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PA Bulletin, Doc. No. 14-2443



Quality Strategy

[44 Pa.B. 7423]
[Saturday, November 22, 2014]

 The Department of Public Welfare (Department) is modifying and updating the current HealthChoices Medicaid managed care strategy as required by Federal regulations in 42 CFR Part 438, Subparts D and E (relating to quality assessment and performance improvement; and external quality review) to incorporate the Healthy Pennsylvania Section 1115 demonstration waiver. This Quality Strategy will take effect January 1, 2015. The Department is seeking public comment by publication of this notice in the Pennsylvania Bulletin.

 The Quality Strategy is required by Federal regulations and the Centers for Medicare and Medicaid Services. The Quality Strategy sets forth the Commonwealth's strategy for assessing and improving the quality and efficient health care by the managed care organizations (MCO) and Pre-Paid Inpatient Health Plans (PIHP) with an agreement with the Department. It is not intended to comprehensively describe all the activities that the Department undertakes to assure the quality of care rendered to Medicaid beneficiaries.


 Medicaid currently operates a Statewide, fully capitated managed care through its HealthChoices Program that includes five behavioral health PIHPs and eight physical health MCOs operating under the authority of a 1915(b) waiver. In 2009, the Department obtained Federal approval for a PIHP under the authority of a 1915(a) waiver to create the Adult Community Autism Program (ACAP) in four counties in this Commonwealth. In August 2014, the Department obtained approval for its Healthy Pennsylvania private coverage option (PCO) under the authority of a 1115 demonstration waiver.


 Beginning January 1, 2015, the Statewide PCO managed care plans will offer both physical and behavioral health benefits that meet essential health benefit standards of the Affordable Care Act for newly eligible Medicaid beneficiaries. The Quality Strategy will describe the strategies and activities for assessing and improving the quality and appropriateness of care within the managed care programs.

 The Quality Strategy will serve to assure that the Department's managed care programs are in compliance with agreement terms, have committed resources to perform monitoring and ongoing quality improvement, contribute to the improvement of health for the Medicaid population and incorporate new programmatic changes to assure Medicaid beneficiaries have timely access to high quality care.

 The Department has implemented various quality improvement initiatives to increase the quality of care for the Medicaid population. The Office of Medical Assistance Programs, Bureau of Managed Care Operations key initiatives are centered around value-based purchasing, and include reducing preventable admissions and readmissions, increasing preventative dental services in children, coordinating and implementing physical health and behavioral health quality improvement projects, MCO and Provider Pay for Performance programs and wider implementation of community-based care management teams.

 The Office of Mental Health and Substance Abuse Services' key quality improvement initiatives include implementation of telepsychiatry services, use of mobile mental health treatment services to serve nonmobile beneficiaries, expanding mental health and substance use screening strategies within Person-Centered Medical Homes (PCMH), and establishing PCMH options for individuals with serious mental illness and substance use disorders.

 Key quality initiatives for the ACAP include increasing the number of community-based services for adults 21 years of age or older, improving coordination across multiple systems that provide support for individuals with autism and improving the service delivery system to address the diversity of individuals on the autism spectrum.

 Healthy Pennsylvania will incorporate various components of value-based purchasing, including identifying opportunities for improving access and quality while realizing cost savings, evaluation of beneficiary satisfaction, focused managed care plan monitoring to prioritize improving health outcomes, emphasize teaming with the PCO managed care plans to set and reach quality improvement targets and reduce unnecessary administrative burden.

 The Quality Strategy, in its entirety, can be viewed at

Public Comment

 Interested persons are invited to submit comments regarding this notice to the Department at Comments received within 30 days will be reviewed and considered for any subsequent revision to the Quality Strategy.

 Persons with a disability who require an auxiliary aid or service may submit comments using the Pennsylvania AT&T Relay Service at (800) 654-5984 (TDD users) or (800) 654-5988 (voice users).


Fiscal Note: 14-NOT-918. No fiscal impact; (8) recommends adoption.

[Pa.B. Doc. No. 14-2443. Filed for public inspection November 21, 2014, 9:00 a.m.]

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