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January 13, 2014 Beverly Mackereth, Secretary Pennsylvania Department of Public Welfare Health & Welfare Building 625 Forster Street Harrisburg, PA 17120 Re: Draft Healthy Pennsylvania 1115 Demonstration Application Dear Secretary Mackereth: Thank you for this opportunity to comment on the Draft Healthy Pennsylvania 1115 Demonstration Application (Healthy PA). We applaud the Administrations willingness to address critical healthcare issues facing the Commonwealth. However, we believe that Healthy PA, as proposed, would be less efficient and would produce poorer outcomes than the Commonwealths current successful HealthChoices Program. Moreover, the Healthy PA plan does not build on the successful Behavioral Health Managed Care Program that the Commonwealth initiated and has supported for over sixteen years. In particular, Pennsylvania has been a key innovator in the delivery of behavioral health services that we believe is a national model for the provision of a broad range of services and supports necessary to prevent and treat behavioral health challenges. Furthermore, Philadelphia, as a major urban center in southeastern Pennsylvania, has committed to and fostered an array of integrated physical health and behavioral health initiatives as well as prioritized services for high need populations. This includes people experiencing homelessness, children in the child welfare and juvenile justice systems, people with serious mental illness who have been discharged from the state hospital and children in the public school system. The Philadelphia Department of Behavioral Health and Intellectual disABILITY Services (DBHIDS) has a long history of serving the needs of individuals and families with behavioral health challenges in a manner that is effective and efficient largely due to the current HealthChoices structure. Healthy PA would disrupt this system resulting in higher overall costs and higher unmet needs of individuals. I. Pennsylvania should expand Medicaid eligibility utilizing the existing HealthChoices system in the Commonwealth. The Affordable Care Act (ACA) offers an unprecedented opportunity to provide comprehensive health coverage to hundreds of thousands of Pennsylvanians. By delaying any type of expansion until January 1, 2015, Pennsylvania stands to lose 2.5 billion dollars of federal funding.1 Each day the Commonwealth fails to act on this opportunity our most vulnerable residents go without access to necessary services and treatment.
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For States that Opt Out of Medicaid Expansion: A Rand Report. Health Affairs. Available at http://www.rand.org/pubs/external_publications/EP50279.html

As a Certified Application Counselor organization we have witnessed firsthand the unfortunate irony of individuals seeking coverage that are too poor for premium subsidies through the Marketplace, yet too rich for Medicaid coverage in the Commonwealth. One individual that we assisted, Tom2, has a long history of mental health challenges, but has never been afforded the opportunity to get health coverage. Toms income is 96% of the federal poverty level (FPL) disqualifying him for Medicaid eligibility and for a premium subsidy. When he came to us for assistance, Tom expressed genuine frustration and confusion since he saw the ACA and the Marketplace as his chance to finally get the coverage he needs to help him become healthy. He was aware of the fact that the ACA finally requires health insurers to provide services for mental health challenges and he was hopeful that he would benefit from this. Since Tom did not qualify for Medicaid or a subsidy, he picked a private plan in the Marketplace; however, he stated forthright that he would never be able to afford the monthly premium for the plan without any assistance. The fact that Tom represents over 500, 000 individuals in the Commonwealth who would benefit from traditional Medicaid expansion in the state and are being denied that opportunity is nothing less than heartbreaking in addition to being fiscally irresponsible. We strongly urge the Commonwealth take the opportunity to expand Medicaid eligibility today. II. Healthy PA would disrupt the current HealthChoices system resulting in higher overall costs and higher unmet needs of individuals. In order to the meet cost neutrality requirements set forth by the federal government, Healthy PA relies on a set of troubling financial assumptions that lack evidentiary support. We firmly believe that the cost containment strategies set forth in Healthy PA will lead to increased costs overall. A. Privatizing the current Medicaid system in the Commonwealth will increase costs and decrease efficiency. Evidence shows that Medicaid is a much more cost-effective system than the private health insurance industry. Kaiser Family Foundation reports that costs per enrollee are lower under Medicaid than they are under employer-sponsored coverage.3 In Philadelphia, the HealthChoices behavioral health administrative agency, Community Behavioral Health (CBH), has consistently kept administrative spending under 6.5%, far below the average spending within private and employer-based health insurance. Administering benefits through the existing Medicaid system is a better investment for Pennsylvania citizens than through the private health insurance industry. We urge that the Commonwealth maintains and strengthens the current Medicaid system rather than dismantle it in favor of more costly, less efficient private system. B. The Medicaid reforms proposed in Healthy Pennsylvania will result in higher costs overall due to limiting access to necessary services and by narrowing the scope of benefits offered.
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Name has been changed. Kaiser Commission on Medicaid and the Uninsured, What Difference Does Medicaid Make? (May 2013). Available at: http://kaiserfamilyfoundation.files.wordpress.com/2013/05/8440-what-difference-does-medicaid-make2.pdf.

