MA expansion PHMC 10-28-14 final 10-30

Changes to Pennsylvania
Medicaid Starting
January 2015
Louise Hayes
John S. Whitelaw
Community Legal Services
October 28, 2014
Agenda for Today
• Who is newly eligible for MA starting in January?
• How to apply, and how to get help.
• Changes to how MA is provided.
(that is, what card is issued)
• Changes to what services are covered by MA.
Not Covered Today
• Details of the Healthy PA proposal – which pieces
were approved and which rejected.
• See handout.
• Coverage through the Marketplace (open
enrollment starts Nov. 15).
Main Messages for Today
• Spread the word: MA is expanding! Almost all lowincome people now qualify.
• Help people to apply.
• Help people with serious medical needs – or who
need to be in CBH – get the “Healthy Plus” (high
risk) plan.
• Appeal service denials as needed.
• Send clients who are denied MA to legal services.
Great News: Medicaid Expansion
• Starting January 1, adults below age 65 with
income below 138% of poverty qualify for
Medical Assistance.
• They are eligible even if they are working,
and do not have children or a disability.
Roughly 600,000 Pennsylvanians!
• No asset test, no criminal record restrictions.
Income Limits for
Expansion Population
Household Size
Monthly Income
A Few Exceptions
• Expansion covers EVERYONE in Pennsylvania under
138% of poverty, with a few exceptions:
• People over 65
• People receiving Medicare.
• Both these populations are still eligible for Healthy
Horizons if their income is below 100% of poverty and
they meet asset limits.
• MAWD is still available for working people under 65 with
disabilities and higher income or assets.
• No changes to rules for immigrants.
• 5-year bar remains in place.
Income-Counting Rules
For Expansion Population
• DPW will use MAGI income-counting rules for almost
everyone applying for MA.
• MAGI = Modified Adjusted Gross Income.
• Used for the expansion population and also children,
pregnant women, parents, and former foster kids.
• Current SSI income-counting rules still apply to people
with disabilities or aged 65+. (E.g., count only half of
earned income.)
MAGI Income-Counting Rules
• Based on tax rules
• Two steps:
• Who is in the household?
• Based on expected tax filing status for the year of application,
with some exceptions.
• Non-tax-filers: generally count parents, step-parents, and
children together.
• What income counts?
What Income Counts?
• Taxable income counts. This does not include the following:
Workers’ compensation
Veterans’ benefits
Child support
Income of children (unless they must file their own taxes)
• Social Security does count.
• Medicaid counts current monthly income, not a projection
of annual income.
Some Medicaid Remains the Same
• The Affordable Care Act did not change Medicaid
for seniors or people with disabilities.
• Programs include:
Healthy Horizons,
Nursing Home programs, and
Automatic MA for SSI recipients.
Healthy Horizons Medicaid
• Individuals may receive Healthy
Horizons if they are 65 and older or
have disabilities that will last for
twelve months or longer.
• $2,000 asset limit for single adults;
$3,000 for couples and families.
2014 Income Limits* –
100% FPIG
$ 973
$ 1,311
* $20 income disregard; $65
plus 50% earned income
Medical Assistance for Workers
with Disabilities (MAWD)
• Individuals with too much income or
assets for Healthy Horizons may receive
Medical Assistance for Workers with
Disabilities (MAWD) if:
• They have disabilities that last for twelve
months or longer.
• They work at least one hour per week.
• AND they are under age 65.
• They will be required to pay a premium
based on income (5%) – usually $50 to
$100 per month.
2014 Income Limits* –
250% FPIG
$ 2,432
$ 3,278
* $20 income disregard; $65
plus 50% earned income
• $10,000 asset limit for everyone.
Other Remaining Medicaid
• Parents with very low incomes (TANF-related)
• A subset of the expansion population
• Young adults aging out of foster care (to age 26)
• No income limits!
• Breast and Cervical Cancer Treatment Program
Immigrant Eligibility for Medicaid
and CHIP
• The rules for immigrant eligibility for Medicaid have not
changed under the ACA.
• Lawfully present immigrants who are pregnant or children
are eligible for Medicaid without a wait.
• Certain other “qualified immigrants” – refugees, asylees,
Cuban-Haitian entrants, and some others – are eligible
without a wait.
• Most other qualified immigrants – LPRs especially -- must be
lawfully present for five years to qualify for federally funded
• Called the “five-year bar.”
