OLTL Moving Forward with Terminating Certain Medicaid HCBS Participants

Starting June 1st, Community HealthChoices (CHC) Plans, at the direction of DHS’ Office of Long-Term Living (OLTL), will begin a process to end the CHC Waiver for some participants who have not been annually reassessed and found clinically (medically) eligible for the waiver.  Impacted individuals will receive a written notice about their Home and Community Based Services (HCBS) Waiver ending from their County Assistance Office and should immediately appeal.  

Medicaid Home and Community-Based Services Waiver rules require reassessments of participants at least once a year. This annual assessment is used to verify that participants continue to meet the required clinical (medical) level of care to remain eligible for Medicaid Waiver services. The participants at risk of losing their eligibility for the CHC waiver are those who have not received an annual reassessment because 1) the CHC plan cannot reach them or 2) the participant refused the yearly assessment.   Waiver participants who had a reassessment in the past year, even if it was not formally called an “annual” reassessment, will not be impacted.  According to OLTL, every reassessment, regardless of the reason for the reassessment, resets the clock for when the next annual reassessment is due.  For example, a participant who had an annual reassessment in February 2020, and a reassessment in November 2020 due to a hospitalization would not be due for their next annual reassessment until November 2021. 

Additional guidance about this change is expected in early June. At the May Consumer Subcommittee of the Medical Assistance Advisory Committee meeting, OLTL staff detailed what they expect of the CHC plans before the plan can notify the County Assistance Office (CAO) that CHC Waiver benefits should end.  When someone cannot be reached, the CHC plan must contact the participant at various times of the day or evening.  Then, a Service Coordinator (or other plan representative) must attempt to visit the participant at their home.  Regardless of whether the participant cannot be reached or has refused the reassessment, the CHC plans must send a certified letter informing the participant that they must act within a certain amount of time or their CHC Waiver benefits will end. This letter is in addition to the written notice the CAO will send.  So far, the CHC plans have identified less than 350 people across Pennsylvania who have refused to have their yearly assessments. They are still gathering data about how many participants cannot be reached.  

Readers may be surprised that OLTL is moving forward with ending CHC Waiver benefits during the COVID-19 Public Health Emergency because continuous eligibility protections are still in place.  The federal Families First Coronavirus Response Act (FFCRA), passed in March 2020, largely prohibits states from ending Medicaid or Medicaid Waiver eligibility during the ongoing federal COVID-19 Public Health Emergency.  This protection includes allowing people to continue getting Medicaid even if they fail to complete a renewal of benefits or are found to no longer qualify for Medicaid.  Nevertheless, toward the end of 2020, the federal government issued emergency regulations creating exceptions to the continuous eligibility provisions allowing coverage to be terminated in some cases and reduced in others.  These new regulatory changes direct conflict with the FFCRA provisions.  On December 7, 2020, Pennsylvania’s Department of Human Services (DHS) implemented policy changes expanding the exceptions to the continuous eligibility protections.   

DHS’ new guidance does not cover situations in which a person has been unable to be reached for or refuses an annual Waiver clinical eligibility redetermination.  However, OLTL is still moving ahead by asking the CHC plans to terminate such individuals from the CHC waiver.  

PHLP has created some tips for people in the CHC Waiver:  

  • To avoid having their CHC Waiver terminated, CHC Waiver participants should cooperate with the yearly reassessment by their CHC plan.  People who are comfortable having an in-person assessment must be allowed to get one at this time.  

  • Participants who refuse the yearly reassessment or cannot be reached, will have their cases referred to the County Assistance Office (CAO). The CAO will send a termination notice that can be appealed.  

  • PHLP urges participants who get a termination notice to appeal that termination immediately and then work with their CHC plan to arrange the annual reassessment.   

  • Appealing quickly, generally within 15 days of the mail date on the notice, keeps benefits in place during the appeal process. The appeal rules that normally apply when people are notified that their Medicaid benefits are ending are more flexible during the COVID public health emergency. If people miss this deadline, they can still ask to have their benefits continued during the appeal.  

  • Those who do not appeal timely or lose their appeal will lose their Waiver services and benefits. They will either keep full Medicaid benefits or be moved to a program that only pays their Medicare Part B premium.  This will depend on someone’s income and resources. Some people will get both full Medicaid and payment of the Medicare Part B premiums.   

People who are impacted by this change are encouraged to call PHLP’s Helpline at 1-800-274-3258 or email us at staff@phlp.org. People can also contact us if they are having difficulty scheduling an in-person assessment or if their in-home services are reduced or changed as a result of the assessment they get.