*05/01/2009

New draft NFCE standard released for comments. The state has finally released a draft NFCE clarification and guidance to the field. This would set the standard for who can and who cannot get home and community based services through a Medicaid Waiver program. Comments should be submitted to Brian Lester at blester@state.pa.us. PHLP's comments will be posted shortly. For more information about this issue, please see our April/May edition of SHN and prior SHN editions.

*02/06/2009

Rendell Releases Proposed 2008/2009 Budget. Click here for more details.

Governor Rendell announces proposed budget for 2009-2010. Read PHLP's Summary of the Proposed Budget.

*10/07/2008 More Information About Act 62

Act 62 recently was signed into law on July 9, 2008 and mandates that large group insurers cover the diagnosis and treatment of autism and autism spectrum disorders for persons under the age of 21. The Act takes effect July 1, 2009.   The PA Department of Public Welfare, PA Insurance Department and PA Department of State are working closely together to implement the new law and communicate with families and other stakeholders. 

The PA Department of Public Welfare  will soon be launching a website for  about the new Autism Insurance law . Plans for the website's contents include helpful information about the new legislation, frequently asked questions,  information  for  certified behavioral health specialists and other autism health providers, education sessions and a description of the  appeals  process.  The website is called www.PAAutismIinsurance.org and is scheduled to be launched October 15, 2008.   

As an important resource for families, the PA Department of Welfare in conjunction with the PA Insurance Department  and PA Department of State  also  established an e-mail account where families can submit specific questions concerning autism diagnosis, treatment and insurance coverage. The two agencies will strive to provide timely answers directly to the family submitting the question. The questions, and their corresponding answers, may also be posted on the new website for others to view. The e-mail account is now open for use, and its address is ra-in-autism@state.pa.us .

*02/01/2009

PHLP Welcomes Its New Director. Click here for a full update.

* 05/01/2008

PHLP Releases Manual: How To Obtain Mental Health and Drug & Alcohol Services in Pennsylvania (May 2008). Click here for the manual.

*05/14/2008 Feds Approve PA Autism Waiver!

On May 14, 2008, the Centers for Medicare and Medicaid Services (“CMS”) approved Pennsylvania's request to use federal Medicaid funds to establish a program that provides home and community based services for adults with autism. This program is know as the Autism Waiver and is the first such program for adults in the nation to receive federal approval. The $20 million-a-year waiver program will serve up to 200 individuals initially. Waiver eligibility is limited to people who:

•  Have a diagnosis of Autism Spectrum Disorder (ASD), Childhood Disintegrative Disorder; Pervasive Developmental Disorder-Not Otherwise Specified; Rett Disorder as determined by a licensed psychologist or physician.

•  Are 21 years old or older.

•  Have significant functional limitations

•  Have countable income below $1,911 (for 2008) and assets (not including house or car and other “exempt” assets) below $8,000. Parent's income and assets do not count.

The Autism Waiver is designed to provide community-based services and supports to meet the specific needs of adults with ASD. The participant will choose a Supports Coordination Agency which will then conduct state-specified assessments and work with the participant and individuals he or she chooses to develop an Individual Support Plan (ISP). Services include Day Habilitation, Respite (for caregiver family members), Supported Employment, Therapies, Assistive Technology, Behavioral Specialist, Community Inclusion, Community Transition, Environmental Modifications, Family Counseling, Family Training, Job Assessment, Nutritional Consultation, Temporary Crisis, and Transitional Work. The waiver offers only agency-managed services. The Department of Public Welfare (DPW) intends to submit a waiver amendment to add participant-directed services at a later date.

Individuals may request services by calling a new toll-free number for DPW's Bureau of Autism Services at 1-866-539-7689. Waiver slots will be divided by regions with persons who are not receiving state or federally funded “long term care” services (including other waivers) having top priority. During the first 6 weeks, slots for these people will be given out on a random basis. Persons receiving state or federally funded long term care services or on other waivers will only be eligible for the autism waiver slots if every applicant without services has already received a waiver slot.

