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CHIP

The Department of Human Services (DHS) has made the Medical Assistance (MA) and Children’s Health Insurance Program (CHIP) Managed Care Quality Strategy (MCQS) for the Commonwealth available for public review and comment. The MCQS is an updated version of the previous strategy submitted to the Centers for Medicare and Medicaid Services (CMS) in December 2020 and accounts for the ongoing post-pandemic delivery system pressures that have affected how managed care organizations (MCOs) deliver care. The MCQS may be viewed online. Comments may be submitted via email, and those received within 30 days will be reviewed and considered. Additional information is available on the Pennsylvania Bulletin.

If you have any questions, please contact Fady Sahhar.

The Centers for Medicare and Medicaid Services (CMS) released two notices of proposed rulemaking (NPRM): Ensuring Access to Medicaid Services and Managed Care Access, Finance, and Quality.

If adopted as proposed, the rules would establish national standards for access to care regardless of whether that care is provided through managed care plans or directly by states through fee-for-service (FFS). Specifically, they would establish access standards through Medicaid or CHIP managed care plans, as well as transparency for Medicaid payment rates to providers, including hourly rates and compensation for certain home care and other direct care workers. The rules would also establish other access standards for transparency and accountability and empower beneficiary choice.

The proposed rules together include new and updated proposed requirements for states and managed care plans that would establish tangible, consistent access standards and a consistent way to transparently review and assess Medicaid payment rates across states. The rule also proposes standards to allow enrollees to easily compare plans based on quality and access to providers through the state’s website.

Other highlights from the proposed rules include:

  • Establishing national maximum standards for certain appointment wait times for Medicaid or CHIP managed care enrollees, and stronger state monitoring and reporting requirements related to access and network adequacy for Medicaid or CHIP managed care plans, which now cover the majority of Medicaid or CHIP beneficiaries;
  • Requiring states to conduct independent secret shopper surveys of Medicaid or CHIP managed care plans to verify compliance with appointment wait time standards and to identify where provider directories are inaccurate;
  • Creating new payment transparency requirements for states by requiring disclosure of provider payment rates in both fee-for-service and managed care, with the goal of greater insight into how Medicaid payment levels affect access to care;
  • Establishing additional transparency and interested party engagement requirements for setting Medicaid payment rates for home and community-based services (HCBS), as well as a requirement that at least 80 percent of Medicaid payments for personal care, homemaker, and home health aide services be spent on compensation for direct care workers (as opposed to administrative overhead or profit);
  • Creating timeliness-of-access measures for HCBS and strengthening necessary safeguards to ensure beneficiary health and welfare as well as promote health equity;
  • Strengthening how states use state Medical Care Advisory Committees, through which stakeholders provide guidance to state Medicaid agencies about health and medical care services, to ensure all states are using these committees optimally to realize a more effective and efficient Medicaid program that is informed by the experiences of Medicaid beneficiaries, their caretakers, and other interested parties;
  • Requiring states to conduct enrollee experience surveys in Medicaid managed care annually for each managed care plan to gather input directly from enrollees; and
  • Establishing a framework for states to implement a Medicaid or CHIP quality rating system, a “one-stop-shop” for enrollees to compare Medicaid or CHIP managed care plans based on quality of care, access to providers, covered benefits and drugs, cost, and other plan performance indicators.

The proposed rules will be published in the May 5, 2023, Federal Register, and comments will be accepted through July 3, 2023.

Pennsylvania is preparing for a major change in renewal processes for Medicaid and Children’s Health Insurance Program (CHIP) recipients.

Starting April 1, 2023, Pennsylvania is required by federal law to review Medicaid and CHIP recipients’ eligibility every year, which means that recipients must submit a renewal. While the Department of Human Services (DHS) still sent renewals during the height of the COVID-19 pandemic, most people were not disenrolled from Medicaid or CHIP because of a change in eligibility.

DHS encourages everyone to share the following information with Medicaid and CHIP recipients to help them stay informed about renewals.

What Should I Do Right Now?

The best thing that Medicaid and CHIP recipients can do right now to prepare for their renewal is to make sure that their contact information is up-to-date with DHS. By making sure that their information is current, recipients can receive timely updates about their renewal. They also can opt-in to receiving text and email alerts about their benefits.