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In order to contain healthcare costs it is essential that we meet the needs of individuals with behavioral health challenges. In 2007, 12 million emergency room visits involved a diagnosis related to mental health or substance use.4 In order to prevent costly emergency room visits and hospitalizations, it is crucial that we provide comprehensive services including prevention and treatment to those with behavioral health challenges. Access to Medicaid is critical for low-income individuals with behavioral health needs because, according to Kaiser Family Foundation, Medicaids behavioral health benefits are generally more comprehensive than those offered by other payers, and in some cases, Medicaid is the only insurer that covers a service needed by those with behavioral health problems.5 This statement accurately reflects coverage in Pennsylvania where the scope of benefits offered through traditional Medicaid is much more comprehensive than that of private health insurance. The Healthy PA proposal to consolidate the existing Medicaid benefit plans into two Alternative Benefit Plans (ABP) will limit access to necessary services and treatment for individuals, especially those with behavioral health challenges. We have grave concerns with the proposed benefit limits for the ABPs including: A 30 day per year limit on inpatient psychiatric hospitalization and inpatient drug and alcohol treatment for individuals in the low risk plan; 45 days for individuals in the high risk plan; A 30 day per year limit on outpatient mental health treatment and outpatient drug and alcohol treatment for individuals in the low risk plan; 45 days for the high risk plan; Limiting prescription clozapine to only individuals with a diagnosis of schizophrenia Limiting psychiatric partial hospital to 540 hours per year; Limiting peer support services to 4 hours per day or 900 hours per year; Failing to provide targeted case management except for individuals with a diagnosis of serious mental illness that are in the high risk plan; and Limiting laboratory services to $250 per year for the low risk plan; $350 per year for the high risk plan.

It is estimated that 5.8% of individuals that will be newly eligible for Medicaid in Pennsylvania will have a serious mental illness; 14.1% will have psychological distress; and 16.4% will have a substance use challenge.6 These individuals will be best served by the existing behavioral health Medicaid system in place. Currently in Philadelphia, CBH offers a comprehensive range of services providing coverage that meets individuals needs based on medical necessity criteria. Reducing the scope of
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Owens P.L., Mutter R., Stocks C. Mental Health and Substance Abuse-Related Emergency Department Visits among Adults, 2007. HCUP Statistical Brief #92. July 2010. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcupus.ahrq.gov/reports/statbriefs/sb92.pdf 5 Kaiser Family Foundation, Kaiser Commission on Key Facts, Medicaid and the Uninsured, The Role of Medicaid for People with Behavioral Health Conditions (November 2012). Available at: http://kaiserfamilyfoundation.files.wordpress.com/2013/01/8383_bhc.pdf.!! 6 Sources: 2008 - 2010 National Survey on Drug Use and Health (Revised March 2012). 2010 American Community Survey.
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coverage to reflect commercial-like plans will limit access to necessary services and treatment critical for individuals to remain healthy in the community.

