Policy Areas

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Yesterday, the US Department of Health and Human Services (HHS) announced a new payment model for emergency ambulance services that aims to allow Medicare fee-for-service (FFS) beneficiaries to receive the most appropriate level of care, at the right time and place, with the potential for lower out-of-pocket costs.

Beginning in early 2020, the new model – Emergency Triage, Treat, and Transport (ET3) Model – will make it possible for participating ambulance suppliers and providers to partner with qualified health care practitioners to deliver treatment in place (either on-the-scene or through telehealth), and with alternative destination sites (such as primary care doctors’ offices or urgent-care clinics), to provide care for Medicare beneficiaries following a medical emergency for which they have accessed 911 services. In doing so, the model seeks to engage health care providers across the care continuum to more appropriately and effectively meet beneficiaries’ needs. Additionally, the model will encourage development of medical triage lines for low-acuity 911 calls in regions where participating ambulance suppliers and providers operate. The ET3 Model will have a five-year performance period, extending through 2025.

Currently, Medicare primarily pays for unscheduled, emergency ground ambulance services when beneficiaries are transported to a hospital emergency department (ED), creating an incentive to transport all beneficiaries to the hospital even when an alternative treatment option may be more appropriate. To counter this incentive, the ET3 Model will test two new ambulance payments, while continuing to pay for emergency transport for a Medicare beneficiary to a hospital ED or other destination covered under current regulations:

  • Payment for treatment in place with a qualified health care practitioner, either on-the-scene or connected using telehealth; and
  • Payment for unscheduled, emergency transport of Medicare beneficiaries to alternative destinations (such as 24-hour care clinics) other than destinations covered under current regulations (such as hospital EDs).

The ET3 Model encourages high-quality provision of care by enabling participating ambulance suppliers and providers to earn up to a five percent payment adjustment in later years of the model based on their achievement of key quality measures. The quality measurement strategy will aim to avoid adding more burden to participants, including minimizing any new reporting requirements. Qualified health care practitioners or alternative destination sites that partner with participating ambulance suppliers and providers would receive payment as usual under Medicare for any services rendered.

The model will use a phased approach through multiple application rounds to maximize participation in regions across the country. In an effort to ensure access to model interventions across all individuals in a region, CMS will encourage ET3 Model participants to partner with other payers, including state Medicaid agencies.

Contact Melissa Dehoff, RCPA Director of Rehabilitation Services, with questions.

Effective February 1, 2019, Supports Coordinators (SCs) are to follow the interim guidance given in ODP Announcement 19-013 on how to complete ODP’s revised Prioritization of Urgency of Needs of Services (PUNS) form that will go-live in the Home and Community Services Information System (HCSIS) on February 1, 2019. ODP also provided an Interim Guidance document. The revisions to the PUNS form were limited to text changes only. The format of the tool and HCSIS functionality remain the same.

The reasons for the changes are:

  • Refinement of questions to collect more accurate information about needs and stressors;
  • Emphasis on conversation between SC, individual, and family about short-term and long-term needs;
  • Better align the PUNS Form with the current waiver; and
  • Allow better planning for the needs of individuals locally as well as the overall ODP system.

SCs should continue to use the PUNS Disagreement Form and letter located at www.dhs.pa.gov until the updated PUNS bulletin and attachments are published.

If you have questions, please reach out to your regional PUNS Lead:

Kristin Ahrens, Deputy Secretary for ODP and Ryan Hyde, Acting Executive Director for Office of Vocational Rehabilitation (OVR), signed a joint bulletin on February 14, 2019 to become effective on February 15, 2019. Bulletin 00-19-01 provides updated guidance regarding requirements for when individuals must be referred to OVR to align with the requirements in the current Consolidated Waiver, Person/Family Direct Support (P/FDS) Waiver, Community Living Waiver, and Adult Autism Waiver (the ODP Waivers), and the Workforce Innovation and Opportunity Act (WIOA) (Pub.L. 113-128) and clarifies that the guidance in this bulletin applies to employment-related services funded through base-funding provided for by the Mental Health and Intellectual Disability Act of 1966 (50 P.S. §§ 4101-4704).

