Pennsylvania Undertakes Massive Health Care Overhaul

Hundreds of thousands of Pennsylvania residents left out of coverage under the 2010 federal health care law now have a chance to get insurance as the state undertakes a massive overhaul to health care for the poor.

On Monday, enrollment begins in the Healthy Pennsylvania program, the name given to Pennsylvania's Medicaid expansion by outgoing Republican Gov. Tom Corbett. Coverage will begin Jan. 1, and state officials say some 600,000 people — primarily low-income, single working adults — are newly eligible for coverage under guidelines set by the 2010 law.

The application process comes as the Corbett administration is overhauling benefits in Pennsylvania's existing Medicaid program. That will affect coverage for approximately 900,000 other adults who already are covered by the program, primarily the elderly, disabled, low-income parents or low-income pregnant women.

All can pick from among plans offered by private insurers that the state pays to administer the managed-care coverage.

"This is an extremely complicated policy for the state to implement," said Joan Alker, who follows state Medicaid policies closely as the executive director of the Georgetown Center for Children and Families in Washington. "That's a lot of work to get those complicated benefits packages sorted out and figure out who's going into which plan. And the managed care plans have to know who is getting which benefits package. That's a heavy lift."

Medicaid benefits for children under 21 will not be affected. But for the adults, the changes take effect Jan. 1.

Democratic Gov.-elect Tom Wolf has said he opposes what he views as an unnecessarily complicated process and bureaucracy being set up by Corbett, and Wolf could gradually unwind some elements of Corbett's plan after he takes office Jan. 20.

Meanwhile, the federal government has not approved the final benefit packages proposed by the Corbett administration for both the overhaul and expansion of Pennsylvania's Medicaid program, injecting more uncertainty into how exactly everything will change.

Under the existing Medicaid program, adult enrollees have had have a choice of plans that seven approved insurers across 14 benefit levels divided up among five geographic regions of Pennsylvania. The Corbett administration is sorting them into one of two new benefit levels — low risk and high risk — based on the extent of their medical needs, according to the state Department of Human Services.

Kristen Dama, a lawyer with Community Legal Services of Philadelphia, a public interest law center that helps the poor get access to services, said the overhaul will mean a cut in benefits for every adult, some a little and others a lot. She questioned whether enrollees will end up in the right benefits level, understand the new coverage limits or get the care they need.

Under the expansion of Medicaid's income guidelines, many more people will be eligible for coverage. Now, childless adults making up to $15,600 a year — that's 133 percent of the federal poverty level this year — can apply for coverage. Some parents also will become eligible, depending on income and children.

The coverage plans they can choose from are divided up among nine geographic regions and are offered by eight insurers. Not all are expected to apply right away.

Details of those plans were not yet public, though some hospitals will not accept every plan available in its region. Sicker people will be moved into a high risk plan offered under the existing Medicaid program, state officials say.

The Medicaid expansion could get particularly complicated for some people.

People who earned about $11,500 to $15,300 last year were eligible to buy subsidized coverage through the federally run marketplace that opened last Jan. 1 as part of the 2010 federal law, but they must switch into Pennsylvania's Medicaid system now that its income guidelines are expanding, officials say.

Federal and state officials were unable to say how many people that might affect, but health care advocates worry that the switch could sow confusion.

The expanded Medicaid subsidy became available to states in 2014, but it was delayed a year in Pennsylvania because Corbett had sought federal approval to make changes to it. In broad terms, though, there is little difference between Healthy Pennsylvania and Medicaid.

Both will cover visits to the physician, emergency room and specialists, and prescription drugs.

Effective Jan. 1, Pennsylvania will expand its Medicaid guidelines to make an additional 600,000 people eligible for taxpayer-provided health care, while an overhaul of its existing Medicaid program will affect benefits for an estimated 900,000 adults already on Medicaid. Here's a look at the changes:


  • Named Healthy Pennsylvania, there is little difference between Healthy Pennsylvania and a Medicaid expansion, as it was envisioned by the 2010 federal law.
  • The expansion will make health care available to childless working adults under 65 with incomes up to $15,500 this year. Until now, they were largely ineligible for Medicaid.
  • The expansion also will make health care available to many more low-income parents under 65.
  • The basic benefits package is here under the PCO column.
  • Healthy Pennsylvania will not reimburse insurers for dental coverage or renal dialysis, but insurers may offer it anyway, and it will not subsidize nonemergency transportation to help get people to appointments until 2016.
  • Co-payments are in effect. In 2016, some enrollees will see premiums replace copays, with the exception of an $8 copay for nonemergency use of the emergency room.
  • On Monday, people can begin enrolling online or by telephone, or 866-550-4355, or by going into a county assistance office. Find one here.
  • A broker, PA Enrollment Services, will help enrollees pick a plan. The website is and the hotline is 844-465-8137.


  • About 900,000 adults who are on Medicaid currently will be sorted into one of two new benefit levels based on the extent of their medical needs. Previously, 14 benefit levels had been available.
  • The two new benefit levels are referred to as high risk or low risk. The benefits packages are listed here.
  • Filling out a four-page questionnaire helps sort enrollees into one of the two benefit levels. Afterward, enrollees are to receive a notice indicating which benefit plan they will be placed into.
  • Previous eligibility categories will continue to exist for parents, pregnant women, the disabled, workers with long-term disabilities and the elderly.
Copyright AP - Associated Press
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