Immigrant Eligibility for Medicaid
and CHIP (cont’d)
• Immigrants subject to the “five-year bar” may qualify for
state funded Medical Assistance if they meet very low
income limits – though DPW has said this program is ending.
• Otherwise, lawfully present immigrants who are not eligible
for Medicaid because of their immigration status, as well as
undocumented immigrants, may qualify for Medicaid only if
they have an emergency medical condition.
• Lawfully present immigrants may qualify for subsidies
through the Marketplace, even if their income is below
100% of poverty.
• Undocumented immigrants and those with DACA status may
not receive Marketplace subsidies.
How to Apply
• Starting December 1, 2014, people can apply directly to
the Department of Public Welfare (DPW):
• Online, via COMPASS:
• By telephone: (866) 550-4355.
• By mail.
• In person, at their local County Assistance Offices.
• Applications can be submitted year-round.
Application Processing
• Under state law, Medicaid eligibility determinations
must be made within 30 days of application.
• DPW must send a notice.
• Applicants who are turned down may appeal and
request fair hearings within 30 days.
• Check the status of your application by calling:
• (215) 560-7226 in Philadelphia.
• (877) 395-8930 in all other Pennsylvania counties.
Help with Applications
• People who have trouble applying online or by
phone can get help with their applications.
• Same number for phone or in-person help via
Certified Application Counselors:
(855) 486-9331
• Callers will get help with the application, or an
appointment for face-to-face help.
Under the ACA, electronic records are a primary
source of information:
• DPW must search federal and state databases for certain
kinds of proof of eligibility, like social security or UC
income or citizenship information.
• Other kinds of proof, like state residency, can be proved
by self attestation.
• DPW will not have access to some income information
until 2015, so many people will still have to provide
paper documentation of income.
Very Limited Auto-Enrollment
• DPW will automatically enroll people getting GArelated MA into the expansion group.
• DPW will not automatically enroll people receiving
SelectPlan for Women, which is ending 12/31/14.
• These women must reapply.
• DPW will not automatically enroll other people
whose income it has already verified, such as
• People on SNAP, or
• Parents whose children receive MA.
What Card Will I Use?
• Managed care (HealthChoices) for most:
• One set of managed care plans for physical health (e.g.,
Keystone First, Health Partners).
• Separate managed care plans for behavioral health. CBH is the
behavioral health plan for Philadelphia.
• Fee-for-service (Access) for some:
Everyone in the initial weeks before enrollment in a plan;
Retroactive coverage;
People on Medicare and/or receiving waiver services
A few others.
Third System Starting in 2015:
Private Coverage Option
• Many people will remain in their HealthChoices
managed care plans.
• This includes everyone in an SSI-related MA category
(such as Healthy Horizons) or who is “medically frail.”
• No change in who gets fee-for-service.
• Most of the “expansion population” and some
current MA recipients will be enrolled in the new
Private Coverage Option (PCO) Medicaid managed
care system.
Private Coverage Option
• Pennsylvania is setting up a “private coverage option”
(PCO) with 8 managed care companies operating across
9 regions.
• PCO plans will share some features with Marketplace
plans, but the PCO will be a Medicaid managed care
system that operates separately from the Marketplace.
• The PCO will also operate separately from the existing
Medicaid managed care system, called HealthChoices,
which has7 managed care companies across 5 regions.
PCO Plans
HealthChoices Plans
PCO (cont’d)
• The PCO is different from Iowa’s and Arkansas’s
expansion plans, which use Medicaid dollars to buy
Marketplace coverage.
• Enrollees can choose among PCO plans in their
region, with the help of DPW’s enrollment broker.
• We will address which MA enrollees gets which
plan, and what services, after a break for questions.
Problems with the PCO
• Confusing to have separate systems of health plans.
• Not all contracts are signed– can they be ready?
• Network adequacy issues.
• Problems with transitioning from one system to
another as income or health changes.
• PCO will not have separate behavioral health plans.
• CBH will not be the insurer for PCO enrollees in
• Behavioral health providers in Philadelphia will have to
sign up with PCO plans.
What Medical Services Do I Get?
• No changes to children’s benefits (up to age 21).
• But for adults, cuts in services proposed for
everyone, not just the expansion population.
• Three options for adults:
• Two of them will be administered through
HealthChoices plans (or fee-for-service).
• One of them will be administered by the PCO (or FFS).
