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Here’s how Pennsylvania’s Medicaid expansion plan works

corbett healthy pa announcement

Almost exactly one year ago, Pennsylvania’s Republican governor Tom Corbett announced that rather than implement Obamacare’s Medicaid coverage to anyone making less than 138% of the poverty line, he was putting forth his own plan. Named “Healthy Pennsylvania,” it would slash benefits to new and existing Medicaid recipients, charge premiums, institute a work requirement, and put new enrollees into private plans.

All of this needed federal approval, and after a long negotiation with the White House and Corbett have reached an agreement. The final version contains some elements of Corbett’s plan, but it looks much more like the state’s existing Medicaid system. If you’re a Pennsylvania resident, here’s what you should know about it.  

When does it start?

Enrollment starts December 1, with coverage beginning on January 1, 2015. After January 1, the date you apply is the date your coverage starts.

Also, coverage can be retroactive to help pay for medical bills from up to three months prior to your application. However, according to Community Legal Services of Philadelphia, it probably won’t apply to medical bills from before January 1, 2015– so the retroactive coverage is really only a protection for those who enroll later.

How many people are expected to get coverage?

Nearly 500,000 people are eligible. Around 281,000 of them fell into the “coverage gap” this year– in other words, they didn’t qualify for traditional Medicaid, but didn’t make enough to qualify for subsidies on the Obamacare exchanges.

Also, while people who have incomes between 100% and 138% of the poverty line currently qualify for subsidies on the exchanges, once PA’s expansion starts those subsidies will go away. Most of this group will likely transfer into Medicaid as well.

Who’s eligible?

Anyone making less than 138% of the federal poverty line. The dollar amount depends on the size of your household:

poverty levels by family size

How is it different from the regular Medicaid expansion in other states?

Premiums: Starting in 2016, new enrollees with incomes above the federal poverty line can be required to pay monthly premiums of up to 2% of their income– less than what Corbett proposed, but likely still a burden for low-income families.

One bright side though is that if you’re paying premiums, you won’t have to pay the copays the state typically charges, except for an $8 copay for non-emergency ER visits. There’s also a wellness program; enrollees who “complete specified healthy behaviors” each year (like getting a regular checkup) will be eligible for reduced premiums.

You can lose coverage for failing to pay premiums for three consecutive months; however, if you do lose coverage this way, you can re-enroll (after paying the outstanding premiums) without an additional waiting period.

Non-emergency medical transportation: Medicaid typically covers the cost of transportation for beneficiaries without cars so they can get to doctor appointments. Pennsylvania doesn’t have to do this for those who gain coverage through the expansion, but only in 2015– in 2016 the transportation requirement kicks back in.

Benefits package: The benefits might be stingier than what Medicaid has traditionally covered (more on that in a sec).

Is Pennsylvania’s Medicaid being privatized?

Governor Corbett has been referring to this Medicaid expansion plan as a “private coverage option,” but that’s a little misleading. Enrollees will still get Medicaid, it’s just being administered by private managed care organizations (HMO’s basically) instead of by the state directly– this is no different from how Pennsylvania runs its current Medicaid system. As Joan Alker, who runs Georgetown University’s Center for Children and Families told Philadelphia’s Newsworks:

“Pennsylvania already has private insurers delivering the vast majority of the services in your Medicaid program today, and it’s going to be those same companies that will be providing the services going to this new population, so we’re talking about a lot more rhetoric here than reality.”

What happened to the job search requirement?

Corbett’s original proposal said that to get Medicaid coverage, you’d have to be working, actively looking for work, or enrolled in a job training program. He softened that a bit later; the version submitted for federal approval only asked for permission to charge higher premiums to people who weren’t doing those things. The federal government, as expected, denied this request.

Confusingly though, a press release from the Corbett administration suggested that those who are working/looking for work may still be able to get lower premiums:

“Medicaid participants and Healthy PA enrollees will be able to reduce their health care cost-sharing obligations through job training and work-related activities, with each participant receiving assistance to do so from a Healthy PA Career Coach.”

They’re calling this new program “Encouraging Employment,” and because this would be a separate program set up with state funds (and not directly part of Medicaid), it sounds like it does get around the federal government’s rejection.

Changes to the existing Medicaid program

This is the most worrying part of the agreement, although the specifics haven’t been released yet. We do know that there will be three different benefit packages:

  • High risk plan. This would be for anyone who is considered “medically frail”– in other words, anyone with a lot of medical needs. Certain groups will automatically be enrolled in this plan: those who receive SSI, nursing home residents, long term home-care recipients, and those who also qualify for Medicare. Everyone else will have to fill out a health screening questionnaire, which would then go through a validation process.
  • Low risk plan. For those who currently qualify under the old Medicaid rules, who don’t qualify for the high-risk plan.
  • Essential benefits plan. For those who will gain coverage under the new Medicaid expansion, who don’t qualify for the high-risk plan.

To get a sense of how benefits under these different plans would compare with the old Medicaid plan, Philly’s Community Legal Services put together a helpful chart. Just in keep in mind that this is only what the state asked for; we don’t yet know what actually got approved, so the actual benefits packages could look very different:

PA Medicaid benefit plans compared

The state wanted to go further

When the state submitted its plan to the Department of Health and Human Services, the state requested 24 waivers from existing Medicaid rules– it got four. Here are some of the things the state asked for that got rejected or modified:

pa waiver requests and denials

What happens if there’s a new governor next year?

There’s an election coming up in November, and with Corbett trailing by double digits in the polls, there’s a very good chance that he won’t be in office much longer. His opponent, Tom Wolfe has said that he would pursue the standard Medicaid expansion:

“If I’m elected governor, I’ll just expand Medicaid. The waivers allow the next governor to do that. As far as I can tell, just the plain expansion of Medicaid, as it’s been presented, will allow Pennsylvanians to get health care at a lower cost than Healthy PA.”

Wolf is right about the waivers; they say what the state can do that’s different from regular Medicaid, but don’t say that the state has to do those things. The one snag is that if Wolf is elected, his ability to make changes may be determined by the terms of contracts that are being signed with managed care organizations now. But there’s a good chance that the benefit cuts (whatever they end up being) and premium requirements will be reversed come January.

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