MISSION

The mission of the MAAC is to provide the Department of Public Welfare with advice about access to and delivery of good quality health care services in an efficient, economical, and responsive manner to low income individuals and families.

Agenda Temple University, Harrisburg, Pennsylvania

10:00 AM – 12:00 PM, April 25, 2013

10:00-10:05 Introduction of MAAC Members and Guests

10:05-10:05 Minutes of March 28, 2013 meeting – published via listserv and members notified 16 April.

10:05-10:25 Subcommittee Reports

Consumer Subcommittee (met 24 April)

Fee-For-Service Delivery System Subcommittee (mts 08 May)

Long Term Care Delivery System Subcommittee (met 09 April)

Managed Care Delivery System Subcommittee (met 11 April)

10:25-10:40 ACA Status Update – Acting Secretary Mackereth

10:40-10:50 OMAP Update

PCP Fee Increase – Robert Gardner

10:50-11:10 OLTL Update - Bonnie Rose

Status of Waiver Renewals

Service Coordination Rate Review Process

Mercer Contract to review and streamline eligibility process for HCBS

11:10-11:45 Affordable Care Act Eligibility and Enrollment Systems Update

Systems Update – CIO Jim Weaver

11:45-11:55 Medical Assistance Bulletins and Regulations

List of Bulletins – published to listserv 04/23/2013

Proposed Prior Authorization Requirements and Medical Necessity Guidelines or One feedback document posted 4/18/13

11:55 Old Business

11:55 New Business

12:00 Adjournment

The next MAAC Meeting is scheduled for Thursday, May 22, 2013, Lecture Hall 246/248, Temple University Harrisburg, 234 Strawberry Square, Harrisburg, Pennsylvania.

Please be considerate and turn off all electronic devices.

Please be considerate and turn off all electronic devices.

Interpreters for persons with hearing loss are available upon request via MAAC Email at MAACMail@state.pa.us two weeks prior to any scheduled MAAC meeting. MAAC minutes and presentations are available to the public via the MAAC listserv on the DPW website at: http://listserv.dpw.state.pa.us/maac-meeting-minutes.html

Independent Fiscal Office April 23, 2013

Analysis-in-Brief: Medicaid Expansion in Pennsylvania

The Commonwealth is considering whether to expand the state Medicaid program under the provisions of the federal Patient Protection and Affordable Care Act (ACA). The Independent Fiscal Office (IFO) has performed an analysis of the potential economic and fiscal impact of such an expansion in Pennsylvania. The analysis considers only the incremental impact of expanding Medicaid. Numerous provisions of the ACA take effect regardless of the decision on expansion, and those provisions are not included in the analysis.

Overview of the Methodology

The IFO uses a systematic approach to determine the potential fiscal and economic impacts of expansion. Assumptions used to facilitate the projections are identified throughout the analysis.

The analysis first projects the number of new enrollees by determining the affected groups, estimating the eligible population for each of them and applying appropriate participation rates.

Cost parameters specific to each group are applied to the new enrollees to derive the projected federal and state costs and savings. The state savings include the transfer of the General Assistance population to Medicaid. State costs include the additional administrative, personnel and information technology expenses incurred under expansion.

Projections for new federal funds flowing into the Commonwealth due to expansion are used to determine the impact on gross state product and taxable income. The additional funds used for the economic analysis adjust for amounts that replace current federal, state or household spending on healthcare.

New tax revenues attributable to the gains in economic activity are estimated. These estimates include additional revenues from the gross receipts tax imposed on Medicaid managed care organizations. Due to the mechanics of the tax, only the federal match is counted as new revenue.

Results of the Analysis

Projections for the number of new enrollees, new federal spending and the net budgetary impacts are listed in the tables below. The projections for the first fiscal year represent only a partial year due to normal lags in spending and revenue collections.

The budgetary savings to the Commonwealth are driven largely by the transfer of individuals from General Assistance to Medicaid. Some of the impact will depend on the details of decisions yet to be made by the federal government, including the allocation of required reductions in disproportionate share hospital payments.

Additional details are available in the full report, which is available at www.ifo.state.pa.us.