Proposed Benefits Packages
• Pennsylvania has proposed three benefits
• Healthy Plus: a more generous “high risk” plan
• Delivered via HealthChoices plans or FFS
• Healthy: a less generous “low risk” plan
• Delivered via HealthChoices plans or FFS
• Healthy PA PCO: the same essential health benefits
package that Marketplace enrollees get, plus “wraparound” services like choice of family planning provider.
• Delivered via the PCO or FFS
Proposed Benefits Packages
• Current Medicaid recipients with significant
medical needs will get the Healthy Plus package.
• Others will get either the Healthy package or the
Healthy PA PCO package.
• Newly eligible people who are “medically frail” will
get the Healthy Plus plan.
• Everyone else will get the Healthy PA PCO package.
Proposed Benefits Cuts
18 (excluding
PCP visits)
FQHC Visits
Lab Work
No limit
No limit
No limit
Inpatient Acute
No limit
Healthy Plus
Healthy PA PCO
No limit
8 per year
$450 per year
3 admits per
year (nonemergency)
4 per year
(excluding PCP
6 per year
6 per year
$350 per year
2 admits per
year (nonemergency)
No limit
$1,000 per year
No limit
$1,000 per year
No limit
No limit
No limit
No limit
No limit
No limit
Uncertainties about Benefits Cuts
• The limits listed for the Healthy (low risk) package
are fairly certain.
• The limits for the Healthy Plus and Healthy PA PCO
packages are less certain.
• The Healthy Plus and Healthy PA PCO packages will
likely be very similar.
• MCOs may choose not to implement the cuts.
More on the Healthy PA PCO
Covered services will be comparable to the Healthy Plus
package but:
• No non-emergency medical transportation (MATP)
• 2015 only – CMS will require MATP starting 2016
• CBH is not the behavioral health insurer in Philadelphia
• Each PCO plan will have its own behavioral health network.
• Potential continuity of care problems, as current
recipients’ doctors may not accept their new PCO plan.
• Inability to change PCO plans after 3 months (until 1
Challenging Service Denials
• Service denials can be appealed, but the standard for a
“benefits limits exception” is very strict:
• A person must prove that s/he “has a serious chronic systemic
illness and denial of the exception will jeopardize the life of or
result in the serious deterioration of the health of the recipient.”
• The appeals process is complicated and time consuming,
and most requests are denied. But the fight may be worth
• To make the benefits limits exceptions process less
burdensome, Pennsylvania could choose to “automate”
exceptions for certain recipients who bump up against
certain benefits limits.
Who Gets Which Package?
Healthy Plus (high risk)
Healthy (low risk)
Healthy PA PCO (Essential
Health Benefits)
Administered by
HeatlhChoices plans or
fee-for-service (FFS or
Administered by
HealthChoices plans or
Administered by PCO
plans or FFS
• People 65+ or
disability MA
categories like Healthy
Horizons or MAWD
• Anyone who is
“medically frail “
• Some others
For people who are not
medically frail and who
• Parents or caretakers
receiving MA in the
TANF category, or
• Former foster care
For people who are not
medically frail and who
• In the expansion
population, or
• Currently eligible for
MA in a state-funded
Who Gets the Healthy Plus
(High Risk) Plan?
• Some Medicaid recipients will qualify for Healthy
Plus automatically:
• People on SSI or in disability categories, including
Healthy Horizons or MAWD.
• People in nursing homes or receiving long term care at
• Pregnant women.
• People over 65.
• Anyone who is “medically frail” will also qualify.
Who Is Medically Frail?
• Establishing medical frailty is the key to getting the
Healthy Plus (high risk) package.
• Therefore it is also the route to getting into CBH.
• DPW has a definition, a screening questionnaire,
and a “validation” process. It is unclear how these
processes fit together.
• DPW decisions on medical frailty can be appealed.
Definition of Medical Frailty
(see handout)
Individuals with:
• A disabling mental disorder
• A chronic substance use disorder
• Serious and complex medical conditions
• A physical disability
• An intellectual or developmental disability
• A Social Security disability determination
Determining Medical Frailty For
Current MA Recipients
• DPW has reviewed its claims data for all current MA
recipients for medical frailty.
• This review was automated via software that focuses
primarily on physical health issues.
• Based on claims data, some current recipients have
been found medically frail and will be moved to Healthy
• These are in addition to those who are 65+ or receiving
Healthy Horizons or other SSI-related MA, who will also
receive Healthy Plus.
• DPW may review claims data for medical frailty midyear, and shift some recipients to Healthy Plus.
