January 2005.pdf

Newsletter of the Pennsylvania Health Law Project Statewide Help Line: 1-800-274-3258 On the Internet: www.phlp.org TTY: 1-866-236-6310 Medical Assistance to Change in Rural PA on March 1
Access Plus to Feature Disease Management, Require Referrals
in 42 Counties
Last year DPW decided for the foreseeable future not to expand HealthChoices (mandatory man-aged care for MA recipients) beyond the counties where it currently operates. Instead, the Depart-ment will implement a “managed Fee For Service” system in the remaining 42 counties that it is call-ing ACCESS Plus. DPW announced in December that it had awarded the ACCESS Plus contract to manage the program in all 42 counties to McKesson Health Solutions. How Is ACCESS Plus Different from FFS?
Under ACCESS Plus, consumers (adults and children) must choose a Primary Care Practitioner
(PCP) from whom they will get most of their physical health care. Those who do not make a choice
INSIDE THIS EDITION
CHIP Eligible Children
Prior Authorization Now Required for Cox2 Paying For Health Care
Inhibitors, Proton Pump Inhibitors and Erec-tile Dysfunction Drugs There are currently 8,500 children enrolled in a DPW Invites Bidders to Run Medical Trans- low cost, limited benefit health insurance plan offered by Blue Cross plans across the state Changes to Distribution of SSI and State called Special Care. Most, if not all, of these children are eligible for free, more comprehe n-sive health insurance coverage from CHIP. Good News! Child’s/Survivor’s Benefits Not Counted As Income for MA Disabled The Blue Cross plans are contracted, by the In- surance Department, to administer CHIP, a pro- gram which provides comprehensive health cov-erage for free to children in families with income Revised Requirements for Consumer/Family under 200% of the federal poverty level and at Satisfaction Teams Hold Promise for More Meaningful Consumer Input a low cost to families with i ncome under 235% of the federal poverty level. Expedited Enrollment in Behavioral Health MCOs Effective Jan. 1, 2005 The Blue Cross plans also offer Special Care, a limited benefit policy, to families with income un- der 185% of federal poverty level. Families DPW Announces Plan to Pay Less for Drugs Prior Authorization Now Required for
Cox2 Inhibitors, Proton Pump Inhibitors and
Erectile Dysfunction Drugs
The Office of Medical Assistance Programs (OMAP) will prior authorize access for certain drugs in its Fee-for-Service program starting on February 7, 2005. The drugs affected are COX-2s, proton pump inhibitors, and erectile dysfunc-tion drugs. OMAP began requiring prior authorization for COX-2 inhibitors last year. The new proposed changes will decrease the age threshold to 65 years old for prior authorization. The change would also allow a pharmacist to override a rejec-tion due to the prescription being refilled too soon if the consumer’s therapy is being changed. The proposed changes regarding proton pump inhibitors will make Prilosec Over-the-Counter the preferred drug. The Department will require a prior authorization when a prescription is for a drug other than Prilosec Over-The-Counter, including regular Prilosec, or when the prescription is for an amount higher than the FDA recommendations or for longer than 4 months. Finally, FFS consumers who receive erectile dysfunction drugs must first undergo diagnostic testing and a medical evaluation. Approvals will be valid for 24 months though a prescription can still be for no more than a 6 month or five refill supply. These changes will not affect Medical Assistance consumers in Managed Care. DPW Invites Bidders to Run
Medical Transportation in Philadelphia
Philadelphia County is the only county in Pennsylvania that does not receive funds directly from DPW to run a Medical Assistance Transportation Program (MATP) for its residents on MA. Instead, the state has a contract with a private entity to provide MATP services to the over 440,000 MA re-cipients who reside in the county. Wheels of Wellness has been the MATP contractor in Philadel-phia. The current contract ends in June 2005 DPW has announced that it is issuing a Request for Pro-posals (RFP) seeking bids to run Philadelphia’s MATP pro-gram beginning July 1, 2005. The initial contract will be for a 3-year period, which could be renewed for an additional 2 years depending on the contractor’s performance. Public comments to the Draft RFP were due on January 14th. PHLP submitted a number of comments, focusing in par-ticular on the need to reach out to and accommodate per-sons with limited English proficiency. The Final RFP will be posted on the state’s Department of General Services (DGS) website on February 4, 2005. The Website is lo-cated at www.dgs.state.pa.us. (ACCESS Plus, Continued from page 1) Enrollments
