Pediatric Palliative Care Waiver

Workgroup Meeting June 11, 2018

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Agenda Welcome and Introductions

Purpose of Meeting

Pediatric Palliative Care (PPC) Waiver Overview Overview of Early and Periodic Screening, Diagnostic, and Treatment ( EPSDT) Services Transition Plan – Specific Elements

Open Discussion and Breakout Session

Final Comments and Next Steps

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Welcome and Introductions

Sarah Eberhardt-Rios Chief, Integrated Systems of Care Division Department of Health Care Services

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Purpose of Meeting

Sarah Eberhardt-Rios Chief, Integrated Systems of Care Division Department of Health Care Services

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Purpose of Meeting

Today, we will be discussing Pediatric Palliative Care (PPC) Waiver services Understanding EPSDT services Understanding PPC services in Medi-Cal Managed Care and fee-for-service (FFS) delivery systems Planning and discussing a transition strategy for current waiver participants

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Purpose of Meeting (continued)

Current PPC Waiver status

Department of Health Care Services (DHCS) discussions with Centers for Medicare and Medicaid Services (CMS) regarding PPC Waiver

Termination of PPC Waiver and transition of services to appropriate Medi-Cal Managed Care and FFS providers

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Pediatric Palliative Care Waiver Overview

Sarah Eberhardt-Rios Chief, Integrated Systems of Care Division Department of Health Care Services

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Pediatric Palliative Care Waiver Overview

PPC Waiver first approved by CMS in December 2008

Began as a t hree-year demonstration pilot program on April 1, 2009

Renewed for an additional five-year waiver term on December 27, 2012

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The PPC Waiver was approved for 1,800 slots and to o perate within 12 counties

There are ten participating counties, with four active providers Participating counties: Alameda, Los Angeles, Marin,

Monterey, Orange, San Francisco, Santa Clara, Santa Cruz, Sonoma, and Ventura

Ventura is withdrawing from waiver participation; San Diego previously withdrew

Pediatric Palliative Care Overview (continued)

Enrollment has been historically low and r emains at around 200 participants at any given time

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Pediatric Palliative Care Waiver Overview (continued)

process to identify proposed changes to the waiver to be addressed through the PPC Waiver renewal application

DHCS held three in-person stakeholder meetings to facilitate input: August 31, 2016 – PPC Waiver Renewal Kick-off Meeting April 14, 2017 – Northern California Technical Advisory Workshop May 2, 2017 – Southern California Technical Advisory Workshop

DHCS engaged in an extensive stakeholder

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The PPC Waiver renewal application was submitted for CMS’ review on September 29, 2017

DHCS submitted three temporary extension (TE) requests to facilitate CMS’ review of the PPC Waiver renewal application First TE submitted October 12, 2017 extended current waiver term from December 27, 2017 through December 31, 2017 to align new waiver term with the new year (January 1, 2018)

Second TE approved by CMS on February 1, 2018 extended the current waiver term through May 15, 2018

Third TE approved by CMS on May 3, 2018 extends the current waiver term through August 13, 2018 11

Pediatric Palliative Care Waiver Overview (continued)

Pediatric Palliative Care Waiver Overview (continued)

Discussions with CMS included case management and assessment approaches per CMS Technical Guidance as applicable to all States

Separations for conflict of interest between assessing and care planning entities

Service delivery design challenge

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Pediatric Palliative Care Waiver Overview (continued)

As a result of these challenges, DHCS has determined the best direction is to end the PPC Waiver and transition current beneficiaries into other systems of care

Transition will occur over a period of time, through a streamlined process including a warm handoff

The transition approach is what we are here to discuss today and will occur by January 1, 2019

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History

PPC waiver established with Assembly Bill 1745, 2006

Need for a program to provide supportive care at the same time as curative care

PPC enrolled first patient in 2010

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Affordable Care Act (ACA) Concurrent care, provision of ACA that permits concurrent hospice and curative care

