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COMMUNITY PROVIDERS OF BEHAVIORAL HEALTH AND INTELLECTUAL DISABILITY SERVICES___________

Paula P. Schaller, Executive Director e-mail: schaller! hilacoalition.or" &&&. hilacoalition.or"

1218 Chestnut Street, Suite 705 Phila#el hia, Penns$lvania 1%107 Phone: 215-2'8-(0%2 )ax: 215-2'8-%2%*

Comments on Draft Healthy Pennsylvania 1115 Demonstration Application January 10, 2014 +he Phila#el hia Coalition is an association o, the com rehensive Communit$ -ehavioral .ealth an# /ntellectual Disa0ilit$ Centers that serve in#ivi#uals an# ,amilies in the "reater Phila#el hia area. 1ur mem0er or"ani2ations have 0een the 3e$ sa,et$ net rovi#ers in Phila#el hia an#, as such, have serve# the most vulnera0le in the cit$ ,or over *0 $ears. 1ur or"ani2ation has &or3e# closel$ &ith state&i#e coalitions to su ort the ex ansion o, 4e#icai# in Penns$lvania, as our mem0ers are all too ,amiliar &ith the #eleterious im act o, in#ivi#uals an# ,amilies not havin" access to health care covera"e. 5hile &e a reciate the ,act that 6overnor Cor0ett7s a#ministration is ,inall$ #evelo in" a lan to cover those &ithout insurance, &e are #isa ointe# that the Common&ealth is #ela$in" this covera"e ,or another $ear, &hen over 500,000 Penns$lvanians coul# 0e covere# this $ear, &ith the 4e#icai# ex ansion su orte# 0$ a 1008 ,e#eral match in the ,irst $ear. 4e#icai# in P9 is an e,,icient ro"ram that serves as a vital sa,et$ net ,or 1.2 million seniors, eo le &ith #isa0ilities, chil#ren an# re"nant &omen. %(8 o, 49 ,un#in" "oes to health care rovi#ers ,or me#ical care, &hereas commercial insurance com anies have much hi"her overhea# costs. /n Phila#el hia, the .ealth Choices 0ehavioral health an# a#ministrative a"enc$, Communit$ -ehavioral .ealth :C-.; has consistentl$ 3e t a#ministrative s en#in" un#er (.58. +his is ,ar 0elo& the avera"e s en#in" &ithin rivate an# em lo$er-0ase# health insurance. Phila#el hia Coalition mem0ers can con,i#entl$ state that covera"e ,or in#ivi#uals &ith 0ehavioral health an# intellectual #isa0ilities has 0een ,ar su erior un#er C-. that it is throu"h rivate insurers. 4oreover, the service mana"ement throu"h .ealth Choices has allo&e# an$ savin"s to 0e reinveste# in ro"rams that su ort recover$ an# resilienc$ in our communit$. Penns$lvania has 0een a 3e$ innovator in the #eliver$ o, 0ehavioral health services an#, as such, is a national mo#el ,or the rovision o, a 0roa# ran"e o, services an# su orts necessar$ to revent an# treat 0ehavioral health challen"es. )urthermore, Phila#el hia has committe# to an# ,ostere# an arra$ o, inte"rate# h$sical health an# 0ehavioral health initiatives as &ell as rioriti2e# services ,or hi"h nee# o ulations inclu#in" eo le ex eriencin" homelessness, chil#ren in the chil# &el,are an# <uvenile <ustice s$stems, eo le &ith serious mental illness &ho have 0een #ischar"e# ,rom the state hos ital an# chil#ren in the u0lic school s$stem. We ur e the a!ministration to move for"ar! "ith e#pansion no" throu h our e#istin , effective state$"i!e %e!icai! Health Choices pro ram& 5e ver$ much a reciate the o ortunit$ to comment on the #ra,t 1115 Demonstration 9 lication. -elo& are some ,urther "eneral comments an# then some more s eci,ic comments .

