Slide 1

Medicaid Expansion and Managed Care Organizations Ronda Goldfein, Esq. goldfein@aidslawpa.org AIDS Law Project of Pennsylvania 1211 Chestnut Street, Suite 600 Philadelphia, PA 19107 (215) 587-9377

Slide 2

Medicaid Expansion As of January 1, 2015, Pennsylvania has an expanded Medicaid program A Brief History Before the expansion: o To be eligible, must be low income AND fit into a category Categories included: over 65; disability; pregnant; child; or parent After the expansion: o All low-income adults between 18-64 are eligible. No additional condition required. Low income = income less than 138% of the Federal Poverty Line (FPL)

Slide 3

Medicaid Expansion contd What is 138% FPL? o For an individual: $1,354 per month / $16,248 per year (full time minimum wage worker earns $15,080 per year) o For a family of four: $2,789 per month / $33,468 per year What income is counted? o MAGI : Modified Adjusted Gross Income Basically, if the income is taxable, it counts; if it isnt, it doesnt. o Workers Comp and Veteran Benefits are generally NOT taxable o Unemployment Compensation generally IS taxable.

Slide 4

Medicaid Expansion According to the state Department of Human Services estimates, the expansion expands eligibility to over 600,000 adult Pennsylvanians. As of February 2015, nearly 2.5 million Pennsylvanians are enrolled in Medicaid.

Slide 5

How we got here Pre- Affordable Care Act: o Eligibility: Income + Category o Medicaid administered through Managed Care Organizations (MCOs). o State divided into 5 regions. Each region had an option of at least two MCOs. o MCO system is called HealthChoices. o The MCOs administers state-approved benefits packages. o Those parts of the state with insufficient MCO networks are Fee-For-Service, in which state pays providers directly.

Slide 6

Post-ACA Part I The ACA mandated that states expand their Medicaid programs to cover all adults with income less than 138% or lose all federal funding for existing Medicaid program. The Supreme Court, while upholding many parts of the ACA, concluded that forcing states to expand by threatening all Medicaid funding was coercive. As a result, states were given the choice to expand. On January 1, 2014, expansion became available throughout the United States. Pennsylvania, under Gov. Corbett, opted not to expand Medicaid.

Slide 7

Post-ACA Part 2: Healthy PA After initially refusing expansion, Gov. Corbett changed course. He opted to expand Medicaid with some modifications. The major modification was creation of 3 benefits packages: o Healthy/Low-risk: Coverage for traditionally eligible people without serious health problems. Less coverage than Medicaid provided pre-expansion. Administered through MCO system. Mental health coverage provided through separate Behavioral Health Organization. o Healthy Plus/High-risk : Coverage for traditionally eligible people with serious health problems. Similar to what people had pre-expansion. Administered through MCO system. Mental health coverage provided through separate Behavioral Health Organization. o Healthy PA Private Coverage Option : For newly eligible (i.e., income with no category). Benefits based on Essential Health Benefits mandated by ACA for private plans. Administered through new PCO system (see next slide). Includes mental health coverage.

Slide 8

Healthy PA PCO Map 9 regions HealthChoices MCO Map 5 regions

Slide 9

Post-ACA Part 3: HealthChoices Gov. Wolf opted to replace Healthy Pennsylvania with a new program, HealthChoices (the same name as the pre-ACA MCO network). HealthChoices will have 1 benefits package for all adults on Medicaid, whether traditionally or newly eligible. Healthy, Healthy Plus, Healthy PA PCO will be eliminated. The Adult package will be administered by the MCO system. The first phase of the transition from Healthy PA is underway. The second and final phase will be completed by September 30 th.

Slide 10

The Transition to HealthChoices Phase 1 Everyone in Health and Healthy Plus will keep their current MCO plan, but the underlying benefits package will change to the Adult package. As the plans are similar, enrollees should not see a major change. The switch to the Adult package will eliminate the 6 prescription drug limit. Anyone in a PCO who had Medicaid prior to 1/1/2015, will be transitioned into an MCO adult package. On April 27, these enrollees were assigned to the Adult Package. o Between 4/27 and 6/1, people will remain in their PCO and use their ACCESS card for any care not covered by the PCO. o Starting June 1, this group will be transferred into an MCO plan ( instead of a PCO). Where possible, enrollees will be switched to sister plans. For example, people in Keystone Connect (PCO) will be switched to Keystone First (MCO).

Slide 11

The Transition to HealthChocies Phase 2 Anyone still in a PCO on July 28, will receive Adult package benefits. o Between 7/28 and 9/1, people will remain in their PCO and use their ACCESS card for any care not covered by the PCO. o Starting September 1, this group will be enrolled into an MCO instead of a PCO. Where possible, enrollees will be switched to sister plans. For example, people in Keystone Connect (PCO) will be switched to Keystone First (MCO). By September 1, all adult Medicaid enrollees will be in MCO plans. On September 30, Healthy PA officially ends

Slide 12

What do health providers need to know? By September 30, all adult patients on Medicaid will be in an MCO. All will have the same benefits package. May still have to complete: o Employability Assessment Form (PA-1663) o Life Sustaining Medication Form (PA-1671) Why? o Some patients will not qualify for Medicaid under the expansion rules: Patients with Medicare Patients with income over 138% FPL

Slide 13

Traditional Categories Traditional eligibility still exist. Some traditional categories have income levels higher than 138% FPL and/or use different counting rules. Traditional categories related to disability require forms to be completed by a healthcare provider. The most commonly-used categories are: o Healthy Horizons: Coverage for people over 65 or disabled making 100% FPL or less, even though only half of earned income is counted for eligibility. o Medical Assistance for Workers with Disability (MAWD): Coverage for people between 18-64, with a job, with income less than 250% FPL (with half of earned income disregarded)

Slide 14

To qualify for benefits, either box 1 or 2 must be checked. For box 2, a range of dates greater than 12 months must be provided. Healthcare providers have no liability for their judgment, as long as the diagnosis listed (see next slide) is backed by the medical record.

