Pennsylvania Gov.-elect Tom Wolf will face federal, state and contractual hurdles should he try to overturn his Republican predecessor's alternative Medicaid expansion initiative for the expansion plan he favors. The Democrat will also confront a challenge in trying to stop the state from restricting benefits for those in the traditional Medicaid program, another Republican initiative.
Open enrollment began Monday for Healthy Pennsylvania, outgoing Gov. Tom Corbett's alternative expansion model for which as many as 600,000 people may be eligible. As part of the initiative, the state built a second Medicaid managed-care system, separate from the existing Medicaid system that serves about 1.6 million residents. .
Undoing Corbett's alternative expansion will require CMS approval, according to Kati Gillis, a spokeswoman for the state's Department of Public Welfare. Another issue is that the state has binding contracts with eight health plans to offer coverage under Healthy Pennsylvania and it's unclear if those can be broken without financial penalties, she said.
Politically, the state's General Assembly has a Republican majority in both its chambers, meaning any move by Wolf to push Medicaid expansion will run into fierce opposition there.
“It is important to note that although Gov. Corbett was defeated, the Republicans increased their control of the chambers in both the state House and Senate. The Legislature is likely to resist some of Gov. Wolf's changes, making it difficult to predict at this point how this will all pan out,” said Izanne Leonard-Haak, a managing principal in Health Management Associates' Harrisburg, Pa., office, in a November analysis on Healthy Pennsylvania (PDF).
Wolf had asked Corbett to stop implementing Healthy Pennsylvania because he planned to institute a simple expansion of the state's existing Medicaid program. The Corbett administration declined the request.
“In order to ensure 600,000 have coverage by Jan. 1, we need to move forward as planned,” Gillis said.
The state also is moving ahead with its plans to alter benefits of those in the traditional Medicaid program, even though it's yet to get the necessary CMS approval to do so, Gillis said. The changes were initially outlined in the same waiver that created Healthy Pennsylvania.
Wolf has said he opposes the proposed Medicaid changes because he views them as a reduction of benefits for the poor.
Federal policy allows states to move forward with these proposed state Medicaid plan amendments while waiting on CMS approval, Gillis said. Gillis said she expects the federal agency to issue its formal ruling on the alterations by March 2015. All the changes can be scrapped should the CMS ultimately not consent, Gillis said.
A request for comment from the CMS was not returned. The state's decision to move forward with benefit changes that the CMS could ultimately veto will likely add to the confusion providers already are feeling about the implementation of Medicaid expansion in the state, according to Dennis Olmstead, chief strategy officer for the Pennsylvania Medical Society. Some are still waiting to find out which Healthy Pennsylvania plans they are in, he added.
Pennsylvania plans to split the traditional Medicaid population into a high-risk and low-risk group based on historic utilization data. Those in the low-risk group are believed to be healthier and those in the high-risk plan group will be people who have more complicated medical situations.
In the past, most services were covered without limits. Now the state is adding restrictions to benefits. For instance, those considered low risk will be limited to two non-emergency hospital admissions annually, while those in the high risk group will be limited to three.
In another example, high-risk traditional Medicaid beneficiaries will be limited to eight radiology tests per year, while those in the low-risk group will be limited to six.
Wolf did not return a request for comment.
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