Determining Medical Frailty For
Current MA Recipients (cont’d)
• All current recipients will be sent a letter in
November, saying what benefit package DPW plans
to give them.
• For people whom DPW plans to give the Healthy or
Healthy PA PCO package, the letter will offer the
chance to complete a health screening form.
• The form can be completed online on COMPASS.
• It can also be completed by phone: (844) 290-3448
Determining Medical Frailty For
Current MA Recipients (cont’d)
• The screening form will ask questions like:
• How many visits have you made to a hospital or ER in
last 12 months?
• How many prescriptions do you take?
• How would you describe your mental health?
• Do you have any of the following diagnoses? …
• Is a friend concerned about your use of drugs or
• Have you been treated for substance use problems in
the last 12 months?
Determining Medical Frailty For
Current MA Recipients (cont’d)
• Completing the health screening form is optional, but
current enrollees who are invited to complete it, and
do not, will not get Healthy Plus.
• They will get the Healthy or the Healthy PA PCO package
instead, depending on their current category of MA.
• If people complete the screening form, DPW medical
staff will review their answers and “validate” the
information through calls to treating doctors .
• The standard DPW medical staff will use to determine
medical frailty based on the screening form is unclear.
Determining Medical Frailty For
Current MA Recipients (cont’d)
• Formal notices of assignment to one of the three
benefits packages will be sent in December.
• The notices will not say that benefits are being cut,
or that the Healthy plan is worse than the Healthy
Plus plan.
• People with serious medical needs should appeal
the notice assigning them to Healthy or the Healthy
PA PCO package, and submit an PA 1663 if possible.
Determining Medical Frailty
for New Applicants
• Health screening form will be included with the
• DPW clinical review team may “validate” the
screening form with claims data, if available, and/or
calls to treating doctors.
• Unclear what standard DPW will use, as many in
this uninsured population will have no claims data
and not have treating doctors yet.
Problems with Medical Frailty
• Difficulties with completing the screening form
Literacy or language issues
Concerns about confidentiality
No “other” box for identifying unusual diagnoses
Won’t capture new conditions
• Relationship of screening form to definition of
medical frailty is deliberately opaque.
• Calls to doctors are intrusive.
What If I Need the Healthy Plus
Plan Between Redeterminations?
• DPW will only offer the health screening form at
application and redetermination.
• If one needs to switch to Healthy Plus between
redeterminations, use a different form: the PA
1663 Employability Assessment Form (EAF).
• EAF is familiar to doctors.
• Likely box 1 or box 2 must be checked
• Box 1 or 2 has long been the entryway into Healthy
Horizons or MAWD.
• 12 month disability can include a retroactive period
Employability Assessment Form
(PA 1663)
Employability Assessment Form
• The language on the form (PA 1663) is confusing:
• EAF claims to measure whether clients are unable to
engage in “any gainful employment” because of
• In practice, EAF measures disability rather than
employability – otherwise, programs like MAWD could
not exist!
Use of EAF to Switch to
Healthy Plus
• DPW says if someone hands the EAF to the welfare
office between redeterminations, DPW will assess
to see if the person should be put in Healthy
Horizons or MAWD.
• If category is changed to Healthy Horizons or MAWD, the
person will be put in Healthy Plus.
• If the person does not qualify for a change in
category (e.g., because of assets), CAO will forward
EAF to medical team to decide medical frailty.
Disagreeing with Medical Frailty
• DPW’s decision that someone is not medically frail can
be appealed.
• Recipients will get a notice of which package they will
get, with an appeal form.
• People who need Healthy Plus should appeal!
• Providers should help by giving patients an EAF
checking box 1 or box 2 (for 12 month disability), ideally
to be submitted with the appeal.
Major Concerns With New System
• Readiness/ network adequacy of PCO plans
• Lack of CBH carveout from PCO in Philadelphia
• Continuity of care for those transferred to the PCO.
• Churning across plans
• Service denials (due to benefits cuts)
• Difficulty getting into Healthy Plus plan when
circumstances change
• Lack of transparency and consistency in who gets
Healthy Plus
Main Messages for Today
• Spread the word: MA is expanding! Almost all lowincome people now qualify.
• Help people to apply.
• Help people with serious medical needs – or who
need to be in CBH – get the “Healthy Plus” plan.
• Appeal service denials as needed.
• Send clients who are denied MA to legal services.
• Louise Hayes
• [email protected]
• (215) 227-4734
• John S. Whitelaw
• [email protected]
• (215) 227-2403

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