Healthy PA: Impact on Persons with Disabilities 1 Janice Meinert Allison Dowling March 5, 2014 All lines are muted Using GoToWebinar Submit questions and comments via the Chat Box If you lose your internet connection, reconnect using the link emailed to you If you lose your phone connection, re-dial the phone number and re-join Note: Today s presentation is being recorded 2 1
Session Topics 3 Healthy PA impact on current MA Healthy PA impact on new eligibles Opportunity for comments Recap of Healthy PA Proposal Two Main Components: Change PA s existing Medical Assistance program for adults (no changes for <21), and Creates a Private Coverage Option for adults under 133% FPL 4 2
Recap of Concerns Regarding Current MA Program: Eliminates MAWD Work/ Work search requirements Premiums Creates High Risk and Low Risk Alternative Benefit plans Relies on self-assessment to determine which benefit plan for those not automatically High Risk Decreases benefits 5 Recap of Concerns (cont.) Regarding Private Coverage Option (PCO): Self-assessment determines PCO vs. MA No MA wraparound for those in PCO No MATP services No appeal rights No right to continued benefits during appeal Lose right to 24 hour turnaround on Rx prior authorization requests No retroactive coverage 6 3
Changes to MA: MAWD Impact of eliminating MAWD (covers up to 250% FPL) Currently ~34,000 people Duals on MAWD no longer get MA Medicare plans and supplements only option All those between 133% and 250% FPL lose MA Marketplace/ other commercial insurance will be the only fall back MAWD allows people to get waiver services when over income or resources for waiver Eliminates safety net for those in Medicare waiting period with incomes above 133%FPL Essentially discourages employment 7 Changes to MA: Work Requirement Final proposal still requires work/ work search now called Encouraging Employment program Working 20 hours a week or complying with work search activities required in Demonstration Year 1 (2015) but no penalties until Year 2 (2016) Not completing work search activities will result in lock out periods. 1 st Lock out- 3 months, lock out period increases as number of occurrences accrue. Participants reviewed every six months. Despite commenters objections those on waivers, in group homes and on SSDI (unless on Medicare) still not exempt from work requirement 8 4
Work Requirements 2 Adults on waivers (including group home residents) would not be exempt from work requirements unless they requested and received an exemption Exemptions may be requested from DPW if an individual has a crisis, serious medical condition, temporary condition or other situation that prevents them from searching for work. (p.37-38 of final 1115 Application) Registration on JobGateway (used by UC program) 12 Work Search Activities per month Job training activities can meet the work search requirement if approved by the department 9 Work Requirements 4 10 PA would be 1 st state to tie Medicaid to work search requirements Difficult to administer- assumes multiple systems can effectively communicate with one another JobGateway not designed for persons with disabilities People will need training on how to use JobGateway 5
Groups Exempt from Work Requirements 11 SSI recipients Pregnant women (including the postpartum period), Individuals 65 years of age and older, Individuals under 21 years of age, Individuals who are institutionalized, and Individuals who are dually eligible for Medicare and Medicaid. Changes to MA- Premiums Premiums are the amount an individual has to pay each month to get coverage- regardless of amount of services used If not exempt, must participate in cost sharing (next slide) Exempt groups for premiums are: SSI recipients and individuals deemed SSI eligible, 65+ years of age, Persons in institutions, and Persons on both Medicare & MA. Pregnant Women Household income does not exceed 100% poverty level Under age 21 12 6
Premiums for non-exempt persons Income Current Year 1 Years 2-5 Individuals w/ household income below 100% of FPL $0- $973 (1 adult) $0- $1,311(2 adults) No premium unless on MAWD Minimal co-pays paid to provider Care cannot be denied services for failure to pay co-pays 13 No premium Minimal co-pays paid to provider Care cannot be denied services for failure to pay No premium, minimal, co-pays paid to the state on a monthly basis, asking for permission to implement premium based on data. Individuals w/ household income between 100-133% FPL $974-$1,294 (1 adult) $1,311 - $1,774 (2 adults) MAWD 5% premium Minimal co-pays paid to provider Care cannot be denied for failure to pay copays No premium Minimal co-pays paid to provider Care can be denied for failure to pay. No co-pays; $25 premium per month for household with 1 adult; $35 premium for household with 2 or more adults. Starting in Year 2, a $10 copayment for non-emergent use of the ER will be implemented for all MA eligible adults and PCO recipients without regard to income, only exempt category is people living in an institution. Premium Cost Concerns Does DPW have the capacity to collect and process premium payments? 14 Complexity of determining who is subject to premiums & the amount for each person Major problems recently regarding inability of DPW to timely process MAWD premium payments- does DPW have the staff? Will premiums be affordable? Not paying premiums for 3 consecutive months results in loss of eligibility for 3 months, 2 nd failure for 3 months results in 6 months of ineligibility, 3 rd failure is 9 month lock-out 7
