9/29/2017 Update: There will be no changes to the way rehab services are currently provided and reimbursed under Community HealthChoices and HealthChoices in 2018. During 2018, Pennsylvania will be collecting outcomes data, and any changes to reimbursement practices will take place in 2019.
The state of Pennsylvania is moving full steam ahead toward implementation of changes to the state’s Medicaid program. In parts of the state, Medicaid recipients will soon begin to decide which affiliated plan they want to enroll in. But questions remain: What will the soon-to-be-implemented MLTSS program mean for rehabilitation services?
First, let’s take a look at the basics of MLTSS in Pennsylvania. Under Pennsylvania’s MLTSS model, there are two programs—Community HealthChoices and HealthChoices.
Both are managed care organizations, but HealthChoices is for Medical Assistance recipients, while Community HealthChoices is for those who are dually eligible for Medicare and Medicaid. Through both programs, providers receive capitated payments for care and are responsible for ensuring quality care and positive outcomes.
The programs will utilize managed care organizations (MCOs) to coordinate medically necessary care and long-term services, including rehabilitation services, for eligible patients. There are three affiliated MCOs:
- AmeriHealth Caritas
- Pennsylvania Health and Wellness (Centene)
- UPMC for You
While MLTSS implementation has seen delays, it’s now on track toward beginning a gradual roll-out of care. Patients in the Phase 1 implementation zone, which encompasses the southwest portion of the state, will select and enroll in the plan of their choice between September and November of this year. If they do not enroll, a plan will be assigned to them. The actual plan will begin coverage on January 1.
July 2018 will see implementation for the southeast portion of the state, including Philadelphia, while implementation in the remainder of the state is slated to occur in January 2018.
While some details are emerging and enrollment has begun, there are still many unanswered questions about how MLTSS will affect rehab services, including the provision of physical therapy, occupational therapy, and speech language therapy. Let’s take a look at five of the most common lingering questions.
Question 1: How Will MLTSS Treat Rehab Services?
Will MCOs cover rehab services as an addition that requires preauthorization, or will these services be covered under the umbrella of care?
Question 2: What Will the Financial Impact Be for Rehab Services?
How will the shift to a managed care model impact your Skilled Nursing Facility’s profit margin? How should you adjust your center’s payer mix as a result?
Question 3: How Will the MCOs Define Caps for Rehab Services?
Therapy caps tend to differ from insurance plan to insurance plan—with each having a different max duration for rehab services. What will that look like for the three MCOs affiliated with Community HealthChoices and HealthChoices?
Question 4: Will More Patients Receive Rehab Services as Outpatients Rather than Inpatients?
With managed care’s emphasis on the provision of community-based care, will more rehab services be provided on an outpatient basis after discharge from a Skilled Nursing Facility rather than on an inpatient basis to residents during an SNF stay?
Question 5: Will Managed Care Regulations Change the Definition of “Quality” in Rehab Services?
The definition of quality care varies greatly, depending on the regulatory agency in charge—and those definitions seem to evolve continually as new standards emerge. What will MCO regulations bring?
As we move toward next year’s implementation, details will continue to emerge about how these plans will work. As we gain new insight, we’ll share that information with you, along with how it may potentially affect therapy services.
Changes are ahead. Apex Rehab can help your team stay ahead of the curve. Get started today by calling (412) 964-9698.