June 12, 2024
Over the past several months, many issues have emerged that are impacting member eligibility and provider payment. We want to acknowledge the challenges impacting members who receive Long-Term Services and Supports (LTSS) and thank members, advocates, and providers for swiftly identifying them.
Our LTSS system is being impacted by several challenges at the same time, including:
- Increased county workload due to the end of the Public Health Emergency (PHE) combined with a record number of Medicaid and Supplemental Nutrition Assistance Program (SNAP) renewals;
- The implementation of IT system changes that has resulted in additional workload and frustration for case managers; and
- Unanticipated complications with the transition of members to new case management agencies (CMAs) to achieve conflict-free case management.
The impact of all three occurring at once - which was not intended - is causing short-term challenges to member eligibility, provider reimbursement, CMA processing and member service response time. In the coming months, the IT innovations and case management redesign modernizations will create a better system for members, providers and CMAs.
Our top priority is ensuring ongoing coverage for LTSS members while mitigating payment delays for LTSS providers so members can access needed services. We have identified both short and long-term solutions to urgently address the most pressing issues.
Protecting Coverage for LTSS Members
- Expedited Backlog Processing
- Approving Eligibility When an LOC is not Current
- Temporarily Pausing Terminations and Mitigating Future Terminations
- Reinstating Eligibility
- Missing Documentations and Verifications
- Address Delays in Disability Determination
Paying Providers Timely to Protect Access to Services
- Provisional Provider Payments
- Prior Authorization Request (PAR) Extension
- Benefit Plan Extension
- Fill in Eligibility Gaps
Identifying and Resolving Known Issues in the CCM
- Known Issue Identification
- Case Management Support Structure
Reducing Case Management and County Backlog
- Address County Backlog
- Implement County Monitoring
- Implement Case Management Agency Monitoring
- Distribute CMA Stabilization Funds
- Allow for Case Management Policy and Program Flexibility
Addressing Appeals and Escalations Backlog
- Address Appeals Backlog
- Address Escalations Backlog
- Improve the Escalation Webform
Protecting Coverage for LTSS Members
Expedited Backlog Processing: The Department of Health Care Policy and Financing (HCPF) expedited an eligibility system change to process the backlog of Level Of Care (LOC) certification entries.
- This system change went into effect in early May 2024.
Approving Eligibility When an LOC is Not Current: HCPF has implemented a system change to approve eligibility if current members do not have an active Level of Care (LOC) in the HCPF’s eligibility system. HCPF has applied a 12-month extension in our eligibility system to all Long-Term Care (LTC) LOC end dates that are ending as of March 1, 2024 or later. This solution went into effect on April 13, 2024.
Temporarily Pausing Terminations and Mitigating Future Terminations: HCPF will temporarily pause terminations for most reasons for LTSS members for two months past the member’s original termination date unless the termination is for a member who has moved out of state or has passed away.
- HCPF will continue this manual reinstatement at least through August 2024 when we plan to implement a system change to automate the process.
Reinstating Eligibility: Although active LTSS members are in a status where they should not be disenrolled, there is still a possibility that a few individuals may have coverage terminated. As such, HCPF will continue to monitor and manually reinstate eligibility for all LTSS members when their eligibility is set to end. Once HCPF reinstates a member’s eligibility, they will remain active until their case can be properly processed.
- Additionally, HCPF will begin outreach to members who were procedurally terminated in prior months, past the 90-day consideration period, and have not resumed coverage.
Missing Documentations and Verifications: If the member's eligibility is still pending due to missing documentation or verifications, county workers may manually implement a pause by applying a Good Faith Extension, further delaying termination until the member’s case can be fully reviewed.
- HCPF reissued guidance to county workers on the Good Faith Extension on March 1, 2024 and will be monitoring this closely to watch for any inappropriate terminations and work to reverse those identified.
Address Delays in Disability Determination: HCPF is addressing backlogs and issues related to obtaining medical records with our disability determination vendor to make disability determinations.
- HCPF has worked with hospitals to speed up the release of medical records.
- Electronic fund transfer has been established to expedite payments.
- HCPF is meeting weekly with the disability determination vendor to review and address backlog issues.
- HCPF has launched a new back office team that will assist with entering completed determinations to help address the backlog.
Paying Providers Timely to Protect Access to Services
Provisional Provider Payments: HCPF put in place a Provisional Provider Payment to assist providers who were seeing an increase in denied or suspended claims resulting in a lack of payment.
