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February 2014 Healthy PA Proposal Includes Severe Medicaid Benefits Cuts

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February 2014 Healthy PA Proposal Includes Severe Medicaid Benefits Cuts

Date Posted: 
12/19/2013

Updated September 4, 2014. This article references the proposal submitted by DPW in February 2014. Community Legal Services has received verbal information from DPW that Pennsylvania is still in negotiations with CMS. The chart in this article reflects the most current information provided by DPW.

DPW’s Healthy Pennsylvania proposal slashes benefits for 1.1 million Pennsylvania adults who already rely on the Medicaid program, most of whom are pregnant, elderly, sick, or have disabilities. 

Both people with disabilities and people without disabilities would face new, drastic annual limits on coverageThe chart in the attached document lists the limits included in the DPW proposal submitted to CMS in February 2014, updated with more recent information where available. The limits may be subject to change following further negotiations between DPW and CMS.

Most current Medicaid recipients would be placed into the most restrictive “low-risk” plan. Some Medicaid recipients with disabilities or other special health care needs would be placed in the “high-risk” plan.  The 600,000 newly eligible people would be enrolled in Medicaid managed care coverage that is similar to private insurance, and receive the Essential Health Benefits package.  More information on these categories, and on the exception process, is below

Q: Who would receive the high-risk plan under DPW’s proposal?

A: Adult Medicaid recipients who:

  • Are receiving Supplemental Security Income (SSI) from the Social Security Administration (or are former SSI recipients treated as if they are as current recipients);
  • Live in an institution;
  • Receive waiver services from DPW;
  • Receive both Medicare and Medicaid;
  • Are pregnant; or
  • Are “medically frail.”  They must have:
    • A mentally disabling disorder (must be one of 7 specified diagnoses);
    • A chronic substance abuse disorder;
    • A permanent physical disability that significantly impairs functioning;
    • An intellectual disability;
    • Autism spectrum disorder requiring institutional level care;
    • A disability based on Social Security disability criteria; or
    • A serious and complex medical condition.  The recipient must:
  •  Have one of an enumerated list of about 10 conditions; or
  •  Live in a long-term care or intermediate care facility or be enrolled in hospice; or
  •  Have 2 more or inpatient admissions in 12 months and 3 or more ER visits in 6 months and 4 or more prescriptions per month.

Q: Who would receive the low-risk plan?

A: All current adult Medicaid recipients who:

  • Do not qualify for the high-risk plan; or
  • Do not complete Pennsylvania’s proposed new health screening questionnaire.  Many people who would otherwise qualify for the high-risk plan will have trouble completing this questionnaire, especially people with limited literacy or cognitive ability, or with limited English proficiency.

Q: Who would receive the Essential Health Benefits package through private insurance?

A: Adults who:

  • Currently receive Medical Assistance for Workers with Disabilities (MAWD), SelectPlan for Women, General Assistance-related Medical Assistance, or Medically Needy Only Medical Assistance – unless they are medically frail (see above); or
  • Are among the 500,000 adult Pennsylvanians between the ages of 21 and 65 who have income below 138% of the poverty level and would be newly eligible for coverage.

Q: Who could qualify for an exception to the benefits limits in the new plans?

A: DPW will grant exceptions to the benefits limits in the high- and low-risk plans only if:

  • The recipient has a serious chronic systemic illness or other serious health condition and denial of the exception will jeopardize the recipient’s life or result in serious deterioration of his or her health; or
  • Granting the exception is a cost-effective alternative for the Medicaid program; or
  • Granting the exception is necessary to comply with federal law.
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