'eneral Comments (mpact on the )afety *et+ • +his ro osal a ears to cut 4e#icai# covera"e ,or those &ith the "reatest nee#s, as a con#ition o, ex an#in" insurance to &or3in" lo&-income ,amilies an# maintainin" cost neutralit$. -ecause as much as 758 o, 4e#icai# s en#in" in P9 is ,or the care o, seniors an# eo le &ith #isa0ilities, alon" &ith in#ivi#uals &ith serious health ro0lems that revent them ,rom &or3in", the limits that are ro ose#, even in the .i"h =is3 lan, &ill ut vulnera0le in#ivi#uals at even more at ris3. • +he im osition o, remiums on those &ho are 0elo& the overt$ line stri3es us as unconsciona0le. 5e un#erstan# that the remiums ma$ not 0e a lie# to those &ith #ocumente# #isa0ilities, &ho are re"nant or &ho ,all into other s ecial nee#s cate"ories. >onetheless, man$ o, the eo le &ho can 0ene,it ,rom 49 ex ansion are livin" on the e#"e. Coalition mem0ers have seen that &hen co- a$s have 0een re?ueste#, access to care has 0een re#uce#@ in#ivi#uals have o,ten not returne# ,or treatment. ,he imposition of premiums for those "ith very lo" incomes "ill !eter people from o-tainin an! .eepin insurance covera e& • +his ro osal ,rames the remiums an# &or3 re?uirements as incentives that &oul# lea# to in#e en#ence. 1ur rea#in" o, the #ocument, ho&ever, is that these re?uirements are 0oth onerous an# unitive. 4an$ eo le are &or3in" art time 0ecause it is all the$ can mana"e #ue to chil# care or el#er care res onsi0ilities, their o&n health issues or other le"itimate circumstances. Aet, un#er this ro osal, i, the$ #o not see3 ,ull time em lo$ment, the$ coul# lose their health care covera"e. /n#ivi#uals or ,amilies una0le to a$ a remium 0ecause the$ have chose to a$ ,or ,oo# or heat or to clothe their chil#ren, can also lose their insurance an# otentiall$ 0e una0le to "et it 0ac3 ,or u to % months. +his is not "oo# u0lic olic$. A!ministrative /ur!en an! (ncrease! 0verall Costs • 4ost eo le &ho nee# insurance throu"h 49 ex ansion are &or3in", at least art time. +he ro ose# lan &astes time an# mone$ on a ro0lem that #oes not exist in creatin" a man#ate ,or &or3 search. 4ost in#ivi#uals &ant to &or3 i, the$ are a0le an# i, <o0s are availa0le@ in ,act man$ o, those &ho are uninsure# are &or3in" more than one art time <o0 to tr$ to ma3es en#s meet an# su ort their ,amilies. • 5e ?uestion the cost e,,ectiveness o, 0oth the &or3 search re?uirements an# the remiums in terms o, the erson o&er that &ill 0e re?uire# to trac3 ever$ in#ivi#ual covere# 0$ 4e#icai#. )or eo le &ith 0ehavioral health #isa0ilities, &or3in" art time ma$ 0e the 0est o tion ,or maintainin" their sta0ilit$ an# ,unctionin" e,,ectivel$ in the communit$. =e?uirin" <o0 search activities ,or such in#ivi#uals an# havin" to trac3 them is 0ur#ensome 0oth ,or the in#ivi#ual an# the state. • /n our ex erience, the current s$stem has "reat #i,,icult$ 3ee in" u &ith those &ho are currentl$ covere#. /t is #i,,icult to ima"ine ho& the Common&ealth &ill trac3 all o, these re?uirements ,or an a##itional 500,000 in#ivi#uals. • /n or#er to contain all health care costs, it is critical that the nee#s are met ,or in#ivi#uals &ith 0ehavioral health challen"es. +hese in#ivi#uals have the hi"hest inci#ence o, chronic me#ical con#itions an# thus are the hi"hest users o, all me#ical care. +he ro osal to consoli#ate the existin" 4e#icai# 0ene,it lans into t&o alternative 0ene,it lans :9-P; &ill limit access to necessar$ services an# treatment ,or in#ivi#uals, es eciall$ those &ith 0ehavioral health challen"es. +his lan &ill increase rather than #ecrease costs.

