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Appendix A: DBHIDS Draft Healthy PA 1115 Demonstration Waiver Questions Healthy PA Section 3.1(1) Provision Eligibility Groups Questions 1.

What is meant by “likely to reside or has already resided in a medical institution?” 2. How is “medical institution” defined? 3. What determines when an individual is “likely to reside” in a medical institution? 1. Will retroactive coverage be provided for individuals in the traditional MA program in the High Risk ABP? 2. How will medically frail individuals be informed of their choice of to enter to the High Risk ABP or the Private Option? 3. If medically frail individuals do not choose either the High Risk ABP or the Private Option what will the default enrollment be? 1. How would penalizing an entire household meet the goals of the personal responsibility and accountability? 2. What methods will be used to determine when a household or an individual will be penalized for nonpayment? 3. What process for appealing penalties will be in place for individuals to contest suspension or disqualification? 4. Who will monitor and track premium payments and nonpayment? 1. Which questions will be included in the Health Risk Assessment (HRA)? 1. How will the Administration assist individuals who have limited access to the internet or technology register on JobGateway? 2. What penalties will students face if they do not register for JobGateway since they are exempt from participating in work search activities? 3. What is the process for applying for an exemption to the work search activity requirements? 4. Who will make the determination on allowing exemptions to work search activities? 5. Will individuals returning the community after receiving treatment for substance use challenges be eligible for an exemption from work search activities?


Eligibility Standards & Methodologies


Eligibility Standards & Methodologies- Premium Requirements

3.2(2) 3.2(2)

Eligibility Standards & Methodologies- Premium Reduction Eligibility Standards & Methodologies-Work Search Activities

Healthy PA Section 4.1(3)

Provision Benefit Chart

Questions 1. At what point if any will post partum women be transitioned from the High Risk Alternative Benefit Plan into the Low Risk or Private Option plan? 2. How will parity be monitored and enforced in addition to the Essential Health Benefit requirements of the Private Option plans? 1. Which questions will be asked as part of the screening tool? 2. Who will interpret the results of the screening and determine which benefit plan to enroll an individual? 3. What process will be in place for an individual to challenge the results of the screening tool? 4. How will the Administration assist individuals who have low literacy rates, are disabled, or have difficulty understanding and administering the screening? 1. How were the benefit limitations determined? 2. What process must individuals follow to apply for exceptions to benefit limits? 3. What length of time must an individual wait before receiving denial or approval of a benefit limit exception? 4. What is meant by “serious deterioration of health?” 5. Who will determine when exceptions are granted? 1. What measures will be taken to protect confidentiality for individuals; especially those with mental health or behavioral health challenges during the screening process? 2. What is the algorithmic process that will be used to determine benefit eligibility? 3. How will individuals who are unsure of their medical history or conditions be assisted with the screening? 4. How will individuals who are placed in the wrong benefit category be moved into the correct category? Who will make this determination? 5. What process is in place if an individual’s life circumstances or health changes prior to the annual redetermination? 6. How will the Commonwealth serve the significant churn that will occur due to individuals completing the screening and moving from one benefit plan to another? 1. How will individuals who are deemed “medically frail” be notified of their choice to enroll in either the Private Option or a High Risk ABP? 2. What type of education will be provided to individuals to help them make an informed choice of which benefit plan to choose? 2


Alternative Benefit Plans


Table 2: Benefit Plan Comparison


Health Screening


Medically Frail

Healthy PA Section 4.8(c) 4.9 4.10 5.2

Provision Wrap-around benefits and cost-sharing Cost Sharing Participant Copayments and Deductibles Delivery System Type

Questions 3. How is “active chronic substance abuse disorder” defined? 1. How will the Commonwealth ensure that there is an adequate network of behavioral health provides within the Private Option? 1. Is the premium truly “sliding scale” or two different amount imposed on two different financial categories? 1. What standard will be used to determine “non-emergent” emergency use? 1. For plans outside of the Federally Facilitated Marketplace, how will the Commonwealth monitor compliance with EHB and parity?