III. The Healthy PA key reformative proposals are counterintuitive to the basic tenets of the ACA and the Medicaid program. The Governors proposal to reform the Medicaid in Pennsylvania contains key provisions that are seemingly contrary to the laws and regulations governing the Medicaid program. In this way, the proposal will undoubtedly face scrutiny and further debate with the U.S. Department of Health and Human Services (HHS); thereby further delaying improved access to comprehensive, affordable health coverage, for thousands of Pennsylvanians, as set forth by the ACA. The plans key reformative measures include: condensing the fourteen existing Medicaid benefit plans into two alternative benefit packages; applying a $10 co-payment for inappropriate emergency room use; requiring applicants and beneficiaries to comply with work search requirements; and attaching a monthly premium for individuals who have incomes as little as 50% of the federal poverty level. These measures will fail in achieving cost-containment and accountability goals and will act as unnecessary barriers to care. A. The imposition of a monthly premium will act as a significant barrier to care. The Healthy PA plan proposes to attach a monthly premium to Medicaid benefits imposed on individuals and families with incomes as low as 50% of the FPL ($5,745/year). The legality of such a provision is questionable under existing Medicaid rules and regulations.7 Arkansas will not impose any monthly premiums on enrollees.8 Iowas proposal to impose a monthly premium on individuals with incomes as low as 50% FPL was denied by the federal government.9 Additionally, the practical consequences of such premiums will far outweigh the perceived cost benefits. While $25 per month does not seem like much money to individuals who have steady incomes, for low-income individuals, it will act as a significant barrier to coverage and care forcing them to choose between basic life necessities and health coverage. B. A work search requirement is an unacceptable provision for Medicaid programs. The Governors proposal to require work search requirements for all unemployed, working age Medicaid beneficiaries is inappropriate and inconsistent with the goals of the ACA and the Medicaid program. Currently, no other state in the nation applies a work search requirement to its Medicaid benefit. The work search requirement is likely to be challenged by HHS due to its conflict with
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42 CFR Sec. 447.52! Arkansas 1115 Waiver Application (2013). Available at: https://www.medicaid.state.ar.us/Download/general/comment/FinalHCIWApp.pdf 9 Kaiser Family Foundation, The Kaiser Commission on Medicaid and the Uninsured, Medicaid Expansion Through Premium Assistance: Arkansas, Iowa and Pennsylvanias Proposals Compared. (December 2013).

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existing federal rules and regulations. Neither Arkansas nor Iowa, the first states to have an alternative Medicaid expansion plans approved through 1115 Waivers, included a work search requirement. We strongly urge the Commonwealth to remove the work search requirement from its plan. C. Co-payment requirements for inappropriate emergency room usage will cause confusion and precipitate unaddressed crisis situations. One of the more alarming provisions set forth in the plan, without clarification or description, is a $10 co-payment for non-emergent emergency room usage. The plan fails to define or describe situations when using the emergency room would be inappropriate as opposed to appropriate. The plan also fails to explain how this co-payment would be collected or who would be responsible for determining when the co-payment should be imposed on an individual. Individuals and families who might be experiencing serious medical conditions could delay seeking emergency treatment due to this co-payment. The Emergency Medical Treatment and Labor Act (EMTALA)10 was enacted to ensure all individuals had access to necessary health services in times of crises regardless of ability to pay. Enacting a policy such as this can confuse individuals about their right to receive care in these settings, and unjustifiably penalizes the poor. We strongly urge the Commonwealth remove the $10 co-payment for non-emergent emergency room use from the plan. D. Harsh punitive measures will disrupt continuity of care leading to poor health outcomes and higher overall costs. Imposing harsh punitive measures on individuals who cannot afford to pay an advanced monthly premium will result in disrupted care and higher emergency services utilization. Many individuals with behavioral health challenges face significant financial barriers that might interfere with submitting a premium a month in advance. These punitive measures will increase the likelihood of churn due to individuals and households continually losing and gaining coverage. We strongly recommend eliminating the harsh penalties associated with inability to pay the monthly premium.

IV. Healthy PA will be detrimental for adults with behavioral health needs. The current carve-out model of behavioral health has proven to be cost-effective while providing high quality care to individuals. The Administration should consider evaluating the scope of coverage offered by individuals in private health insurance plans compared to behavioral health managed care organizations operating in the Commonwealth. A. The current HealthChoices behavioral health system is better equipped to manage the needs of individuals with behavioral health challenges than private insurers. The HealthChoices carved-out behavioral health system was created due to a need to improve the care for individuals with mental health and substance use challenges because the carved-in system
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42 U.S.C. 1395dd Emergency Medical Treatment and Active Labor Act.