Access to /ehavioral Health )ervices ,hrou h Commercial (nsurers • Currentl$, 0ehavioral health rovi#ers in Phila#el hia contract &ith commercial insurers on a ver$ limite# 0asis 0ecause o, restrictive re?uirements, 0ut all o, our mem0ers #o contract &ith 4e#icai# throu"h .ealth Choices. 5e have serious concerns as to &hether there &ill 0e su,,icient access to 0ehavioral health services in the ro ose# rivati2ation o, 4e#icai# ,or the ex ansion o ulation. • 1ur ex erience &ith chil#ren &ho have autism an# &ho shoul# 0e covere# ,or services un#er their rivate insurance conse?uent to 9ct (2, has 0een that services are ver$ limite#. )or exam le, most o, these rivate insurers &ill not cover 0ehavioral health services rovi#e# in the schools, &here care can 0e most e,,ectivel$ rovi#e# ,or $oun" chil#ren. • /n#ivi#uals an# ,amilies livin" in overt$ or <ust a0ove overt$ level ten# to have more severe h$sical an# 0ehavioral health nee#s that are com licate# 0$ s$chosocial issues relate# to lac3 o, an a#e?uate #iet, heat, availa0le trans ortation, etc. +hese issues o,ten re?uire a level o, care mana"ement that is not availa0le or ina#e?uatel$ a##resse# throu"h rivate insurers. 4an$ o, the rovi#ers &ho currentl$ contract &ith rivate insurers #o not have the s3ille# ersonnel nor the in,rastructure nee#e# to &or3 e,,ectivel$ &ith the 0ehavioral o ulation &hich has hi"h level o, s$chosocial an# 0ehavioral health nee#. ,he propose! mo!el "ill limit access to 1ualifie! -ehavioral health provi!ers an! the "i!er ran e of effective services availa-le throu h the current %e!icai! Health Choices system& Doin so "ill further increase !eman!s for all health care an! increase associate! costs, "hile re!ucin healthy outcomes& )pecific Comments (ncrease! Provi!er Access 2 p& 10 9s note# in our earlier comments, &e 0elieve that there are li3el$ to 0e some si"ni,icant access issues ,or in#ivi#uals &ith serious 0ehavioral health concerns. /t has not 0een the ex erience o, our mem0ers that P9 4e#icai# a$ment rates ,or 0ehavioral health services are lo&er than 4e#icare or commercial a$ers@ in ,act, &ith .ealth Choices the o osite is true. +here are more care o tions &ith .ealth Choices an# rates are 0etter than &ith either 4e#icare or commercial a$ers. Wor. )earch Activities 2 p& 12 /n#ivi#uals &ho are &or3in" an$ amount o, hours shoul# not have to #emonstrate &or3 search activities to maintain health care covera"eB Wor. )earch Activities 2 p&32 +he list o, in#ivi#uals &ho are exem t ,rom re?uire# &or3 search activities shoul# inclu#e those &ho are activel$ artici atin" in intensive 0ehavioral health #a$ treatment ro"rams such as Communit$ /nte"rate# =ecover$ Pro"rams, Partial .os itali2ation an# DC9 /ntensive 1ut atient Pro"rams. Each o, these t$ es o, 0ehavioral health ro"rams encoura"es &or3 search &hen the in#ivi#ual is rea#$ ,or it. +hose &ho are in an acute sta"e o, a mental illness or su0stance use #isor#er shoul# not 0e re?uire# to see3 em lo$ment in or#er to 3ee their health insurance. /ehavioral Health /enefits 2 p&34 5e have extremel$ serious concerns &ith the ro ose# 0ene,it limits ,or the 9P-s, as the$ relate to covera"e ,or -ehavioral .ealth Services inclu#in":

