Starting on January 1, Pennsylvania will employ a preferred drug list for its Medicaid program – a list that applies to both fee-for-service and managed care patients.

And as many as 150,000 of the state’s 2.8 million Medicaid beneficiaries may find themselves facing changes in their prescription drugs.

The purpose of the PDL is to save money – an estimated $85 million a year, according to the Pennsylvania Department of Human Services, which administers the state’s Medicaid program.

While physicians may submit requests to the state for exemptions for specific patients for specific purposes, those exemptions may be relatively uncommon:  the managed care plans that serve the vast majority of the state’s Medicaid population face daily fines starting at $1000 a day if their adherence to the new PDL falls below 95 percent.

Learn more about Pennsylvania’s new Medicaid PDL and how it may affect providers and patients in the Philadelphia Inquirer article “Nearly 150,000 in Pa. could be forced to change medications beginning on Jan.1.  Here’s why.”

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The cost of treating Medicaid patients who suffer from hepatitis C is posing a challenge to Pennsylvania’s Medicaid program.

As new, more expensive, but more effective hepatitis C drugs reach the market, the state’s costs for treating Medicaid patients with the disease have doubled since 2013.

Meanwhile, the state continues to consider at what point in the progression of their hepatitis C Medicaid patients should be offered the most expensive drugs.
Current guidelines are evolving both in the state and nationally, with medical authorities and federal regulators weighing in with their views. Recently, an advisory committee to the Pennsylvania Department of Human Services offered its own recommendations for criteria for prescribing the most expensive drugs.

Learn more about the issue, the cost of treatment, and current Pennsylvania Medicaid policy on when hepatitis C patients must be offered the most expensive drugs and how that policy might be changing in this Pittsburgh Post-Gazette article.…

The Pennsylvania Department of Human Services (DHS) has issued a request for proposals (RFP) for organizations interested in serving the state’s Medicaid population through its HealthChoices Medicaid managed care program.

The HealthChoices program, introduced in 1997, currently serves nearly 2.5 million Pennsylvanians. Among them, 200,000 have enrolled in the program since the state’s Medicaid expansion began in January.

The new contracts will put a greater emphasis on value-based purchasing and will require participating insurers to provide at least 30 percent of their services in a value-based or outcomes-based manner within three years.   Among the tools managed care organizations are expected to employ to achieve this goal are accountable care organizations, bundled payments, and patient-centered homes.

With a projected value of about $17 billion, the RFP is expected to attract interest from national organizations that have not necessarily served Pennsylvania’s Medicaid population in the past.

To learn more about the state’s HealthChoices plans, see this news release from the Department of Human Services and this Philadelphia Inquirer article. Find the RFP itself here.…

150,000 Pennsylvanians have enrolled in Medicaid since the Wolf administration officially launched its HealthChoices expansion on April 27.

Added to the 289,000 who enrolled during the Corbett administration’s Healthy Pennsylvania program, that means about 439,000 Pennsylvanians have obtained Medicaid coverage since the state expanded its Medicaid program as authorized by the 2010 federal health care reform law.

To learn more about the latest Medicaid enrollments, their financial impact on the state, and how the HealthChoices expansion works, see this Wolf administration news release.…

Pennsylvania seniors would have improved access to home- and community-based care services under a new proposal announced by Governor Tom Wolf.

Under the proposal, Pennsylvania would:

• make home- and community-based long-term-care services available to 5500 more Pennsylvania seniors;
• phase in Medicaid managed long-term care;
• improve long-term living waiver enrollment and the service plan development process;
• make greater use of home modifications;
• implement an online home care registry; and
• ensure that seniors have choices about where they age.

The Wolf administration envisions achieving this through a combination of budget, legislative, and executive actions.

To learn more about the new governor’s plans for long-term care for the elderly, see its news release on the subject here.…