Healthy PA: Medicaid Expansion. Ann Bacharach PA Health Law Project February 20, 2014

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1 Healthy PA: Medicaid Expansion 1 Ann Bacharach PA Health Law Project February 20, 2014

2 Healthy PA Medicaid Proposal A waiver proposal to: 2 Make substantial changes PA s existing Medical Assistance program for adults Benefits changes do not require a waiver Expand Medical Assistance to cover adults whose income is less than 138% of the poverty level

3 Change to Existing Medicaid Healthy PA would: Change the benefits package Require monthly premiums for those above 100% of the poverty level in Year 2 Would continue co-payments in Year 1 for all Would eliminate co-pays except for non-emergency use of ER in Year 2 Co-payments continue for those below 100% in all years Limited to 5% of income Add a work search requirement Encouraging Employment Add wellness requirements Eliminate MAWD and Healthy Horizons 3

4 Change to Existing Medicaid Healthy PA would: Create a Healthy Pennsylvania Safety Net Pool Later waiver request To make specific payments to health care providers implementing health care reforms that embody the Governor s goals and support the innovation plan. Federal funds, unspent DSH funds, provider tax revenue, and additional savings realized from implementation Require inclusion of FQHC s and Rural Health Centers in all plan networks Reimbursed at prospective payment rate 4

5 Change to Existing Medicaid -Benefits Create two benefits packages for adults* Low-risk and High-risk Physician services, including primary care Outpatient services Emergency room services and emergency transportation (ambulance) Hospitalization Maternity and newborn care Mental health and substance use disorder services and treatments Lab services, x-rays, imaging (MRI, CT, etc.) Rehabilitation and habilitation services and devices Preventive and wellness services Prescription drugs Dental services 5

6 Benefits Comparison 6 Services Current Benefit Package for Adults Proposed Low Risk Plan Proposed High Risk Plan Primary Care Visits 18* No limits No limits Other Visits Radiology No limit 6 tests 8 tests Outpatient Surgery No Limit 2 visits/year 4 visits/year In patient Acute Hospital No limit 2 non-emergency admissions per year 3 non-emergency admissions per year Inpatient Rehab Hospital Durable Medical Equipment 1 admission per year 1 admission per year 2 admissions per year No limit $1000 per year $2,500 per year Medical Supplies No limit $1,000 per year $2,500 per year Skilled Nursing Facility 365 days per year 120 days per year 365 days per year Lab Work No limit $350 per year $450 per year Outpatient Mental Health visits 60 1 hour or minute visits per year 30 per year 60 per year Outpatient Substance Abuse visits 60 per year 30 per year 60 per year

7 Automatic High-risk groups Those deemed Medically Frail Persons in institutions On SSI or deemed SSI eligible High or Low Risk? Enrolled in Home and Community Based services In the Living Independently for the Elderly (LIFE), PACE, PACENET or PACE Plus Medicare programs for older adults On both Medicare & Medical Assistance Pregnant women 7

8 Medically Frail? A disabling mental disorder psychotic disorder schizophrenia schizoaffective disorder major depression bipolar disorder delusional disorder High or Low Risk? anxiety disorder (obsessive compulsive disorder, post-traumatic stress disorder, or severe panic disorder ) An active chronic substance abuse disorder A serious and complex medical condition A physical, intellectual or developmental disability that significantly impairs their functioning A determination of disability based on SSA criteria For all others will depend on answers to questions on application or annual review and applied algorithm process 8

9 Medically Frail? High or Low Risk? A serious and complex medical condition Receiving chemotherapy or radiation therapy for cancer Enrolled in hospice A resident of LTC facility or public/private ICF Has any of the following medical conditions- hemophilia, Gaucher s disease, immune deficiency, HIV/AIDS, sickle cell, cystic fibrosis or post-transplant of lung, heart, liver, pancreas, or small bowel Is ventilator dependent Receives Dialysis treatments 9 Has 2 or more inpatient admissions within 12 months AND has 3 or more ER visits in 6 months AND has 4 or more prescription medications per month.

