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PA Bulletin, Doc. No. 20-1398



Medical Assistance Quality Strategy for the Commonwealth

[50 Pa.B. 5718]
[Saturday, October 10, 2020]

 The Department of Human Services (Department) is making available for public review and comment the Medical Assistance (MA) and Children's Health Insurance Program (CHIP) Managed Care Quality Strategy for the Commonwealth.


 The Centers for Medicare & Medicaid Services (CMS) requires states to draft and implement a written quality strategy for assessing and improving the quality of health care and services furnished by managed care organizations that have a contract with the Department (see 42 CFR 438.340 (relating to managed care State quality strategy)). As a result, the Department has developed the MA and Children's Health Insurance Managed Care Quality Strategy for the Commonwealth (Quality Strategy), which discusses the various quality improvement initiatives the Department has implemented to increase the quality of care for individuals receiving services through its managed care programs. The Quality Strategy for the Commonwealth is not intended to comprehensively describe all the activities that the Department undertakes to assure the quality of care rendered to individuals who are receiving services through managed care programs.

 The Department is required by 42 CFR 438.340(c)(2) to update its managed care quality strategy as needed. The updates included in this version of the Quality Strategy reflect developments in the Community HealthChoices program, changes made to improve alignment among the various managed care programs, new value-based purchasing, targets, and updated goals, objectives, and quality improvement initiatives. All Federal regulatory references have been updated to refer to the current version of the Medicaid managed care final rule.


 The Quality Strategy will be used to assure that the contractors that are implementing the Department's managed care programs are in compliance with the terms of their agreements with the Department and have committed resources to meet the following: to perform monitoring and ongoing quality improvement; to contribute to the improvement of health for the populations they serve; and to incorporate new programmatic changes to assure that the individuals they serve have timely access to high-quality care.

 Across the Department, the focus is on increasing alignment among the various managed care programs, moving toward compliance with Federal law by reporting on the CMS Core Set by 2024, and improving the provision of services to Pennsylvanians who are especially vulnerable, including individuals with disabilities, individuals with serious persistent mental illness and individuals with opioid use disorder.

 The Office of Medical Assistance Programs' (OMAP) key initiatives continue to be centered around value-based purchasing, and include reducing preventable hospital admissions and readmissions, improving coordination and integration between physical health and behavioral health managed care programs, and incentivizing hospitals to follow-up on opioid-related emergency department admissions. OMAP is also encouraging expanded use of community-based care management teams, as well as continued implementation of the Patient Centered Medical Home model and the development of a Perinatal Quality Collaborative.

 The Office of Mental Health and Substance Abuse Services' key quality improvement initiatives include value-based purchasing arrangements, expansion of telepsychiatry services, implementation of a Section 1115 Demonstration Waiver to provide substance use disorder treatment services, suicide prevention and tobacco cessation initiatives, and further expansion of the evidence-based programs available for Behavioral HealthChoices consumers.

 The Office of Long-Term Living (OLTL) has implemented Community HealthChoices, a Statewide mandatory managed care program. Eligible individuals include: (i) adults that are eligible for MA and need long-term services and supports; and (ii) individuals who are dually eligible for MA and Medicare. As this program matures, OLTL will focus on developing value-based purchasing models for home and community-based services and will use Performance Improvement Programs to reduce potentially avoidable nursing facility admissions.

 The Office of CHIP recently transitioned to become a part of OMAP. As a result of this transition, CHIP will be making changes in its policies and procedures to better align with the procedures and resources of MA, allowing individuals to easily transition between the CHIP and MA Programs.

 Finally, key quality initiatives for the Adult Community Autism Program (ACAP) include increasing the number of community-based services available for individuals who receive services through ACAP, improving coordination across multiple systems that provide support for adults with autism and improving the service delivery system to address the diversity of needs of individuals who are diagnosed with autism.

 The MA Quality Strategy for the Commonwealth can be viewed at

Public Comment

 Interested persons are invited to submit comments regarding the MA Quality Strategy for the Commonwealth to the Department at Comments received within 30 days must be reviewed and considered before the Quality Strategy is submitted to CMS for review (see 42 CFR 438.340(c)(1)).

 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-1410. No fiscal impact; (8) recommends adoption.

[Pa.B. Doc. No. 20-1398. Filed for public inspection October 9, 2020, 9:00 a.m.]

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