Pennsylvania Submits Alternative Medicaid Expansion Waiver to CMS
February 26, 2014 02:05 PM
On February 19, Pennsylvania submitted its Section 1115 demonstration waiver application (the Waiver Application) to the Centers for Medicare and Medicaid Services (CMS) for an alternative to traditional Medicaid expansion. This followed a public comment period beginning on December 6. CMS will in turn submit the proposal for a 30-day public comment period, after which CMS and the State will negotiate the final waiver. Pennsylvania hopes to begin instituting the program, called Healthy Pennsylvania, in January 2015.
If granted as currently formulated, the waiver 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 submitted Waiver Application are discussed below.
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. Dual eligibles will be exempt from paying premiums beginning in year two of the demonstration.
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. For the first three years, “healthy behaviors” include: paying premiums on time, getting health risk assessments, and getting annual wellness visits.
The precise incentives will vary but incentives will continue for the first three years of the demonstration. 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. Dual eligibles are one such group exempt from work search requirements.
Alignment of Populations
The Waiver Application realigns the traditional Medicaid program by establishing the High Risk Benefit Plan (HRBP) and the Low Risk Benefit Plan (LRBP). HRBP 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 Application enrolls recipients of home and community-based services (HCBS), as well as dual eligible and those in Pennsylvania’s PACE program LIFE (Living Independence for the Elderly), PACENET, and PACE Plus Medicare programs, in the HRABP. Those deemed “medically fragile” will be enrolled in HRBP but have the option to enroll in LRBP.
Home Health, ICF/ID, and ICF/ORC. For HRBP, 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 per year coverage of Intermediate Care Facilities for Individuals with an Intellectual Disability (ICF/ID) and Intermediate Care Facilities for Other Related Conditions (ICF/ORC). LRBP enrollees are entitled to 60 visits per year in home health care, and are not covered for either ICF/ID or ICF/ORC.
Hospice. For hospice coverage in both LRBP and HRBP, as stated in the Waiver Application, “the only key limitation is related to respite care, which may not exceed a total of 5 days in a 60-day certification period.”
Therapy. Therapy (hearing, language, speech) is covered in both LRBP and HRBP, as stated in the Waiver Application, “only when provided by a hospital, outpatient clinic, or home health provider.”
For a full chart of covered services, see pages 44-49 of the WaiverApplication, here. For full details of Healthy Pennsylvania, clickhere.