DBHIDS Healthy PA Appendix A

8/13/2019 DBHIDS Healthy PA Appendix A

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Appendix A: DBHIDS Draft Healthy PA1115 Demonstration Waiver Questions

Healthy PA

Section

Provision Questions

3.1(1) Eligibility Groups 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?

3.2(2) Eligibility Standards &Methodologies

1. Will retroactive coverage be provided for individuals in the traditional MA program inthe High Risk ABP?2. How will medically frail individuals be informed of their choice of to enter to the HighRisk ABP or the Private Option?3. If medically frail individuals do not choose either the High Risk ABP or the PrivateOption what will the default enrollment be?

3.2(2) Eligibility Standards &Methodologies- PremiumRequirements

1. How would penalizing an entire household meet the goals of the personal responsibilityand accountability?2. What methods will be used to determine when a household or an individual will bepenalized for nonpayment?3. What process for appealing penalties will be in place for individuals to contestsuspension or disqualification?4. Who will monitor and track premium payments and nonpayment?

3.2(2) Eligibility Standards &Methodologies- PremiumReduction

1. Which questions will be included in the Health Risk Assessment (HRA)?

3.2(2) Eligibility Standards &

Methodologies-Work SearchActivities

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 areexempt from participating in work search activities?3. What is the process for applying for an exemption to the work search activityrequirements?4. Who will make the determination on allowing exemptions to work search activities?5. Will individuals returning the community after receiving treatment for substance usechallenges be eligible for an exemption from work search activities?


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Healthy PASection

Provision Questions

4.1(3) Benefit Chart 1. At what point if any will post partum women be transitioned from the High RiskAlternative Benefit Plan into the Low Risk or Private Option plan?

2. How will parity be monitored and enforced in addition to the Essential Health Benefitrequirements of the Private Option plans?

4.2(4) Alternative Benefit 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 enrollan individual?3. What process will be in place for an individual to challenge the results of the screeningtool?4. How will the Administration assist individuals who have low literacy rates, are disabled,or have difficulty understanding and administering the screening?

4.3 Table 2: Benefit PlanComparison

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 abenefit limit exception?4. What is meant by serious deterioration of health?5. Who will determine when exceptions are granted?

4.4 Health Screening 1. What measures will be taken to protect confidentiality for individuals; especially thosewith 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 assistedwith 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 individuals life circumstances or health changes prior tothe annual redetermination?6. How will the Commonwealth serve the significant churn that will occur due toindividuals completing the screening and moving from one benefit plan to another?

4.5 Medically Frail 1. How will individuals who are deemed medically frail be notified of their choice toenroll 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 informedchoice of which benefit plan to choose?


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Healthy PASection

Provision Questions

3. How is active chronic substance abuse disorder defined?

4.8(c) Wrap-around benefits and

cost-sharing

1. How will the Commonwealth ensure that there is an adequate network of behavioral

health provides within the Private Option?4.9 Cost Sharing 1. Is the premium truly sliding scale or two different amount imposed on two different

financial categories?

4.10 Participant Copayments andDeductibles

1. What standard will be used to determine non-emergent emergency use?

5.2 Delivery System Type 1. For plans outside of the Federally Facilitated Marketplace, how will the Commonwealthmonitor compliance with EHB and parity?

Documents

DBHIDS Healthy PA Appendix A