  • Visit COMPASS and log into their My COMPASS Account.
  • Use the free myCOMPASS PA mobile app.
  • Call 877-395-8930 or 215-560-7226 (Philadelphia), Monday – Friday from 8:00 am – 4:30 pm.

What Else Do I Need to Know?

Completing Medicaid and CHIP Renewals
Renewals should be completed when they are received, even if recipients receive them before April 1, 2023. Recipients will receive a renewal packet in the mail when it is time to renew their coverage. Information about their renewal will start to arrive 90 days before it is due. It is very important that renewal forms are completed and returned even if nothing has changed. Completing a renewal allows DHS to determine eligibility for MA or CHIP coverage. Coverage will continue for recipients who are still eligible.
There are a few ways for recipients to complete a renewal:

  • Complete the forms DHS sends and mail them back in the envelope included in the packet.
  • Drop completed forms off at the local county assistance office (CAO).
  • Complete the renewal online.
  • Complete the renewal over the phone by calling 866-550-4355.

What is Continuous Coverage?

Under the continuous coverage requirement, individuals covered by Medicaid and/or CHIP have been able to keep their health coverage even if they would have otherwise become ineligible for the program based on other factors.

Evaluating Eligibility

Once the continuous Medicaid and CHIP coverage requirement ends, recipients will have to complete a renewal to maintain their coverage as long as they are eligible.

Are You Ineligible for Coverage?

DHS will provide instructions on how to re-enroll or share options for coverage if individuals are no longer eligible. Options for free or low-cost health coverage are available online.

Get more information and resources at DHS’s website.

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Because of the continuous coverage requirement, states were able to use additional money from the federal government during the federal public health emergency (PHE) for health care programs like Medicaid if they kept people covered. Therefore, Pennsylvanians did not lose their Medicaid/Medical Assistance (MA) or CHIP coverage if their income changed or they did not complete a renewal during the PHE.

However, starting April 1, 2023, Pennsylvania and other states will have to start disenrolling people if households are ineligible for MA at the time of their renewal or do not complete their renewal. The Pennsylvania Department of Human Services (DHS) will have to return to normal renewal processing procedures for Pennsylvanians enrolled in MA and the CHIP. Renewals will be completed over 12 months. Everyone with MA or CHIP coverage will need to submit a renewal to see if they are still eligible.

In Pennsylvania, approximately 3.5 million people rely on Medicaid. Last year, it was estimated that about 500,000 of those would lose coverage when the continuous coverage requirement ended, creating access issues for individuals and exacerbating financial challenges for providers.

The Pennsylvania Department of Human Services has created an online resource, including a stakeholder toolkit as well as a guide on how to become a helper, that provides resources for groups like providers to communicate ways for Pennsylvanians who receive MA or CHIP coverage to continue their coverage.

A new report finds that there have been substantial gains on the issue of making addiction and mental health coverage equal to physical health coverage. Much work still needs to be done, especially for children, according to Ron Manderscheid, PhD, Executive Director of the National Association of County Behavioral Health and Developmental Disability Directors (NACBHDD) and the National Association for Rural Mental Health. “Children can’t speak for themselves on the issue of parity,” Manderscheid says. “That’s why it’s very important for the Department of Health and Human Services (HHS) and state health insurance commissioners to protect the rights of children around parity. Any child who has health insurance coverage through the individual marketplace under the Affordable Care Act (ACA), or through the ACA’s Medicaid expansion, is entitled to parity protection, but we don’t really know how well it’s working.” The estimated 8.4 million children enrolled under the Children’s Health Insurance Program, which is part of Medicaid, are not covered by parity protections, Manderscheid noted. “The field has so focused on problems with implementing parity with adults that children haven’t gotten equal attention in this process.” In October, the White House Mental Health and Substance Use Disorder Parity Task Force issued a report that concluded that overall, state-level substance use disorder parity laws have helped to increase the treatment rate by approximately 9 percent across substance use disorder specialty facilities and by about 15 percent in facilities that accept private insurance. This effect was found to be more pronounced in states with more comprehensive parity laws.

“The concept of parity is simple, but the implementation of it is incredibly complex,” said Manderscheid. The trickiest part of parity is a concept called non-quantitative treatment limitations, which are processes that managed care firms use to determine who will and won’t get care, he explains. Currently, the burden chiefly falls on the consumer to report to the federal or state government if their claims for addiction or mental health treatment are denied. “The enforcement burden should fall on HHS, state insurance commissioners, and the insurance companies themselves.”