AIDS Care Group

Medical, Dental, and Social Services in Delaware County, PA

PA’s Insurance Update

Kevin Moore, PsyD talks about PA’s Insurance Update in his presentation he did for our medical offices.
Healthy PA is the new Medicaid
•The 14 current eligibility categories are being reduced to 3 categories as of Jan 1
–Low Risk “Healthy”
–High Risk “Healthy Plus”
–Private Coverage Option (PCO)
•Notification letters have been mailed to all Medicaid recipients
•Everyone will receive new Medicaid cards
Healthy PA will expand the number of people who can be covered
•The newly eligible earn $11,670 to $16,104 for a single adult (add $4,060 per each dependent)
•This is estimated to be 600,000 Pennsylvanians
•They will not pay a monthly premium in 2015
•It is only in this sense that Healthy PA is “Medicaid expansion”- it expands the number of people covered
Healthy PA is Medicaid reduction
•“Healthy” plans limits annual benefits to $350 for lab work, 2 inpatient admits, 30 D&A outpatient visits, 30 MH outpatient visits, 4 specialist visits, 6 radiology tests, and yet-to-be seen pharmacy formulary changes.
•“Healthy plus” plans limits annual benefits to $450 for lab work, 3 inpatient admits, 60 D&A outpatient visits, 60 MH outpatients visits, 8 radiology tests, and yet-to-be seen formulary.
What is the low/high risk distinction?
•Enrollment is designed to put as many people into low risk “Healthy” plans as possible
•Adults will get “Healthy Plus” if they
–Receive MA in an SSI related category
•Healthy Horizons
•Nursing Home MA
•Home and Community Based Services
•MAWD (more on this later)
–Over 65
–“Medically frail”
What is “Medically Frail”?

Serious and complex medical conditions

–HIV/AIDS or immune deficiency
–On a ventilator or dialysis or hospice
–Chemo/radiation therapy for cancer
–Sickle cell or hemophilia
–Cystic fibrosis or Gaucher’s disease
–Resident of a LTC facility or public/private ICF
–Or 2+ hospital admits in 12 mo AND 3+ ER visits in 6 mo AND 4+ prescriptions per month
•Physical disability such as MS or paraplegia
•Disability designation by Social Security
•Certain mental disorders: major depression, bipolar disorder, schizophrenia spectrum (including schizoaffective, delusional disorder, and “psychotic disorder”), anxiety disorder (OCD, PTSD, “severe panic disorder”)
•Chronic substance use disorder
•Intellectual or developmental disability
How is the low/high risk distinction made?
•By a medical review board
•By a claims review board
•By completing Employability Assessment Form (PA 1663) with box 1 or 2 checked
•By completing a “health screening form”
–Form not released- “just questions that are asked”
–Only available through phone or COMPASS (on-line), not available at County Assistance Offices
–November 26th deadline!
What about the PCO option?
•PCO will be run through new PCO marketplace, i.e. not existing Medicaid HMOs nor Health Insurance Marketplace
•This will likely be even more problematic than was last year
•Plans aren’t available yet but Keystone First, Aetna, and United Health Care speculated to all have plans
•Enrollment will be on-going through 2015, which is good: no end to open enrollment
PCO benefits
•On the one hand, PCO has fewer limitations than low or high risk: only limits on D&A, MH
•On the other hand, if you are “medically frail” you get “Healthy Plus” anyway!
•Need to apply through new PCO marketplace, even though end up in the same place
•PCO marketplace site not ready although is running and presumably where it will be hosted
Recommendation for Action

To maximize the chance to get Medicaid patients enrolled in “Healthy Plus,” I recommend:

•Proactively inform your patients immediately
•Prompt them to open their mail and make sure they will be enrolled into “Healthy Plus”
•If not assigned to “Healthy Plus,” complete a “health

screening” through COMPASS ( or phone number (866-550-4355) before Nov 26th

Medical Assistance for Workers with Disabilities (MAWD)
•MAWD survived being cut this year because it is a great program, although it will be less great when it becomes the “Healthy Plus” plan
• You are eligible for initial enrollment up to $29,175 (250% Federal Poverty Level) regardless of how much you work.
•Typical premium about $50/month, but no co-pays, deductibles, or co-insurance- only “Healthy Plus” service limits
•ACA is inferior to MAWD in that it has higher monthly premiums, deductibles, co-insurance, and co-pays even if thought it does not have the services limits.
•Therefore if you qualify for MAWD, I recommend you take it. If not, ACA is the best option.
•Reminder that there is a tax penalty in 2015 of 2% of income to a maximum of $325 for not having insurance.
I recommend the following:
•If under $11,670, try to get “Healthy Plus” through COMPASS
•If under $16,104, try to get PCO and thus “Healthy Plus” through
•If under $29,175, try to get MAWD and thus “Healthy Plus” through COMPASS
•If under $46,680, buy a “Silver” ACA plan through
“Silver” ACA Plans in the Health Insurance Marketplace
•“Silver” plans have the premium tax credit and the cost-sharing subsidies. Educate patients not to bother looking at other plans unless above $46,680 as it averages half the cost.
•Generally cover 70% of costs with different plans varying around how much premium, deductible, co-insurance, and co-pays.
•I recommend IBX plans because they have an open panel approach (credentials any provider who asks) while Aetna has a closed panel (you can only see their providers)
•Advantage Plans (Part C plans) are predatory entities with an aggressive sales force in PA
•New data shows that Advantage Plans are inferior for patients with complex medical needs
•Pros are simpler cost-sharing arrangements and some perks like gym memberships
•Cons are service restrictions that are nearly always problematic for anyone with a chronic care condition and premiums average the same as adding together Part B and Part D premiums
Assist Patients with Medicare
•Can only change plans once a year
•Open Enrollment ends December 7th
•I recommend advising people to drop Advantage Plans and enroll in Part B/ “straight Medicare” and Part D plans
•I’ve seen patients with Part B who didn’t know they could enroll in Part D -> education
•I’ve seen patients with Medicare who are dual eligible but not enrolled in Medicaid -> education

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