This week, DPW begins mailing all adult Medical Assistance (MA) recipients a letter introducing them to benefit changes tied to the Healthy PA initiative. The letter tells each adult recipient which of three benefit packages they will likely receive starting January 1, 2015.

Please note: the MA benefit package for children under age 21 is not being changed.

Adults assigned to the Healthy or Healthy PA Private Coverage Option (PCO) may need to take action to be sure they have coverage for needed services next year. Individuals placed in these two groups who fail to act may end up with a benefit package that does not meet their needs and they may be unable to change this package until the end of 2015.

To help people understand these notices and what action, if any, is needed, PHLP offers this summary of the benefit packages so you can better help your adult clients on MA. Examples of the particular mailings being sent for each benefit package are linked below.

• Healthy Plus – Also referred to as “high risk,” Healthy Plus is the benefit package assigned to all adults in a disability-related MA category (i.e., Healthy Horizons, Medical Assistance for Workers with Disabilities, Home and Community Based Services Waivers, those on Medicare, those in Nursing Homes or other institutional settings), and any adult found to be “medically frail.” This will become the most comprehensive MA benefit package. No action is needed if someone is given this benefit package.
• Healthy – Also referred to as “low risk,” Healthy is a benefit package that will have limits on a number of services. For example, radiology will be limited to six tests per year and lab work will be limited to $350 per year. This package is assigned primarily to adults in the low-income parent and caretaker category who have not been found to be “medically frail.”

Any adult assigned this benefit package who needs regular, ongoing physical or behavioral health care services should seek the Healthy Plus package by completing a health screen questionnaire before November 26th either (i) online through My COMPASS account or (ii) by phone at (844) 290-3448.

• Healthy PA Private Coverage Option (PCO) – The Healthy PA PCO benefit package will have service limits. It will be given to adults in the General Assistance-related MA category who are not “medically frail.” These individuals will also be moved out of their current HealthChoices managed care plan and into the new Private Coverage Option. To pick a PCO plan for coverage starting January 1, 2015, these recipients should call enrollment services at (844) 465-8137.

Any adult assigned this benefit package who needs regular, ongoing physical or behavioral health care services should seek the Healthy Plus package by completing a health screen questionnaire before November 26th either (i) online through My COMPASS account or (ii) by phone at (844) 290-3448.

Individuals assigned to the Healthy or Healthy PA PCO benefit package who miss the November 26th deadline for completing the health screen could still seek the Healthy Plus package by completing an Employability Assessment Form (EAF). If the doctor checks box 1 or box 2 on the form, this can help someone qualify for a MA category that automatically gets the Healthy Plus benefit package. The form will need to be submitted to the individual’s local County Assistance Office after it is completed by the individual and the doctor. We encourage individuals to include a note with the EAF asking that their eligibility be reviewed using this new information.

Each letter includes a general listing of services expected to be covered under each benefit package, but no details are given about the amount of services or limitations on services. All adults on MA will receive a notice in December confirming which benefit package they will receive in 2015. If they disagree with the assignment, they can file an appeal at that time. PHLP may be able to help with those appeals.

For a printable version of this alert, click here.