In accordance with the Employment First Act (62 P.S. §§ 3401-3409), competitive integrated employment is the preferred outcome for individuals receiving services funded through the ODP Waivers or base-funding and OVR services. An employment outcome is the first and preferred outcome because it provides many benefits to the individual including, but not limited to: increased opportunities for economic self-sufficiency, an opportunity to contribute to the community, a chance to build a network of social relationships, and the creation of opportunities for lifelong learning. An employment outcome is also consistent with the overall goals and recommendations in Everyday Lives: Values in Action, the document that provides guiding principles for the Office of Developmental Programs (ODP).

The employment recommendation in Everyday Lives: Values in Action states: “Employment is a centerpiece of adulthood and must be available for every person. The benefits of employment for people with disabilities are significant and are the same as for people without disabilities.” In addition, Everyday Lives: Values in Action includes the following value statement developed by self-advocates: “I want to work and/or have other ways to contribute to my community. My family, supporters, and community support me to find and keep a real job that I like with good wages and benefits or start and run my own business, and/or volunteer the way I want in my community.”

ODP and OVR have been working closely together to ensure that all individuals enrolled in ODP Waivers or receiving base-funded services have access to experiences and services that will enable them to obtain an employment outcome and receive the benefits that come from being employed. Supports Coordinators must refer an individual to OVR for OVR to determine the individual’s eligibility for services when an individual who is enrolled in an ODP Waiver or is receiving base-funded services indicates an interest in seeking employment or requests that the following employment-related services be added to his or her Individual Support Plan (ISP):

Consolidated, P/FDS, and Community Living Waivers:

  • Advanced Supported Employment;
  • Supported Employment;
  • Small Group Employment;
  • Community Participation Support; and
  • Education Support.

Adult Autism Waiver:

  • Supported Employment;
  • Career Planning; and
  • Transitional Work.

All other services offered by the ODP Waivers do not require a referral to OVR.

Once an individual is referred to OVR, OVR will determine using its own eligibility standards and criteria if the individual is eligible for OVR services. OVR will not make a determination if employment-related services provided through ODP Waivers or base-funded services are needed or appropriate for the individual.

It is critical that OVR staff and Supports Coordinators engage in ongoing conversations during the OVR referral and eligibility determination process to ensure that timely eligibility determinations are made. Ongoing conversations allow OVR staff and Supports Coordinators to discuss the following topics:

  • Whether additional information is needed by OVR staff to make an eligibility determination.
  • If OVR staff has any concerns about the individual. For example, OVR staff may report that the individual has experienced a prolonged illness that has impacted OVR staff’s ability to set up meetings and determine the individual’s eligibility for OVR services.
  • The date that OVR staff expects to make an eligibility determination.
  • Services and supports that OVR staff is exploring with the individual.

In some circumstances, OVR may not have the capacity to serve every individual referred by a Supports Coordinator in a timely manner. In such cases, there are special provisions in the ODP Waivers that allow the Supports Coordinator to access Waiver funding without receipt of an OVR eligibility determination.

Please see the bulletin and:

Contact Carol Ferenz, RCPA IDD Division Director, with questions.

ODP Announcement 19-017 provides guidance for assisting individuals with transitioning from nursing facilities into waiver services. When an individual is in reserved waiver capacity status, due to requiring hospital and/or nursing home care beyond 30 days, or has been identified as eligible to receive services offered in an ODP waiver upon discharge from the nursing facility, the AE, county MH/ID program, SC, or TSM provider will need to assist the individual in transitioning from the nursing facility. As part of the transition process, a PA 1768 form needs to be completed.

It is important that the PA 1768 form is completed and submitted to the County Assistance Office (CAO) prior to the individual’s discharge, so that there is no interruption in service. The submission of the PA 1768 form in advance of the anticipated discharge date allows the CAO to enter a waiver code in the individual’s record.

The nursing facility will coordinate with the individual and family, the AE, county MH/ID program, SC, or TSM provider as appropriate, to determine an anticipated date of discharge from the nursing facility. The individual must begin to receive waiver services on the day he or she is discharged from the nursing facility.