PA Impact of Medicaid Expansion

Calendar Year 2014 2015 2016 2017 2018 2019 2020 2021

New Enrollees w/o expansion (000’s) 100 134 169 171 173 176 179 182

New Enrollees w/ expansion (000’s) 253 339 427 430 434 440 446 451

Transfers w/ expansion (000’s) 131 132 133 134 135 136 137 138

Total New Enrollees (000’s) 483 605 729 735 742 752 761 771

New Federal Spending ($ millions) 1,750 2,485 3,029 2,988 3,108 3,194 3,200 3,330

State Fiscal Year Ending 2014 2015 2016 2017 2018 2019 2020 2021

Net Budget Savings ($ millions) 170 465 361 309 217 215 153 73

New Gross Receipts Tax ($ millions) 0 78 94 112 111 115 119 120

Other New Tax Revenue ($ millions) 11 77 88 98 99 102 104 106

Net Budget Impact ($ millions) 181 620 543 518 427 432 376 299

Affordable Care Act System Implementation

MAAC April 25, 2013 Jim Weaver

2

Agenda

Pennsylvania's Exchange Direction

Recent Progress

Supporting Eligibility and Enrollment System Changes

Next Steps

3

Pennsylvania's Decision How to Implement an Exchange

Each state had the opportunity to select how they wanted to implement their

health insurance exchange by December 14th, 2012.

State Based

•

•

•

•

State Based Exchange (SBE)

Built and maintained by each state

State Example: Washington, Kentucky

35% of states

State Partnership

•

•

•

•

Partnership Exchange

Hybrid Model where State assumes certain responsibilities

State Example: Delaware, West Virginia

14% of states

Federally Based

•

•

•

•

Federally Facilitated Marketplace (FFM)

Built by the Federal government, each state establishes an interface with the FFM to receive applications from consumers

State Example: Pennsylvania, Texas

51% of states

4

Key ACA System Activities in past 6 months

•

•

•

•

•

•

•

•

•

Governance Structure formed

• Joint ownership of project by DPW and the PID/CHIP

IAPD submitted and approved for enhanced funding

Business requirements developed and approved by joint DPW/CHIP teams

System Design sessions occurring by joint DPW/CHIP teams

CMS Communications and Reviews

• 4 gate reviews

•

•

•

•

Planning - April 30

Detailed Design Review – Summer 2013

Implementation Review – Prior to 10/2013

Operations and Maintenance Review

System Release Planning

Procurement of Independent Verification and Validation (IV&V) vendor

Training

o

o

o

ACA Awareness

Policy – Eligibility Rules

New and Changed System Functionality

End User Support Material Development

System Modifications Supporting ACA Enablement through 2013

6

Commonwealth ACA Systems Interaction

Applicants will access health

insurance and insurance affordability

options through a number of

channels:

•

•

•

•

•

FFM

COMPASS

CAOs (eCIS)

Chip Contractors (CAPS)

Telephone

Every door will use same MAGI/CHIP

eligibility rules

• Rules will be maintained in a

single location, accessible by

CAPS, COMPASS and eCIS.

PROMISe will send new enrollments

to the MA MCOs.

7

Federal Data Services Hub Starting October 1 additional electronic data sources will be available to the Commonwealth to

verify information with the goal to improve program integrity and reduce the verification burden

for families.

Social Security Administration (SSA)

Social Security Number (SSN) verification

Citizenship verification

Incarceration verification

Quarters of coverage information

Title II benefit income information (monthly

and annual amounts)

Department of Homeland Security (DHS)

-

-

-

-

-

-

-

Citizenship verification

Immigration status verification, as

well as a translation to indicators

for lawful presence, qualified non-

citizen, and five year bar status.

8

ACA Release in 2013 - 2/2A ACA Release 2 - September 2013

Focused on core requirements for ACA, with system modifications across iCIS and CAPS. MAGI data

collection and eligibility, with FFE integration and a real time interface with the Federal Data Services Hub.

Additionally, includes MAGI Reporting and supporting infrastructure initiatives.

ACA Release 2A – December 2013

This releases would include system modifications to enhance MAGI eligibility and renewal processing, as

well as prioritized change requests and resolution of issues identified from the initial release.