Slide 15

Who can complete form? Doctor, Physicians Assistant, Certified Registered Nurse Practitioner, Psychologist Must sign, date, and give provider number. Stamp/labels are not acceptable. DHS almost always accepts a Doctor's judgment on this form as long as the diagnoses are verifiable.

Slide 16

Health Sustaining Medication Form: This form can be used as an alternative to the EAF for those patients applying for MAWD.

Slide 17

Waiver Waivers offer an array of services and benefits such as choice of qualified providers, due process, and health and safety assurances. The name waiver comes from the fact that the federal government "waives" Medical Assistance/Medicaid rules for institutional care in order for Pennsylvania to use the same funds to provide supports and services for people in their homes. In Pennsylvania, the Department of Human Services administers multiple Medical Assistance/Medicaid waivers. Each waiver has its own unique set of eligibility requirements and services. 1211 Chestnut Street, Suite 600, Philadelphia, PA 19107 (O) 215-587-9377 (F) 215-587-9902 Intake: Monday through Friday, 9:30 a.m. to 1:00 p.m.

Slide 18

AIDS Waiver Ending Soon but dont panic! Eligibility To be eligible for the AIDS Waiver you must: Be 21 years or older Have symptomatic HIV Disease or AIDS Meet the level of care needs for a Skilled Nursing Facility Meet the financial requirements as determined by your local County Assistance Office. Services available are: Home Health Services Nutritional Consultations Specialized Medical Equipment and Supplies Personal Assistance Services 1211 Chestnut Street, Suite 600, Philadelphia, PA 19107 (O) 215-587-9377 (F) 215-587-9902 Intake: Monday through Friday, 9:30 a.m. to 1:00 p.m.

Slide 19

Attendant Care Waiver Eligibility To be eligible for Attendant Care Services, you must: Be a resident of Pennsylvania Meet the level of care needs for a Skilled Nursing Facility Be between eighteen (18) and fifty-nine (59) years of age Be capable of a) hiring, firing, and supervising attendant care worker(s); b) managing your own financial affairs; and c) managing your own legal affairs For the Medicaid Home and Community Based Waiver Services Attendant Care Program, meet the financial requirements as determined by your local County Assistance Office. Have a medically determinable physical impairment that is expected to last of a continuous period of not less than twelve (12) calendar months or that may result in death To take advantage of the Attendant Care Act 150 Program, you may be assessed a minimal co-payment. This co-payment is based on your income and will not be more than the total costs of services Services that may be available to you include: Community Transition Services (available only through Medicaid Home and Community Based Waiver Services) Participant-Directed Community Supports Participant-Directed Goods and Services Personal Assistance Services Personal Emergency Response System (PERS) Service Coordination 1211 Chestnut Street, Suite 600, Philadelphia, PA 19107 (O) 215-587-9377 (F) 215-587-9902 Intake: Monday through Friday, 9:30 a.m. to 1:00 p.m.

Slide 20

Independence Waiver Eligibility To be eligible for Attendant Care Services, you must: Be a Pennsylvania resident Be 1 8-60 - Individuals that turn 60 while in the waiver will be able to continue to receive services through the Independence Waiver. Individuals who are physically disabled (but not with mental retardation or have a major mental disorder as a primary diagnosis, or who are ventilator dependent), who reside in a Nursing Facility (NF) or the community but who have been assessed to require services at the level of nursing facility level of care. In addition, the disability must result in substantial functional limitations in three or more of the following major life activities : o Self-care, o understanding and use of language, o learning, o mobility, self-direction and/or o capacity for independent living. Meet the financial requirements as determined by your local County Assistance Office. Services available may include: Adult Daily Living Services Accessibility Adaptations, Equipment, Technology and Medical Supplies Community Integration Community Transition Services Financial Management Services Home Health Non-Medical Transportation Personal Assistance Services Personal Emergency Response System (PERS) Respite Service Coordination Supported Employment Therapeutic and Counseling Services 1211 Chestnut Street, Suite 600, Philadelphia, PA 19107 (O) 215-587-9377 (F) 215-587-9902 Intake: Monday through Friday, 9:30 a.m. to 1:00 p.m.

Slide 21

Waiver Income & Resource Limits Income eligibility not based on FPL but rather the Federal Benefit Rate (that is, the SSI amount) 3 x SSI FBR 2015: $2,199/month Resource: $8,000 but special rules for spousal impoverishment 1211 Chestnut Street, Suite 600, Philadelphia, PA 19107 (O) 215-587-9377 (F) 215-587-9902 Intake: Monday through Friday, 9:30 a.m. to 1:00 p.m.

Slide 22

Waiver Application Cannot apply at CAO. Must apply through Maximus an independent Enrollment Broker: 877.550.4227 Maximus will come to home and determine if medically qualify. Office of Long-term Living (part of DHS) will determine if meet financial criteria. 1211 Chestnut Street, Suite 600, Philadelphia, PA 19107 (O) 215-587-9377 (F) 215-587-9902 Intake: Monday through Friday, 9:30 a.m. to 1:00 p.m.