Began 2011

PPC continued for some children requiring palliative care and curative services because: Not eligible for hospice care Do not have access to State palliative care services as described in Numbered Letter (NL) 04-0207, or

Required services not available under the state plan

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Pediatric Palliative Care Options Waiver Concurrent Care

Age Under 21 Under 21

Geographic Limited counties: Alameda, Statewide Los Angeles, Marin, Monterey, Orange, San Francisco, Santa Clara, Santa Cruz, Sonoma, Ventura

Medical Eligibility Life threatening California Children’s Medical doc tor certification Services (CCS) eligible condition, of life expectancy less than expected 30 days in hospital i n six months coming year

Insurance FFS Medi-Cal Medi-Cal, Healthy Families

Agency Partners for Children (PFC) approved Hospice hospice or home health agency (HHA)

Palliative Care Agency-based nurse, social worker, Hospice physician, nurse, Service Provider licensed vocational nurse (LVN), social worker, LVN, CNA,

certified nursing assistant (CNA) chaplain

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Pediatric Palliative Care Options (continued)

Waiver Concurrent Care Services Provided Care coordination, 24/7 on-call nur sing, Waiver except expressive

home based pain and symptom therapies, plus spiritual care management, expressive therapies and practical assistance, (including art, music, and massage), care coordination family education, pre and post death bereavement support, respite

Setting Most services at home, but care coordination may be partly in a clinic;

Home or hospice

out of home respite may be provided at a congregate living health facility (CLHF)

Number Allowed 1,800 slots Unlimited

Authority 1915c Waiver Medi-Cal Hospice benefit

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Overview of Early and Periodic Screening, Diagnostic, and

Treatment Services

Lisa Albers Medical Consultant

Department of Health Care Services

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EPSDT services are a benefit of the State’s Medicaid program (Medi-Cal) that provides comprehensive, preventive, diagnostic, and treatment services to eligible children under the age of 21, as specified in Section 1905(r) of the Social

Security Act.

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EPSDT is designed to ensure thatchildren receive early detection and care,so that health problems are averted ordiagnosed and treated as early as

possible.

EPSDT has always been a benefit of both the managed care and FFS delivery

systems.

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EPSDT

Early: Assessing and identifying problems early, starting at birth

Periodic: Checking children’s health at periodic, age-appropriate intervals

Screening: Providing physical, mental, developmental, dental,hearing, vision, and other screening tests to detect potentialproblems

Diagnostic: Performing diagnostic tests to follow up when a risk is identified

Treatment: Control, correct, or reduce identified health problems

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EPSDT Services Screening Services Comprehensive health and developmental history Comprehensive unclothed physical exam Appropriate immunizations (according to the Advisory Committee on Immunization Practices)

Laboratory tests (including lead toxicity screening Health education (anticipatory guidance including child development, healthy lifestyles, accident and disease prevention)

Vision Services Hearing Services Dental Services

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EPSDT Services (continued)

Other necessary health care, diagnostic services, treatment, and other measures described in section 1905(a) to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the State plan, if those services can be covered under Medicaid.

Other necessary services would include palliative care for children under the age of 21 when medically necessary to ameliorate their underlying condition.

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EPSDT Services (continued)

EPSDT includes services that are medically necessary, regardless of whether such services are covered under Medi-Cal.

Service does not need to cure a condition. Services that maintain, sustain or support the child’s current health condition, prevent a condition from worsening, or prevent development of additional health problems are covered because they “ameliorate” a condition.

