September 22nd, 2011

Summary of the  Medical Assistance Advisory Committee (MAAC) Consumer Subcommittee Meeting on September 21, 2011:

 Dental: Changes to dental benefits under United and Gateway provider plans will begin September 30. Notices alerting consumers to these changes have been sent.

 Pharmacy:  Changes to Medical Assistance (MA) recipients of pharmacy benefits are tentatively scheduled to begin January 2012.  These changes will standardize denial code language and, as such, are geared toward providers.  As a result of this language standardization, providers will receive instant computerized notice that the benefit limit has been exceeded, and prescriber exemption is required for its receipt. Auto-exceptions will be counted among the six drug limit.

Expansion of HealthChoices (replacement plan for AdultBasic recipients):  AccessPlus is being retained in the expansion. In the proposal are two MCOs operating under a fee-for-service framework.  The proposal retains the current PCP requirements and is scheduled for implementation on September 1, 2012 in the Western Zone and March 1, 2013 in the Eastern Zone.

 Keystone Mercy: There was concern expressed at the meeting that three hospital panels were barred access to primary care doctors with insufficient notice, as letters were sent only to providers, and not consumers, altering the panels’ closing.  As such, access to care has been greatly hindered for these individuals.

 In response, Keystone Mercy representatives present at the meeting explained that consumers could have asked for a cap or enrollment expansion, and that those individuals formerly under Keystone Mercy have options for coverage under other plans.  It was also stated that the closing of these facilities forced negotiations between providers and hospitals, thus resulting in further coverage options.  Additionally, access to specialty services within affiliated practices can still be offered —  it is only owned access at Jefferson et al. that’s been limited.

Gateway and Hershey Contract:  June 30 2015 – contract extension successful. The smooth contractual transition for Aetna, among others, was also mentioned.

Office of Long-Term Living:  The letter of intent for dual-eligibles is being sent. Notice of the rate change implementation and service definition changes for Community Care and other additional waivers are also being sent.

 Two new Triple A agreements being drafted in relation to:

1. Aging related services
2. Medicaid support and services

 Also noted was that, recently, long-term care provider groups have voiced concerns with the 5010—a claim format affective to providers. Under these new provisions, forms must now be submitted with a diagnosis code. This should not affect consumer services in any way. Further, additional service plan reviews are being conducted by CMS and enrollment is being managed into waivers. Currently, there are no wait lists barring access to service.

 Life rate methodology changes submitted to CMS and a Community Integration Bulletin will be issued as soon as CMS approval comes through.