More information on distribution of slots

More information on covered services

 

*03/17/2008 Pennsylvania House Votes to Help Uninsured Adults

AdultBasic Program to be Replaced by More Comprehensive "ABC" Program

On March 17, the Pennsylvania House of Representatives voted to expand subsidized health insurance to uninsured adults between the ages of 19 and 64 with household income up to 200% of the federal poverty level under a new program to be called Pennsylvania Access to Basic Care (ABC). The program would succeed the current adultBasic program, which began under the Ridge Administration. In addition to covering prescription drugs and behavioral health services, which are not paid for by adultBasic, the new program would provide sufficient funding to eliminate the adultBasic waiting list, which now exceeds 81,000 persons. AdultBasic presently covers just over 53,000 Pennsylvanians. The vote on the measure was bi-partisan, with seventeen Republicans joining the House Democrats in support. The legislation (SB 1137) is expected to face significant opposition in the Pennsylvania Senate.

Cost to Purchase Coverage

Under ABC there would be no health insurance premium for adults whose income is below 150% of the federal poverty level. ABC would charge a monthly premium of $40.00 for those with income between 150% and 175% of poverty, and $50.00 for those between 175% and 200%. As currently structured, persons with income between 200% and 300% of the poverty level could purchase the insurance at cost. Those with income above 300% of poverty could purchase it at cost but only upon demonstrating that other coverage is unaffordable or that they were refused other coverage due to a preexisting condition. There would be no pre-existing condition exclusions under ABC.

Conditions of Eligibility

Only Pennsylvania residents (for 90 days) who are legally residing in the United States could qualify for ABC. An applicant would have to have been without health insurance for a period of six months, unless health insurance was lost due to unemployment, divorce, separation, death of a family member, or if the individual is transferring from another publicly financed health insurance program. Persons eligible for Medicare or Medical Assistance could not qualify for ABC.

Encouraging Employers to Offer Coverage

Small, low-wage employers with between 2 and 50 employees who pay an average annual wage below 300% of the poverty level ($31,200) and who have not offered health insurance for 6 months could buy into the ABC program for their employees by paying half the cost of coverage. These employers would have to offer their employees an option to pay their share of the premium in pre-tax dollars.

Unlike the Governor's "Cover All Pennsylvanians" plan, ABC would not penalize employers for not offering health insurance. Instead, in addition to offering premium subsidies to small, low-wage employers, SB 1137 would establish a pool of money to offset the cost of health care for employers who have offered health insurance to their employees for 12 months. This money would be distributed in the form of tax relief called "Continuing Access with Relief for Employers" (CARE) grants.

Funding for ABC

ABC would be paid for by rolling over the current funding for the adultBasic program; adding untapped reserves from the Medical Care Availability and Reduction of Error (MCARE) fund that pays provides malpractice insurance relief to physicians; drawing down federal matching funds; and imposing a tax on smokeless tobacco.

Prospects for Expanded Coverage

SB 1137 permits ABC subsidies to be expanded to help those with income up to 300% of the poverty level ($63,600 for a family of four), if the federal government is willing to provide matching funds. Last year, the federal government agreed to support Pennsylvania 's Cover All Kids initiative under the CHIP program, which extended subsidized coverage to kids up to the 300% of poverty level. However, since that time, the Bush Administration has taken a much harder line on health insurance expansion, and it will likely take a change in administration before Pennsylvania can extend coverage beyond the 200% level ($42,400 for a family of four).

 

*02/12/2008 Autism Waiver Update- Comments due by February 27th

The draft Autism Waiver is now available for comment. It can be downloaded at http://www.dpw.state.pa.us/ServicesPrograms/Autism/News/2008NewsAnnouncements/003677257.htm There are 9 sections. The waiver uses a federally mandated template. The waiver would provide a broad range of community-based services to persons age 21 and older with autism spectrum disorders. Children and youths under 21 would not be eligible for the autism waiver but would continue to be eligible for services under other programs such as EPSDT (including wraparound), Early Intervention (for infants and pre-schoolers) and the mental retardation waivers (if IQ below 70).

Despite what is stated on the web site, comments will be accepted until close of business on February 27 th .

Comments via email should be sent to DPW-AutismOffice@state.pa.us with the subject line, "Comments on Autism Waiver".

Comments via regular mail should be addressed to:
Bureau of Autism Services
Office of Developmental Programs
PA Department of Public Welfare
P.O. Box 2675
Harrisburg PA 17105-2675

While the draft waiver states that the waiver does not provide for participant directed services, we have been assured by the Director of the Autism Bureau that the Waiver will be amended to include participant directed services. The only reason they are not mentioned in this draft is that autism waiver participants who choose to self direct will be required to use the Office of Developmental Programs' new state-wide ISO (fiscal intermediary) to handle payroll and taxes and the Office of Developmental Programs had not finalized its contract with the new ISO at the time the autism waiver was drafted.

