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

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
—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 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
—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 ( 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
—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
—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
“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
—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, 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
Thank You!

Please email me questions/comments/ corrections:

4 Responses

  1. B. Pekarovich says:

    daughter approved for healthypa plus effective 1/1/2015.
    at first opportunity, selected a insurance provider (upmc for you??). got notice that insurance with selected provider would start on 3/15. meanwhile , she has visited a doctor at least 2 times and paid for the service. does the system allow for any back billing for reimbursement of these expenses. to further confuse the issue, this particular doctor will not file any insurance claims, will only provide receipts and diagnosis forms.

  2. Kevin Moore says:

    “Unfortunately, no. Private insurance plans will only honor services rendered after the start date of an insurance plan. It is illegal for the medical provider to postdate services rendered, so I do not think your daughter’s two medical visits will be covered. As you say the provider only gives receipts, you need to make sure that the plan you picked will cover “out of network” providers or even after the insurance starts, you will still not be covered for services that provider renders. We would highly recommend you spend some time on the site to give you more information on how to work with health insurance plans. It is a complicated and difficult topic of its own. Please feel free to ask us more questions. Take care.”

  3. Justin says:

    if I have an HMO through MA, do I still get to use healthy plus with my standard state ID number?

    (since the HMO’s have limitations on in and out of network providers) I am out of my “service area” yet had my HMO not been effective, I would have had continuity of care with my Healthy Plus plan.

  4. Neva says:

    I am currently recipient of MAWD and have learned that my employer is now offering us a health care plan that is very expensive with large copays and deductibles. Can i keep my MAWD?

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