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IMPORTANT COMMUNICATION: Immediate Actions to Stabilize LTSS
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. We hear you, and we are taking action. The intent of the actions we are implementing is to mitigate and ultimately eliminate inappropriate LTSS terminations at least through Dec. 31, 2024, while LTSS eligibility processes at case management agencies and counties stabilize. In addition, our intent is to collaborate closely with select counties and case management agencies to retrospectively review procedural terminations. Ensuring coverage is maintained for LTSS members is a top priority for HCPF.
HCPF is pursuing a number of solutions to immediately address these issues and protect coverage for LTSS members through system and process changes, mitigating payment delays for providers so members can access needed services, and easing the backlog and capacity challenges being experienced by the counties and case management agencies.
New Actions to Protect Coverage of LTSS Members:
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Expedited Backlog Processing: HCPF will expedite an eligibility system change to process the backlog of Level of Care (LOC) Certification entries.
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Preventing Termination During Processing: HCPF will implement a system change to prevent financial eligibility terminations for missing the LOC while the LOC is being processed.
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Temporarily Pausing Terminations: HCPF will temporarily pause terminations for all 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. This system change will replace the 60-day extension for the renewal period for Long-Term Care (LTC), individuals on Home and Community Based Services (HCBS), and Buy-In recipients who have yet to return their renewal packet on time. Instead, the system will apply a two-month extension for all denial reasons. A notice will be sent to members to let them know they have a two-month extension.
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Reinstating Eligibility: Until the eligibility system change described above can be implemented, HCPF will continue to reinstate eligibility for all LTSS members when their eligibility is set to end, similar to what occurred in February 2024 when HCPF reinstated eligibility for LTSS members after a system update unintentionally terminated their coverage. Once HCPF reinstates a member’s eligibility, they will remain active until their case can be properly processed through the two eligibility system changes described above.
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Monitoring and Reversing Inappropriate Terminations: If the member's eligibility is still pending due to missing documentation or verifications after the two-month extension, 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.
New Actions for Timely Provider Payments to Protect LTSS Member Access to Services:
HCPF is implementing system adjustments to ensure providers receive timely payment for covered services.
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Prior Authorization Request (PAR) Extension: HCPF will extend Prior Authorizations for LTSS eligible members who do not have a current Prior Authorization in our claims payment system for an additional year.
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Benefit Plan Extension: In addition, HCPF will extend the member’s current benefit plan (e.g., HCBS BI - Brain Injury Waiver) for an additional year. This will allow 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 through the HCPF Bridge system.
If providers are unable to locate a Prior Authorization in the HCPF Provider Portal, we encourage them to verify eligibility for LTSS benefits and provide services they have traditionally provided to the LTSS eligible member and submit a claim for services, so HCPF has a timely record of the service being billed. HCPF may have the ability to pay for those services at a future date without requiring the provider to resubmit the claim. Case management agencies can continue to complete and update PARs for newly enrolled members through their normal process. If the member’s needs change, the case manager will be able to edit Service Plans and PARs to make that adjustment.
We commit to overcoming the challenges through actions, focus, partnership, transparency, and effective communication. Please visit the new Stabilizing Eligibility and Case Management for LTSS Members webpage to learn more.
We sincerely appreciate your continued engagement. As we work to implement the above solutions over the coming weeks, we encourage you to continue to use our escalations form to bring individual cases to our attention so we can address our individual member’s needs.
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