The AE, county MH/ID program, SC, or TSM provider is responsible to complete the PA 1768 form. The completed PA 1768 form will be sent to the CAO at least two weeks prior to the anticipated date of discharge. For more information about completing the PA 1768, please refer to ODP bulletin 00-18-02, Home and Community-Based Services (HCBS) Eligibility/Ineligibility/Change Form (PA 1768) and Instructions.

The nursing facility is responsible to complete and submit the Long Term Care Admission Discharge Transmittal form (MA 103) to the CAO when the individual is discharged from the nursing facility. During the transition process, if the AE, county MH/ID program, SC, or TSM provider becomes aware that the nursing facility did not complete and submit the MA 103 to the CAO, a request should be made to the nursing facility to complete and submit this form. Enrollment into a waiver cannot be completed until the CAO receives the MA 103. Depending on the individual’s circumstances, the actual discharge date may be sooner or later than the originally anticipated discharge date, or the individual may not be discharged at all.

Please direct questions regarding this Announcement to the appropriate ODP Regional Office.

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On February 11, 2019, the Office of Long-Term Living (OLTL) released Bulletin 59-19-03, Hearings and Appeals. The bulletin provides the responsibilities of Service Coordination Entities (SCEs) with respect to the notice and fair hearing requirements. Also included with the bulletin are the following attachments:

  1. MA 561 – Notice of Service Determination and the Right to Appeal
  2. MA 562 – Decision to Withdraw an Appeal Request
  3. MS 561 – MA 561 Form Instructions for Service Coordinators
  4. Bureau of Hearings and Appeals Agency Appeal Cover Sheet
  5. Bureau of Hearings and Appeals Agency Appeal Cover Sheet Instructions
  6. OHA 147 – Bureau of Hearings and Appeals Agency Expedited Information Sheet
  7. BHA Regions Chart

The bulletin is updated to reflect expedited appeals requirements that were established by the Medicaid Eligibility Final Rule and can be found in 42 CFR Part 431.224. The SCEs are responsible to understand the rights and procedures set forth in the state regulations and federal regulations. The bulletin highlights the many requirements of the SCEs.

OLTL has scheduled a webinar for Monday, February 25, 2019 at 2:00 pm to answer questions SCEs may have in relation to this bulletin. Please register here. After registering, you will receive a confirmation email containing information about joining the webinar. Contact Melissa Dehoff, RCPA Director of Rehabilitation Services, with questions.

All provider members of RCPA became full members of ANCOR at the beginning of the calendar year 2019. Join in this webinar to learn about the benefits now available to you as an RCPA/ANCOR member. Gabrielle Sedor, Chief Operations Officer, will lead a discussion explaining all the resources now available to you, including:

  • Monday Capital Correspondence;
  • Friday Weekly Update;
  • Conference and webinars at member rates;
  • Action Alerts;
  • Access to the ACC; and
  • Federal Updates.

The welcome webinar will be held Wednesday, February 27, 2019, 4:00 pm – 4:30 pm. This webinar will be recorded so if you are unable to participate, you may view it at a later time. Register here to participate. For questions about ANCOR, please visit the ANCOR official website.

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The Department of Defense (DoD) issued a proposed rule to add certified or licensed physical therapy assistants (PTAs) and occupational therapy assistants (OTAs) as TRICARE-authorized providers, to engage in physical or occupational therapy, under the supervision of a TRICARE-authorized physical or occupational therapist, in accordance with Medicare’s rules for supervision and qualification when billed by under the supervising therapist’s national provider identification number. This rule will align TRICARE with Medicare’s policy. Comments on this proposed rule will be accepted until Tuesday, February 19, 2019. Contact Melissa Dehoff, RCPA Director of Rehabilitation Services, with questions.

The Coalition to Preserve Behavioral HealthChoices, which includes RCPA, has signed onto a letter that will be sent out to members of the General Assembly stating “strong opposition to House Bill 335.” This bill calls for elimination of the Behavioral Health Carve-Out, known as Behavioral HealthChoices (BHC). BHC is the statewide program through which every county delivers mental health and drug & alcohol services to vulnerable Pennsylvanians enrolled in the Medical Assistance program, and their families. Please contact RCPA Director of Government Affairs Jack Phillips with any questions.