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was failing individuals with behavioral health needs. This system has proven to be greatly successful in improving health and maintaining costs. The Healthy PA enrollment process would shift many individuals with complex behavioral health needs, but that might not meet medically frail criteria, into the Private Option; this proposal will prove to be costly and ineffective. The current HealthChoices Behavioral Health program has built a network of behavioral health providers expert in delivering high quality services and care to individuals. Many of these providers are out of network of the private health insurance plans operating in Pennsylvania. Newly eligible individuals limited to the Private Option may find it difficult to obtain necessary behavioral health services due to network inadequacy. Additionally, individuals who will now be taken out of the current HealthChoices system and placed in the Private Option will have their care disrupted and will find it unlikely that their current providers are in-network with a new private plan. We recommend the Commonwealth allow the current HealthChoices behavioral health program manage the needs of individuals with behavioral health conditions. B. The proposed self-assessment screening process will impact individuals with behavioral health needs and other disabilities negatively resulting in the wrongful assignment of benefit plans. We have serious concerns with the proposed benefit plan enrollment process utilizing a selfassessment to determine the scope of benefits for individuals. We firmly believe that: 1. The Commonwealth should publicly share the screening tool it plans on utilizing. Because the Commonwealth has not shared the tool, we cannot provide informed recommendations on how accurately the tool would determine whether an individual should be placed in a low or high risk plan or whether the screening tool would accurately identify behavioral health needs. The tool should have been included in the draft Healthy PA plan for public comment. 2. Individuals who fail to complete the screening should not default to the Low Risk Benefit Plan or Private Option. Individuals who cannot complete the screening should not be automatically enrolled in the Low Risk or Private Option plans. Individuals who face literacy challenges, do not have access to the internet, or who are unaware of the screening process are more likely to have ongoing medical conditions and will be better served in the High Risk Alternative Benefit Plan. Automatically placing these individuals in the Low Risk Benefit Plan or the Private Option will fail to meet their needs thus leading to higher administrative costs to move them into the correct benefit plan or higher utilization costs when they exceed benefit limitations. 3. Individuals with behavioral health challenges are more likely to be enrolled in the wrong benefit plan.

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It is well known that historically individuals with mental health and substance use challenges have faced great stigma in our society. This fact may cause many individuals to under report or hide the fact that they suffer from these challenges in the self-assessment process. This will lead to individuals being wrongly enrolled in the Low Risk Benefit Plan or Private Option plans. The Commonwealth cannot assume that individuals will receive assistance from providers in completing the self-assessment or that they will understand that the information disclosed on the self-assessment will be kept confidential. 4. We share the Mental Health Association of Southeastern Pennsylvanias concerns11 that in order for the self-assessment screening to be successful the following assumptions must hold true: a. Individuals must have been diagnosed (many individuals with behavioral health needs are undiagnosed); b. Individuals must be aware of their diagnosis; c. Individuals must be willing to share medical conditions; and d. Individuals must have additional support if a cognitive impairment may impact awareness of disability status or participation in self-assessment. C. Individuals in the General Assistance category are best served through the HealthChoices program. A recent analysis of CBH utilization data illustrates that individuals in the General Assistance program have higher behavioral health needs than those in the general Medicaid population. Data analysis of 2013 enrollment and utilization shows that 76% of individuals enrolled through the General Assistance category utilized behavioral health services. This demonstrates the significant need for comprehensive quality behavioral health services for this population. We urge the Commonwealth to maintain individuals in the General Assistance category within the HealthChoices program to best meet their needs. D. Clarity is needed regarding the process in which individuals will move from the Low Risk Plan to High Risk Alternative Benefit Plan when necessary. Healthy PA lacks clarity regarding the process of how an individual will be moved from a Low Risk Benefit Plan to High Risk Alternative Benefit Plan when they have a need for more comprehensive coverage and services. We recommend that a process be in place that does not disrupt services and allows for immediate access to services when needed.

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Written Comments Regarding Healthy Pennsylvania, Jacob Bowling, Mental Health Association of Southeastern Pennsylvania, (January 3, 2014).