will be auto-assigned to a PCP. Consumers At the end of January, 2005 materials will be sent who need to see a specialist must first obtain a out to consumers who will then begin to enroll referral from their PCP. However, referrals are into ACCESS Plus. The first group enrolled will not needed to obtain dental care, family pla n- be the children in these counties who are now in ning, OB/Gyn care or to go to the Emergency the Family Care Network (FCN). In addition, Room. Individuals who need mental health or newly-eligible MA recipients will be enrolled into drug/alcohol services will continue to receive ACCESS Plus. For these consumers, ACCESS services as they have in the past-that is, Plus will begin on March 1 st. All o ther consumers through their county’s MH/MR or Drug and Al- (i.e adults who are already on MA) will be e n- rolled next and ACCESS Plus will begin for them on May 1 st. DPW has contracted with ACS Another feature of ACCESS Plus is “disease (formerly known as Benova) to help consumers management” for those with one or more tar- choose a PCP and enroll into ACCESS Plus. In the 26 counties that have Voluntary Managed Asthma, Diabetes, Chronic Obstructive Pulmo- Care, ACS will also take over the enrollment of nary Disease, Coronary Artery Disease and those consumers who choose to join a Voluntary Congestive Heart Failure. Disease manage- ment services are designed to educate and as-sist consumers and their providers to better manage these diseases and stay as healthy as regularly in this Newsletter as ACCESS Plus rolls out. A Regional Approach
The 42 counties involved in ACCESS Plus are separated into three regions -Northwest, Central and Northeast. Consumers will be able to choose a PCP from within their region and ac-cess any MA specialty providers to whom they are referred within or outside the region. Each (CHIP, Special Care Continued from page 1) ACCESS Plus region will also have an Advi- must pay an additional $45.85 to cover their chil- sory Committee made up of consumers, advo- dren under the program. Special Care does not cates, providers, community organizations and have the same citizenship and income verifica- other agencies that will meet regularly to advise McKesson on ACCESS Plus policies and pro- CHIP is superior to Special Care in virtually every way. The income limits are higher, the benefits are better and, for any child that qualifies for Who Will Be in ACCESS Plus?
All MA consumers in the 42 counties must e n-roll in ACCESS Plus unless they fit into one of The Pennsylvania Health Law Project and Com- the exception categories. Those who will not be munity Legal Services brought this problem to the attention of the Insurance Department last Fall. Since then, the Department has met with the Blue Cross plans who appear willing to con- ???Consumers who are “dually eligible” (on duct an outreach to families with children on Spe- cial Care to inform them of the availability of ???Consumers enrolled in HIPP (the Health If you know of any families with children who are currently enrolled in Special Care please refer them to the Pennsylvania Health Law Project Helpline, 1-800-274-3258. Changes to Distribution of SSI
PHLP Thanks the Philadelphia
and State Supplement Checks
Bar Foundation for its Support
Beginning in January, 2005, there will be a PHLP is pleased to announce that it recently change in the way recipients of Supplemental received a grant of $10,000 from the Philadel- Security Income (SSI) receive their payments. phia Bar Foundation to support our work in as- Currently, the money that consumers get from serting the legal rights of Philadelphians to the Social Security Administration (SSA) in- health care coverage and services. We truly cludes both a federal payment (SSI) and an ad- appreciate the support of our colleagues in the ditional payment, called the State Supplemen- legal community, who contribute so much to tary Payment (SSP). Currently, the monthly help the city’s public interest law firms! amount of the SSP is $27.40 for an individual and $43.70 for a couple in which both individu-als are eligible. Starting in January, 2005, Good News!
