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New Benefits Packages Starting January 2015 Include Severe Medicaid Benefits Cuts

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New Benefits Packages Starting January 2015 Include Severe Medicaid Benefits Cuts

Date Posted: 
12/19/2013

Updated November 21, 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 initiative will cut benefits for 1.1 million Pennsylvania adults who already rely on the Medicaid program, most of whom are pregnant, elderly, sick, or have disabilities.

Parents with children and young adults who aged out of foster care face new, drastic annual limits on coverage.  The chart in the attached document lists the limits that DPW proposed to the federal government, as of November 2014.  The limits may be subject to change based on federal review, but they are scheduled to go into effect in January 2015.

Many current Medicaid recipients will be placed into the most restrictive “Healthy” plan – especially very low-income parents with children. Medicaid recipients aged 65 or older, or with disabilities or other special health care needs, will be placed in the better “Healthy Plus” plan.  Most of the 600,000 newly eligible people will be enrolled in a new Medicaid managed care system, and receive the “Healthy PA PCO Benefits” package.  More information on these categories, and on the exception process, is below.

Q: Who will receive the “Healthy Plus” high-risk plan under DPW’s proposal?

A: Adult Medicaid recipients who:

  • Are receiving Medical Assistance in an SSI-related category, including:
    • Healthy Horizons,
    • Nursing Home MA,
    • Home and Community Based Services, and
    • Medical Assistance for Workers with Disabilities;
  • Are over age 65;
  • 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 will receive the “Healthy” low-risk plan?

A: All current adult Medicaid parents or caregivers, or former foster care children, who:

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

Q: Who will receive the Healthy PA PCO Benefits package?

A: Adults who are not medically frail (see above) and who:

  • Currently receive General Assistance-related Medical Assistance, or Medically Needy Only Medical Assistance; or
  • Are among the 600,000 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 Healthy Plus and Healthy 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.

To learn more about the limits included in DPW's proposal, download the document below.

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