Health Update - Feb 24, 2014: Manatt on Medicaid: Pennsylvania Submits Waiver Application for Approval to Implement ACA Medicaid Expansion

by Manatt, Phelps & Phillips, LLP

Editor’s note: Projected to cover a record 65 million Americans in 2014--and as many as 1 in 4 by 2020--Medicaid will play a significant role in shaping the strategies and plans of all healthcare stakeholders in the years ahead. Recognizing the importance of a growing and changing Medicaid in shaping the new healthcare environment, the Medicaid team at Manatt will be producing a series of briefs—Manatt on Medicaid—throughout the year. The third edition, summarized below, focuses on Pennsylvania’s waiver application to the Centers for Medicare and Medicaid Services (CMS) requesting approval to move forward with ACA Medicaid Expansion. Click here to read the full brief.

On February 19, 2014, Pennsylvania submitted to CMS an application requesting approval under Section 1115 of the Social Security Act to implement the Affordable Care Act (ACA) Medicaid expansion effective January 1, 2015.

Under the Healthy Pennsylvania Private Coverage Option (Healthy Pennsylvania), individuals in the new adult group, so long as they are not medically frail, would be covered through premium assistance for private insurance—either Qualified Health Plans (QHPs) purchased through the Health Insurance Marketplace (Marketplace) or employer-sponsored coverage.  The key features of the Healthy Pennsylvania program include the following:

  • Eligibility. All individuals over age 21 in the new adult group, excluding those individuals determined to be medically frail, are eligible for Healthy Pennsylvania. 
  • Coverage Models. Pennsylvania proposes to purchase coverage for all newly eligible adults through one of two types of premium assistance. Individuals would be required to enroll in a QHP or employer-sponsored coverage (if available).
  • Benefits. Under the ACA, covered benefits for newly eligible adults in Medicaid (the Alternative Benefit Plan or ABP) are based on ACA-defined Essential Health Benefits with certain additional requirements, including nonemergency transportation. Pennsylvania has requested a waiver of the requirement that Medicaid separately cover any ABP benefit that is not covered under the QHP or employer-sponsored coverage benefit packages.
  • Premiums. Healthy Pennsylvania enrollees with incomes from 100%–133% of the FPL would be required to pay a monthly premium of $25 or $35, depending on the number of adults in their household.
  • Cost-Sharing. For year 1 of the demonstration, all Healthy Pennsylvania enrollees would be required to make cost-sharing payments in amounts consistent with federal Medicaid law. In year 2, all Healthy Pennsylvania enrollees would be required to pay $10 in cost-sharing for nonemergency use of the emergency room—more than the $8 currently permitted under federal Medicaid law.  Healthy Pennsylvania enrollees with incomes above 100% of the FPL would only be required to pay cost-sharing for nonemergency use of the emergency room, while enrollees with incomes below 100% of the FPL would continue to pay cost-sharing amounts on other services in addition to the cost-sharing for nonemergency use of the emergency room.
  • Healthy Behavior Incentives. Healthy Pennsylvania enrollees may have their premium and cost-sharing obligations reduced if they adopt specified healthy behaviors.
  • Work Requirements. All new adults who are either unemployed or working fewer than 20 hours per week would be required to complete 12 job-search or job-training activities per month to maintain Medicaid eligibility.
  • Retroactive Coverage. Pennsylvania has requested a waiver of the requirement to provide coverage for the three months prior to the date an individual applied for Medicaid coverage. Coverage would become effective on the first day of the individual’s enrollment in a private plan, which could be several weeks after a person is determined eligible.

Similarities and Differences with Iowa and Arkansas

The Healthy Pennsylvania demonstration proposal marks the third expansion waiver (Arkansas and Iowa are the others) to use premium assistance to purchase QHP coverage for individuals in the new adult group.  Like Arkansas, Pennsylvania intends to buy QHP coverage for all new adults except those who are medically frail.  By contrast, Iowa is using QHP premium assistance only for new adults with incomes above 100% of the FPL.

There are, however, important differences between Pennsylvania’s proposed program and those CMS approved for Iowa and Arkansas.  For instance, Pennsylvania’s program:

  • Includes premiums that exceed 2% of income for some individuals
  • Could deny coverage for failure to pay premiums 
  • Imposes work requirements as a condition of eligibility
  • Seeks to waive federal requirements related to benefits, retroactive coverage and cost sharing

All in all, Pennsylvania requests significantly more waivers of federal requirements (24 in total) as compared to the Arkansas and Iowa waivers. Given the number of waivers Pennsylvania seeks and its request for several waiver authorities CMS has not previously granted, states and other stakeholders will be closely watching Pennsylvania’s expansion demonstration.

