Medicaid after Healthy PA: Eligibility, Benefits, and Delivery Systems. Kyle Fisher October 2014

Transcription

1 Medicaid after Healthy PA: Eligibility, Benefits, and Delivery Systems Kyle Fisher October 2014

2 Session Topics Healthy PA Demonstration Overview & cost-sharing changes Medicaid Eligibility Newly eligible Adult Group Existing categories overview <break> Delivery Systems Private Coverage Option vs HealthChoices Benefit Reforms Medical Frailty 2

3 Commentary 3 Governor Corbett is the first governor to tackle muchneeded Medicaid reforms since the program s creation, with the goal of protecting Pennsylvania taxpayers and looking ahead to maintain a safety net for those who most need public assistance. -DPW Secretary Bev Mackereth, 8/28/14 Press Release "They can bristle as much as they want - this is Medicaid expansion, full out. There are no work requirements, and none of the other provisions the administration was pushing a year ago. -State Senator Vincent Hughes, 8/30/14 Phila. Inquirer

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6 Healthy PA Overview 6 SPECIFIC WAIVER REQUESTS & APPROVAL OUTCOMES

7 Overview 7 Pennsylvania Request Impose Premiums Status Following Waiver Approval Approved in part. Monthly premiums of up to 2 percent of income are allowed beginning in 2016 for certain recipients. Recipient lock out for nonpayment of premiums Impose work search requirements/incentives for new and existing recipients Denied. Recipients may have their coverage terminated for nonpayment of premiums after a 90 days grace period, but must be allowed to reapply immediately. Denied. Medicaid funds cannot be used to incentivize work. DPW will set up a state-funded Encouraging Employment program in 2016 to allow participants to reduce their Medicaid cost sharing through certain work activities.

8 Overview 8 Pennsylvania Request Status Following Waiver Approval Eliminate MAWD Retracted. DPW announced in July 2014 that it will preserve the Medical Assistance for Workers with Disabilities (MAWD) program. No retroactive coverage for new eligibles Denied. New eligibles can receive up to three months of retroactive coverage to pay recently incurred medical bills. Delay coverage for new eligibles Denied. New eligibles will enroll as of the date of application.

9 Overview 9 Pennsylvania Request No medical transportation for new eligibles No Medicaid appeal rights for new eligibles Restrict choice of family planning provider Status Following Waiver Approval Approved in part. Non-emergency medical transportation is waived in 2015, but must be provided to new eligibles beginning in Denied. New eligibles will be entitled to participate in DPW s hearings and appeals process for eligibility or service denial disputes. Denied. Reduce benefits for current adult recipients Pending. DPW and CMS are negotiating State Plan Amendments to alter the benefit packages for current adult Medicaid recipients.

10 Cost Sharing - Premiums 10 Year One 2015 Years Two (2016) Five No change Authority to impose 2% ($19-27) premiums on Certain recipients over 100% FPL Newly Eligible Adults HCBS Waiver Recipients (unless exempt)

11 Premiums Exemptions: Pregnancy Cost Sharing - Premiums Over age 65, or under age 21 Dually eligible for Medicare and Medicaid Enforceability DPW allowed to terminate coverage for non-payment of premiums after 90 day grace period Must allow recipient to re-apply and re-enroll Without requiring repayment of back premiums 11

12 Cost Sharing - Copayments 12 Year One 2015 Year Two 2016 $8 copay for nonemergency ED use MA providers can refuse service for failure to make copay Recipients 100% FPL only Must be general practice Requires EVS changes Shifts collection of copays from provider to DPW Eliminate copays for recipients subject to premiums

13 Cost Sharing Reductions Cost Sharing - Incentives Personal responsibility element of Healthy PA Beginning in 2016 Based on: 1. Healthy behaviors 13 Annual wellness visit Timely payment of copays 2. Employment & Job training Jobs Gateway; 20 hours per week?

14 Medicaid Eligibility after Healthy PA 14 WHO IS ELIGIBLE FOR COVERAGE IN JANUARY 2015?

15 Adults age Income under 138% FPL Newly Eligible Adults % FPL (2014) annual Household of 1 Household of 2 Household of 3 $16,104 $21,707 $27,310 No asset test Cannot qualify for Medicare

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17 Estimated at 600,000 Most, not all, uninsured Includes: Newly Eligible Adults 80,000 currently in GA-related MA Transferred automatically on Jan. 1, unless medically frail Part of 88,000 Select Plan for Women recipients Not being transferred automatically Adults at % FPL receiving Marketplace (QHP) coverage with subsidies 17

18 Medicaid Eligibility Basics 18 Residency Immigration Status Category Income & Resources

19 Medicaid Eligibility Basics 19 3-step analysis for each person 1) What category does the person fit in? 2) What is the person s household size? 3) Is the person under the income limit for that category and household size?

