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Institute Prescription Drug

Monitoring Program
Promote Good Public
Health
Support Older
Pennsylvanians &
Persons with Disabilities
Advance Telemedicine
Promote Access to
Primary Health Care
Get All Kids Insured
Reform PAs Medical
Liability System
Reform Pennsylvanias
Medicaid Program
Healthy Pennsylvania Plan
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HPA Chronology
ACA passed
in 2010. US
Supreme
Court ruling
in 2012
April 2, 2013
Gov. met with
Secretary
Sebelius on PA
specific solution
Sept. 16, 2013
Governor
launched
Healthy
Pennsylvania
Dec. 2013 Jan. 2014
DPW held 7 Public
hearings across state
& 2 webinars; 1,000
attendees & 170 live
testimonies
Feb. 19, 2014,
Healthy
Pennsylvania
waiver officially
submitted to CMS.
May 8, 2014,
DPW released
Request for
Application for
private coverage
to insurers
June 10, 2014,
DPW received
bids from nine
PA health care
insurers
August 28, 2014
Pennsylvania
and CMS reach
agreement on
Healthy
Pennsylvania
This is a Pennsylvania-specific plan to reform Medicaid,
protect taxpayers, and increase access to quality,
affordable health care.
Pennsylvania is the first state in the country to have a
sweeping common sense, state-based Medicaid reform
plan approved by the federal government.
Increases access to coverage for more than 600,000
eligible Pennsylvanians
Enrollment to begin on December 1, 2014 with an
implementation for coverage effective on J anuary 1,
2015

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Key Facts
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A Pennsylvania-specific Plan
Medical Assistance
(Vulnerable
Pennsylvanians)

Low income
parents/
caretaker
relatives with
incomes up to
133% FPL
Children
Medically frail
Individuals with
disabilities
Seniors
Private Coverage
Option
(January 1, 2015)

Childless adults
Adult
parents/caretaker
relatives
Incomes up to
133% FPL
Working poor
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Healthy Pennsylvania
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Medicaid
Reforms
Reduce # of plans: 14 plans to Low Risk & High Risk
Benefit Changes: Limit #of visits & limit types of
benefits provided based on commercial standards and
needs of individual
Eligibility Changes: Move categories of people from
Medical Assistance to private coverage
Private
Coverage
Create new private commercial products to
increase access to coverage for more than 600,000
eligible Pennsylvanians: Plan similar to employer-
sponsored coverage
Healthy Pennsylvania
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Personal
Responsibility
Employment: PA first state allowed to
offer incentivized employment program
to reduce cost sharing. Participants will
be assigned a HPA Career Coach and
enrolled in J ob Gateway.
Healthy Behaviors: Healthy behaviors
to allow reductions in health care cost
sharing
Healthy Pennsylvania
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Cost
Sharing
Premiums:
1. First state allowed to require a premium of 2%
of household income for individuals with
incomes greater than 100%FPL, starts in Year 2
2. One of only a few states allowed to dis-enroll
individuals for failure to pay premiums for 90
days
Co-Payments:
1. $8 co-pay for non-emergency use of ER
2. Provider can refuse service for failure to make
co-pay for those above 100% FPL

Healthy Pennsylvania
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Reformed Medicaid
Currently eligible aged 21-
64 and medically frail up
to 133% FPL
Private Coverage Option
Adults 21-64 with incomes
up to 133% FPL, not on
Medicaid
Benefits
Reduce #of benefit plans from 14 to low risk & high risk

Low risk/high risk benefits aligned with recipient needs

Private commercial product with essential health benefits

Encouraging Employment
Incentivized employment and job training

Cost Sharing
Copayments in Year 1 of Healthy PA

Copayments in Years 2-5 of Healthy PA

Premium of 2% of household income for individuals over 100%
FPL

Disenrollment for failure to pay premiums after 90 Days

$8 copayment for non-emergency use of the ER

Provider can refuse service for failure to make copayment for
those above 100% FPL

Healthy Behaviors
Healthy behaviors can reduce cost sharing

Healthy PA Private Coverage Across the State
Region 1: United Healthcare, UPMC,
Gateway Health, Vista

Region 2: UPMC, Gateway Health, Vista,
Keystone Health Plan West/Highmark

Region 3: Geisinger Health Plan, United
Healthcare, Vista

Region 4: United Healthcare, Aetna Better
Health, UPMC, Vista, Keystone Health Plan
West/Highmark, Gateway Health

Region 5: United Healthcare, UPMC,
Gateway Health,Vista

Region 6: Geisinger Health Plan, United
Healthcare, Gateway Health, Vista, Capital
Blue Cross
Region 7: Geisinger Health Plan, United Healthcare, UPMC, Gateway Health, Vista, Capital Blue Cross

Region 8: United Healthcare, Aetna Better Health, Health Partners, Gateway Health, Vista

Region 9: United Healthcare, Aetna Better Health, Gateway Health, Vista, Capital Blue Cross
The Healthy Pennsylvania Private Coverage Option will begin providing
coverage on J an. 1, 2015.
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Healthy Pennsylvania Taxpayer Savings
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FY 14-15 FY 15-16

ACA $218,954,121 $331,046,519
Administrative Costs $39,751,000 $38,091,000
Healthy PA (savings) ($125,405,377) ($616,396,847)

Total in First 2 Years $133,299,744 ($247,259,328)

Cumulative Total by Year 8 = $4.5 Billion