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EPSDT Medicaid Requirements

State Medicaid agencies are required to: Inform all Medicaid-eligible individuals under age 21 that EPSDT services are available, and of the need for age-appropriate immunizations

Provide or arrange for the provision of screening services for all children

Arrange (directly or through referral) for corrective treatment as determined by child health screenings, and

Report EPSDT performance information annually via Form CMS-416

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EPSDT All Plan Letter DHCS recently released All Plan Letter (APL) 18-007 on the requirements for coverage of EPSDT services for Medi-Cal members under the age of 21

APL does not represent a change in policy but rather reinforces existing regulations regarding the provision of EPSDT services

DHCS is amending Title 22 to eliminate references to ‘EPSDT supplemental services’ as there is no distinction between EPSDT services and ‘supplemental services’

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EPSDT APL (continued) There are exceptions to services that managed care health plans (MCPs) are required to provide (carved out of the contract): Dental services provided by dental personnel Non-medical s ervices provided by Regional C enters (e.g., respite care) Alcohol and substance use disorder treatment services Specialty mental health services CCS services (not included in the capitated rate and excluding Whole Child Model counties)

However, MCPs are required to coordinate the provision of services with other entities, including providing appointment assistance, and transportation to medically necessary care

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Transition Plan – Specific Elements

Lisa Albers Medical Consultant

Department of Health Care Services

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Transition Plan

As of January 1, 2019, due to the end of the PPC Waiver, children enrolled in PPC Waiver will transition to MCPs or FFS

A majority of these children are already enrolled in managed care

MCPs have experience providing palliative care for adults as a result of Senate Bill 1004

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Transition Plan - Members Noticing to Members DHCS will send notices to members 60 and 30 days prior to the transition date Informing members of the pending transition How to continue the benefit Continuity of care requirements

Many of these children are already enrolled in MCPs

DHCS will share pertinent data files for these children with MCPs prior to transition date

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Continuity of Care Continuity of care requirements to assist Medi-Cal members who transition into Medi-Cal managed care are outlined in APL18-008 Members transitioning into an MCP have the right to request continuity of care in accordance with state law and the MCP contracts, with some exceptions

All MCP members with pre-existing provider relationships who make a continuity of care request to an MCP must be given the option to continue treatment for up to 12 months with an out-of-network Medi-Cal provider

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PPC Waiver Counties/MCPs County MCPs

Alameda Alameda Alliance for Health, Anthem Blue Cross

Fresno CalViva, Anthem Blue Cross

Los Angeles LA Care, Health Net

Monterey Central California Alliance for Health

Orange CalOptima

San Francisco San Francisco Health Plan, Anthem Blue Cross

Santa Clara Santa Clara Family Health Plan, Anthem Blue Cross

Santa Cruz Central California Alliance for Health

Sonoma Partnership Health Plan

Ventura Gold Coast Health Plan

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Transition Plan - MCPs APL Update Palliative Care APL MCPs to submit updated polices and procedures for palliative care to DHCS MCP contract amendments to reflect the benefit Updates to Member Handbooks Monitoring Current palliative care reporting template is under review for potential updates

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Outlined in APL 17-015 for managed care: Current APL requires MCPs to authorize palliative care, regardless of patient-age, when general eligibility criteria are met, as well as, at least one of four disease-specific eligibility criteria Disease-specific criteria are adult-focused and will have to be modified

Palliative Care in Managed Care

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Palliative Care APL Seven basic services: Advance Care Planning PC Assessment and Consultation Plan of Care Palliative Care Team Care Coordination Pain and Symptom Management Mental Health and Medical Social Services Includes psychotherapy, bereavement counseling, medical social services, and discharge planning

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Palliative Care APL (continued)

MCPs may authorize additional palliative care not described in the APL at their discretion and cost For example, a 24/7 telephonic palliative care support line, separate from a routineadvice line Expressive therapies

RN

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Open Discussion and Breakout Session

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Final Comments and Next Steps

Sarah Eberhardt-Rios Chief, Integrated Systems of Care Division Department of Health Care Services

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Final Comments and Next Steps

Continue working with CMS on transition approach and timeline based on today’s conversation

Prepare a transition plan to be submitted to CMS for review and approval

Request a final temporary extension from CMS for PPC Waiver through December 31, 2018

Work with MCPs to ensure each beneficiary receives the necessary care

Will closely monitor the provision of the benefit in the first six months and then traditional monitoring ongoing

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Thank you!

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