Pennsylvania Insurance Update: Healthy PA, MAWD, & ACA
Pennsylvania Insurance Update:
Healthy PA, MAWD, & ACA
Kevin Moore, PsyD
December 18, 2014
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 MA cards but not new Medicaid HMO cards, e.g. Keystone First, etc..
Healthy PA Will Expand the Number of People who Can Be Covered
The newly eligible earn $11,670 to $16,105 for a single adult (add $4,060 per each dependent)
This is estimated to be a maximum pool of 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” has NO SERVICE LIMITS.
”Private Coverage Option” (PCO) plans will lose their current health plan and CBH/Magellan coverage. They will not have transportation nor dental benefits. They can choose (or will be assigned to) a new PCO plan with very restricted provider networks. For example, many hospitals only take one or two of the four plans.
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
Nursing Home MA
Home and Community Based Services
MAWD (more on this later)
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 the state’s medical review board
By the state’s claims review board
By completing Employability Assessment Form (PA 1663) with box 1 or 2 checked
By appealing an incorrect determination within 10 days, call the statewide customer service line: 1-877-418-1187. This appeal can not be done at “DPW”, the County Assistance Offices, but only over the phone.
(By the way, DPW is changing its name to DHS which will surely confuse everyone in Philly because those initials are already used by the child welfare service.)
Who can I asked general questions about a possible appeal?If you have HIV, Jacob Eden, Attorney
AIDS Law of Pennsylvania
1211 Chestnut Street, Suite 600, Philadelphia, PA 19107
But isn’t the PCO for expansion?
Yes, but we’ve seen some current Medicaid recipients placed in PCO plans by mistake.
Even more strangely, even if you are correctly applying for a PCO plan through COMPASS because you are in the expansion category, you are screened for low/high risk and high risk places you in a “Healthy Plus” plan.
Read about PCO palns at healthypa.com
Enrollment will be on-going through 2015, which is good: no end to open enrollment.
Recommendation for Action
To maximize the chance to get Medicaid patients enrolled in “Healthy Plus,” I recommend:
Prompt all patients to open their mail and make sure they will be enrolled into “Healthy Plus.”
Clients who have not received a notice may call the DHS/DPW Change Center at 215-560-7226
or their local county assistance office to find their plan assignment.
If not assigned to “Healthy Plus,” complete a “health screening” through COMPASS (www.compass.state.pa.us
) or phone number (866-550-4355)
Health Screening Tips
•Whether on COMPASS or on the phone, patient will be asked about 14 questions to subjectively rate their physical and mental health, e.g. “How would you rate your physical health: a) excellent, b) good, c) fair, d) poor, e) very poor?”
•If patient responses with “good” across the questions, they can be classified as “Healthy.”
People need to say they feel “poor” in order to be correctly classified as “Healthy Plus.”
Expansion Enrollment Tip
We have seen a few people who make 133-138% of Federal Poverty level, who get referred out of COMPASS to an healthcare.gov.
This is a mistake on the states part having to do with the 5% disregard. Please help people get around it.
When COMPASS says “not eligible”, you can still click the “APPLY NOW” button at the bottom right hand corner and it will let you apply!
Medical Assistance for Workers with Disabilities (MAWD)
MAWD survived being cut this year because it is a great program.
MAWD recipients will receive a “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
MAWD vs ACA
ACA is inferior to MAWD in that it has higher monthly premiums, deductibles, co-insurance, and co-pays.
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 (paid by April 15, 2016).
I Recommend the Following:
If under $11,670, try to get “Healthy Plus” through COMPASS
If under $16,105, try to get PCO and thus “Healthy Plus” through COMPASS
If under $29,175, try to get MAWD and thus “Healthy Plus” through COMPASS
If under $46,680, buy a “Silver” ACA plan through healthcare.gov
“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 plans with an open panel approach (credentials any provider who asks – such as IBX) vs. plans with a closed panel (you can only see their providers – such as Aetna).
Already Had an ACA Plan?
Should update information on healthcare.gov
Ensures correct premium tax credits and cost sharing subsidies
Different plans available, some slight increases in plan prices in Philly area
Consider MAWD if under $29,175
If you do nothing, same plan will continue
Full Medicaid Expansion is Coming
Governor elect Wolf calls it a “top priority”
Will be inaugurated Jan 20
Staff needs to write a request to CMS
Obama’s administration says they are ready to approve quickly, “within a few weeks”
At best: March, but probably later
Historically, MA lets you back bill 90 days, so Healthy PA could be retrospectively eliminated
With Full Medicaid Expansion
Restoration of no service limits
Simplified application: no asset test
If under $16,105, apply for Medicaid through COMPASS
If under $29,175, apply for MAWD and thus Medicaid through COMPASS
If under $46,680, buy a “Silver” ACA plan through healthcare.gov, if eligible for a special enrollment period
Healthy PA is Medicaid reduction as of Jan 1
This is a dark cloud and we need to act now to protect the people we serve
Check their letter for “Healthy Plus”
Silver lining #1: more people can be covered
Silver lining #2: Healthy PA is only temporary