Beruflich Dokumente
Kultur Dokumente
using the Pennsylvania Client Placement Criteria (PCPC % This com!orts $ith &est !ractice guidelines and should &e maintained in the revised !rogram% 7either &enefit !ac'age includes intensive out!atient and in!atient non(hos!ital deto+, reha& and half$ay house services% 2o$ever, these services are levels of care in the PCPC, and they are included in the current 2ealthChoices &ehavioral health !rogram% .t is crucial that the full continuum of su&stance a&use treatment services continue to &e availa&le in Pennsylvania*s /edical Assistance !rogram% ,hat $ill ha!!en $hen an individual reaches the defined limit for a given ty!e of service $ithin his &enefit !ac'age, &ut medical necessity criteria indicates that the &est course of action is to continue $ith the same level of care6 ,hat ty!e of a!!eal mechanism $ill e+ist, and ho$ $ill an e+!edient res!onse &e ensured to !revent a counter!roductive disru!tion in care6 8or e+am!le, if an individual has e+hausted his in!atient services &enefit for a given year, $hat $ill ha!!en if he rela!ses and re9uires deto+ services6 ,ho $ill &e res!onsi&le $hen an individual reaches a &enefit limit, &ut medical necessity criteria indicates he is not ready to move to a lo$er level of care6 ,ill !roviders &e held financially lia&le if they retain an individual $ho has ma+ed out his &enefit at a given level of care !ending the outcome of some ty!e of a!!eal !rocess6 ,hat $ill the !rocess &e for moving individuals &et$een the 2igh -is' and 5o$ -is' &enefit !lans6 ,hat criteria $ill &e used6 2o$ $ill this &e accom!lished in an efficient manner that doesn*t disru!t care6 2o$ $ill the creation of se!arate &enefit !ac'ages translate into rate setting to ensure ade9uate funding for &ehavioral health services6
Pennsylvania*s Act 10: of 1;";3 This la$ re9uires all commercial grou! health !lans, 2/<s and the Children*s 2ealth .nsurance Program to !rovide com!rehensive treatment for alcohol and other drug addictions% Act 10: includes non(hos!ital as an eligi&le form of in!atient% This is im!ortant for three reasons3 1 it ensures access to a full continuum of care= 2 a ma>ority of !eo!le $ho need in!atient treatment do not need to &e in a hos!ital setting= and ? non(hos!ital deto+ and reha& o!tion are much more afforda&le than hos!ital &ased% .t $ill &e im!ortant to confirm that Act 10: $ould a!!ly to any healthcare coverage through the !ro!osed Private Coverage <!tion for &oth current and ne$ly eligi&le /edicaid reci!ients%
2ealth #creening3 0nrollment in either the 2igh -is' or 5o$ -is' &enefit !lan $ill &e &ased on a self( administered health screening% )iven that one of the hallmar's of addiction is denial, $e are s'e!tical that a self(administered screen $ill &e com!leted accurately &y those $ith a su&stance a&use disorder% 8or those that do recogni@e they have a !ro&lem, $ill they &e $illing to document their use of their illegal su&stances andAor their addiction as !art of an online government a!!lication !rocess6 The tendency to minimi@e su&stance a&use issues is li'ely to lead to a 5o$ -is' designation $ith a leaner &enefit !ac'age% The re9uirement to com!lete the health screening as !art of the /edical Assistance a!!lication further com!licates an already cum&ersome !rocess%
Premiums3 The 2ealthy PA 1111 !lan calls for monthly !remiums for all /edical Assistance reci!ients unless they are deemed e+em!t% ,ith the e+ce!tion of the first month, !remiums must &e !aid a month in advance% 8ailure to !ay for three consecutive months $ill result in loss of /edicaid eligi&ility% .n the long run, !remiums can &e reduced if certain conditions are met% <ur association strongly su!!orts efforts to encourage individuals to move from de!endence to inde!endence% <ne of the hallmar's of su&stance a&use treatment is that clients are held accounta&le for their actions% 2o$ever, e+!ecting individuals $hose income is 10 !ercent of the federally determined !overty level (8P5 to !ay a monthly !remium does not seem realistic% 0ven for those a&ove 100 !ercent 8P5, ma'ing modest monthly !remium !ayments on a consistent &asis $ill &e challenging% A $hole ne$ layer of administrative overhead and cost $ill have to &e added in order to im!lement the !ro!osed !remium !ayment structure% The re9uirements $ill lead to individuals shifting in and out of eligi&ility% ,e fear this re9uirement $ill &e a &arrier to achieving the stated goal of increasing healthcare access% .f a recovering !erson does lose his /edicaid eligi&ility due to failure to !ay !remiums, $hat $ill ha!!en if he rela!ses and needs additional treatment services6
