Phase Three Launches, CHC Now Statewide
Community HealthChoices (CHC), Pennsylvania’s managed care long-term services & supports program, completed its three-year, three-phase roll out on January 1, 2020 when the program began in the Northwest, Northeast, and Lehigh/Capital regions (Phase Three). Approximately 145,000 Pennsylvanians were impacted by this change, including over 67,500 in the Lehigh-Capital Zone, 49,700 in the Northeast, and 27,900 in the Northwest.
CHC affects older adults and persons with disabilities who are: dual eligible (enrolled in both Medicare and Medicaid), getting long term care at home through an Office of Long-Term Living waiver, or in a nursing home paid for by Medicaid. Specifically, CHC changes how these individuals get their Medicaid coverage. For those getting long term care services, it also changes that coverage.
The Office of Long-Term Living (OLTL) considers the launch of Phase 3 a success, but acknowledges some issues with service authorizations. Like Phases 1 and 2, there have been multiple cases where a service authorization (e.g., home health) was not properly transmitted to the service provider after it transferred to the CHC Plan, causing the provider to be unable to see the authorization. In most cases, the provider was Public Partnerships (PPL), the broker that handles payroll for participants using the consumer-directed service model. OLTL reports they have seen fewer problems than they saw in Phases 1 and 2. OLTL is working through these authorization issues with the CHC Plans.
OLTL has also reported disappointing news regarding provider contracts in Phase 3. Specifically, UPMC-CHC has been unable to reach a provider contract with Geisinger Health System, one of the largest provider systems in the Northeast. If a contract cannot be reached, UPMC-CHC members who were already seeing Geisinger providers prior to CHC will be able to continue seeing them. Also, CHC participants with Medicare as their primary insurance should be able to continue seeing their current Geisinger providers for Medicare-covered services, even if that provider does not accept UPMC-CHC. However, UPMC-CHC members who either 1) do not already have a relationship with a Geisinger provider or 2) do not have Medicare, may be left with limited options within the UPMC-CHC network.
Compared to Phases 1 and 2, a larger percentage of Phase 3 participants actively selected their CHC Plan, rather than being auto-assigned. Between 40 and 50 percent of Phase 3 participants affirmatively chose their CHC Plan. Among participants receiving HCBS (Waiver) services, the selection rate was even higher: 61-67% for dual-eligible waiver participants, and 72-80% of Medicaid-Only waiver participants. Plan selection was particularly important for these groups since waiver recipients, notably those with Medicaid as their only insurance, were at the highest risk of a disruption in their healthcare services. OLTL considers the high rate of affirmative plan selection, particularly among waiver participants, as a success.
PHLP wants to hear from CHC Participants in Phase 3 who are having difficulty with the transition to CHC; contact our Helpline at 1-800-274-3258.
Service Coordination Entity (SCE) Termination Update
In our November-December newsletter, we reported that Keystone First CHC and UPMC CHC were terminating most of their contracts with external service coordination entities (SCEs) and taking service coordination in-house. More than 20,000 participants in Southeastern Pennsylvania were affected.
By now, all affected participants should have received notice that their service coordination is changing. As a reminder, participants may choose a new service coordinator who works directly for their CHC plan or choose one from the external service coordination agencies still contracted with their CHC plan.
Participants who have not heard from their new service coordinator, or who do not know who their new service coordinator is, should contact their CHC Plan immediately at one of the numbers below:
Keystone First: 1-855-349-6280 (Personal Care Connector Line)
UPMC: 1-833-672-8078 (Service Coordination Southeast PA)
Grievance and Appeals Issues in Phase 3
CHC Participants trying to challenge denials and reductions of services (e.g., home care, personal assistance services) have reported to PHLP and other advocates that CHC Plans failed to follow the rules governing appeals. The violations reported include failing to provide required notices and hearings in a timely manner, and failing to keep participants’ services in place pending resolution of their appeal.
As a reminder, when a CHC Plan decides to deny, reduce, change, or terminate services such as personal assistance services, the following rules apply:
The CHC Plan Must Provide a Written Notice. If the CHC Plan is reducing or denying a service the person is already receiving, the denial notice must be issued at least 10 days prior to the effective date of the decision. Verbally notifying a participant over the phone is NOT enough.
Participants May Appeal (File a Grievance): If the participant disagrees with the CHC Plan’s decision, they must request a grievance within 60 days of the denial notice.
Participants Have the Right to Continuing Benefits: If the denial notice reduces services the participant already receives, and the participant appeals within 10 days of the date of the denial notice, the CHC Plan must keep the existing services in place until the appeal is decided. Participants who miss this 10-day window can still appeal for up to 60 days, but they do not get to keep the existing hours in place.
Participants Have the Right to Participate: Participants may participate in their grievance by phone OR in person. The grievance panel must allow the participant to have a “reasonable opportunity” present evidence and testimony to support their need for services. Participants should call their CHC Plan to let them know they intend to participate, and if they will have someone representing them.
Participants Have the Right to Documents: The participant may request copies of all documents or information the CHC Plan used to make its decision to reduce services. This may include copies of the Person-Centered Service Plan, in-home assessments, and medical records. The CHC Plan must provide these materials free of charge and sufficiently in advance of the grievance for the participant to review them. PHLP recommends that participants request these documents as early as possible and follow up with their CHC Plan to ensure these documents are provided.
Participants May Have a Representative: Participants may have a lawyer, family member, or another person represent them in their grievance. PHLP invites participants seeking representation to call PHLP’s Helpline at 1-800-274-3258.
The CHC Plan must hold the grievance (appeal) hearing and issue a written grievance decision within 30 days of the grievance request. This may be extended to 45 days if the participant gives permission.
If the grievance (appeal) decision is unfavorable, participants may request both an External Review and a State Fair Hearing:
External Review: The participant’s file is sent to an outside medical expert, who reviews the grievance decision based on the paper record. Participants must request an External Review within 15 days of the written grievance decision, or within 10 days to keep continuing benefits pending the external review decision. Participants may submit additional materials, and will receive a decision within 60 days of the external review request
Fair Hearing: The participant may choose to have their appeal heard by an administrative law judge. Participants must request a fair hearing within 120 days of their grievance decision, or within 10 days to keep their current benefits in place while they wait for a fair hearing decision.
PHLP wants to hear about problems with appeals! Call our Helpline at 1-800-274-3258 if you need assistance with your grievance or appeal.