• • • • • • •

9 '0 #a$ er $ear limit on inpatient psychiatric hospitalization an# inpatient drug and alcohol treatment ,or in#ivi#uals in the lo&-ris3 lan@ *5 #a$s ,or in#ivi#uals in the hi"hris3 lan@ 9 '0 #a$ er $ear limit on outpatient mental health treatment an# outpatient drug and alcohol treatment ,or in#ivi#uals in the lo&-ris3 lan@ *5 #a$s ,or the hi"h-ris3 lan@ Dimitin" rescri tion Clo2a ine to onl$ in#ivi#uals &ith a #ia"nosis o, schi2o hrenia Dimitin" psychiatric partial hospital to 5*0 hours er $ear@ Dimitin" peer support services to * hours er #a$ or %00 hours er $ear@ )ailin" to rovi#e targeted case management exce t ,or in#ivi#uals &ith a #ia"nosis o, serious mental illness that are in the hi"h-ris3 lan@ an# Dimitin" laboratory services to E250 er $ear ,or the lo&-ris3 lan@ E'50 er $ear ,or the hi"h-ris3 lan.

Per in,ormation that has 0een "athere# 0$ the Phila#el hia De artment o, -ehavioral .ealth, it is estimate# that 5.88 o, in#ivi#uals that &ill 0e ne&l$ eli"i0le ,or 4e#icai# in Penns$lvania &ill have a serious mental illness@ 1*.18 &ill have s$cholo"ical #istress@ an# 1(.*8 &ill have a su0stance use challen"e. +hese in#ivi#uals &ill 0e 0est serve# 0$ the existin" 0ehavioral health 4e#icai# s$stem in lace. Currentl$ Phila#el hia7s .ealthChoices Pro"ram o,,ers a com rehensive ran"e o, cost-e,,ective services rovi#in" covera"e that meets in#ivi#uals7 nee#s. =e#ucin" the sco e o, covera"e to re,lect Fcommercial-li3eG covera"e &ill limit access to necessar$ services an# treatment critical ,or in#ivi#uals to remain health$ in the communit$. Health )creenin 2 p& 41 5hile com letion o, the health screenin" tool is not a con#ition o, eli"i0ilit$, i, in#ivi#uals &ho are currentl$ eli"i0le ,ail to com lete it, the$ &ill 0e enrolle# into the Do& =is3 -ene,it Plan er this ro osal. Some in#ivi#uals &ho have severe mental illness or other #isa0ilities &oul# ,ail to com lete this screenin", either 0ecause the$ are una&are or una0le to #o so. >onetheless, these in#ivi#uals shoul# ro erl$ 0e in the .i"h =is3 Plan. We recommen! that a mechanism -e !evelope! to assure that those "ho shoul! -e in the hi h ris. plan -e assi ne! there re ar!less of their a-ility to complete the health screenin & Cost )harin 2 p& 45 /t is state# that there &ill 0e onl$ t&o rates: one ,or a sin"le a#ult, an# another ,or a househol# o, t&o or more a#ults, 0ecause no remiums are assesse# to chil#ren. .o&ever, the num0er o, chil#ren in a househol# &ill si"ni,icantl$ a,,ect the a,,or#a0ilit$ o, a health care remium. )or exam le a lo&-income sin"le erson &ith no chil#ren mi"ht 0e a0le to a,,or# a minimal remium 0ut, ,or a lo&-income sin"le arent &ith * chil#ren, the same remium &oul# 0e entirel$ una,,or#a0le. We recommen! that, if a premium is impose!, the si6e of the family -e consi!ere!, re ar!less of the fact that separate premiums are not assesse! for chil!ren& 7uality$-ase! )upplemental Payments 2 p& 83 +his section states that the Common&ealth &ill 0rin" to"ether all relevant sta3ehol#ers inclu#in" consumers, h$sical an# 0ehavioral health care rovi#ers, commercial insurers, etc. to #esi"n ne& a$ment an# #eliver$ mo#els ,or health care services in P9 to ,ocus on ?ualit$ o, care rather than ho& much care is rovi#e#. +he Phila#el hia Coalition &oul# ver$ much li3e to artici ate in this rocess an# &ill 0e ha $ to i#enti,$ a re resentative &hen $ou are rea#$ to convene such a "rou . 5e than3 the 6overnor an# his sta,, ,or all the &or3 that has "one into #evelo in" this 1115 Demonstration 9 lication. 5e ho e our comments &ill 0e hel ,ul in ex an#in" health covera"e to all Penns$lvanians.