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Public Comment regarding Healthy Pennsylvania 1115 Application for Medical Assistance Expansion

January 10, 2014

The Pennsylvania Association of County Drug and Alcohol Administrators (PACDAA is an affiliate of the County Commissioners Association of Pennsylvania (CCAP re!resenting the 4" #ingle County Authorities of the Common$ealth% #ingle County Authorities (or #CAs are res!onsi&le for managing local net$or's that !rovide !u&lic(funded drug and alcohol !revention, intervention and treatment services in Pennsylvania communities% PACDAA shares )overnor Cor&ett*s commitment to addressing the current e!idemic of death and overdose from !rescri!tion and illicit drugs, and $e are !leased to see that tighter monitoring of !rescri!tion medication and encouragement of medication collection &o+es throughout the state are !art of the overall strategy for im!roving health services in Pennsylvania% ,e are also su!!ortive of our state*s current Justice -einvestment initiative $hich focuses on the !rovision of su&stance a&use and mental health treatment as a more effective and cost efficient alternative to incarceration for non( violent offenders% .n order for these efforts to &e effective, there must &e a com!rehensive a!!roach that increases access to su&stance a&use intervention, treatment and su!!ort services% .n !articular, the current continuum of su&stance a&use services must &e maintained% PACDAA is su!!ortive of )overnor Cor&ett*s decision to formulate a !lan for Pennsylvania*s !artici!ation in /edicaid 0+!ansion in order to increase healthcare access for more than 100,000 uninsured Pennsylvanians% 2o$ever, if $e are to &e successful in addressing the overdose crisis and other su&stance a&use and &ehavioral health issues, $e &elieve the follo$ing areas of concern regarding s!ecific com!onents of the !ro!osal must &e addressed3 4enefit Pac'ages3 The 2ealthy PA 1111 a!!lication includes reforming /edicaid to convert the e+isting adult &enefit !ac'ages into t$o commercial(li'e !ac'ages3 2igh -is' and 5o$ -is'% 0ach of these !ac'ages has a defined set of &enefit limits on &ehavioral health services% ,hat is the rationale for the limits in each &enefit !ac'ages6 ,hat is the research &asis for these !articular sets of services and limits6 .n Pennsylvania*s current /edical Assistance &ehavioral health !rogram, clinical decisions regarding su&stance a&use level of care !lacement are governed &y medical necessity criteria

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