Services where participant direction will be an option are:

• Community inclusion
• Respite
• Supportive living

* 11/01/2007 Two Bills Introduced to "Cover All Pennsylvanians"

Legislators in the Pennsylvania House and Senate have introduced stand alone bills to establish Governor Rendell's proposed program, called "Cover All Pennsylvanians" or "CAP," to insure 700,000 adults currently without health insurance. House Bill 1870, introduced by Representative Sturla, and Senate Bill 1117, introduced by Senator Costa, would create the program to provide subsidies for low-income families and small employers that the governor first described in January as part of his "Prescription for Pennsylvania."

The bills essentially lift the CAP piece from House Bill 700, which also contains many other reforms, and puts it into its own legislation. HB 1870 and SB 1117 are very similar. Both bills propose to reduce the number of uninsured adults in the state by offering affordable health insurance to persons 19-64 that they can obtain either as an employee of a small, low-wage business or by purchasing coverage individually. Individuals with household income less than 200% of the federal poverty level (FPL) who have been without insurance for at least 90 days would pay:

• $0/mo. if income is less than 150% FPL
• $40/mo. if income is between 150-200% FPL

Individuals with income greater than 200% FPL who have been uninsured at least 180 days would pay:

• $60/mo. if income is 200%-300% FPL
• $267/mo. if income is above 300% FPL

The basic benefit package that each bill proposes would include: annual wellness and health assessments; inpatient hospital care; ER visits; emergency ambulance; outpatient care (up to 18 visits/year); prescription drugs, and limited mental health and drug & alcohol treatment.

Both bills propose creating a restricted account known as the Cover All Pennsylvanians (CAP) Fund that would be funded through a combination of: money received from the federal government, Tobacco Settlement Funds dedicated to the adultBasic Program (those with adultBasic coverage as well as those on the waiting list would be moved over to the CAP program), and other appropriations.

The major difference between the two bills is that the House Bill contains an employer Fair Share Assessment of 3% on all wages paid by employers who do not offer qualifying health care coverage to their employees. The Senate Bill does not contain this penalty which has been opposed by some employers across the state, citing reasons similar to those raised against the minimum wage increase last year. Other employers have supported the assessment, arguing that they are carrying the burden for employers who do not provide health insurance for employees, since 6.5% of their health insurance costs go to covering the uninsured.

SB 1117 was referred to the Senate Banking and Insurance Committee on October 25 th . House Bill 1870 was referred to Insurance Committee of the House on October 3 rd . To check the progress of these and other Bills, one can go to www.legis.state.pa.us/cfdocs/legis/home/session.cfm?papowerNav=1 .

*07/17/2007

For years, Pennsylvania has considered the need to develop separate licensure and regulation of assisted living residences. In numerous prior legislative sessions, there have been bills proposing to license and regulation assisted living. This 2007-08 session there have been four Assisted Living Bills introduced in the Pennsylvania Legislature.

Senator Vance's Assisted Living Bill – SB 704

Senate Bill 704 becomes law as Act 56 of 2007.  Regulations process anticipated to begin in fall 2007.

Representative Mundy's Assisted Living Bill – HB 1583

Representative Watson's Assisted Living Bill – HB 375

Representative McIlvaine-Smith's Assisted Living Bill – HB 1213

Rendell Administration releases draft Assisted Living bill.  Click here to view Administration's draft bill and click here to view Administration's statement of principles . This draft bill was prepared for Representative Mundy to introduce as HB 1583.

Most consumer groups feel that assisted living must contain several key elements. The Consumer Subcommittee of the Medical Assistance Advisory Committee, for example, urged the Administration to ensure that the Mundy bill (which the Administration was drafting for Representative Mundy) contained at least the following critical elements:

• A separate controlled public funding stream must be dedicated and existing HCBS waiver programs must be protected.
• There must be sufficient, accessible, private living space and bedroom for all consumers, regardless of income and Access to assisted living.
• Privacy, dignity, self-direction, choice, independence, and autonomy in residency and services, including choice of services provider must be ensured.
• A complete list of unwaivable residents' rights must be articulated.
• A consumer's individual needs and preferences must be evaluated and frank discussion and service planning must take place as to how those needs and preferences will be met prior to a contract for residency in an Assisted Living Facility.
• All requirements and expectations must be fully, fairly, and understandably disclosed in writing prior to a contract for residency in an Assisted Living Facility.
• All facilities must meet the most current standards for safe construction and physical site design, no exceptions.
• Residents must not be forced expressly or by threat of discharge to sign negotiated risk agreements.
• An affirmative obligation to reasonably accommodate needs and preferences must be included.
• Licensure and enforcement tools must be articulated in statute and these must greatly exceed the inadequate array of tools currently operating in the personal care home enforcement activities.
• There must be articulated clear minimum standards for staff and administrator qualifications and initial training requirements that must be satisfied with demonstrated competency prior to independent work with residents as well as continuing education requirements, with no grandfathering.