Enrollment of individuals from the FFM – January 1, 2014

Phase 2

March 25th

2013

Mar. April May June July Aug. Sept. Oct. Nov. Dec. Jan.

Phase 2A

9

Next Steps in next 60 days

•

•

•

•

•

CMS Gate Review in Baltimore – April 30

System Design completion

System Development begins

Planning for communications and training

Onboarding IV&V Vendor

MEDICAL ASSISTANCE ADVISORY COMMITTEE MEETING

MARCH 28, 2013

Mr. Nick Watsula, Chair, called the March 28, 2013, meeting of the Medical Assistance Advisory

Committee (MAAC) to order at 10:06 am. Members and guests were asked to introduce themselves.

Ms. Yvette Long made the motion which Ms. Minta Livengood seconded, to approve the minutes from the

February 28, 2013, meeting. The motion carried.

Subcommittee Reports

Consumer Subcommittee

Mr. Laval Miller-Wilson gave the Consumer Subcommittee report which met on

March 27, 2013.

Mr. Miller-Wilson stated the subcommittee was pleased to have acting Secretary Mackereth attend the

consumer subcommittee meeting.

The subcommittee discussed what’s working in the Medicaid system.

The subcommittee discussed a proposed expansion of the human services block grant, and received an

update on how the block grant is working in the 20 counties that were selected. The subcommittee was particularly

interested in the level of consumer engagement and involvement in the counties when the block grant is going

forward as counties make a decision about how to spend the funds. The subcommittee plans to have additional

dialogue with the Department of Public Welfare (Department). The subcommittee has some hesitation about the

expansion plans for the human services block grant.

The subcommittee received a report from the Office of Medical Assistance Programs (OMAP) about the

HealthChoices New East expansion.

Ms. Bonnie Rose, Deputy Secretary for the Office of Long-Term Living (OLTL) gave a PPL update. The

subcommittee was pleased to hear about the improvements that have come on claims processing by PPL and the

increased number of claims that have gone out.

There was a very in-depth discussion regarding the pharmacy and dental benefit limit exceptions. The

Department presented data from the managed-care plans that have implemented the pharmacy and dental benefit

limits which included approvals, denials and appeals. Some numbers gave the subcommittee pause but the

subcommittee will work with the Department and managed care organizations (MCOs) to reach an understanding

about how consumers are impacted.

The next meeting of the subcommittee is April 24, 2013.

A member of the audience asked if Mr. Miller-Wilson could expand on the numbers that gave the

subcommittee pause. Mr. Miller-Wilson stated the subcommittee would like to discuss this further before

commenting on the numbers.

Fee-for-Service Delivery System Subcommittee (FFSDSS)

The FFSDSS did not meet. The next meeting is May 8, 2013.

Long Term Care Delivery System Subcommittee (LTCDSS)

The LTCDSS did not meet. The next meeting is April 9, 2013.

Managed Care Delivery System Subcommittee (MCDSS)

Mr. Joe Glinka gave the update from the MCDSS meeting.

The MCDSS met March 14, 2013.

The MCDSS received a New East expansion update from Ms. Darlene Demore, Bureau of Managed Care

Operations.

The bulk of the discussions at the meeting centered around behavioral health specialist regulations and the

mandate to be licensed by May 26, 2013. There are a lot of concerns with that. The subcommittee discussed

provisional licensing for those eligible to provide services under supervision. The subcommittee has since found out

the mandate to be licensed has been moved to May 26, 2014. There are conditions to that extension. One of the

conditions is you have to apply by May 26, 2013, and you have to demonstrate that you are eligible to be licensed.

The subcommittee discussed Medicaid expansion. One of the items discussed was that the Affordable Care

Act (ACA) eliminates semi-annual reporting so there will be questions as to how renewals are addressed. There will

also be a discussion as to what happens if Pennsylvania doesn’t expand.

The next meeting of the MCDSS is April 11, 2013.

Department Of Public Welfare Reports

Ms. Beverly Mackereth, Acting Secretary for the Department, introduced herself to the members of the

MAAC and the audience and gave some background information on herself.

