or outcome-based reason for including the program. 

 One reason the state sites for including early intervention services in MLTSS is care coordinators need to “see” all the services a person receives in order to better manage their care.  Currently they cannot.  And, the state would probably argue that other states that included early intervention in their managed care plans did not include them in Managed Long-Term Service plans.  In other words, their early intervention services were included in Medicaid managed care programs more like our Bayou Health program—specifically health-related and not disability specific.  Louisiana’s MLTSS program will have a contract specifically for individuals with developmental disabilities.  But will that really make a difference? MCOs are still health-based organizations using medical models and medical professionals (doctors, nurses, etc.) on care coordination teams to determine level of services.  Their experience in early intervention is still a huge problem and, we still would have to reconcile issues with IDEA requirements and funding stream issues.

 Suggested Compromise

 The MCO model probably will not work for early intervention.  MCOs make money by taking a risk that they can “manage” your care costs below what the state pays them to care for you.  An Administrative Services (AS) arrangement instead might be a solution.  An AS agreement saves money by providing infrastructure for administrative services at a specific rate.  Managed care contracts are becoming more flexible with combinations of cost-saving methodology imbedded to make contracts attractive.  Compromise would dictate the program could be written into a combination contract where Early Steps services are handled administratively as opposed to “managed.”  Services could still be integrated into the database systems, MCO could see the services and other services could be managed through the MCO.

I have proposed this compromise to the state and PAN representatives and was told by the state this is under consideration.  PAN still feels Early Steps should be carved out and that an administrative service  arrangement should only be an alternative if carve out is not possible.  I have also requested that, when MLTSS meetings begin again, that MLTSS Advisory Group take on this discussion more in depth.  Watch the blog for updates on this issue and let the state know how you feel about early intervention services under MLTSS….

HOW TO COMMENT ON MLTSS IN LOUISIANA

YOUR VOICE IS IMPORTANT. THESE CHANGES WILL CHANGE HOW YOU OR YOUR LOVED ONE RECEIVES WAIVER SERVICES.  Learn more and send your comments by visiting the following links:

Find out More, Visit:  http://new.dhh.louisiana.gov/index.cfm/page/1684/n/379

Send Comments to:  dhh.louisiana.gov/index.cfm/page 1684/n/379.

For questions regarding this blog, contact:

Karen Scallan, kcscallan@gmail.com