Changes coming in the pipeline for Medical Assistance delivery systems

BROOKVILLE — Big changes are about to land in Jefferson County for recipients of the ACCESS Plus Medical Assistance delivery system.

"This is a really major change that's coming up," said Francesca Chervenak, senior attorney and director of client representation for the Pennsylvania Health Law Project (PHLP) in Pittsburgh.

The PHLP hosted a presentation on Tuesday at the Heritage House in Brookville designed to explain the specifics of the change, who it will affect and how to adjust to the new healthcare environment in Jefferson County.

"Every time there's a big change, there's a lot of information floating around that might not be accurate," said Chervenak, who presented the program. It was the purpose of the presentation to set the record straight.

Known as Medicaid at the federal level, Medical Assistance is the name that is used for the overarching program at the state level in Pennsylvania.

It refers to a federal/state health insurance program for low-income families, persons with disabilities and the elderly. However, these items alone are not enough to qualify it.

Entry into Medical Assistance is based on dozens of qualifications, called categories of eligibility.

Each category operates under different income and asset guidelines.

Children under 21 on Medical Assistance receive all medically necessary healthcare and services as a result of the EPSDT mandate.

Adults, on the other hand, are not entitled to all of the same benefits, as each category of eligibility offers a particular set of them.

"It's a complex program to navigate," Chervenak said.

The new changes are not targeted specifically at Medical Assistance but rather its methods of delivery to consumers. Said changes promise to be a bit more complicated in Jefferson County.

"It's a lot easier to do this in urban areas," Chervenak said, citing the increased number of doctors and medical facilities in city centers.
Medical Assistance currently has three methods of delivery: fee-for-service, ACCESS Plus and managed care.

Chervenak described fee-for-service as being the most "wide-open" system. Recipients are provided with an access card that allows them to go to any doctor or medical facility that accepts Medical Assistance.

ACCESS Plus works in a similar manner but is slightly more controlled overall. Consumers under ACCESS Plus are required to have a primary care provider (PCP). They also must get referrals for speciality care.

Otherwise, it is still open and allows a considerable degree of freedom.
Finally, managed care is the most controlled delivery system.

Previously, it had been voluntary, allowing consumers to enter and exit as desired. Now, for most of the people on Medical Assistance, it is about to become mandatory.

Pennsylvania is currently in the process of phasing out ACCESS Plus statewide. It will be replaced by a new overarching program called HealthChoices.

HealthChoices will become the new Jefferson County healthcare modus operandi starting on Oct. 1. Consumers on Medical Assistance will be required to select a plan under the new program by Sept. 6 or otherwise been randomly auto-enrolled in one.

The Department of Public Welfare (DPW) calls HealthChoices mandatory managed care for Medical Assistance consumers.

Under HealthChoices, all applicable consumers must be enrolled in a Physical Health Managed Care Plan (MCO) and get all their care through that plan unless they fall into an exempt group.

The exempt groups are the following: full dual eligibles (anyone enrolled in both Medicare and Medical Assistance), those enrolled in the PDA waiver, those enrolled in the LIFE program, those in HIPP (Health Insurance Premium Payment Program) and woman on Medical Assistance through the Breast and Cervical Cancer Prevention and Treatment Program.

Exempted parties will be treated under fee-for-service coverage.
There are also special circumstances carved out for people in nursing homes and juveniles in detention centers.

Individuals currently in nursing homes will not see any change and are considered exempt.

Any individuals who move into a nursing home on or after Oct. 1 will be fully covered for thirty days before switching fully to fee-for-service coverage.

This will remain the case unless the individual in question later moves out of the nursing home.

The plan works similarly for juveniles in detention centers.

The only difference is that fee-for-service won't kick in for them until the end of a 35-day period.

They, too, will be covered under that program until such a time that they are no longer in a detention center.

HealthChoices is currently in the process of expanding. Over the next year, it will be going statewide, eliminating ACCESS Plus.

On July 1, the HealthChoices-Southwest zone expanded to include Bedford, Blair, Cambria and Somerset counties, and the HealthChoices-Lehigh/Capital zone expanded to include Franklin, Fulton and Huntingdon counties.

On Oct. 1, HealthChoices will kick off in the New West zone, which incorporates Jefferson, Clearfield and Clarion counties, along with Erie, Crawford, Mercer, Venango, Warren, Forest, Elk, McKean, Cameron and Potter counties.

Its expansion will conclude on March 1, 2013 with the New East Zone, comprised of 22 counties.

In Jefferson County's zone — the New West — consumers will be able to choose from four healthcare plans: Coventry Cares, Gateway Health Plan, AmeriHealth Mercy and UPMC For You.

Coventry Cares and AmeriHealth Mercy are both relatively new in the region.

In addition, United Healthcare was not one of the plans chosen by the DPW and will no longer do business in the New West zone effective Oct. 1.

Anyone on Medical Assistance who is not exempted and who does not choose one of these plans and enroll by Sept. 6 will be randomly assigned one.
All consumers who will go into HealthChoices will receive written information from the DPW regarding the change and plan choices.

"By the end of this week, everyone should have gotten a letter," Chervenak said.

Anyone who is currently covered under ACCESS Plus and/or had a plan with United Healthcare will need to select a new plan.

