Medicaid Expansion in Pennsylvania

Premium Assistance and the Medicaid Waiver Process

PREMIUM ASSISTANCE DEMONSTRATIONS

• PA is seeking a waiver under Sec. 1115 to substitute “Premium Assistance” for regular Medicaid

• The proposal is called “Healthy Pennsylvania”• Under the plan PA would purchase insurance

on the private market • Other states have sought similar

demonstrations

What does Section 1115 say?

• Sec. 1115. [42 U.S.C. 1315] (a) In the case of any experimental, pilot, or demonstration project which, in the judgment of the Secretary, is likely to assist in promoting the objectives of title … XIX in a State or States—

• (1) the Secretary may waive compliance with any of the requirements of section … 1902, as the case may be, to the extent and for the period he finds necessary….

How would the new program be different?

• Work requirement for all adults who are not disabled or 65+

• Premiums (monthly payments) required for individuals and families above 50% of poverty

• Coverage through the Marketplace using commercial plans

• Fewer benefits for all enrollees

§ 1115 Demonstrations:Background, Purpose and

Scope1. Experimental, pilot or demonstration project

• Demonstration purpose must be evident• Proper methodologies and evaluation required

2. Must promote the objectives of the Medicaid Act

3. Secretary may:• Waive compliance with requirements of § 1902• Provisions not expressly waived still apply

4. Special rules for Premium Assistancesee March 2013 CMS paper

Procedural Requirements

• Budget Neutrality• Cost to federal government with demonstration would not

exceed federal costs without the demonstration

• NEW!!! Public Process and transparency required• Regulations finalized at 77 Fed. Reg. 11,696 (Feb. 27,

2012)• 42 C.F.R. §§ 431.400-428

• Evaluation and reporting requirements• Public hearing 6-months post-implementation• Annual reports

Public Process

• Web-posted “comprehensive” description of the proposed demonstration

• 30-day state comment period before submission to CMS

• At least two public hearings 20-days before submission to CMS

• One 30-day federal comment period• CMS posts record on Medicaid.gov

Special Process for Waiver to Allow Premiums

SSA § 1916(f) – No deductible, cost sharing or similar charge (including premiums) may be waived under any waiver authority unless it undergoes a public notice and comment and meets tightly circumscribed criteria:

• Tests a unique and previously untested use• Is no more than 2 years• Expected benefits to enrollees at least equivalent to risks• Based on reasonable hypotheses and sound methodology,

including control groups• Is voluntary or makes provision for assumption of liability for

preventable damage to the health of enrollees resulting from involuntary participation.

What next?• Work requirements and premiums will be very

controversial – what will CMS do?• What will benefits package look like?• Who will be considered “medically frail” and

will they get better benefits package?• What does PA mean by saying beneficiaries

will not be considered Medicaid beneficiaries?• When if ever will PA expand?

Timeline

• December 6, 2013: Pennsylvania reveals its “comprehensive” proposal, publishes it on the web and in the Pennsylvania Bulletin. Public comment period begins.

• Pennsylvania holds 6 hearings; limits oral comments to 3 minutes.

• January 13, 2014: State public comment period ends.

Timeline II

• February 19, 2014: Pennsylvania responds to comments, makes changes and submits waiver to federal government (CMS).

• February 27, 2014: CMS decides whether submission is “complete.” If incomplete, time stops until state submits satisfactory information.

• March 5, 2014: PA revises work search proposal

Timeline III

• March 17, 2014: (estimated) CMS starts 30 day federal comment period.

• April 11, 2014 (6:00 am): Federal comment period ends.

• Thereafter: CMS makes decision to approve, deny or requests further information or modification (which may require a new state comment period).