OMAP Update

Mr. Robert Gardner, Director, Bureau of Policy, Analysis and Planning, gave the OMAP update.

Mr. Gardner gave an update on the ACA physician increase State Plan Amendment (SPA). The SPA was

submitted to the Centers for Medicare and Medicaid Services (CMS) on January 31, 2013. Two evolving issues

have happened since the Department submitted the SPA. First, the way the rate is calculated has changed. The table

provided to the Department by CMS in January was incorrect. CMS provided the Department with a corrected table

several weeks ago. The resultant rates are weighted toward the lower paying counties. The table will be published

in a bulletin as soon as the SPA is approved.

The second is the vaccine codes. The Department uses the vaccine product codes. In the final ruling, CMS

used the admin vaccine codes: those were the specific set of codes the physicians could get their 100% Medicare

rate increase for. Approximately 3 weeks prior to the MAAC meeting, the Department had a face-to-face meeting

with CMS and the Department outlined the problem. After further discussions with CMS, the Department agreed to

do a crosswalk of the vaccine codes and will now be able to receive up to 100% federal match and the vaccine

product codes will count toward the 60% eligible code qualifier. This information is tentative based upon CMS final

SPA approval.

Dr. Eve Kimball stated as the Department does the crosswalk, make sure both sets of admin codes from

CMS are crosswalked.

Mr. Bernie Lynch asked if these codes will be implemented at the same time as the other ones or is this

something that will take a little longer. Mr. Gardner stated he does not see this taking any longer.

Mr. Bob Greenwood asked if a physician were to enroll and attest and decided they don’t want to be in the

system can they de-enroll. Mr. Dan De Lellis stated a physician can revoke their attestation. Mr. Greenwood then

asked, guidance was issued by the Department as to who would or would not be eligible and it was subsequently

determined that the guidance was inaccurate, for someone who did or didn’t enroll based on what was being told to

them after April 1st, would they be able to enroll and have the retroactive payment. Mr. Greenwood went on to

illustrate that providers are concerned about being locked into a decision based on information that may not be

correct.

Mr. Gardner stated this brings up a myriad of questions like who is telling providers this and what the

providers are being told. Information to the providers from the Department came from the MAAC or was written in

the quick tips or bulletins.

Mr. Greenwood responded and said a question raised specifically about whether a physician needed to have

a primary specialty of just one of the three or not. The answer came back was the primary specialty needs to be one

of the three specifically identified. Where the question came up was a lot of physicians have secondary specialties

that would be eligible. CMS clearly seems to be saying you can meet that second specialty and a lot of physicians

have been told not to enroll by DPW..

Mr. Greenwood stated another issue that seems to be coming up is unnamed MCO’s telling providers if you

are going to be in this program you need to be paid on a fee-for-service basis and you need to amend your contracts

in order for this to occur and by signing up you are obligated to do that. Ms. Leesa Allen stated the information has

not been addressed by CMS and it is something the Department is going to have to follow up on.

Dr. Kimball stated there have apparently been some providers who have been on access and are now going to

MCO’s that have been told they need to submit a claim to MA first and the primary insurance second. She

suggested we issue a bulletin clarifying the policy.

Mr. Matt McGeorge gave an update on the Electronic Health Record (EHR)/Health Information Technology

(HIT) program.

86% of professionals and 87% of hospitals have received at least one payment. 910 professionals have

received meaningful use (MU) payments. All professional types have received a MU payment. 35% that received a

2011 payment have returned for a 2012 MU payment.

Some of the things the Department is doing to engage providers include best practices, webinars, and a

MAPIR focus group. Health Information Exchange (HIE) support includes direct subscriptions, behavioral health

and long-term living providers that have identified HIE as a priority, and through a Commonwealth internal HIE.

Ms. Darlene Demore, Bureau of Managed Care Operations, gave the managed care expansion update.

On March 1, 2013, the last phase of HealthChoices expansion was implemented in the 22 counties in

northeastern Pennsylvania. Approximately 204,000 consumers had to choose one of the three plans operating in that

zone: Coventry Cares, Amerihealth Northeast and Geisinger Health Plan. 5,751 consumers did not have to choose

because they were already in Amerihealth Mercy health plan, a voluntary plan in that area, and they just moved to

Amerihealth Northeast.