Anyone currently in a voluntary plan with Gateway or UPMC for You can choose either to stay where they are, in which case they don't need to do anything and will be enrolled into HealthChoices with the same plan, or to change to a new plan.

Individuals whose plan is unaffected but want to change anyway will need to do so by Sept. 6 as well.

Before enrolling in a plan, Chervenak recommended that consumers first check that all of their important providers, such as PCP, specialists and hospitals, are included in the plan's network.

This can be accomplished by calling the providers and asking which plans they participate in, contacting PA Enrollment Services at 800-440-3989 or contacting the plans themselves.

Chervenak advised performing a similar check with regards to medication. She encouraged consumers to ensure that all of their necessary medications are covered under the plan they are considering.

This can be determined by calling the plan to determine if the medications are in the plan's formulary and if the plan requires prior authorization or has other rules such as quantity limits or step therapy.

Consumers who choose a plan that does not cover all of their healthcare providers or medications can still visit and use them, but they will have to foot the bill themselves.

When consumers are ready to enroll, they can do so by contacting PA Enrollment Services or going online at

It is important that consumers know going into the enrollment process who the PCP will be for each person being enrolled.

If someone is approved for Medical Assistance after the Oct. 1 start date in the New West zone, he or she will initially go into fee-for-service and use the ACCESS card for his or her care for the first 4-6 weeks, depending on a variety of factors.

They'll then receive a HealthChoices packet from PA Enrollment Services with information on the plan choices. If they fail to enroll into one of the plans, they too will be auto-assigned.

Following enrollment, the managed care plan will send member consumers a card that may or may not indicate the PCP.

Beginning Oct. 1, said consumers will have to use that plan card — not their ACCESS card — when obtaining health services.

The managed care plan will also send out member handbooks describing co-pays, member rights, appeal information and how to obtain services from the plan.

Consumers will get all of their physical health services and prescription medications through their new plans.

They must obtain all of their care through providers in their plans' individual networks and can only go outside if the plan approves an out-of-network referral in advance.

The out-of-network provider must also accept payment from that particular plan in order to perform covered services.

In addition, consumers can only go to network specialists if they have a referral from their PCP, with exceptions for the following: vision, dental care and OB/Gyn services.

There are continuity of care rules in place for MCOs regarding prior authorized services.

If an individual is receiving services that were prior authorized by the DPW at the time of the transition into HealthChoices, said individual's provider must call the MCO in question. That MCO will then be required to continue to cover the service.

For adults, the MCO will cover the service either up to 60 days or until the plan does a clinical review to determine if there is a continuing need.

For children under 21, the MCO is required to continue coverage until the end of the authorization period.

These rules would also apply to prior authorized prescription medications.

Consumers will also have the right to continue receiving prior authorized services even if they are obtaining them from a provider who is not inside the MCO network.

(However, said provider will still have to agree to accept the MCO rates.)

If the out-of-network provider wants to continue services beyond the approved timeframe, that provider will have to submit a request to the MCO before the end of the approval period.

If the MCO opts not to continue to cover the services, it must provide notice. Appeal rights will still apply.

Continuity of care rules will also apply to pregnant women, who will be permitted to continue seeing an out-of-network provider throughout the pregnancy and postpartum period (60 days after the birth of the child).

If an MCO decides to reduce or terminate services, it is required to provide written notice, and the consumer will have a right to appeal.
The appeal must be made within 10 days in order to continue services during the appeal process.

If a prescribed treatment or medication is denied coverage by an individual's plan, he or she can choose either to appeal to the plan, where the appeal will be considered either a complaint or a grievance, or appeal to the DPW's Bureau of Hearings and Appeals, in which case it will be handled as a fair hearing.

An appeal is considered a complaint if a service is denied, reduced or terminated due to a reason unrelated to medical need.

It is deemed a grievance if it is denied, reduced or terminated based on medical need. In the latter case, if the prescribing doctor certifies that the individual would be harmed by waiting for the normal process, the plan will be required to expedite the process to a 48-hour period.

The complaint and grievance appeal processes both have two levels and then an external review.

Fair hearings can also be expedited in the case of determined medical necessity.

Decisions there are made by the administrative law judge.

If an individual disagrees with the judge's decision, reconsideration can be sought through the Secretary of the DPW.

The Physical Health MCO will cover physical health services and all prescription medications and will not affect behavioral health services.

These will still be obtained through the BH-MCO chosen by the county — the Community Care Behavioral Health Organization, in the case of Jefferson County.

Consumers in HealthChoices will be permitted to change their plan or PCP at any time.

To change the former, they will need to contact Enrollment Services; to change the latter, they will have to contact the plan. Most changes should take effect within 4-6 weeks.

The PHLP is a non-profit law firm not connected to the state that provides free services.

It works with low-income families, older adults and persons with disabilities to help them access public healthcare coverage and services.

Unlike most law firms, healthcare matters are its sole focus.

Chervenak said that public health insurance programs, specifically, are the organization's area of expertise.

Individuals seeking more information can sign up for PHLP's newsletter, visit the organization's website at, contact its helpline at 1-800-274-3258 or call Chervenak directly at (412) 434-5779.