No Prior Authorization needed for certain services
The Department of Human Services (DHS) has temporarily removed prior authorization requirements for certain services. The following services will not require prior authorization (permission from the insurer) for the duration of the COVID-19 emergency:
- Hospice services (prior authorizaiton is required after 30 days for individuals in Physical Health MCOs or Community HealthChoices MCOs);
- Emergency or urgent inpatient hospital admissions;
- Long-term care acute hospitalization, for the first 30 days of care;
- Certain Durable Medical Equipment (DME) and supplies including feeding supplies, respiratory supplies, urinary catheters, and ostomy supplies (see above link for full list of items not requiring prior authorization);
- CT scans of the chest related to the diagnosis or treatment of COVID-19;
- Sublocade injections;
- Inpatient rehabilitation, for the first 30 days of care;
- Nursing home services, for the first 30 days of care;
- Home health aide services, for the first 28 days of service; and
- Skilled nursing (i.e. shift nursing) if the request is to continue the currently-authorized number of hours
The Department has also expanded the types of providers that may order home health services during the pandemic. Specifically, licensed practitioners practicing within their scope of practice, including but not limited to nurse practitioners and physician assistants, may order home heath services during the crisis.
No change in MA or CHIP eligibility criteria
In accordance with guidance issued by the Centers for Medicare & Medicaid Services (CMS), Pennsylvania will maintain Medicaid and CHIP eligibility standards, not charge premiums that exceed those that were in place as of January 2020, and cover any cost sharing, testing, services and treatments related to COVID-19.
No Termination of coverage during the crisis
Pennsylvania will provide continuous MA, CHIP, LTC (nursing home) and Waiver coverage for the duration of the public health emergency. People who had MA, CHIP, LTC, or Waiver coverage on or after March 18, 2020 cannot lose that coverage until the end of the emergency.
Unfortunately, PHLP has already heard from consumers whose coverage was wrongfully terminated during the crisis; the state has committed to reopening these individuals' benefits as soon as possible, in accordance with this Policy Clariffication released on April 24, 2020.
If you had MA, CHIP, LTC, or Waiver coverage on March 18 and your coverage is terminated while the COVID-19 crisis is still going on, call PHLP's Helpline at 1-800-274-3258!
Feds Approve PA’s Request For Medicaid Flexibility
During a disaster or emergency such as COVID-19, the federal government may temporarily waive or modify certain Medicare, Medicaid, and CHIP requirements to ensure that sufficient health care services are available to meet the needs of consumers.
Knowing that Pennsylvania Medicaid officials were preparing their waiver application, on March 17, PHLP and dozens of other advocates and providers urged the state to ask for permission to halt all terminations of Medicaid coverage and to direct MCOs insurers to halt all service denials. The entirely of our recommendations can be found here.
On March 27, the federal government approved Pennsylvania's request for Medicaid flexibility during the Coronavirus emergency. Click here to view CMS’s approval notice. The federal government’s “approval” of the waiver does not change all things. The state must still take action to use the authority granted by the waiver, which applies to the Medicaid Fee-for-Service Program, HealthChoices managed care for physical and behavioral health services, Community HealthChoices (CHC), and Home and Community Based Services (HCBS) waivers.
Through a different pathway, known as Appendix K, the federal government also approved changes to waivers operated by the Office of Long Term Living (OLTL) and the Office of Developmental Programs (ODP). The changes are effective for the Adult Autism Waiver and the Community HealthChoices waiver from March 6, 2020 through June 30, 2020; and from March 11, 2020 through March 11, 2021 for the OBRA, Consolidated, P/FDS, and Community Living Waivers. Click here to see a list of the Appendix K approvals.
Under Appendix K, initial Level of Care Assessments using the Functional Eligibility Determination (FED) tool, as well as Annual Reassessments and Comprehensive Needs Reassessments, may be conductedusing phone or video conferencing. The face-to-face requirement is temporarily waived for these assessments.
There should be no reduction in waiver services like Personal Assistance Services (PAS) hours, no termination of services, and no reassessments of long-term services and supports during the COVID-19 emergency. OLTL has also said that consumers who appear to lose their eligibility in the system during the emergency should continue to receive waiver services.