Of the 204,000 that had to choose, approximately 89,000 did do so during the open enrollment period. The

self-selection rate was about 44%. The remaining members that did not select were auto assigned and split evenly

between three plans. After the initial open enrollment period, approximately 13,000 members switched plans for an

April 1, 2013 effective date. Member movement has been decreasing and is expected to stabilize.

A member of the audience asked which plans the consumers switched from.

Ms. Demore responded that members switch from plan to plan but a large contingent switched to Geisinger.

OLTL Update

Mr. Mike Hale, Office of Long-Term Living (OLTL), provided an update on PPL.

Mr. Hale stated there is between 97 and 98% in validated timesheets being paid to direct care workers.

Mr. Hale stated the biggest issue right now is the enrollment of new direct care workers. This is due to some

of the paperwork being confusing.

ODP UPDATE

Ms. Patty McCool, Office of Developmental Programs (ODP), discussed the waiver amendment on reserved

capacity.

CMS approved the ODP five-year waiver renewals for the Consolidated and the Person Family Directed

Support waivers on May 24, 2012. The approved waiver renewals were effective July 1, 2012. The budget for 2012

– 2013 that was signed on June 30, 2012, gave ODP additional funding for a waiting list initiative. CMS allowed

Pennsylvania to submit a retroactive amendment to include the waiting list for 2012 – 2013 since the waiver

renewals were signed before the budget was signed.

Many of the individuals who are eligible for the waiting list are living at home with their families. As such,

ODP expects the majority of waiting list individuals will access the Person Family Directed Support waiver. The

additional capacity included in that waiver amendment was necessary since the number of individuals enrolled in the

Person Family Directed Support waiver has consistently been close to the maximum approved in the renewal. The

Commonwealth wanted to ensure that individuals eligible for the waiting list initiative would be able to access that

waiver easily. Any waiting list eligible individual that has access to the Consolidated waiver are able to do so

through the existing capacity that was approved in the renewal, which has proved sufficient for this purpose given

the estimates originally included in that waiver.

Ms. McCool discussed the changes for the Adult Autism waiver. That amendment includes years two

through five, they are going to request an increase of the unduplicated number of participants to 330. Also for years

two through five, they want to increase the limit on the number of participants served at any given time by 15. The

Adult Autism waiver already states that the provider qualifications are verified every other year.

OMHSAS Update

Mr. Dennis Marion, Deputy Secretary for the Office of Mental Health and Substance Abuse Services

(OMHSAS), gave the OMHSAS update.

Mr. Marion stated during discussions at the Consumer Subcommittee meeting, it was brought to his attention

that the Subcommittee has never had any information about the general strategies that counties indicated they were

going to use with the block grant. OMHSAS is putting together a presentation for the next Consumer Subcommittee

meeting. He added that they are also evaluating what the non-block grant counties are doing. Mr. George Kimes

asked if it’s the assumption that OMHSAS is the responsible party. Mr. Marion stated OMHSAS is still partnered

with the other agencies.

Mr. Marion stated OMHSAS is still holding stakeholder meetings around the Commonwealth. He reiterated

their concern for individuals in transition such as childhood to adult, adult to older adult.

Ms. Dianna Fullem asked if there would be any stakeholder meetings in south-central Pennsylvania. Mr.

Marion stated yes there will be. Ms. Fullem then asked how stakeholders would be informed about the meetings.

Mr. Marion stated these would be posted on the list serve for OMHSAS. Mr. Marion stated if anyone has

suggestions as to getting information out, please email him the suggestions.

Mr. Miller-Wilson stated it would be OMHSAS’s role to make sure the block grant is administered the way

it was intended. Mr. Marion stated OMHSAS does not own the block grant and counties can explore how they can

improve services by taking advantage of the flexibility that a block grant can provide.

Ms. Yvette Long stated there is still more clarification needed regarding the block grant. Ms. Long stated

flexibility in the block grant should come at the end and not off the top.

Mr. Kimes stated OMHSAS interest in the block grant should be because the majority of funds come from

OMHSAS, but the question becomes where is the responsibility in the Department for monitoring the block grant

process and looking at how those funds are expended. Mr. Marion stated he’s been meeting with other offices in the

Department on the various issues as they arise.

