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What's in the approved Healthy Pa. Medicaid expansion alternative plan

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The approved Healthy Pennsylvania agreement includes two parts: Reforming Pa.'s current Medicaid system, and offering the Healthy PA Private Coverage Option for eligible Pennsylvanians.

However, one notable aspect of the plan that Corbett initially requested -- work-search requirements and incentives -- was not approved. 

"The state plans to fund and administer a separate program to link people gaining coverage under the waiver to job training and placement services for those who choose to participate," the Centers for Medicare & Medicaid Services said in a news release. "Health coverage will not be affected."

The two components of the Healthy Pa. plan that were approved include the following four innovations, according to a news release from Corbett.

 • Alignment with private, commercial health care benefits

"The current Medicaid program will change from 14 benefit plans into 'low risk' and 'high risk' benefit packages that include essential health benefits and meet standards for mental health and drug and alcohol coverage uniformity. This change will better tailor health care benefits to the needs of the different populations served in the program.

"A new, innovative commercial benefit plan will be offered under the Healthy PA PCO to the more than 600,000 eligible Pennsylvanians."

• Encouraging employment

"The Encouraging Employment program will assist low-income, able bodied Pennsylvanians to improve overall health and well-being and move out of poverty. Pennsylvania is the first state to advance an incentivized employment program to reduce health care cost sharing."

• Cost sharing

"To encourage personal responsibility, individuals enrolled in the Healthy PA PCO and Medicaid program will participate in cost sharing:

- Year One: Eligible individuals will pay the same Medicaid copayments that exist today.

- Year Two: Eligible individuals with incomes greater than 100 percent of the Federal Poverty Level (FPL), unless otherwise exempt, will be required to pay 2 percent of their income toward a monthly premium. Current copayments will be eliminated. An $8 copayment for non-emergency use of the emergency room will be introduced. Individuals who do not pay premiums for more than 90 days will be disenrolled, with limited exemptions from premiums for individuals meeting certain criteria."

• Cost-sharing reductions

"Individuals in the Healthy PA PCO and Medicaid program will have the opportunity to reduce their cost-sharing obligations by engaging in certain healthy behaviors.

"Medicaid participants and Healthy PA PCO enrollees will be able to reduce their health care cost-sharing obligations through job training and work-related activities, with each participant receiving assistance to do so from a Healthy PA Career Coach.

"Paying cost-sharing amounts in a timely fashion and having an annual wellness visit in the first year of the program will allow for cost-sharing reductions in the second year. In future years, completion of approved healthy behaviors will continue the cost-sharing reduction and will be reassessed every 6 months."

Who's eligible for what

The following chart outlines which Pennsylvanians are eligible for the new innovations in the Healthy Pennsylvania plan.  

 

Reformed Medicaid

Currently eligible ages 21-64 and medically frail up to 133% FPL

 

Newly Eligible

Adults 21-64 with incomes up to 133% FPL, not on Medicaid

Benefits

 

 

High Risk Benefit aligned with recipient needs

X

 

Low risk Benefit aligned with recipient needs

X

 

Private Commercial Product with essential health benefits

 

X

Encouraging Employment

 

 

Incentivized Employment and Job Training

 

X

X

Cost Sharing

 

 

Copayments in Year 1 of Healthy Pennsylvania

 

X

X

Copayments in Years 2-5 of Healthy Pennsylvania

 

X

 

Premium of 2% of income for 100–133% FPL in Year 2-5

 

 

X

Disenrollment for failure to pay premiums after 90 Days

X

X

$8 copayment for non-emergency use of the ER

X

X

Provider can refuse service for failure to make copayment for those above 100% FPL

 

X

Healthy Behaviors 

 

 

Healthy behaviors can reduce cost sharing

X

X

 

Heather Stauffer

Heather Stauffer

Heather Stauffer covers Lancaster County, nonprofits, education and health care. Have a tip or question for her? Email her at heathers@cpbj.com. Follow her on Twitter, @StaufferCPBJ.

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