 

* 07/17/2007 Governor and General Assembly Reach Agreement on 2007-08 Budget

On Tuesday, July 17, 2007 the Governor signed the state budget bill (HB 1286) that was passed by the General Assembly late the night before. A number of other pieces of legislation passed the General Assembly as part of the budget negotiations and have either been signed or are awaiting his signature. The budget includes funding for substantial reduction of the MR waiting list, including elimination of the entire list of persons waiting for outpatient services. The Welfare Department will not be tossing its HMO contractors out of 26 counties where managed care is an option for Medical Assistance recipients, as the governor had proposed. Nor will the state be taking over responsibility for all Medicaid prescription drug coverage from the HMOs, a carve-out which had been proposed by the governor to cut costs for a second year in a row. The budget gave DPW more than twice what the Governor had asked for in funds for autism services. The $9,955,000 in state funding should draw down an additional $13,029,000 in federal funds.

On July 20, the Governor signed a series of bills (HB 1251 through 1255 and SB 455) which should have the effect of improving access to health services by expanding the scope of practice for several types of practitioners. These include: physician assistants, certified registered nurse practitioners, clinical nurse specialists, nurse midwives, and dental hygienists. This expansion was part of the governor's "Prescription for Pennsylvania." A second part of Rx for PA to pass was legislation aimed at reducing health care facility acquired infections. Pursuant to SB 968, health care facilities and ambulatory surgical facilities will be required to develop infection control plans, and those that reduce the number of health care facility acquired infections by 10% in a year will qualify for a bonus payment starting in 2009.

One major disappointment was the passage of SB 704, the Assisted Living law. The bill is barebones legislation that allows persons who need the nursing home level of care to be served in a newly created type of facility called Assisted Living. This should have the effect of reducing Medical Assistance costs, but will also reduce standards of care. It allows for the so-called negotiated risk between ownership and residents, which has been used in other states to extract unwarranted waivers of liability from unsuspecting residents. It leaves much to regulation, but requires only that the standards for Assisted Living be at least as good as for personal care homes. It gives priority for home and community based services waivers to residents of assisted living facilities, thereby potentially cannibalizing the other waivers for the elderly and those with disabilities.

HB 1295 contains language stating that the Medical Assistance Transportation Program (MATP) is only to be used as a payment of last resort for eligible MA recipients. It remains to be seen how DPW will interpret this, but some advocates fear that it could be used to revitalize past practices of harassment such as forcing patients to justify why they do not switch physicians to one whose office is closer to where the patient lives, or to prove that they cannot get a ride with a friend or relative.

* 3/2/2007- Cover All Kids Takes Effect on March 1, 2007

On March 1, 2007, Pennsylvania expanded its CHIP program to make health insurance available to virtually all children who are citizens or in a qualified immigrant status. CHIP provides free or low-cost comprehensive health insurance through private insurance companies to children under age 19 whose families have low-income but do not qualify for Medical Assistance. The initiative is called Cover All Kids.

Here's how it works :

•  Children in families under 200% of the Federal Poverty Limits (about $41,300 for a family of 4) will qualify for CHIP with no monthly premiums. These children will also have no copays for services.

•  Children in families from 200% to 300% of the Federal Poverty Limits (about $41,300 to $61,950 for a family of 4) will qualify for CHIP with a monthly premium from $38 to $60 per month. These children will have reduced-cost copays (such as $6 for a generic medication and $10 for a specialist visit).

•  Children in families over 300% of the Federal Poverty Limits (about $61,950 for a family of 4) will still qualify for CHIP for a monthly premium of $150, if they do not have other coverage which is affordable and available. These children will have copays (such as $10 for a generic medication and $25 for a specialist visit).

CHIP offers extensive coverage, including prescriptions, check-ups, immunizations, emergency care, hospitalizations, specialists, dental, vision, and more!

