Pa. online health insurance marketplace opens

Pennie, Pennsylvania’s official online health insurance marketplace, is now open to all state residents to apply, compare plans, and enroll in high-quality health coverage.  

The annual Open Enrollment Period is an opportunity for Pennsylvanians to take advantage of substantial savings on 2023 coverage created by the American Rescue Plan and extended by the Inflation Reduction Act. 

Nine out of 10 Pennie customers qualify for financial savings and thus are eligible for subsidized monthly premiums on their health insurance. Nearly 40% of Pennie customers pay less than $75 per month. Pennie helps keep costs down amid rising inflation, and Open Enrollment is an opportunity for Pennsylvanians to protect their health and wallets by getting the coverage and care they need. 

“Easy access to affordable quality health coverage for all Pennsylvanians who want it is the bedrock on which Pennie was founded. As we strive to maximize the number of insured Pennsylvanians, the goal isn’t just to have insurance but to have insurance someone can actually use,” Pennie Executive Director Zachary W. Sherman said in a statement. “For anyone not insured through their job, Medical Assistance, or Medicare, I encourage them to explore their options through Pennie to see how we can help lower monthly premiums on high-quality health coverage from the top insurance companies across the commonwealth.” 

Representatives from Pennie, the Pennsylvania Insurance Department (PID), and Pennsylvania Association of Community Health Centers (PACHC) celebrated the start of the Open Enrollment period recently at Sadler Health Center in Carlisle.  

Pennsylvania Acting Insurance Company Commissioner Michael Humphreys said the Open Enrollment period marks the premier time to explore options and shop to find a plan, even for those who have insurance. He added that quality, comprehensive health care coverage has never been more affordable or more within reach for Pennsylvanians. 

“The Insurance Department’s goal of increased competition in the Marketplace has resulted in more choices, and increased affordability for consumers across the commonwealth,” said Humphreys. “We encourage consumers to research and compare plans to find coverage that best fits their needs and provides robust benefits for themselves and their families.” 

A recent change in federal policy has improved the affordability of health insurance for family members with insurance through a spouse or parent’s work. In 2023, Pennsylvanians paying more than 9.2% of their household income for a family plan through a family member’s job apply through Pennie to receive premium savings to reduce their cost of coverage. Families previously locked out of receiving Affordable Care Act subsidies can apply or update their application to enroll and receive the savings. 

“Our network of Community Health Centers continues to play a key role in ensuring Pennsylvanians gain the security of health coverage and access to quality affordable care.  In-person, unbiased Certified Enrollment Assisters are available to help patients and customers wade through the complexity of applying for health insurance at many locations statewide,” said Tia Whitaker, Statewide Director of Outreach and Enrollment at the Pennsylvania Association of Community Health Centers. 

As the Inflation Reduction Act has helped to provide additional savings and lower costs of premiums making it easier to enroll in coverage, Whitaker advised those interested to find a local Community Health Center by visiting pachc.org. 

Pennie and PID encourage those seeking coverage to go to Pennie.com prior to Jan. 15 and enroll in one of the options available in their area. Pennie’s Open Enrollment Period extends to Jan. 15, 2023. The deadline for coverage starting Jan. 1 is Dec. 15. For those enrolling between Dec. 15-Jan. 16, coverage will start Feb. 1, 2023. 

COVID-era waivers expanding telehealth reimbursements set to end this year

Health care providers supercharged their telemedicine offerings as a result of the pandemic—however, how those providers will be reimbursed for virtual care moving forward is in question.  

Prior to the pandemic, most providers did not receive enough reimbursements from insurance companies to justify expanding their telehealth coverage.  

That changed when the Centers for Medicare & Medical Services, a federal agency that oversees Medicare and Medicaid programs across the country, introduced leniencies on HIPPA requirements on video software and broadened access to Medicare telehealth services.   

Third party payers followed suit by expanding their telehealth service coverage, offering advanced payments to independent health care providers and waiving fees for members using virtual care.  

Coverage that was previously based on the discretion of insurance companies, has become common across insurers, said Andy Carter, president and CEO of the Hospital Association of Pennsylvania (HAP). 

“The number one impediment to telehealth expansion was that there was no payment model that you could get return on your investment because a lot of insurers wouldn’t pay for telehealth consults or appointments,” said Carter. “COVID changed that dramatically, where immediately public payers and private payers were paying for it across the board.”  

