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Pennsylvania’s Medicaid plans poised for overhaul

The Associated Press

HARRISBURG — Gov. Tom Corbett’s administration is telling hundreds of thousands of adult Medicaid enrollees that their benefits will change as part of an overhaul of the coverage plans beginning Jan. 1.

Notices were mailed last week, and adult enrollees will be sorted into one of two plans that best fit their needs, a spokeswoman for the Department of Public Welfare said Tuesday.

Precise plan changes were unavailable, because the department does not have the federal government’s approval yet, spokeswoman Kait Gillis said. “They are working with us,” she said.

The overhaul in medical plans under the traditional Medicaid program — which insures many nursing home residents, childless adults with no income and some low-income parents — is separate from the vast, federally funded expansion of Medicaid eligibility set to take effect in Pennsylvania on Jan. 1.

Changes to coverage under the traditional Medicaid program will simplify the lineup of 14 plans to two and save money by better tailoring benefits to the needs of each enrollee, the Corbett administration says. Benefits for children younger than 21 will not change.

Democratic Gov.-elect Tom Wolf, who will take office Jan. 20 after beating Corbett in last week’s election, has said he opposes the changes because he views them as a reduction of benefits for the poor.

Community Legal Services of Philadelphia, a public-interest law center that helps the poor get access to services, said the changes will mean a cut in benefits for every adult — some a little and others a lot.

The plans include a “high risk” one for people with chronic health problems and more generous benefits, and a “low risk” one for healthier people who do not need as much medical care.

Every Medicaid enrollee who is in a nursing home, 65 or older, pregnant, mentally or physically disabled or dealing with a chronic medical condition or substance abuse will go into the high-risk plan, according to the Department of Public Welfare.

But many working-age adults who are on Medicaid will go into the low-risk program, which will limit the reimbursement for many services.

Under a draft of the low-risk program distributed by the Department of Public Welfare, an enrollee would be able to visit a physician’s office four times a year. Visits to other health care facilities would be limited — for instance, six per year to a federally qualified health center and two per year to an outpatient surgery center. Reimbursed purchases of durable medical equipment and medical supplies would each be limited to $1,000 per year. Radiology tests would be limited to six per year and reimbursed lab work would be limited to $350 per year.

There is no limit on any of those services, and Gillis said there would be no limits on visits to an enrollee’s primary care doctor. The plan would still cover an unlimited number of ambulance rides and visits to emergency rooms or family planning clinics.


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