,or' #earch -e9uirements3 Bnless determined to &e e+em!t, adults &et$een the ages of 21 and :1 $ho are $or'ing less than 20 hours !er $ee' $ill &e re9uired to com!lete 12 a!!roved $or' search activities !er month during their first si+ months% 8ailure to do so $ill result in loss of /edicaid eligi&ility% <ur association su!!orts the encouragement of $or' search activities for those $ho are em!loya&le once their su&stance a&use disorder has &een sta&ili@ed% ,e !resume these $or' search re9uirements $ill &e $aived $hile individuals are receiving hos!ital or non(hos!ital in!atient treatment% ,e are concerned that as $ith the monthly !remiums, a $hole ne$ layer of administrative overhead and cost $ill &e re9uired in order to monitor these ne$ $or' search re9uirements%
7o -etroactive Coverage3 8or the ne$ly eligi&le !o!ulation, eligi&ility $ill &ecome effective on the first day of enrollment in a !rivate coverage !lan% There $ill &e no retroactive coverage% /any individuals only a!!ly for /edicaid after they &ecome ill% Denying retroactivity $ill leave !roviders $ithout reim&ursement until the enrollment date% .f retroactive coverage is not !rovided, it $ill &e es!ecially im!ortant to maintain ade9uate funding for county(managed su&stance a&use treatment services in order to cover this ga!%
<ut(of(7et$or' #ervices3 .f !roviders are not enrolled in the net$or's for the various C!rivate coverage !lansD, they $ill not &e a&le to !rovide services to clients covered &y those !lans% This could have significant im!act on !roviders &ased on their current contracts and a&ility to esta&lish contracts $ith those !lans% ,ill there &e any re9uirements for the !rivate coverage !lans to $or' $ith any $illing !rovider to ensure ade9uate !rovider ca!acity in their net$or's6
Transition of )A !o!ulation to Private Coverage <!tion3 The 1111 a!!lication !ro!oses to move those !artici!ants $ho are currently covered through Pennsylvania*s )eneral Assistance ()A /edical Assistance, as $ell as a num&er of other current eligi&ility categories, into the Cne$ly eligi&leD grou!% They $ould then &e su&>ect to all the re9uirements and limitations of this ne$ Private Coverage <!tion% ?
A ma>ority of current /edicaid reci!ients $ho receive su&stance treatment fall into the )A category of eligi&ility% The net effect of the !ro!osed change $ill &e to reduce &enefits and increase o&stacles to sustained eligi&ility and access for these currently eligi&le /A reci!ients% 8or many of the reasons cited else$here in these comments, PACDAA sees this as a counter!roductive ste! &ac'$ards%
PACDAA is truly e+cited that Pennsylvania is see'ing a $ay to !artici!ate in the e+!ansion of access to health care for our citi@ens $ho currently lac' health insurance% ,e a!!laud )overnor Cor&ett*s efforts to develo! a creative and $or'a&le alternative% ,e have t$o final overall o&servations to offer% 8irst, since the !lan is so am&itious, it is also very, very com!licated% As noted else$here in these comments, this com!le+ity $ill ma'e it difficult to administer% The state County Assistance <ffices are riddled $ith staffing !ro&lems and already find it challenging to !rocess /edical Assistance a!!lications in a timely and efficient manner% The addition of &enefit limits, differing &enefit !lans, !remium !ayments, $or' search re9uirements, and a more com!licated a!!lication !rocess involving a self( screen $ill add &oth cost and com!le+ity% ,e $ould favor a more sim!lified !rocess% #econd, if any of the ne$ re9uirements are retained in Pennsylvania*s e+!anded /edicaid !rogram, it is li'ely that many individuals $ill fall in and out of eligi&ility on a fre9uent &asis% )iven the urgent nature of much su&stance a&use treatment (e%g% res!onding to a drug overdose or an individual need for medically monitored deto+ification la!ses in eligi&ility $ill &e !ro&lematic% The maintenance of sufficient funding for county(managed services $ill &e critical to ensure access to urgent care and to minimi@e disru!tion in ongoing care% ,e a!!reciate the o!!ortunity to !rovide feed&ac' regarding this !ro!osal and loo' for$ard to $or'ing $ith the administration as the 2ealthy PA !lan !rogresses% Than' you%
/ichele Den', 0+ecutive Director Pennsylvania Association of County Drug and Alcohol Administrators (E1E 2?2(E114 + ?104 8a+ (E1E 2?2(21:2 /den'F!acounties%org $$$%!acdaa%org