Additionally, for the duration of the COVID-19 emergency, OLTL has temporarily allowed spouses, legal guardians, and persons with power of attorney to serve as paid direct care workers (e.g. PAS workers) when scheduled workers are not available due to COVID-19 and when the participant’s emergency backup plan cannot be implemented.
Appeal deadlines extended
The County Assistance Office must give individuals an extra 60 days to appeal MA and Waiver denials or terminations. This means individuals who lose MA or Waiver during the crisis will have 90 days to appeal the decision, rather than the typical 30 day deadline. But remember: anyone who had MA or Waiver on or after March 18 cannot lose that coverage for the duration of the crisis!
Grievances & Fair Hearings during COVID-19 Crisis
CHC-MCOs are not allowed to reduce or terminate any waiver services (e.g., Personal Assistance Services) during the COVID-19 crisis. CHC-MCOs can reduce non-waiver services, and Physical and Behavioral Health MCOs can reduce or terminate services during the crisis. Normal Grievance and Fair Hearing rights apply to any reduction or termination of services.
The state has directed BH-MCOs to offer telephonic or videoconference Grievance reviews, if a member’s request for an in-person review cannot be accommodated. PHLP expects the state to issue similar guidance to PH-MCOs and CHC-MCOs.
For the duration of the COVID-19 crisis, DHS Fair Hearings involving MA eligibility matters and service denials will be held exclusively by telephone beginning April 1. The Bureau of Hearings and Appeals (BHA) cancelled all fair hearings scheduled from March 17-31, 2020. Those hearings are being rescheduled to telephone hearings.
PHLP is advocating for interim benefits for those without continued benefits or services in place while this emergency progresses. This would mean that if Fair Hearings are delayed a person would be able to temporarily receive their benefits or services while awaiting the hearing. This is already a requirement when a Fair Hearing decision has not been issued within 90 days of a person first appealing a Medicaid benefits or service denial, but it is not a well-known right.
No Rationing Medical Care Based On Disability; Age
On March 28th, the U.S. Department of Health and Human Services’ civil rights office told medical providers that they may not deny medical care to people based on their disabilities or age during the coronavirus emergency. The directive, released in a bulletin, came days after disability rights advocates filed complaints arguing that protocols to ration lifesaving medical care — adopted by Alabama and Washington State — were discriminatory.
On March 27th, the Pennsylvania Medical Assistance Advisory Committee (MAAC) unanimously approved a resolution exhorting Governor Wolf to ensure that when it comes to the allocation of life-saving treatment 1) patients are not discriminated against because of their Medical Assistance Insurance status, and 2) people with disabilities are not given lower priority because of preexisting disabilities, even when those conditions require more scarce resources. The MAAC also requested that any guidelines developed be developed with the stakeholders and experts listed in the resolution, and that they be released to the public once finalized.
Governor Wolf has also stated his strong commitment to ensuring all Pennsylvanians receive fair and equitable access to lifesaving health care during the COVID-19 pandemic; and will not tolerate discrimination in the allocation of lifesaving resources based on any factor including, but not limited to age, disability and socioeconomic status.
Disability Rights Pennsylvania (DRP) has opened a Health Care Rationing Hotline during the pandemic. Individuals with disabilities who experience discrimination in health care rationing, who are denied effective communication at the hospital, or who are prohibited from bringing a needed family member or staff with them into the hospital should contact DRP's Hotline at 1-800-692-7443 ext. 402.
EVV Delayed Until October
Due to the COVID-19 crisis, Pennsylvania announced it is delaying the implementation date for Electronic Visit Verification (EVV) for direct care workers providing Personal Assistance Services (PAS). The new implementation date is October 1, 2020. For more information, visit the DHS EVV website.
Medicare Part B Applications Can Be Faxed to SSA
In addition to mail, Medicare beneficiaries can now fax the Medicare Part B form, CMS-40B and CMS L564—Request for Employment Information, along with proof of employment, Group Health Plan (GHP), or Large Group Health Plan (LGHP) to the Social Security Administration at 1-833-914-2016. This information is reflected on SSA’s How to Apply for Just Medicare page. As a reminder, the applications for Part A and the Low-Income Subsidy (Extra Help) can be completed online. Source: Justice in Aging.