A publication of the PA Health Law Project
ACTION ALERT! Medical Necessity Change
The Department of Public Welfare (DPW) has issued draft guidelines for the definition of medical necessity for HealthChoices plans, as well as fee-for-service and voluntary managed care plans. DPW proposes using these guidelines along with the medical necessity definition in the HealthChoices Request for Proposal (RFP).
The Consumer Subcommittee to DPWs Medical Assistance Advisory Committee strongly opposes this guideline and recommends that DPW stick to using the definition in the HealthChoices RFP. The RFP has one of the best definitions of medical necessity possible.
The proposed guidelines add more restrictive requirements to the RFP definition and shifts the burden of proof on to the prescribing physician. Consumers must meet four conditions under the proposed guidelines and each condition raises problems:
The guidelines require that the service be medical in nature; this may allow HMOs to deny behavioral health services, assistive technology, personal attendant services, and EPSDT case management services.
Under the proposed guidelines, a service must be proven effective. The burden is so high here that HMOs may even deny well-baby visits, new AIDS protocols, behavioral health services, and palliative, preventive, and maintenance therapies.
In addition, the service must be individualized; this condition might exclude immunizations.
Lastly, the service must also be consistent with efficiency, economy, and quality of care. This makes it hard to get necessary expensive services, an array of services to personally choose from, and the least restrictive settings for care.
The definition of medical necessity is the linchpin to entitlement to all health care under HealthChoices. Please submit comments on this definition immediately to Suzanne Love; fax number 717-772-6366, or mail:
Department of Public Welfare
Director, Bureau of Program Policy and Services Development
P.O. Box 8043
Harrisburg, PA 17105
HMA Prescription Formulary
DPW has approved HMAs formulary, a restricted list of available drugs. DPW is considering formularies from Keystone Mercy and OakTree/Oxford.
HMA may now use a formulary but must take the following steps:
HMA must make drug products not on the formulary accessible through prior authorization.
If the authorization is denied, HMA must provide immediate notification to the member.
HMA must approve a 72 hour supply of FDA approved medication if a medication is needed in an emergency and the medication requires prior authorization.
HMAs formulary includes some behavioral health drugs. PHLP is concerned about the lack of coordination between the HMOs and behavioral health contractors in developing this formulary. Please contact the PHLP Help Line if you are having trouble getting a behavioral health drug because of the formulary.
Members who are having trouble with HMA prescriptions can also call our Help Line at 1-800-274-3258 for assistance.
New Southwest Expansion Schedule
DPW has released a new schedule for implementation of the HealthChoices mandatory Medicaid managed care program into Southwestern Pennsylvania. The new schedule eliminates the phase-in by county that DPW previously proposed.
Implementation will now begin on January 1, 1999. On that date, DPW will enroll MA recipients into the HealthChoices SW program who already enrolled in a managed care program.
MA recipients not already enrolled in a managed care plan can enroll in HealthChoices during the Spring of 1999. After May 19, 1999, DPW will automatically assign recipients who do not choose a HealthChoices plan effective July 1, 1999.
Other important HealthChoices SW dates include:
Release of Final Behavioral &
Physical Health RFPs 10-22-97
Proposals Due 1-15-98
Public Information Campaign &
General Community Outreach 11-13-98 - 1-30-99
Enrollment Period 1-5-99 - 5-18-99
Voluntary Conversion 1-1-99
Enrollment Deadline 5-19-99
Enrollment Effective Date 7-1-99
PHLP is preparing summaries of DPWs plans for HealthChoices SW. Call our Help Line for information at 1-800-274-3258.
Enrollment Assistance Program for HealthChoices Southwest and Lehigh/Capital Zones
The draft RFP for the Independent Enrollment Assistance Program is now available from DPWs Lisa Roscoe at 717-772-6277 for the Greater Allegheny (SW), Capital, and Lehigh Valley areas. This program provides independent assistance in enrolling MA recipients with the managed care plan of their choice.
Three public meetings on the draft will be held as follows:
Harrisburg: Nov. 18, 1997 at 9:30 a.m.
Pennsylvania Game Commission
Auditorium, 2001 Elmerton Ave.
Harrisburg, PA 17110-9797
Allentown: Nov. 20, 1997 at 10 a.m.
Allentown State Hospital
1600 Hanover Ave.
Allentown, PA 18103-2498
Pittsburgh: Nov. 25, 1997 at 9 a.m.
Allegheny County Courthouse
The Gold Room (4th Floor)
542 Forbes and Grant Streets
Pittsburgh, PA 15129-2904
To testify (5 minute limit) contact Christine Enrico at 717-772-7768. Send written comments by December 11, 1997 to: DPW, OMAP, Attn. Christine Enrico, Room 113, Cherry Wood Bldg., #33, Harrisburg State Hospital Grounds, Harrisburg, PA 17110.
People with a disabilities may call 1-800-654-5984 (TDD) or 1-800-654-5988 (voice). For other alternatives call Thomas Vracarich at 717-783-2209.
Health Partners canceled HealthChoices contracts with several of its hospital providers in Philadelphia giving 120 days notice. Health Partners has also issued termination notices to the primary care practitioners affiliated with these hospitals possibly effective as soon as November 30, 1997. DPW is now negotiating with the parties.
Please call the PHLP Help Line if you have problems with Health Partners provider network,
Behavioral Health Denials
The Office of Mental Health and Substance Abuse Services has issued policy clarifications on HealthChoices Behavioral Health services. The Behavioral Health MCO must:
perform an Impartial Review prior to disapproving EPSDT services for children in part or in whole
provide written notice to the member if a service is disapproved
provide written notice to the member if a service is approved but in a lesser amount or duration (for example, 20 hours of psychotherapy requested and only 15 hours approved)
provide written notice to the member if an alternative service from what was requested is approved (for example, Family Based Mental Health Services are requested and Mobile Therapy and MH Clinic services are approved instead).
Please contact the PHLP Help Line if you are having trouble with Behavioral Health denials,
Continuity of Care
DPW has issued draft procedures regarding MA continuity of care for adults and children transferring between fee-for-service and managed care organizations. The Department would like comments to these procedures immediately.
Under the proposal, any adult recipient who transfers into a HealthChoices managed care plan will continue to receive any prior authorized service the individual was getting at the time of the transfer until the end of the original prior authorized period or until the HMO conducts a concurrent review which determines that continuation of the prior authorized service is no longer medically necessary.
For children joining a HealthChoices managed care plan, neither the plan nor the PCP may change, reduce, or terminate previously authorized services through the approved time period.
DPW proposed detailed procedures for continuity of care for prior authorized services for adults and for services that did not require prior authorization under fee-for-service but do require it from the plan.
Starting with the next issue, PHLP will publish two versions of this newsletter; one for HealthChoices Southwest, and another for HealthChoices Southeast. You will receive the newsletter for your area. If you would like to receive both newsletters, please contact Lorraine Jones at 215-625-3662.
Noticias: HealthChoices, the Spanish version of our newsletters, is now available. If you would like to receive the newsletters in Spanish, please contact Claudia Johnson at 215- 625-3848.