In a 2022 report on national survey trends in telehealth use, researchers with the US Office of Health Policy noted that from March to April 2020, telehealth use skyrocketed across the country from 1% to 80% in “places where the pandemic prevalence was high.”  

Today, patient usage of telehealth is significantly down from the days of quarantine, with the report finding that percentage had dropped to around 20% among adult respondents to a survey given between Sept. 29 and Oct. 11, 2021.  

Providers see telehealth usage remaining much higher than pre-pandemic levels with the focus now turning to how providers and insurers can work together to standardize telehealth.  

Standardizing telehealth  

HAP has spent years trying to standardize telehealth protocols and practices, particularly when it comes to reimbursing providers for telehealth services.  

Their most recent effort on that front has been backing Senate Bill 705, legislation that would require insurers to pay providers no matter if that provider is in that insurers’ network.  

Carter said that in the past, the association supported bills that would provide parity between in-person and virtual care, meaning that payers would need to reimburse providers equally for either service, but the association has now agreed to leave pricing to individual payers and providers.  

“We argue that standardization is hugely important,” said Carter. “Insurance is already complicated enough and a patient’s access to care through telehealth should not be a lottery. Parity was a nonstarter for our friends in the insurance community. We agreed to new language as an alternative.”  

HAP is also currently in support of House Bill 2419, which would allow for more flexibility for the state to allow providers to offer mental health services through telehealth permanently.  

House Bill 2419 has been passed in the House and is currently awaiting consideration in the Senate.  

Pennsylvania’s COVID-era waivers that explicitly authorized telehealth services to expand during the pandemic will expire this October. 

The waivers were set to expire at the End of June and were extended by the General Assembly on June 30.  

The waivers expand access to telehealth services, increase vaccine access, allow hospitals to quickly adapt to emergencies by altering space as needed for influxes of patients, and ease regulatory barriers to clinician licensing. 

Pennsylvania does not have any statutes that will prohibit the practice of telemedicine after the waivers expire but payers will be able to stop reimbursing for telehealth.  

“Absent the current COVID driven waivers and flexibilities, we won’t sustain telehealth the way we did before COVID,” said Carter. “It’s not supposed to go away. People got used to it.”  

Providing care in the virtual space  

In the two years since providers have embraced telehealth, virtual care has had a massive impact on how the industry cares for patients.  

Providers are now looking at how things like wearable technology and remote patient monitoring can keep tabs on patient health between visits, said Christopher LaCoe, vice president of virtual health at Penn State Health.  

“We’ve moved to the point where we have all these opportunities to do checkups for diabetes. We might be able to do that stuff here and then send (the diabetic patient) to the eye doctor and not make them drive to our office,” said LaCoe, adding that educators are now taking telehealth services into consideration when they teach incoming providers. “Medical schools are putting this in their curriculum. They used to say you need to see diabetic (patients) every three months and now they say once a year.”  

LaCoe, credited the waivers, calling the changes that happened to telehealth the pandemic’s “silver lining.”  

Pittsburgh-based Highmark Health was early to the market on allowing telehealth for its providers, but prior to the pandemic, providers had little guidance on what that should look like, said Dr. Tim Law, vice president and executive medical director at Highmark.  

“Highmark said you can do telehealth, but we won’t tell you how to do it—it wasn’t front and center,” said Law, noting that changed quickly during the pandemic. “We put together a virtual care playbook. Five years ago, I don’t think anyone would have thought of doing this. It includes where to find supplies, how to access Bluetooth technology so you can do remote patient monitoring and we show them what states allow providers to work across state borders.”  

Highmark provides parity for its covered providers using telehealth with some of the states the payer operates in mandating it.  

However, even though some insurers are ahead of the curve with how they support and pay for telehealth with their covered providers, providers outside of a network may find themselves without telehealth reimbursements, said Carter.  

“Some insurers will say we provide telehealth to our covered lives. It’s only to the telehealth providers they’ve enrolled in their network,” said Carter. “That’s a model that leaves a lot of people without access to their preferred provider. Someone they know and trust.” 