Pennsylvania’s Department of Public Welfare Child’s/Survivor’s Benefits
(DPW) will send the SSP, while the Federal So-cial Security Administration will continue to send Not Counted As Income for MA
the SSI. There will be no change in the amount Disabled Child Category
of benefits or in consumers’ Medical Assistance benefits. Consumers will receive their SSP in the same Social Security Disability Benefits based on the way that they receive their SSI payments. For past earnings of a deceased, disabled or re- example, if you get SSI by direct deposit, then, tired parent will no longer be counted as i n- starting January, 2005, a separate deposit for come when determining MA eligibility for chil- your SSP will appear on your bank statement. If you receive your SSI by check, you will get a MA eligibility requirements for children under second check from Pennsylvania for your SSP. 21 with a severe disability, mental illness or be- The exception to this is for people who receive havior disorder (also known as the PH-95 or their SSI by check and also have an ACCESS “loophole” category) only consider the income card; their SSP will be deposited into the AC- of the child and not the parent. Advocacy CESS account. A recipient can change the way groups raised concerns that children often lose you get your payments by contacting your their much needed MA health coverage if they receive Social Security benefits as a result of the death, disability or retirement of a parent. This change also applies to people who receive only the SSP. Currently, these consumers re- DPW initially revised its policy only for current ceive their payments from the Social Security MA recipients, but has now extended this policy Administration, but, beginning January, 2005, to all new applicants in this category. If you are the payments will come from Pennsylvania’s having problems with this change in policy at your CAO, refer your caseworker to Ops Memo 04-10-01. Remember, all other income of the If you have questions about your SSP benefit or child’s is counted with the exception of court- this change, you can call the SSP Helpline at 1- ordered child support (Ops Memo 00-08-06). 866-502-9105. Individuals with hearing impair- If you have any other questions or problems, ments may call the TDD number at 1-800-451- contact the Pennsylvania Health Law Project at Getting an Extra $600
towards Medications
Due to a recent settlement of a lawsuit be-tween the Pennsylvania Attorney General and Medco, over 3000 people with little or no drug cov-erage can get $600 in credit towards the purchase of generic drugs through the mail. The Pennsylvania Patient Assistance Program (run through the state’s PACE Program) offers assis-tance to people with little or no prescription cover-age and who are 55 or older or are adults of any age with disabilities. The Medco settlement involved providing $600 credits to over 3000 people and there are fewer than 1000 people currently getting the credits. If you know anyone who might benefit from an extra $600 towards their generic medications, please have them contact the Pennsylvania Patient Assistance Program, toll-free, at 1-800-955-0989. Copyright 2005 The Pennsylvania Health Law Project Need help getting
FREE MEDICATIONS
through the Companies That Make Them?
The Pennsylvania Patient Assistance Program (PA
PAP) helps individuals find out about and apply for
free prescription drugs from the companies that make
them. Many pharmaceutical companies provide certain
prescription medications free of charge to people who
meet specific income qualifications and do not otherwise
have access to necessary medications.
The Pennsylvania Patient Assistance Program (PA
PAP) (run through the state’s PACE Program) offers assis-
tance to people with little or no prescription coverage and
who are 55 or older or adults with disabilities (of all ages).
The PA PAP program has no fixed income guidelines
in order to qualify for assistance. The income guidelines
for getting assistance from the companies are as follows:
a single individual should have income of $20,000 or less;
a married person should have income less than
$25,000. These income guidelines are based on the ones
set by the manufacturers, and PA PAP notes that, while
they may be flexible in whom they help apply for assis-
tance, they cannot make any guarantees of gaining cover-
age.
If you would like assistance in applying to a drug
company for free medications (as prescribed by your doc-
tor), call the Pennsylvania Patient Assistance Program,
toll-free, at 1-800-955-0989.
