Continuity of care could be in jeopardy for Pennsylvania residents enrolled in the state's Medicaid expansion program.
Gov. Tom Wolf's administration has been transitioning beneficiaries as he dismantles his GOP predecessor's alternative Medicaid expansion. Under former Gov. Tom Corbett's Healthy Pennsylvania program, the state built a second Medicaid managed-care plan known as the private coverage option (PCO), which was separate from the state's traditional Medicaid program, HealthChoices. About 250,000 people were enrolled in the program as of April. As many as 600,000 residents were expected to be eligible for expanded Medicaid.
In late April, 121,234 PCO enrollees were moved to HealthChoices, and the remaining members will be transitioned by September 1.
Wolf argues that the program's structure, devised to put a conservative spin on expanding coverage, has created confusion for recipients and led to some being placed in the wrong plans.
For the most part, beneficiaries were expected to be able to stay with the same payer, as most companies had both a PCO and HealthChoices offering, but that wasn't the case for Capital BlueCross, which had enrolled 20,000 people in its PCO plan.
The state worked with Capital BlueCross to find a way for it to become a HealthChoices vendor, but the options were few. There is a formal request for proposal (RFP) process to get a contract that can offer coverage under the program but those contracts will not be open for bid until 2016.
One of the state's suggestions to the payer was to partner with a competitor that had a HealthChoices contract, but no companies were interested in doing so, said Gary D. St. Hilaire, CEO of Capital BlueCross. St. Hilaire expressed disappointment that his company could not continue to provide coverage to expansion enrollees, especially considering the work Capital BlueCross committed to the effort.
“We implemented this program in less than four months. Implementing regulated programs usually take anywhere from four to 12 months,” Hilaire said. “It's disappointing…but you move on.”
He said the company has been working with the state to ensure a seamless transition to a new plan for its beneficiaries.
Pennsylvania also will have to contend with the issue of whether the provider community will be willing to see patients, since the PCO paid more than HealthChoices. How much more has been a mystery, since both plans and their providers have generally been unwilling to disclose the differences.
St. Hilaire said his PCO plan was paying 90% of costs for providers, as most of its territory comprised rural areas with few options, so competition for appointments could be steep. The national Medicaid reimbursement average is 60% of costs.
Taking on hundreds of thousands of low-income individuals at once at standard Medicaid rates has been a major concern for hospitals in the state, leading them “to look at their contracts [with plans] to see if they can sustain those payment changes,” said Paula Bussard, chief strategy officer for The Hospital & Healthsystem Association of Pennsylvania.
For now, the state's Department of Human Services has not heard of any widespread concerns about rates, said its spokeswoman Kait Gillis. She added that she remains confident there will be minimal disruptions in patient care.