20 Eligibility Categories 20 Categorical Eligibility Children Pregnant Women Parents & Caretakers Adults (eff. Jan 2015) * All MAGI categories, no resource tests Seniors Persons with Disabilities Temporary Permanent or 12 months+ Workers with Disabilities Has 5% premium

21 Income Eligibility Income Eligibility 21 MAGI Children (age 6-18) Pregnant Women Parents & Caretakers Adults FPL 133% 215% 44% (?) 133% + 5% disregard Non-MAGI Seniors Persons w/ Disabilities (12 month+) Workers w/ Disabilities FPL 100% 100% 250%

22 Questions? 22

23 Medicaid Delivery Systems post-healthy PA 23 PRIVATE COVERAGE OPTION & HEALTHCHOICES

24 Private Coverage Option 24 What is it? A new Medicaid managed care delivery system Not premium assistance Only for newly eligible adults Except (1) the medically frail (2) young adults aged 19 or 20 Will operate alongside HealthChoices

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27 Operational Status: Private Coverage Option PCO procurement & RFA May 8 th Healthy PA Finalized Aug. 28 th Contracts mailed to PCO plans Sept. 22 nd [DPW anticipates] DOH operating authority Oct. 17 th Contracts executed Nov. 15 th Readiness review completed Dec. 5 th Goal: coverage begins Jan. 1 st

28 Private Coverage Option Who will be enrolled in the PCO? 1. Newly Eligible Adults 2. General-Assistance related MA Recipients 28 Exceptions: Unless Medically Frail, or Age [Both will go into HealthChoices]

29 Newly Eligible Adult Medical Frailty Screen YES NO HealthChoices (High Risk Benefit Package) Private Coverage Option (EHB Benefit Package)

30 Private Coverage Option Who will be enrolled HealthChoices? 1. Children 2. Very low-income parents 3. Pregnant women* 4. Adults with disabilities SSI and HCBS waiver recipients, e.g. 5. Newly Eligible Adults & GA-related MA recipients Found to be Medically Frail 30

31 Eligibility Categories 31 Categorical Eligibility Children Pregnant Women Parents & Caretakers Adults (eff. Jan 2015) * All MAGI categories, no resource tests Seniors Persons with Disabilities Temporary Permanent or 12 months+ Workers with Disabilities Has 5% premium

32 Private Coverage Option How is the PCO different from HealthChoices? No MATP in year one No behavioral health carve-out Care coordination impact of working with one MCO? Different benefit packages 32 Provider networks? Healthy PA goal of increasing access through blended rates PCO incorporates state law access standards less stringent than HealthChoices Agreement

33 33 Healthy PA Special Terms and Conditions

34 Private Coverage Option How is it different (continued) All Medicaid managed care protections apply see Appendix D to Healthy PA STC Yet substitutes variety of state and federal commercial insurance regulations There likely will be different: Disenrollment standards Access or network adequacy standards Medical Necessity standards Internal appeal frameworks 34

35 Proposed Benefit Reforms 35 LOW RISK, HIGH RISK, & EHB BENEFIT PACKAGES

36 Proposed Benefit Reforms Central Medicaid reform component in Healthy PA Proposed benefit reforms not finalized Yet agreement on approach Will affect current adult MA recipients & newly eligible Not included in the final Demonstration Being done through State Plan Amendments 36

37 Proposed Benefit Reforms Administration describes as 1 st state to match benefits to health care need, instead of category Propose quantity and dollar caps based on commercial coverage and individual need Proposes to reduce adult benefit packages from 14 to 2 packages: low-risk and high-risk PCO enrollees will get essential health benefits Based on Aetna small group benchmark plan 37

38 Proposed Benefit Reforms 38

39 Proposed Benefit Reforms 39 *Community Legal Services,

40 Medical Frailty 40 Medical Frailty a key concept Performs two functions determines: Delivery System For newly eligible adults Benefit Package For currently & newly eligible adults

41 Currently Eligible Adult Category: Pregnant SSI or SSI-related Dual-eligible, or 65+ HCBS Waiver, or Institutionalized? YES NO YES Medical Frailty Screen NO High Risk Benefits Low Risk Benefits

42 Medical Frailty 42

43 Medical Frailty 43 DPW operationalizing through two methods: Claims data review (for current recipients) Health Care Needs Questionnaire Screen will take place at application & renewal As a voluntary part of the application process COMPASS vs HealthCare.gov

44 Medical Frailty Screen 44

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46 Medical Frailty 46 Medical frailty determination will be appealable Validation DPW will validate some frailty determinations by telephone calls to medical providers Recipients will be put in medical frailty status in the interim Process for recipient who becomes ill mid-year?

47 Resources 47 Medical Assistance Eligibility Handbook COMPASS Benefits Application Health PA Website & Healthy PA Special Terms & Conditions PHLP Helpline: For wrongful Medicaid or CHIP denials