Here's how to apply :

•  Go to the CHIP website and complete an on-line application: www.chipcoverspakids.com

Or

•  Call the CHIP Helpline at 1-800-986-KIDS and enroll over the phone

Or

•  Call the CHIP Helpline at 1-800-986-KIDS and request CHIP send you an application you can submit by mail

If you have problems applying or for further information contact the PA Health Law Project Helpline at 1-800-274-3896

* 1/18/07- Governor Rendell Announces Plan to Provide Health Care Coverage for All Pennsylvanians. On January 17, 2007, Governor Rendell announced his “Prescription for Pennsylvania: Right State. Right Plan. Right Now.” At a briefing at the Governor's Residence in Harrisburg on January 17th, PHLP learned the following:

The Prescription for Pennsylvania is a two pronged plan to address the drastically increasing healthcare costs impacting the Pennsylvania economy (such as the 75.6% increase in healthcare premiums over the past 6 years versus a 13.3% increase in median wages) and to address the problem faced by Pennsylvania's 900,000 uninsured turning to emergency rooms for care that would have been far less costly if delivered before their conditions worsened.

The first prong of the plan is an array of steps designed at Driving Down Health Care Costs in the Commonwealth . The Governors Office of Health Care Reform has identified numerous areas where it says unnecessary healthcare dollars are being spent, and savings can be achieved.

1. Reducing Unnecessary Emergency Room Use. Tremendous dollars are spent on this most costly care, often when the needs of the patient require urgent but not emergent care. As part of the Prescription for Pennsylvania, the Governor would require every hospital to have a non-emergent care center open for 24 hours a day to complement the emergency room and improve efficiencies. The urgent care center would be staffed by nurse practitioners for half the cost. Pennsylvanians use the emergency room 11% more than the national average. Similarly, financial incentives would be created for medical practices to maintain weekend and evening hours for patients with urgent but not emergent problems to deliver care but avoid the costly and unnecessary emergency room visit.
2. Increasing Disease Prevention and Management. The Governor proposes incentivizing or requiring insurers to engage in greater disease management to reduce the unnecessary hospitalizations of individuals with chronic disease. The adoption of the “wagner model” of chronic care management would be implemented with a projected savings in the millions.
3. Reducing Hospital Acquired Infections. Because large sums are spent on unnecessary readmissions or extensions of hospital stays as a result of Hospital Acquired Infections (an additional $150,000 cost per stay), the plan would work to require reductions and, eventually, impose financial penalties for failures to reduce Hospital Acquired Infection rates.
4. Maximizing Healthcare Professionals Scope of Practice. Another area for cost-savings proposed includes maximizing the practices of nurse practitioners, pharmacists, and other healthcare professionals so that the scope of practice takes advantage of the full range of skills and training these professionals have had.
5. Encouraging workforce development and healthcare access in underserved areas. Money will be spent to facilitate development or expansion of FQHCs or nurse managed health centers in underserved areas. Money will be used to provide loan forgiveness to healthcare professionals as well.
6. Paying Insurers and Providers for performance. The plan would undertake payment shifts to hinge payment levels on quality of care.
7. Insuring quality of care. The plan would require all hospitals to have quality management and error reduction systems as a condition of state licensure.
8. Communicating Healthcare Costs. The plan would call for transparency in pricing of pharmaceuticals – so that pharmacists would publish their price to consumers.
9. Reducing health insurance premiums. Coupled with the steps in the second prong of the plan, the Prescription for Pennsylvania would require that insurance premium rates be devised without reference to certain demographic characteristics, and for small businesses, insurers would have to spend at least 85% of premiums to pay for health care.
10. Making Pennsylvania SMOKEFREE. The plan would prohibit smoking in all workplaces, restaurants, and bars to improve overall health and reduce second hand smoking deaths.
11. Improving wellness. The plan would incentivize reduced healthcare costs based on achieving wellness goals. Additionally, public education curricula would be revised to include wellness education and public school breakfasts and snacks would be revamped to include more nutritious foods.

The second prong or part of the Prescription for Pennsylvania is the Cover All Pennsylvanians or "CAP" program. The Governor framed that as an expansion to adults of the new Cover All Kids program and explained CAP as relying on the same basic principles. Because 770,000 of the 900,000 uninsured Pennsylvanians are adults and 71% of these are employed but low-wage earning adults, the plan would subsidize the low-wage earners' employers purchase of CAP insurance. The CAP insurance would be available through the Blue Cross Plans, and would include coverage similar to that which is currently available to working adults under 200% of the federal poverty level through the adultBasic program. However the benefit package would be expanded to include prescription drug coverage and behavioral health coverage. The existing adultBasic coverage program would be subsumed by the new Cover all Pennsylvanians program.