Copyright 2005 The Pennsylvania Health Law Project Revised Requirements for Consumer/Family Satisfaction Teams
Hold Promise for More Meaningful Consumer Input
In our May 2004 edition of Health Law PA News we had an article regarding Consumer Satisfaction Teams (CSTs) – also referred to as Consumer/Family Satisfaction Teams (C/FSTs). C/FSTs are a critical tool for gathering input from behavioral health consumers about the mental health and drug and alcohol services they receive. They are also used to determine the helpfulness and effective-ness of the behavioral health plans in accessing services. The Guidelines for C/FSTs are found in Appendix L of the HealthChoices Behavioral Health RFP. C/FSTs are a unique quality assurance measure because they are comprised of consumers, persons in recovery and family members who interview those very individuals. However, as we shared in our May newsletter, many C/FSTs across the state have struggled to get the support and resources they need to do their job effectively and meaningfully. As a result of those struggles, OMHSAS, with direction and input from The Consumer Satisfaction
Team Alliance of PA (CSTAP), spent many months revising Appendix L. The final version is com-
plete and implementation was effective January 1, 2005. The revised Appendix L clearly conveys
the responsibilities of the primary contractors (generally the County Mental Health Program) to pro-
vide effective oversight of, and meaningful support to, the C/FST Programs and to ensure compli-
ance with the guidelines.
Among the important revisions to the guidelines are the requirements that: 1. A C/FST Director must be a self-identified consumer, person in recovery or family member. (Grandfathering will be granted for existing Directors who are not.) 2. Surveys must identify consumers’ satisfaction with a specific provider as well as their satis- faction with the behavioral health system overall. 3. Primary contractors must establish mechanisms to inform the C/FST Program of newly e n- rolled members and ongoing members who wish to participate in the satisfaction interviews. (Since many C/FSTs have had consiste nt struggles in accessing consumers to interview, this is a very important new requirement.) 4. The primary contractor must ensure timely provider action in response to survey results. OMHSAS will spend the next few months conducting on-site reviews with the primary contractors, the C/FST Directors and the C/FST staff, to explain the revised guidelines and assist the counties in working toward compliance with the new requirements. Staff from CSTAP will also be available on an ongoing basis to provide technical assistance to any primary contractor, C/FST Director or C/FST staff at their request. For a copy of the revised Appendix L please contact Janice Meinert at PHLP at 1-800-274-3258. The Pennsylvania Health Law Project
Thanks the Philadelphia Foundation for its Support
Health Law PA News
PHLP is appreciative of a generous grant recently received from By Email!
the Philadelphia Foundation. The Health Law Project received funding from the Alice H. and Joseph W. Campbell Fund #1, Isa-bel Howell Gest Memorial Fund #2, William P. Gest Memorial Fund #1 and the Charlotte L. Hammell Fund to ensure equal ac- cess to quality health care for low income families and the working The expedited enrollment in the Behavioral Expedited Enrollment in
Health MCOs does not affect enrollment into Behavioral Health MCOs
the Physical Health MCOs. Individuals are still Effective Jan.1, 2005
given time to choose their Physical Health MCO and their Primary Care Provider and typi-cally will not be enrolled into their Physical Health MCO until 30-45 days after they are de- Assistance (MA) in HealthChoices counties If you have any questions about the behavioral health expedited enrollment process contact Janice Meinert at PHLP at 1 -800-274-3258. ioral Health Managed Care Organization. Prior to Jan. 1, 2005, a person’s enrollment in their DPW Plans to Close Harrisburg
county’s Behavioral Health MCO occurred at the same time as their enrollment in a Physical State Hospital