MEDICAL ASSISTANCE BULLETINS AND REGULATIONS

Mr. Gardner stated enrollment has processed approximately 5,400 attestations. There are currently 2,000

pending.

There are provider training sessions that are being conducted by HP. These training sessions are for the

ACA provider fee increase on how to do billing.

Mr. Gardner stated the attestations that are currently being processed cover both fee-for-service and managed

care. The MCO’s will continue to receive file updates from the Bureau of Fee-For-Service Programs.

The list of MA bulletins was posted to the website on March 25, 2013.

There were nine pharmacy documents issued. The comments are due back by

April 11, 2013.

Dr. Kimball asked about the MCO methodology due to CMS by April 1. Dr. Kimball asked if there were

any details. Ms. Allen responded that the methodology was submitted on March 27, 2013, and briefly outlined next

steps. In response to Dr. Kimball’s question,

Ms. Allen agreed to provide Dr. Kimball with a copy of what was submitted.

Old Business

None noted.

New Business

An audience member asked if they could hear about what the Arkansas model for Medicaid expansion

involves. Mr. Gordon stated Pennsylvania it is not only looking at the Arkansas model but other state models as

well. No decision has been made on a model by the Governor at this point.

Dr. David O’Gurek asked if there’s any role for the MAAC to learn of those plans and perhaps provide

guidance or advice on the models. Mr. Gordon stated if the MAAC wanted to provide recommendations they could

do so.

Mr. Glinka stated there is a program within the Department that somewhat resembles the Arkansas model,

called the HIPP Program.

Mr. Miller-Wilson stated that from a consumer perspective the main through line is that people need to get

covered.

Dr. Kimball stated there’s a big difference between coverage and access to care. The HIPP program

provided access to care where there was none; not just coverage. This was because there were providers willing to

take private insurance over Medicaid.

Mr. Glinka stated if the exchange is federally run, Medicaid MCOs cannot participate. Mr. Gardner stated

there will be a presentation at the April MAAC regarding this information.

Dr. O’Gurek made a motion for the Department to provide models that are being considered so the MAAC

can make recommendations. Mr. Lynch seconded the motion.

Mr. Gordon stated the models being considered are the models the Kaiser Foundation speaks about every day in

their updates.

The next meeting of the MAAC will be Thursday, April 25, 2013, in Lecture Hall 246/248, Temple

University Harrisburg, 234 Strawberry Square, Harrisburg, PA.

Adjournment

The meeting was adjourned at 11:54 am.

Department of Public Welfare – Office of Medical Assistance Programs

Prior Authorization

Feedback on Public Input From March 28, 2013 Meeting

1

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Department of Public Welfare – Office of Medical Assistance Programs

Prior Authorization

Feedback on Public Input From March 28, 2013 Meeting

2

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Medical Assistance Bulletin/Regulation Issuance March, 2013

Bulletin

Number(s) Subject/Title Issue Date Effective Date

09-13-20 Pharmacy Benefit Package Update 4/22/13 4/22/13

99-13-03 Medical Assistance Program Fee Schedule

Revisions 04/15/13 04/15/13

99-13-06 2013 Recommended Childhood and Adolescent

Immunization Schedules 04/12/13 02/01/13

24-13-10 Medical Assistance Program Fee Schedule

Revisions for Procedure Code K0606 04/01/13 06/25/12

01-13-13 Prior Authorization of Antipsychotics - Pharmacy

Services 03/29/13 04/22/13

01-13-14 Prior Authorization of Bladder Relaxant

Preparations - Pharmacy Services 03/29/13 04/22/13

01-13-15

Prior Authorization of Chronic Obstructive

Pulmonary Disease (COPD) Agents - Pharmacy

Services

03/29/13 04/22/13

01-13-16 Prior Authorization of Analgesics, Narcotic Short

Acting - Pharmacy Services 03/29/13 04/22/13

01-13-17

Prior Authorization of Bronchodilators, Beta

Agonists, Short Acting Agents - Pharmacy

Services

03/29/13 04/22/13