The CAP program would be available to small employers, individuals, and self-employed persons. Individuals under 200% of the Federal Poverty Level (FPL), would have to have been uninsured for at least 3 months to be eligible and individuals under 300% would have to have had no insurance for 6 months or more to dissuade employers from simply discontinuing health coverage. For employers with less than 50 employees and an average wage less than the state average, CAP could be purchased at an employer cost of $130 for each employee. Employees would pay a monthly premium of between $10 and $70, depending on income and family size. And, the state would pay the remainder of the premiums. Uninsured spouses could also purchase the coverage. Individuals with household income under 300% of the federal poverty level could purchase the insurance directly with premium amounts ranging from $10-70. (Under 100% FPL at $10/month; from 100%-200% FPL at $40/month and from 200-300% at$60/month). And, individuals with household income over 300% of the federal poverty level could purchase the insurance at the state's cost which is reported as being approximately $280/month..

The revenue source for the state premiums would be:

•  federal dollars available through a state Medicaid 1115 waiver for serving individuals up to 300% FPL

•  a new tax on smokeless tobacco and cigars

•  an increased cigarette tax

•  an assessment of 3% of payroll that would be charged to all "free riders" i.e. employers who do not provide health insurance

•  Tobacco Settlement dollars for adultBasic and uncompensated care

The Governor commented that this plan is more comprehensive than the Massachusetts or California plans. At this point, the Commonwealth would like to encourage everyone to get health insurance by making it affordable; however the Governor noted that he is not ruling out a mandate that all individuals with income over 300% of the Federal Poverty Level, and 4-year college and graduate students purchase health insurance.

Governor Rendell described his plan as a work in progress. He will be going to 25 localities in the coming weeks to explain the plan, and additional workgroups and planning meetings will occur. The plan has many parts, and will require, he says, some 47 separate pieces of legislation for full implementation. More information from the Governor's Office of Health Care Reform is available on the GOHCR website www.ochr.state.pa.us . And, more detail is said to be forthcoming in the Governor's February 6 th budget announcement.

* Logisticare takes over Philadelphia Medical Assistance Transportation from MTM on December 1. Logisticare taking reservations for rides on December 1 and afterwards now. Click here for more details.

* 12/4/06- State to refund MA copayments for BCCPT recipients who were wrongly charged copayments. Medical Assistance beneficiaries who are covered through the Breast and Cervical Cancer Prevention and Treatment Program (BCCPT) will be receiving refunds for all co-payments they paid since March 31, 2006. The Budget Reconciliation Act of 2005, allowing states to make cuts in Medicaid services, also included this small bonus – women eligible under BCCPT are exempt from co-pays. The consumer sub-committee of the Medical Assistance Advisory Committee urged the Pennsylvania Department of Public Welfare to facilitate refunds directly to consumers and DPW has accepted the recommendation.

The Department will go through claims forms and identify all persons in the BCCPT program who had visits to providers that required co-pay. Unless the provider indicated that the co-pay was waived, the consumer will receive a refund from DPW. Consumers who receive refunds will be told that if the provider did not collect the co-pay, then the consumer owes that co-pay to the provider.

Women covered under the BCCPT program should no longer owe any co-pays for any Medical Assistance visits. Approximately 1000 women across the state are covered under this program.

* 12/4/06- Governor Signs Cover all Kids Legistlation. Law will make health care available for to most kids in Pennsylvania. The Governor has signed House Bill 2699, which will expand eligibility for subsidized CHIP, increase subsidies for CHIP, and allow many who do not qualify for subsidized CHIP to purchase it at cost. Free Chip will be available for those children who do not qualify for Medical Assistance if their family income is below 200% of the federal income poverty limit. Currently, that amount is $40,000 for a family of 4. There is no resource (asset) test under CHIP. The following subsidies are available for children between 200% and 300% of the poverty level:

·               200% to 250% - 75% subsidy

·               250% to 275% - 65% subsidy

·               275% to 300% - 60% subsidy

Currently, the cost to purchase CHIP is $143 per child per month. Based on this figure, the monthly premium payment for CHIP for any child qualifying for a 75% subsidy will be $36 per month, for a 65% subsidy will be $50 per child, and for a 60% subsidy will be $57 per child.

