Pennsylvania Starts Waiver Application Process Seeking Private Alternative to Medicaid Expansion
December 18, 2013 08:28 AM
On December 6, Pennsylvania began a required 30-day process to seek public comment before formal submission of a Medicaid waiver request (the Waiver Request). The public comment period will last until January 13, after which Pennsylvania will formally submit the Waiver Request to CMS. As currently formulated, the Waiver Request would expand Medicaid coverage via private insurance for those at least 21 years old but under 65 earning up to 133% of the federal poverty level (FPL). This expansion is expected to bring coverage to over 500,000 Pennsylvanians.
Some of the important elements of the Waiver Request are discussed below.
Premium Assistance. Pennsylvania will pay premium assistance on the premium and cost-sharing elements. However, new enrollees will be required to pay a monthly premium. These monthly premiums will not exceed $25 for one adult, and $35 for a household with two or more adults.
Incentives to Reduce Premiums. Beneficiaries can get their out-of-pocket monthly premiums reduced by either “engaging in healthy behaviors” or working at least 20 hours a week, or both. Healthy behaviors must include all of the following: for the first three years, paying premiums on time, and getting annual health risk assessments and physical exams. After three years, Pennsylvania reserves the right to revise the list of “healthy behaviors.”
Work Search Requirements. Unless otherwise exempt, all newly enrolled beneficiaries must be enrolled on a specified online unemployment website, and be searching for work as a condition of continued eligibility.
Alignment of Populations. The Waiver Request realigns the traditional Medicaid program by establishing the High Risk Alternative Benefit Plan (HRABP) and the Low Risk Benefit Plan (LRBP). HRABP is for Medicaid recipients deemed to have “more complex health needs” according to a health screening tool, while those with less complex health needs will be enrolled in the in the Low-Risk Benefit Plan (LRBP). The Waiver Request enrolls recipients of home and community-based services (HCBS), as well as dual eligibles, in the HRABP. Those deemed “medically fragile” have the option of enrolling in the expanding premium assistance plan, or the HRABP.
Covered Services. For HRABP, enrollees are entitled to unlimited home health care coverage within the first 28 days, and 15 days per month thereafter. These enrollees are also entitled to 365 days a year coverage of Intermediate Care Facilities for Individuals with an Intellectual Disability and Intermediate Care Facilities for Other Related Conditions. LRBP enrollees are entitled to 60 visits per year in home health care, and are not covered for Intermediate Care Facilities for Individuals with an Intellectual Disability and Intermediate Care Facilities for Other Related Conditions.
Next Steps: Pennsylvania will hold six public hearings and two webinars on the Waiver Request, with dates ranging from December 19 through January 9.
For full details, click here.