10 Medically Frail? High or Low Risk? A physical, intellectual or developmental disability that significantly impairs their functioning including autism 10 A determination of disability based on SSA criteria For all others will depend on answers to questions on application or annual review and applied algorithm process

11 For Newly Eligible Creates private coverage option Use Medicaid funds to purchase private insurance coverage Could be through the FFM, the private market through a procurement process or through Employer-sponsored coverage 11 Essential Health Benefits - similar to coverage through the Health Care Marketplace No Medicaid protections for coverage decisions appeals, grievances No retroactive coverage coverage start dependent on enrollment date Exception- presumptive eligibility at hospitals starts day of p.e. determination

12 Premiums In Year 1 no premiums but must pay co-payments Year 1 co-payments made to providers Year 2 co-payments billed monthly and paid to State In Year 2 - Monthly premiums for people above 100% of poverty 100% to 133% - $25 for one adult, $35 for two adults Eligibility in Year 2 is contingent on prompt payment of all co-pays and compliance with work search activities Except: SSI recipients and individuals deemed SSI eligible, 65+ years of age, Persons in institutions, and Persons on both Medicare & MA. Children and Pregnant Women 12

13 Premium reductions Premiums Reduction for compliance with wellness activities 13 Completion of health risk assessment Annual physician visit Reduction for working 20+ hours per week (day one) Reduction for working an average of hours per week in a six-month timeframe

14 Premiums Premium penalties lock out 1 st failure to pay premiums for 3 months lose coverage Barred for 3 months 14 2 nd failure to pay premiums Barred for 6 months 3 rd failure to pay premiums Barred for 9 months

15 Work Search Requirements Adults (over 21 and under 65) not working at least 20 hours per week & not otherwise exempt (next slide) Register on Jobs Gateway Online only Complete job search activities or job training Apply for 12 jobs per month for 12 consecutive months 15 Eligibility in Year 2 is dependent on compliance with work search requirements If non-compliant, must demonstrate compliance for 6 months to gain coverage in second six months Non-compliance once covered results in lock out similar to nonpayment of premiums

16 Work Search Requirements 16 Exempt groups are: SSI recipients and individuals deemed SSI eligible 65+ years of age Persons in institutions, and Persons on both Medicare & MA Pregnant Women Full and part time students are exempt from work search, but not registration with Jobs Gateway Individuals may request an exemption if they are suffering a crisis, serious medical condition or temporary condition or situation that prevents them from searching for work

17 Is this expansion? Changes income eligibility to 133% of poverty Would make an additional 500,000 eligible Adds significant requirements Timely Co-payments Risk of missing or late co-payments no eligibility in Year 2 Premiums Risk of missing payments = lock out Paying premiums a challenge for unbanked Work search Bureaucratic challenge in reporting Requires regular internet access to complete job searches Drastically reduces benefits for current adult enrollees 17

18 Is this expansion? Creates administrative burden for DPW Managing co-payments Managing premium payments MAWD not going well now Managing work search requirement Exemptions Crisis Managing work search compliance Interface with Jobs Gateway proof of compliance 18 Managing wellness compliance Interface with health plans/providers to ascertain compliance

19 Is this expansion? Concerned about the most vulnerable People with appropriate high health care utilization People with disabilities People with chronic conditions People with both behavioral and physical health care needs People challenged by Limited English Proficiency and low literacy skills Work search Health Assessment 19

20 Increased Access to Quality Affordable Health Care Reducing benefits and imposing administrative burdens runs counter to best health care practices Oregon saw significant decline in enrollment once premiums were imposed Patients do not have the sophistication necessary to make health care decisions on what is necessary and what is not Pennsylvania s own State Improvement Model (SIM) Increases health care access and care management to improve health outcomes Puts the burden on health plans, not patients, to effectively manage care 20

21 Next Steps Governor s Budget proposal includes the draw down of federal funds and $125 million in savings through Medical Assistance changes Budget hearings State Budget process July 1, 2014 Governor can make the benefits changes to existing Medical Assistance without legislation Federal waiver approval process More than 1,000 comments through state comment process Submitted 2/19/ Opportunity for further comments

22 PA Health Law Project Contact Information Ann Bacharach Helpline For advice on applying, enrolling, renewal, obtaining services 22 For clients who need a lawyer to represent them at hearings and appeals

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