The Insurance Department has been granted authority to set increased co-payments for certain CHIP services, and intends to permit co-payments below.

For families with income between 200% and 300% of the federal poverty guideline:

·            $5.00 for a primary care physician visit

·            $10.00 for a specialist visit

·            $25.00 for an emergency room visit if not admitted

·            $9.00 for a bran name prescription drug and $6.00 for a generic

For families with income above 300% of the federal poverty guideline:

·            $15.00 for a primary care physician visit

·            $25.00 for a specialist visit

·            $50.00 for an emergency room visit if not admitted

·            $18.00 for a brand name prescription drug and $10.00 for a generic

In order to discourage employers from dropping health insurance, no child in a family with income above 200% of the poverty level will qualify for CHIP unless they have been without health insurance for 6 months. This rule will not apply to children under the age of 2 (subject to CMS approval), or where the parent is eligible for unemployment compensation, or where the parent is not eligible for unemployment compensation but had health insurance and is no longer employed. The rule will also not apply if a child is transferring from one government subsidized health care program (i.e. Medical Assistance) to another.

In order for a family with income above 300% of the federal poverty level to qualify to purchase CHIP, the family must show either that: 1) purchasing individual or group coverage would exceed 10% of the family income, or 2) the total cost of coverage would exceed 150% of the CHIP premium, or 3) the family has been refused coverage due to a pre-existing condition.

The law gives the state the right to purchase coverage from an individual's employer rather than CHIP if the insurance meets minimum coverage requirements and the Insurance Department determines that it would be more cost effective.

The new law will be effective 30 days following publication of a notice in the Pennsylvania Bulletin, or on January 1, 2007, whichever is later The CHIP law sunsets on December 31, 2010.

* 7/21/06- DPW Releases Details for Implementation of Citizenship Documentation Requirements for MA Recipients

Ops memo Verifying Citizenship and Identity

DPW Citizenship and ID Procedure

Citizenship and ID Desk Guide

DPW Citizenship and ID Form

Citizenship Applicant Ltr

Citizenship Recipient Ltr

Letter from CMS re: citizenship

What's New: Verifying Citizenship and ID

* Special Pharmaceutical Benefits Program (SPBP) and the Chronic Renal Disease Program autoenroll Medicare Part D eligibles into Medicare Rx plans. Click here for more details.

* State releases list of Medicare Rx plans partnering with PACE/ PACENET/ SPBP/ CRDP. Click here for the list in pdf.

* State passes PACE + Medicare bill. Click here for information from The Department of Aging. Click here for a list of the Part D Plans That PACE/PACENET Members will be Auto-Enrolled into under “PACE Plus Medicare"

* Personal Care Home Provider Lawsuit dismissed. DPW now enforcing new consumer protections. Click here for more details.

* 7/21/06- UPMC Pulling out of Voluntary Managed Care Counties

UPMC is pulling out of four counties where it operated voluntary MA managed care plans. The four counties are Blair, Cambria, Somerset and Venango. This will affect about 4,400 people in total, though about half are in Venango county. The pullout is scheduled to be effective on October 1, 2006, though DPW has said that if necessary, the date could be extended to November 1, 2006.

Notices will go out to affected consumers letting them know their options. In counties where there are other voluntary managed care organizations, consumers will be giving the choice of moving into another voluntary HMO or moving into Access Plus. However, in Venango county, where the most consumers would be affected, there are no other managed care plans. In that county, all consumers will be moved into Access Plus/ Fee-for-Service. Nonetheless, affected persons in Venango County need to select a primary care practitioner (PCP).

 

* 5/19/06- 30,000 people on adultBasic waiting list to be offered coverage in June 2006.

Later this month 30,000 people on the adultBasic waiting list will receive offers of coverage. The offers will go out to eligible people who got on the waiting list on or before June 6, 2005. Notices will be sent by mail. The monthly premium is $33.50 per month.

This is a reduction in the waiting list- with these offers of coverage, the adultBasic waiting list will be reduced to about 40,000 people. This is the lowest level for the waiting list in over 3 years. Currently, there are 49,743 individuals enrolled in the adultBasic program.

PHLP urges uninsured Pennsylvanians to sign up for adultBasic. Those who need treatment while on the waiting list can purchase coverage at cost- about $305/ month.

