Lawmakers and telemedicine advocates say Pennsylvania’s new law will lead to increased health care access – and healthier Pennsylvanians. Read more.

On October 24, the Pennsylvania Department of Human Services (DHS) published the September 2024 Managed Care Enrollment Information. This report contains the number of consumers that are medical assistance eligible and managed care eligible at any time during the month. The data is based on capitation payments and therefore each consumer Medicaid paid for in the month is counted.

The commonwealth’s health insurance marketplace continues to transform four years after the state took ownership from the federal government. Pennie, which was created to provide the opportunity for individuals and families who don’t have access to employer-sponsored health insurance or government-run coverage like Medicare or Medicaid, has allowed the commonwealth and its health partners to maintain local control and operation of customer service, reinsurance programs and more. Read more.

IBX’s Keystone Health Plan East continued to have Pennsylvania’s highest claim denial rate last year among plans sold on the Obamacare marketplace, the Pennsylvania Insurance Department reported this month. Read more.

With Enhanced Premium Tax Credits set to expire at the end of 2025, customer affordability is a huge focus for consumers. The enhanced premium tax credits were first enacted by the American Rescue Plan in 2021 and then were extended by the Inflation Reduction Act in 2022 but without congressional action, millions could see premiums increase by hundreds of dollars. Beginning November 1, customers will likely see an increase in plan premiums on Pennie.com for the 2025 plan year. While the PA Department of Insurance approved rates, some counties will see increased competition and changes to the second lowest-cost silver plan which is used along with income and family size to calculate a household’s premium tax credit. In this article, Pennie Executive Director, Devon Trolley, speaks on affordability and highlights the potential savings available to customers as nine in 10 people receive financial savings to assist with premiums and lowering the cost of copay and deductibles.

DHS issued MA Bulletin 99-24-08 Pennsylvania’s Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program Periodicity Schedule and Coding Matrix, effective Oct. 29, 2024. This bulletin applies to all providers enrolled in the Medical Assistance (MA) Program who provide EPSDT screens for MA beneficiaries in the fee-for-service and managed care delivery systems. Providers rendering services in the managed care delivery system should address any payment related questions to the appropriate MA managed care organization. This is in response to CMS published highly anticipated guidance on early and periodic screening, diagnostic, and treatment (EPSDT) benefit. Under the EPSDT requirements at Section 1905(a)(4)(B) and (r) of the Social Security Act, children under age 21 are entitled to Medicaid coverage of Section 1905(a) services that are medically necessary to correct or ameliorate physical or mental conditions, even if these services are not covered under the state plan.

CMS updated the Medicare Benefit Policy Manual, Chapter 13 (PDF) with CY 2024 requirements and payment policies for Rural Health Clinics and Federally Qualified Health Centers.

The updated booklets can be found using these links:

·       Information for Rural Health Clinics (PDF) booklet

·       Federally Qualified Health Center (PDF) booklet

·       Instruction to your Medicare Administrative Contractor (PDF)

Under Section 5121 of the Consolidated Appropriations Act of 2023, states will be required to provide screening, diagnostic, and targeted case management services to young people who are reentering from incarceration. CMS recently posted a slide deck on the requirements, which outlines relevant State Plan Amendment processes. CMS also recently issued a Notice of Funding Opportunity (NOFO) for planning grants to promote continuity of care during reentry. Grant funds can be used to support Medicaid and reentry efforts, including establishing claims processing systems at correctional facilities, investing in IT to establish bidirectional data exchange between Medicaid and corrections, and setting up processes to screen for Medicaid and CHIP eligibility in correctional facilities. There are two application deadlines for this funding: November 26 for Cohort 1, and March 17 for Cohort 2.

Pennsylvania Governor Josh Shapiro signed legislation that would extend Medicaid coverage to doula services in the state. Under the new law, introduced as HB 1608, Medicaid will reimburse certified doulas for providing childbirth education and support services, including physical and emotional support, during pregnancy, labor and delivery and up to one year postpartum. The law also establishes a Doula Advisory Board to set standards and requirements for doulas practicing in Pennsylvania. The board would include a diverse membership, including practicing providers and representatives from various state agencies. In January 2024, DHS released MA Bulletin 13-24-01 on how Doula’s can enroll in the Medicaid Program. DHS expects to issue an MA Bulletin in the coming months with billing instructions for doulas enrolled in Medicaid. DHS anticipates doulas will be able to bill Medicaid beginning January 1, 2025.

Funding secured in multistate opioid settlements by then-Pennsylvania Attorney General Josh Shapiro, now Governor Shapiro, continues to help Pennsylvania prevent substance use disorder.

 The Pennsylvania Department of Drug and Alcohol Programs (DDAP) announced the availability of $2 million in funding to implement community-based prevention services throughout Pennsylvania to prevent opioid use disorder (OUD). Funding for these grants is provided from the Mallinckrodt Opioid Settlement, which was the result of a multistate investigation spearheaded by then-Attorney General Josh Shapiro that led to billions in settlement agreements with opioid manufacturers and distributors.

“Prevention really is our first line of defense in ensuring substance use disorder doesn’t develop,” said DDAP Secretary Dr. Latika Davis-Jones. “The Shapiro Administration is committed to providing critical prevention supports and resources throughout Pennsylvania’s cities, neighborhoods, towns, and communities as a whole. With this $2 million investment, DDAP will award approximately 10 grants of up to $200,000 each to eligible community-based organizations.”  

Applicants are required to propose activities that focus on the primary prevention of OUD. Primary prevention refers to programs or activities that prevent the initiation of substance use/misuse or prevent use beyond initial experimentation. In addition, all proposed activities must take place in community settings or post-secondary education settings including colleges or universities.

Examples of allowable prevention activities include:

• Community anti-drug coalitions that engage in drug use prevention efforts;
• Supporting community coalitions in implementing evidence-informed prevention, such as reduced social access and physical access, stigma reduction – including staffing, educational campaigns, support for individuals in treatment or recovery, or training of coalitions in evidence-informed implementation, including the Strategic Prevention Framework developed by the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA);
• Engaging non-profits and faith-based communities as organizations to support prevention;
• Evidence-based or evidence-informed community education programs and campaigns for youth, families, and others;
• Youth-focused programs or strategies that have demonstrated effectiveness in preventing drug misuse and seem likely to be effective in preventing the uptake and use of opioids;
• Community-based education or intervention services for families, youth, and adolescents at risk for OUD and any co-occurring substance use disorder and mental health conditions; and
• Evidence-informed programs or curricula to address mental health needs of young people who may be at risk of misusing opioids or other drugs, including emotional modulation and resilience skills.

DDAP is placing a focus on health equity as a part of this grant opportunity. Based on a variety of criteria from the Pennsylvania Department of Health’s 2022 overdose death data, DDAP will select three grantees located in Philadelphia, three grantees located in Allegheny County and four grantees from the remaining 19 qualifying counties located within Pennsylvania with a crude death rate higher than the state average.

All applications must be submitted electronically by 12:00 PM on Friday, December 13, 2024. Applications will be competitively reviewed and scored based upon the applicant’s adherence to the funding announcement guidelines, and a timely submission to DDAP.

Questions regarding the grants and the application process should be forwarded to RA-DAGrantsMgmt@pa.gov.