Premium Cost Concerns 15 New proposal makes cost saving incentives less clear. If premiums are to be collected by the insurance companies, are they willing to do so & who will determine whether individual is exempt or amount of premium due? Unclear what years 2-5 will look like for folks under 100% FPL. No discussion of waiver of premiums for hardship or good cause Changes to MA: Benefit Packages There would be 2 levels of covered services for adults on Medical Assistance: high risk & low risk Current services would be limited or eliminated, even under high risk level Following adults would get high risk coverage: Persons in institutions On SSI or deemed SSI eligible On a waiver or in the LIFE program for older adults (what happens to people on ACAP which is not a waiver?) On both Medicare & MA (dual eligibles) Pregnant women 16 8
Who Else is High Risk/Medically Frail? Persons with: a disabling mental 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 social security administration criteria. 17 High Risk/ Low Risk Plans 18 Level of covered services for others not previously listed would depend on how individual answered certain questions on their MA application/annual review health screening. Answers analyzed by algorithmic process (p.49 of final 1115 Application) If recipient doesn t answer health status questions, they would get the more limited low risk coverage If new applicant doesn t answer health status questions, they would be put into private coverage option 9
Concerns about High/ Low Risk Determinations 19 Since determination is based on answers provided by applicant/recipient, how will that work for people with intellectual disabilities? What if people don t have accurate information about their diagnoses? Relies on people being willing to share diagnoses where there is perceived shame (substance abuse, mental health, HIV, Hep C, etc.) Will people realize the importance of providing full information? Concerns about High/ Low Risk Determinations 20 Will people trust that answers will be kept confidential? Will people know they can appeal their risk category? Will docs assist with the appeal? What accommodations will there be for persons with disabilities? Those with low-literacy? Non-English speaking? Health screening relies heavily on use of the online application 10
Changes to Benefit Limits 21 Services Current Final Low Risk Plan Final High Risk Plan PCO Benchmark Plan Doctor Visits 18* 12* 18* No limit Optometrist Services, Podiatrist Services, and Chiropractor services are Covered NOT COVERED NOT COVERED Radiology No limit 6 tests 8 tests No limit Outpatient Surgery No Limit 2 visits 4 visits No limit In patient Acute Hospital Inpatient Rehab Hospital Durable Medical Equipment No limit 2 non-emergency admits 3 non-emergency admits 1 admit/ year 1 admit 2 admits No limit $1,000 $2,500 No limit Medical Supplies No limit $1,000 $2,500 $2,500 per year Skilled Nursing Facility 365 days No change No change 120 days per year Lab Work No limit $350 $450 No limit Changes to Benefit Limits 22 Services Current Final Low Risk Plan Final High Risk Plan PCO Benchmark Plan Outpatient Mental Health treatment 5 visits per month = 60/ year 30 visits 60 visits 20 visits; SMI: 60 visits Inpatient psychiatric Hospitalization No limit 30 days 45 days 30 days Inpatient Drug and Alcohol Hospitalization No limit 30 days 45 days 30 days / 90 lifetime Outpatient Drug and Alcohol Treatment No limit Therapy: 30 visits Opiate detox: 42 visits Therapy: 60 visits Opiate detox: 42 visits 60 visits / 120 lifetime Targeted Case Management Covered Benefit Not Covered Persons with SMI diagnosis Unclear 11
Benefit Limit Concerns Issue of mental health and substance abuse parity still not addressed 23 Benefit Limit Exception needed to get more services this process is very problematic Waiver application to CMS compares current benefit limits in FFS to proposed limits but FFS limits are not permitted in BH plans How will people know when they are close to or have used their limits What is the Private Option? 24 Benefits are through private coverage plan. Eligibility dependent on work requirements and payment of premium, unless exempt. Plan can be through the FFM Marketplace, Private Commercial Plan, or employer sponsored insurance plan. Covered benefits and limits are determined by private plan. Consumers responsible for cost of out of network care. 12
Who is in the Private Coverage Option? 25 Childless adults (not entitled to Medicare), 21-65 years of age with income up to 133% FPL. Adult parents and caretakers (not entitled to Medicare), 21-65 years of age with income between 33-133% FPL. Includes current MAWD recipients if they meet the new, more limited income limits and do not have Medicare. Unless found to be Medically Frail through the self assessment will have to go into the Private Coverage Option. Private Coverage Concerns Those in the Private Coverage Option Lose: MA as secondary or wrapround to the commercial plan MATP Services 26 All DPW Appeal Rights- appeals must be done through the plan s appeal process (Act 68) Right to continued benefits during the appeal Right to 24 hour turnaround on Rx prior authorization requests 13
Private Coverage Concerns PCO recipients will not have the right to retroactive coverage Eligibility for PCO will be effective on the first day of the private coverage plan enrollment. This could leave significant gap between date of application and date of coverage Only way to get immediate coverage is through Presumptive Eligibility at a PE approved hospital. FFS until the effective date of PCO enrollment. 27 How to Submit Comments to Feds Feds approved PA s application as complete on 2/27/14 http://www.medicaid.gov/medicaid-chip- Program-Information/By- Topics/Waivers/1115/downloads/pa/pa-healthypa.pdf Comment period until March 28 - comments to: 1115DemoRequests@cms.hhs.gov Brief response to CMS questionnaire made at: https://public.medicaid.gov/connect.ti/public.comm ents/view?objectid=1852995 14
Contact Information For more information or if interested in signing on to joint comments, contact: Janice Meinert- jmeinert@phlp.org 412-434-5637 29 15