* 5/6/06- New Law Requires Documentation by Citizens For MA.

Beginning July 1, 2006 Most Medicaid Applicants and Recipients Must Produce

A Birth Certificate and Proof of Identification

The Deficit Reduction Act of 2005 (Sec. 6036) has thrown a significant barrier into the path of Medicaid applicants and recipients. Beginning July 1, 2006, federal law requires those claiming to be US citizens or nationals to provide documentary proof at the time of Medicaid application or redetermination. The rules governing who qualifies for Medicaid are not changing. A PERSON DOES NOT HAVE TO BE A CITIZEN to qualify for Medicaid. However, it will be very hard for many citizens to get the necessary documentation to prove citizenship.

The new federal law specifies that citizens must produce:

1. U.S. Passport or

2. Certificate of Naturalization (Form N-550 or N-570) or

3. Certificate of US Citizenship (Form 560 or 561) or

4. A valid state-issued drivers license (from some states, NOT including Pennsylvania) or

5. Such other documentation as the Secretary of HHS specifies, by regulation, which provides proof of US citizenship or nationality and provides a reliable means of documentation of personal identity.

Those who cannot produce the documents listed above must produce a combination of:

1. A birth certificate or

2. A certification of birth abroad (Form FS-545 or Form DS-1350) or

3. United States Citizenship Identification Card (Form I-97) or

4. Form FS-240 (Report of Birth Abroad of a Citizen of the United States) or

5. Such other document as the Secretary of HHS may specify that provides proof of US citizenship or nationality.

AND

1. Any identity document described in section 274A(b)(1)(D) of the Immigration and Nationality Act or

2. Any other documentation of personal identity of such other type as the Secretary of HHS finds, by regulation, provides a reliable means of identification.

Since most poor people covered by this law do not have a passport, they will have to produce a combination documents from the latter two lists. The Secretary of HHS is expected to issue a "Dear Medicaid Director" letter in the near future, clarifying what forms of proof will be acceptable, and setting forth which individuals are exempt from having to produce these proofs. Based on a draft of the dear Medicaid Director" letter and a conference call with the state Medicaid directors, it is believed that SSI recipients, children receiving foster care payments, and possibly Medicare and/or Social Security recipients may be exempt from the proof requirements. HHS also suggested that hospital records from the time of birth, religious records of birth (baptismal records or a note in the family bible?), and affidavits by two blood relatives of the applicant's/recipient's date and place of birth in the U.S. may be acceptable proofs of citizenship, although they will only be sufficient in combination with an acceptable proof of identity. Proof of identity would likely include a current driver's license with a picture, a state issued identity card (if the state required proof of identity), or such other proof as the state concludes will establish the true identity of the individual.

Obtaining the required documentation could be expensive and difficult if not insurmountable for some persons, especially for elderly persons, those born out of state, those not born in a hospital, the homeless, those who have lost records in a disaster, and those with mental illness. According to the Center on Budget and Policy Priorities, a recent examination by the HHS Office of Inspector General indicates that the new requirement is unnecessary since the authority to investigate suspect claims already exists. Families USA cites a Congressional Budget Office report that the provision will reduce Medicaid spending by $220 million between 2006 and 2010. However, Families USA goes on to suggest that much of the savings will be achieved by denying Medicaid to otherwise eligible citizens rather than ridding the system of immigrants who are illegally obtaining coverage.

As of this writing, DPW is investigating ways to facilitate the electronic transfer of information to DPW from the Department of Health (where birth certificates in Pennsylvania are kept) and from PennDot (where drivers licenses, which can be used to prove identity but not citizenship, are kept). Some advocates are contacting the Secretary of HHS or their elected representatives to urge a reasonable approach, and at least one bill has been introduced (S.2305) to repeal the documentation requirement.

* 2/2006- Smoking Cessation in pregnancy White Paper released by PHLP and the Consumer Health Coalition. Click here to see the white paper.

* Pennsylvania Bulletin detailing changes to Medical Assistance for adults released. Click here for a link to the Bulletin.

* Kaiser paper published by Gene Bishop, MD on Drug Formularies- Implications for Medicare. Click here for a link to the report.

* Holding Blue Cross Plans Accountable: PHLP collaborates on efforts to hold Blue Cross Plans Accountable on Charitable Mission. Click here for briefs and documents related to this initiative.

* Archived information about The Pennsylvania Campaign for Affordable Health Care