LTC Consulting Lens: The 5 letter word shaking up PA

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Find out about the MLTSS changes in Pennsylvania from LTC Consulting’s very own Steve Shain.

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Steve Shain: Hi, welcome back. Today I’d like to talk more about the Pennsylvania rollout of MLTSS beginning in January 2018, right around the corner for the more rural areas and then January 2019 and January 2020 for the more urban areas. MLTSS as you know stands for Medicaid’s little trick saving shekels, right? That’s what they try to do, they try to save money. No, it really stands for Managed Long-Term Services and Supports. The insurance companies that are participating are Amerihealth, PA Health and Wellness and UPMC. The eligibility process – the same as – it’s basically going to be the same as Medicaid. The application process – basically gonna be the same as Medicaid, same forms submitted. Billing process – the basics can be the same as well. There’s gonna be a little bit of a difference when somebody’s pending Medicaid in regards to their coverage, which will be Medicaid at first and then the insurance company, but overall not much is changing. So what really are you gonna see as a difference? Well, aside for a slower cash flow and a more unpredictable cash flow, probably you’re gonna see a more frequent denials on your claims and a more fragmented process from the insurance companies, especially in the beginning while they’re trying to figure things out. A couple of differences between each of these insurers that is worth noting; No. 1 is that the insurance are not requiring the custodial authorization for coverage similar to what a managed care usually would require. Amerihealth is the only one that’s asking for an authorization but they’re gonna be the ones that are going to be covering that process. They’re not gonna put that burden on the facility to make sure that authorization is in place. In contrast to maybe New Jersey for example, where all of the managed MLTSS insurers do require a custodial authorization be obtained by the facility. Another interesting difference is that the other insurance are giving basically a lock-in of your Medicaid rate for the last 4 quarters, and that goes to the extent of the contract. PA Health and Wellness is giving an option; either you can get your rate similar to those other insurers or you can base it off of CMI, your case mix index. So obviously if you feel your CMI is going to be going up or has been on a trend to go up, you probably want a contract with them on that structure that way your rate has a better chance of being higher, if on the other hand you feel that your CMI is not that awesome, you want to lock in your rate as per the last four quarters of your Medicaid rate in order to make sure that you’re getting decent reimbursement. I also wanted to point out if any of you are going to be at the AJAS conference in February, February 13, I will be there speaking on managed care for everybody at the conference. Would love to see there, if you’re going to be there awesome, if you’re not going to be there and you’d like to ask me questions about managed care or about this specific thing, MLTSS, please reach out. If you’d like to talk to your organization, please reach out, I’ve been happy to talk to you if it helps I’m there. Thank you so much for listening take care.