Health MCO. This process generally took 30-45 days from the time an individual was deter- Earlier this month, Secretary Richman a n- mined eligible for MA by the County Assistance nounced that the Department of Public Welfare Office (CAO). During that 30-45 day period, the plans to close Harrisburg State Hospital, an i n- person received MA services through the fee stitution for individuals with mental illness. for service system. However, since the individ- Mental Health advocates from across the Com- ual did not have a choice of their behavioral monwealth applauded the move as a positive health plan, delaying enrollment until the per- step towards the goal of moving individuals out son chose their Physical Health MCO served of institutions and into community settings no purpose. OMHSAS has decided this 30-45 where they can function as an active part of the day waiting period is unnecessary and it has community while still receiving necessary treat- now been eliminated. As of January 1, 2005, the person’s effective enrollment date into their There are currently 258 individuals residing at Behavioral Health MCO will now be the same HSH. DPW expects half of these individuals to as the “system date” which is the date a person be transitioned into community settings such as is found eligible for MA and entered into the Cli- group homes, public housing or living with fam- ily. Other individuals will be transferred to Dan-ville State Hospital in Montour County and Wer- What does this mean for consumers? nersville State Hospital in Berks County. The closure will take place over the course of a year Consumers can now have quicker access to and DPW plans to create a community advisory behavioral health services that are available committee composed of residents, county rep- through their Behavioral Health MCO but that resentatives and other stakeholders to monitor are not available under the MA Fee-For-Service system. For example, consumers can now ac-cess drug and alcohol treatment such as Half- Public comments on the closing will be elicited way House, Non-hospital Detoxification and via public hearings held on January 27, 2005 at Non-hospital Rehabilitation sooner because the Zembo Mosque, 2801 North Third St., Ha r- Behavioral Health MCOs pay for these ser- risburg. There will be two sessions of hearings. vices. Consumers can also have quicker ac- The afternoon session will be from 2-4 pm and cess to certain mental health services such as the evening session will be from 6-9 pm. If you Intensive Case Management and Resource Co- would like to speak at the hearing, DPW asks ordination that are paid for by Behavioral that you contact Lisa Brommer at (717) 772- Pennsylvania Health Law Project Helpline ~ 1-800-274-3258
TTY 1-866-236-6310
Visit us online at www.phlp.org.
Call the Pennsylvania Health Law Project, if you:
~ applied for Medical Assistance and have been denied ~ applied for Medical Assistance and haven’t heard anything or ~ have been receiving Medical Assistance and are getting cut off The Pennsylvania Health Law Project provides free assistance to consumers who are having trouble accessing publicly funded health- care coverage or services. If you are denied or cut off Medical A s- sistance, call the Pennsylvania Health Law Project at 1-800-274- 3258 to review your appeal rights and request representation in your appeal. The Pennsylvania Health Law Project also assists consum- ers who have had healthcare services denied, reduced, or cut off. Pennsylvania Health Law Project Helpline ~ 1-800-274-3258
TTY 1-866-236-6310
Visit us online at www.phlp.org.
DPW Announces Plan to Pay Less for Drugs
In December, DPW told the Medical Assistance Advisory Committee it plans to pay less for generic drugs under the fee-for-service (non-managed care) program. Consumers have asked DPW to set up a system to allow them to report access problems, and to interve ne if necessary on behalf of consumers needing medicines that are not available. DPW intends to soon propose regulations to change its reimbursement system, which cur-rently pays the lower of the federal upper limit (FUL) or the Average Wholesale Price (AWP) minus 10%, to a formula which will pay the lower of FUL, or AWP-25%, or a third price based on what wholesalers are paying in Pennsylvania. Representatives of the pharmaceutical i n-dustry voiced opposition to getting paid less for drugs. Consumer representatives said that while they applaud the state’s efforts to save money, they worry that pharmacies may stop carrying drugs for which the financial return is considered inadequate. DPW spokespersons responded that Pennsylvania’s current reimbursement is very generous, and the new rates will still be lower than in some other states. Interested persons should check upcoming issues of the Pennsylvania Bulletin for details and an opportunity to comment. Pennsylvania Health Law Project
924 Cherry Street, Suite 300
Philadelphia, PA 19107

Source: http://www.phlp.org/PHLP%20NEWS/January%202005.pdf