adultBasic…. Health Insurance for Adult Pennsylvanians Patricia Stromberg Deputy Commissioner of CHIP and adultBasic Pen

1. adultBasic…. Health Insurance for Adult Pennsylvanians Patricia Stromberg Deputy Commissioner of CHIP and adultBasic Pennsylvania Department of Insurance

2. Tobacco Settlement • Pennsylvania’s Share- $11 Billion • Projected annual payment between $397M and $459M • Governor Ridge proposed plan for use of funds in January 2000 • Health Investment Plan to make Pennsylvanians Healthier • Legislation passed by General Assembly in June 2001 (Act 2001-77)

3. Act 2001-77 • Health Endowment Account- where the money is deposited • Home and Community Based Care (Aging) • Tobacco Use Prevention and Cessation (Health) • Research Enhancement (Health) • Hospital Uncompensated Care (Welfare) • Insurance Coverage for Adults (Insurance) • MA for Workers with Disabilities (Welfare) • Community-Based Health Care (Health) • PACE/PACENET (Aging) • Medical Education Loan Assistance (PHEAA)

4. Who is Eligible foradultBasic? • Persons ages 19 through 64 • Family income below 200% of Federal Income Guidelines (e.g. family of four $36,200) • Legal resident of US and resident of PA for at least 90 days • Not eligible for Medicare or Medicaid • Not covered by health insurance plan, self-insurance plan, or self-funded plan • Not covered by health insurance plan, self-insurance plan, or self-funded plan during three months preceding the determination of eligibility

5. What Benefits are Provided? • Hospitalization (no day limit) • Physician Services (including primary care and specialists) • Emergency Services • Diagnostic Tests (e.g. x-ray, mammogram, laboratory and pathology, etc.) • Rehabilitation in lieu of hospitalization • Pharmacy discount (western and Eastern PA only) • Care managed by PCP, no “special” network of providers • Modest co-pays for PCP, specialist and ER (ER not charged if admission occurs)

6. How does enrollment occur? • Insurers complete enrollment (as with CHIP) • Person may complete application for self or for family unit (i.e adults and children together) • COMPASS is available for use by individual applicants or by community groups (www.compass.state.pa.us) • $30 per month payment • PCP selection

7. CHIP and Medicaid Connections • One application for CHIP and adult coverage • “Any Form” practice in place for adult coverage and Medicaid • Same income deductions from gross income as CHIP ($120 monthly work deduction and child care) • Special attention paid to pregnant women and applicants who indicate a serious or chronic illness or disability

8. Impact to Date • Achieved maximum enrollment within eight months • Implemented a waiting list in the ninth month • Current enrollment averages 40,000 per month, waiting list now includes over 96,000 persons • Over 3000 persons are paying full cost while on the waiting list

9. Who is Enrolled? • More women than men • Perfect age demographic “Bell Curve”- the bulk in the 25-55 age range • Majority have income below the Federal Poverty Level • Over 68 percent stay enrolled more than six months (19% one year or longer)

10. Lessons Learned • Tremendous pent up demand • Enrollees use service at a high level • High utilization has had adverse impact on PMPM rates- and exacerbated the funding issues