Community Behavioral Health

January 13, 2014

Beverly Mackereth, Secretary Pennsylvania Department of Public Welfare Health & Welfare Building 625 Forster Street Harrisburg, PA 17120 Submitted via email to ra-PWHealthyPA1115@pa.gov Re: Draft Healthy Pennsylvania 1115 Demonstration Application Dear Secretary Mackereth, Thank you for the opportunity to comment on the Draft Healthy Pennsylvania 1115 Demonstration Waiver Application (“Healthy PA”). The Philadelphia Department of Behavioral Health and Intellectual disabilities Services (“ DBHIDS”) has submitted comments that highlight the major concerns for our behavioral health community however, I wish to add additional comments on behalf of Community Behavioral Health (“CBH”) the not for profit administrative entity that administers the Behavioral Health Program on behalf of Philadelphia’s 470,000 Medicaid recipients. We believe, as DBHIDS has commented, that Medicaid Expansion is in the best interest of the individuals that we serve; however, in the absence of that opportunity, we strongly recommend that individuals with any behavioral health challenge as self identified or as determined by a physician or other health care practitioner be provided the opportunity to be enrolled in the behavioral health HealthChoices program. For individuals with behavioral health needs, Medicaid administered through the HealthChoices Behavioral Health program provides health insurance that supports a comprehensive array of integrated behavioral health services to prevent, treat and support individuals recovery in our community. Commercial Insurers have limited expertise and a poor track record in Pennsylvania in treating individuals with behavioral health needs. Medicaid and community safety net programs were established because commercial insurers abandoned individuals with behavioral health needs by establishing discriminating lifetime limits, offering limited benefit options, and implementing differential co-payments and deductibles. The Insurance Federation, representing commercial insurers, in the late 1980s and early 1990s fought vigorously against any mandated mental health benefit, or parity in benefits, and successfully limited the parity bill offered under the Ridge Administration to adding only nominal benefits for individuals with Serious Mental Illness. Parity was not fully supported until Pennsylvania legislation was passed in 2009, following the passage at the federal level. 1|Page

Community Behavioral Health
The Commonwealth, along with substance abuse advocates sued under Act 68, as private insurers were ignoring their obligations to provide mandated substance use benefits and accept evaluations from providers. Commercial insurers who administer CHIP have historically underutilized behavioral health services, rather moving children with behavioral health issues to the Medicaid program; Implementation of Act 62 provided yet another example of commercial insurers’ reluctance to serve individuals with behavioral health challenges, specifically children on the Autism spectrum. Some insurers refused to offer appropriate services to children in school settings, and others have not contracted with community providers who deliver Applied Behavioral Analysis (“ABA”) and other essential services to children with Autism. In Philadelphia, the private insurers’ poor performance was the precipitating event highlighted in the Philadelphia Inquirer to establishing the public sector option through the county. Creating different benefit packages and shepherding individuals to a commercial plan will create disruption for individuals with behavioral health needs as they may need to navigate between low and high risk plans, different provider systems as well as different services options. Having differential benefit packages, based on self report, presents perverse incentives for individuals to mischaracterize or overstate their illness, as well as under-report due to lack of knowledge or capability. In the existing Medicaid program, having a robust state plan available to all, allows clinicians to determine, in collaboration with an individual, the level of services that are needed, and manage care with a focus on recovery. It is very unclear how individuals will move between benefit plans. In addition to our general concerns about the commercial insurers and the different benefit packages, we want to highlight issues that we believe will specifically impact the Philadelphia Behavioral Health HealthChoices Program. General Assistance: Philadelphia, through our behavioral health program served approximately 12,628 of the 16, 649 enrolled General Assistance category in CY 2013. These individuals are our homeless, former inmates and other single adults who are at the lowest end of the poverty level. Diverting these individuals into the private option plans would impact our ability to serve these individuals with Community Support Services (“CSS”) supplemental services only available in the HealthChoices program. Impact on base funding: Given that individuals enrolled in the low risk benefit plan, or private option plans, will be ineligible for retroactive billing, and ineligible for cost effective alternative Medicaid services, those individuals will seek supports from existing ( capped and limited) county mental health and substance use base funding. Impact on eligibility, predictability of member months: By establishing multiple benefit packages, and pushing individuals off a plan (for lack of premium payment), this proposal creates an uncertain fiscal environment for managed care organizations and providers. The state’s eligibility system is already

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Community Behavioral Health
challenged, and it is unclear how the Commonwealth will track and how member months and capitation will be managed and impacted. Actuarial soundness, administration and profit: The Center for Medicaid and Medicare Services (“CMS”) requires the Commonwealth to assure that Medicaid rates are actuarially sound. Currently our HealthChoices program commits over 90% of its resources to medical expenses or reinvests any savings into its community programs; therefore we are concerned about how many administrative dollars, profit, and per member per month will be shifted to the private sector and how many dollars will remain committed to those most in need. Benefit Limits: The proposal modifies benefits, and does not recognize the cost effective and supplemental benefits in the current HealthChoices Behavioral Health program. Basing future rates on arbitrary limits, as opposed to past experience and needs of the population, will negatively impact our program. Continuity of care will be disrupted for individuals who move in and out of varying benefits and insurances. Currently the success of the HealthChoices Behavioral Health program is that all individuals who are eligible are included, allowing opportunities to do early intervention and coordinate resources. 1915(b) waiver: It is unclear how the 1915(b) waiver will need to be modified in order to support the changes in eligibility, benefit limits etc. Churn: There is significant “churn” now in our current Medicaid program. If the “newly eligible” category includes anyone who has previously been in Medicaid, as well as those new to the system due to expansion, it wills likely result in a number of individuals losing services and benefits. Also the proposal indicates that if a person does not complete the health survey, they default to the private sector. For those who may be in an existing program, and lose eligibility, this will create hardship on the individual and the provider. Community providers: Many of our traditional providers who serve these populations do not and have not been welcomed by commercial plans. Act 62 experiences have shown that it has been very difficult for agencies to coordinate benefits and navigate through these difference insurance plans. Thank you for the opportunity to submit our comments. We strongly encourage you to take these and the comments offered by others in the behavioral health community into strong consideration as you finalize your waiver application.

Respectfully submitted,

Joan L. Erney, J.D. CEO, Community Behavioral Health 3|Page

Community Behavioral Health

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