Overview of the Final Healthy PA 1115 Waiver March 2014

UPDATED with an extended timeline for comments!

On February 19, 2014, the Department of Public Welfare (the Department) submitted its final Healthy Pennsylvania Plan 1115 Waiver Application to the Centers for Medicare and Medicaid Services (CMS).  The Healthy PA 1115 Waiver details the Department’s proposal to (1) limit the existing Medicaid (Medical Assistance) program, and (2) cover uninsured adults ages 21 to 64 whose income is less than 133% of the federal poverty level, and who do not otherwise qualify for Medicaid, by using Medicaid dollars to pay for private health insurance for them.  The Draft 1115 Waiver application can be accessed here.

It is important for the disability community to submit comments to CMS.  The deadline to submit comments is Thursday, April 11, 2014 by 6:00 AM.  Information on how to submit comments is below. 

After the federal public comment period, CMS and the Department will negotiate the terms of the final Healthy PA 1115 Waiver.

The Department is proposing the following significant changes, which will affect persons with disabilities:

BENEFITS:

Medicaid for Adults Ages 21 through 64: The Department proposes to modify the benefits available in the current Medicaid program into two benefits packages, a High-Risk Plan for adults with complex health needs and a Low-Risk Plan for adults with less complex health needs.  Those who are eligible for Medicaid under the current eligibility requirements will be enrolled in one of these two plans.  This includes people already on Medicaid and those who become eligible for Medicaid in the future.

The following people will always be enrolled in the High-Risk Plan unless they choose to be enrolled in a different plan:

• People in institutions;
• Supplemental Security Income (SSI) beneficiaries and people deemed SSI-eligible for purposes of Medicaid eligibility;
• People enrolled in a home and community-based services program;
• Anyone participating in the Living Independence for the Elderly (LIFE) program, PACENET and PACE Plus Medicare programs;
• People who are dually eligible for Medicare and Medicaid; and
• Pregnant women (including the post-partum period).

Other Medicaid-eligible adults will be assigned to a High-Risk Plan or Low-Risk Plan based on the results of the health risk screening tool or review of the Department’s Medicaid claims data.

Reducing the existing benefits packages to only two packages would eliminate some successful and important programs, such as the Medical Assistance for Workers with Disability (MAWD) program.  MAWD provides Medicaid health insurance for people with disabilities who do not meet the general resource and income requirements for Medicaid, typically because they are working.  MAWD provides vital services to recipients so they can maintain their health, remain in a community setting, and continue working.  The elimination of MAWD would impact around 34,000 Pennsylvanians, many of whom will be left without an affordable option for health care outside of the Medicaid system.

New Limits on Medicaid Benefits for Adults: Benefits available under the High-Risk Plan and Low-Risk Plan would have new, lower limits.  For example, medical supplies and durable medical equipment would each have an annual limit of $2,500 in the High-Risk Plan and $1,000 in the Low-Risk Plan.  Outpatient surgery would be limited to four visits per year in the High-Risk Plan and two visits per year in the Low-Risk Plan.  Outpatient mental health visits would be limited to 60 visits per year in the High-Risk Plan and 30 visits per year in the Low-Risk Plan.  See the Healthy PA Benefits Chart at XXX for the proposed limits for other Medicaid services.

Children’s Plan: The Medicaid benefits for children under 21 years of age would not change.

Private Option: Adults ages 21 through 64 with incomes up to 133 percent of the federal poverty level who are not otherwise eligible for Medicaid would receive health insurance coverage through a private, commercial health insurance plan or an employer-sponsored insurance plan.  The bulk of the cost sharing for the plan would be paid by Pennsylvania using federal Medicaid funds.  These private insurance plans must include at least a minimum set of benefits, known as essential health benefits.

Adults in the newly eligible group who meet at least one of the following criteria would be deemed medically frail and given the choice to enroll in the High-Risk Medicaid Plan instead:

• Disabling mental disorder;
• Active chronic substance use disorder;
• Serious and complex medical condition;
• Physical, intellectual or developmental disability that significantly impairs functioning; or
• Determination of disability based on Social Security Administration (SSA) criteria.

COST SHARING:

Copayments: During the first year of the Healthy PA Waiver (calendar year 2015), Medicaid beneficiaries and adults in the private option would pay copays that currently apply for Medicaid services. During years two through five (calendar years 2016 through 2019), all adults with incomes less than 100 percent federal poverty level (FPL) would continue to pay these copays, as well as a new $10 copayment for non-emergency use of emergency rooms.

Medicaid beneficiaries and adults in the private option with incomes above 100 percent FPL would also have to pay the $10 copay for non-emergency use of emergency rooms but would not be assessed any other copayments during years two through five.

All Medicaid beneficiaries under the age of 18 and those residing in an institution are exempt from the $10 copayment for non-emergent use of emergency rooms.

Premiums: For years two through five of the Healthy PA Waiver (calendar years 2016 through 2019), adults ages 21 through 64 who are in Medicaid or who are in the Private Option with incomes above 100 percent FPL would also have to pay a monthly premium.  The premium amount for year two (calendar year 2016) would be $25 per month for an individual and $35 per month for a household.

The Healthy PA Waiver includes language that indicates premiums may also be established for Medicaid or Private Option beneficiaries with incomes below 100 percent FPL.

Certain people would be exempt from paying premiums:

• People on SSI or deemed eligible for SSI;
• Pregnant women:
• People 65 years of age and older:
• Children under 21 years of age
• People who are dually eligible for Medicare and Medicaid; and
• People in institutions.

Premium Reductions for Health Habits: For years two through five of the Healthy PA Waiver (calendar years 2016 through 2019), adults who pay premiums on time may qualify for reduced premiums or copays for participating in healthy behavior activities, such as health risk assessments, preventive services and annual wellness visits

 Premium Reductions for Working: For years two through five of the Healthy PA Waiver, adults who pay premiums on time may qualify for reduced premiums or copays for employment-related activities.

WORK SEARCH REQUIREMENTS:

Work Search Activities: Adults ages 18 through 64 who are in Medicaid or in the Private Option and working less than an average of 20 hours per week would be asked to register with the JobGateway online program and complete approved job training or employment-related activities every month to receive a 15 percent reduction in cost sharing.  People who are working between 20 and 29 hours per week would receive a 25 percent reduction in cost sharing.  People working 30 or more hours per week would receive a 40 percent reduction in cost sharing.

The following people would not have to enroll with JobGateway and would be exempt from the work search requirements:

• People with disabilities;
• Pregnant women (including the post-partem period);
• People 65 years of age and older; and
• People under 18 years of age.

PUBLIC COMMENT PERIOD:

It is important for the disability community to submit comments on the Healthy PA 1115 Waiver application.  Written comments must be submitted to CMS by 6:00 AM on April 11, 2014.  Written comments may be submitted at https://public.medicaid.gov/connect.ti/public.comments/view?objectId=1852995 or emailed to 1115DemoRequests@cms.hhs.gov.  CMS will review and post comments received, but will not respond to each individual comment.

IF YOU HAVE QUESTIONS:

Questions or comments may be directed to Kelly Whitcraft, DRN Policy Coordinator, at kwhitcraft@drnpa.org or 800-692-7443, extension 323.

Thank you,

Disability Rights Network of Pennsylvania
Philadelphia, Pittsburgh, Harrisburg
1-800-692-7443
www.drnpa.org