adultBasic

1

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

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Tobacco Settlement

• Pennsylvanias 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)

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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)

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Who is Eligible for adultBasic?

• 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

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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)

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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

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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

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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

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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)

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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