Written by:

Manatt, Phelps & Phillips, LLP

Manatt, Phelps & Phillips, LLP on:

Readers' Choice 2017
Reporters on Deadline

"My best business intelligence, in one easy email…"

Your first step to building a free, personalized, morning email brief covering pertinent authors and topics on JD Supra:
Sign up using*

Already signed up? Log in here

*By using the service, you signify your acceptance of JD Supra's Privacy Policy.
Custom Email Digest
Privacy Policy (Updated: October 8, 2015):

JD Supra provides users with access to its legal industry publishing services (the "Service") through its website (the "Website") as well as through other sources. Our policies with regard to data collection and use of personal information of users of the Service, regardless of the manner in which users access the Service, and visitors to the Website are set forth in this statement ("Policy"). By using the Service, you signify your acceptance of this Policy.

Information Collection and Use by JD Supra

JD Supra collects users' names, companies, titles, e-mail address and industry. JD Supra also tracks the pages that users visit, logs IP addresses and aggregates non-personally identifiable user data and browser type. This data is gathered using cookies and other technologies.

The information and data collected is used to authenticate users and to send notifications relating to the Service, including email alerts to which users have subscribed; to manage the Service and Website, to improve the Service and to customize the user's experience. This information is also provided to the authors of the content to give them insight into their readership and help them to improve their content, so that it is most useful for our users.

JD Supra does not sell, rent or otherwise provide your details to third parties, other than to the authors of the content on JD Supra.

If you prefer not to enable cookies, you may change your browser settings to disable cookies; however, please note that rejecting cookies while visiting the Website may result in certain parts of the Website not operating correctly or as efficiently as if cookies were allowed.

Email Choice/Opt-out

Users who opt in to receive emails may choose to no longer receive e-mail updates and newsletters by selecting the "opt-out of future email" option in the email they receive from JD Supra or in their JD Supra account management screen.


JD Supra takes reasonable precautions to insure that user information is kept private. We restrict access to user information to those individuals who reasonably need access to perform their job functions, such as our third party email service, customer service personnel and technical staff. However, please note that no method of transmitting or storing data is completely secure and we cannot guarantee the security of user information. Unauthorized entry or use, hardware or software failure, and other factors may compromise the security of user information at any time.

If you have reason to believe that your interaction with us is no longer secure, you must immediately notify us of the problem by contacting us at In the unlikely event that we believe that the security of your user information in our possession or control may have been compromised, we may seek to notify you of that development and, if so, will endeavor to do so as promptly as practicable under the circumstances.

Sharing and Disclosure of Information JD Supra Collects

Except as otherwise described in this privacy statement, JD Supra will not disclose personal information to any third party unless we believe that disclosure is necessary to: (1) comply with applicable laws; (2) respond to governmental inquiries or requests; (3) comply with valid legal process; (4) protect the rights, privacy, safety or property of JD Supra, users of the Service, Website visitors or the public; (5) permit us to pursue available remedies or limit the damages that we may sustain; and (6) enforce our Terms & Conditions of Use.

In the event there is a change in the corporate structure of JD Supra such as, but not limited to, merger, consolidation, sale, liquidation or transfer of substantial assets, JD Supra may, in its sole discretion, transfer, sell or assign information collected on and through the Service to one or more affiliated or unaffiliated third parties.

Links to Other Websites

This Website and the Service may contain links to other websites. The operator of such other websites may collect information about you, including through cookies or other technologies. If you are using the Service through the Website and link to another site, you will leave the Website and this Policy will not apply to your use of and activity on those other sites. We encourage you to read the legal notices posted on those sites, including their privacy policies. We shall have no responsibility or liability for your visitation to, and the data collection and use practices of, such other sites. This Policy applies solely to the information collected in connection with your use of this Website and does not apply to any practices conducted offline or in connection with any other websites.

Changes in Our Privacy Policy

We reserve the right to change this Policy at any time. Please refer to the date at the top of this page to determine when this Policy was last revised. Any changes to our privacy policy will become effective upon posting of the revised policy on the Website. By continuing to use the Service or Website following such changes, you will be deemed to have agreed to such changes. If you do not agree with the terms of this Policy, as it may be amended from time to time, in whole or part, please do not continue using the Service or the Website.

Contacting JD Supra

If you have any questions about this privacy statement, the practices of this site, your dealings with this Web site, or if you would like to change any of the information you have provided to us, please contact us at:

- hide
*With LinkedIn, you don't need to create a separate login to manage your free JD Supra account, and we can make suggestions based on your needs and interests. We will not post anything on LinkedIn in your name. Or, sign up using your email address.