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E. Imposing work search requirements on individuals who are medically frail will result in disrupted care and poor health outcomes. Individuals with mental health and substance use challenges have a significantly more difficult time becoming employed than those who do not. Mandating work search requirements for these individuals will be detrimental to their mental health exacerbating anxiety and depression and will disrupt continuity of care leading to higher utilization of emergency rooms and crisis centers. We strongly recommend that you eliminate the work search requirement in its totality and especially for all individuals who are deemed medically frail. F. Retroactive coverage should be provided to individuals in the ABPs managed through HealthChoices. Individuals with behavioral health challenges might enter the treatment system in times of crises. These individuals may be experiencing their first crisis situation and may have been unaware of a mental health or substance use challenge that they are facing. In these situations it is critical that retroactive coverage be provided to ensure that individuals can receive the services and treatment they need without suffering from financial harm. We recommend providing retroactive coverage for individuals in the Low Risk Plan and High Risk Alternative Benefit Plan. G. Prior authorization for drugs should be addressed in 24 hours as opposed to 72 hours. It is crucial that individuals who rely on pharmaceuticals to keep them healthy and safe be able to receive them without administrative delay. While Healthy PA states individuals would be able to obtain a 72-hour supply of medication in the event of an emergency, there is no information provided about how these requests would be made, approved and acted upon. We strongly urge the Commonwealth mandate that authorization for drugs be made within a 24-hour period rather than 72 hours. H. Wrap-around services should be provided for individuals with behavioral health challenges. Historically private health insurance has failed to meet the needs of individuals with serious behavioral health challenges. In Pennsylvania the behavioral health HealthChoices program has provided critical services to those individuals whose needs were not being met within private coverage. We recommend that the Commonwealth permit HealthChoices to continue to provide critical wrap-around services to individuals in need. I. Non-Emergency transportation should continue to be provided to individuals. Lack of transportation can be a major barrier to accessing services, especially for low-income individuals and individuals with behavioral health needs. Without a way to physically access services many individuals will go without necessary treatment. Individuals with behavioral health needs rely
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on non-emergency transportation to transfer between treatment facilities, this sometimes overlooked service, is a critical component in ensuring continuity of care and safety for individuals. We strongly urge the Commonwealth to provide non-emergency transportation under the Healthy PA plan. V. Healthy PA will be detrimental for children and young adults with behavioral health needs. In addition to having a detrimental effect on adults with behavioral health needs, the Healthy PA plan has significant consequences for children and young adults. The Commonwealth should take efforts to expand comprehensive quality coverage to prevent costly chronic conditions among our children rather than restrict access to care. A. The Commonwealth should take efforts to protect the health of our children and implement provisions of the ACA that expand access and coverage of quality care to children. Under the ACA children in households with incomes up to 133% FPL are eligible for Medicaid.12 Children with behavioral health needs gain far better access and coverage to necessary services in Medicaid rather than CHIP. To date the Commonwealth has not provided families or health care providers with any notice or information about how children will be transferred into the Medicaid program. This type of guidance is critical to ensure continuity of care and an adequate workforce within the Medicaid program to attend to childrens needs. B. Young adults who are former foster youth should not be subjected to monthly premiums and work search requirements. The ACA permits young adults who have aged out of the foster care system to remain within the traditional Medicaid program until their twenty-sixth birthday. Efforts should be made to increase individuals knowledge of this option and assist in enrollment efforts. Imposing barriers such as monthly premiums and work search requirements is in opposition of the ACAs intent to provide access to quality services to this vulnerable population. We strongly urge you to eliminate monthly premiums and work search requirements for any former foster youth up to twenty-six years old. VI. Many unknowns and critical questions regarding the implementation Healthy PA currently exist. Please see the attached appendix enumerating the additional questions of concern we have regarding the implementation of Healthy PA.

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American Public Health Association http://www.apha.org/advocacy/Health+Reform/ACAbasics/medicaid.htm!

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In closing, I urge you to consider the critical issues facing economically challenged and other vulnerable Pennsylvanians and the inherent barriers to affordable and quality healthcare posed by the provisions contained within the Healthy PA proposal. We welcome an open dialogue with the Commonwealth to discuss the best strategies to support our citizens in a way that provides comprehensive quality care to all.

Respectfully submitted,

Arthur C. Evans, Jr., PhD Commissioner, Philadelphia Department of Behavioral Health & Intellectual disABILITY Services
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