Prior Authorization Request (PAR) Extension: HCPF has implemented a temporary system edit that allows providers to bill for previously approved services even if there is not an active PAR in the system.
- HCPF has instructed providers to bill for all services they have provided to LTSS members back to July 1, 2023, even if an active PAR is not in the HCPF Provider Portal.
- When information is available, HCPF is manually extending PARs for LTSS-eligible members who do not have current PARs.
Benefit Plan Extension: In addition, HCPF is manually creating member benefit plans (e.g., HCBS BI - Brain Injury Waiver) when they are missing. This allows HCPF’s claims payment system to continue to pay for services even if the Case Management Agency has not had the opportunity to provide that information.
- HCPF is pursuing an additional solution to automate updates to the benefit plan which will decrease the system errors that are occurring when there is a mismatch between the information on the benefit plan and the PAR.
Fill in Eligibility Gaps: HCPF is manually filling in eligibility gaps for members so providers may be paid. There are approximately 1,200 members who were on Long-Term Care (LTC), had a gap of days to months, then went back to LTC.
Gaps are due to either losing coverage completely or moving to a lower category and then back to LTC.
Identifying and Resolving Known Issues in the CCM
There are a number of known issues within the newly launched Care and Case Management System (CCM) that are not directly impacting member eligibility or provider payments, but are adding to case managers' workload and contributing to the backlog.
Known Issue Identification: HCPF has identified all known issues and is working with the CCM vendor to implement the system changes to ensure the CCM system meets user requirements and needs.
- Additional resources have been added to the vendor to provide training support, call center staffing, and development staff to help implement system changes faster.
Case Management Support Structure: HCPF will implement an improved Case Management Systems Support structure that will improve the way system changes are communicated, identify and work through open issues quickly, and partner with case management agencies to improve overall outcomes for LTSS members and business needs for case managers.
- New support structure is scheduled to launch prior to July 1, 2024.
Reducing Case Management and County Backlog
Due to the overlap of all of these converging initiatives and the challenges they have presented, there are significant capacity issues within the Case Management Agencies (CMAs) and county human services agencies. These capacity concerns resulting in backlogs are primarily being experienced in large urban areas.
Address County Backlog: HCPF will implement and monitor renewal backlog reduction plans at five large counties (accounting for over 70% of the renewal backlog).
- Backlog reduction plans have an end date of December 2024.
- HCPF will continue to monitor the implementation of these plans to ensure follow-through.
Implement County Monitoring: HCPF will monitor county performance against new application contract measures and implement formal improvement action plans as necessary.
Implement Case Management Agency Monitoring: HCPF will monitor CMA stabilization through monthly data collection and review meetings. HCPF will work with the CMAs who have backlogs to create Backlog Reduction Action Plans.
Distribute CMA Stabilization Funds: HCPF will distribute stabilization funds this fiscal year and next fiscal year to support CMAs while they have increased workload and limited capacity.
- More than $27 million was appropriated to support the 15 CMAs who were selected via the formal Request For Proposal (RFP) solicitation process.
- HCPF paid over $23 million directly to CMAs in May 2024 and will pay the remaining $4 million as soon as possible after the start of the new fiscal year on July 1, 2024.
Allow for Case Management Policy and Program Flexibility: Where possible, HCPF has and will continue to provide flexibility in the requirements of case managers to increase capacity and allow them to prevent or catch up on their backlog.
- HCPF has allowed for virtual assessments to address and mitigate the backlog of Level of Care (LOC) certifications.
Addressing Appeals and Escalations Backlog
The compounding issues listed above are impacting both members’ eligibility and access to services and providers' ability to get paid. HCPF’s ability to manage and address member and provider-specific issues has been impacted by the unexpected and rapidly growing number of appeals and escalation requests. View escalation form
Address Appeals Backlog: HCPF has shifted internal staff responsibilities to increase capacity in appeals.
- Training has been provided to internal staff to be able to handle the intake of new appeals. HCPF is also hiring temporary staff to support the accounting team.
- A new workflow has been designed to help with processing the backlog of decisions from the Office of Administrative Courts.
Address Escalations Backlog: HCPF has leveraged American Rescue Plan Act (ARPA) Home and Community Based Services funds to increase escalations support.
Improve the Escalation Webform: HCPF is working to make updates to the form to make it more member-friendly, to improve the functionality, and to make available a Spanish webform.
- New Spanish webform is in development.