Pa.’s independent living services blame low reimbursements for workforce crises 

A group of Centers for Independent Living, individuals with disabilities, caregivers and legislators met on the steps of the capital in November to ask the legislature to increase reimbursements for independent living. PHOTO/PROVIDED

Pennsylvania organizations offering independent living services to people with disabilities are not receiving enough Medicaid reimbursements from the state to keep their employees, say advocates for the state’s Centers for Independent Living, known as CILs.

Earlier this month, a group of CILs, individuals with disabilities, caregivers and legislators met on the steps of the capital to ask the legislature to increase reimbursements for independent living.

The organizations say staffing was an issue among CILs because of low reimbursements before the pandemic and is now in a full-blown workforce crisis because employees left the industry for better paying work.

Reimbursement rates for CILs vary across the state with some receiving $17.88 to $19.88 an hour. Reimbursement in neighboring states, such as Ohio and Delaware, are at least $4 higher, said Shona Eakin, CEO of Erie-based Voices for Independence, one of the state’s largest in-home care providers for individuals with disabilities.

Low reimbursements mean that CILs can’t offer employees more than $8 to $12 an hour for homecare work.

“In order for there to be a sustainable market with wages, and maybe even for the first time ever a little bit of health insurance, we need to see a $5 increase,” said Eakin. “We need to see some investment in these rates of reimbursement.”

The last increase in reimbursements was 40 cents in early 2020, which allowed Eakin to increase her employees hourly wage by 70 cents.

“Getting a 40-cent increase after five years of no increases is great but it puts a Band-Aid on a gaping wound,” she said.

Following the rally, Gov. Tom Wolf committed some of his staff to work with the CILs to find solutions to the problems the CILs have posed, but according to the administration, an effort to improve the workforce problem for CILs is already underway.

The state Department of Human Services is awaiting approval from the federal Centers for Medicare and Medicaid Services to allow the state to fund a number of initiatives that would target direct care recruitment and retention, said Brandon Cwalina, press secretary for the department.

The initiatives will be funded through the American Rescue Plan Act, which allows states to leverage a temporary 10% increase in Medicaid reimbursements for home and community-based services.

“This work is essential and life-sustaining, and we are committed to helping recruit and retain dedicated individuals to these positions, as the Wolf Administration has been prior to the pandemic,” said Cwalina. “We are currently awaiting our conditional approval from the Centers for Medicare and Medicaid Serivces, and once that is received, we’ll be able to move forward with implementation.”

The rally, titled the “Rally for Our Lives,” highlighted another problem CILs are seeing: people with disabilities are reassessed annually by the state and given the number of hours that they can receive services from a CIL weekly. Those hours have been cut drastically for many Pennsylvanians, said Pam Auer, director of advocacy and community engagement at the Center for Independent Living of Central PA.

“People with disabilities receiving services are getting reassessed and that means the services they are receiving are getting reduced,” she said. “Some are saying that the state is going out of order, and they don’t understand why they are being assessed.”

Auer went on to say that some individuals’ hours have been cut so dramatically that they have gone from 126 hours a week with a CIL to 40 seemingly arbitrarily.

“If you had 126 hours and you were cut to 40, how could your needs be met adequately?” said Eakin. “Everyone says that they understand that people want to live at home and not in institutions, but they don’t understand the nuances that are causing the problem.”

Part of the problem is that the state relies too much on informal support, such as someone’s family or friends and not enough on CILs, said Auer.

St. Luke’s shares savings with federal government for controlling Medicare costs

St. Luke’s University Health Network (SLUHN) shared $18.6 million in savings with the Federal Government as a reward for controlling costs while providing quality medical care to Medicare patients in 2020.

On Monday, St. Luke’s was paid one-half of its savings, or $9.2 million, because it achieved a 100% quality score while providing cost-effective care to older and disabled patients in 2020.

St. Luke’s is the only health network in the Lehigh Valley in 2020 to achieve both a perfect quality score and earn a payment from the Medicare Shared Savings Plan (MSSP), which is administered by the Centers for Medicare & Medicaid Services (CMS), a health network statement said.

“St. Luke’s is proud to have earned the distinction of being the only health care network in the Lehigh Valley to earn a MSSP payment,” said Dr. Ken Bertka, family physician and vice president of Clinical Integration at St. Luke’s. “St. Luke’s achieved this remarkable accomplishment by keeping costs lower than expected even as it delivered the highest quality care. This is all the more impressive considering it took place amid a pandemic.”

An accountable care organization (ACO) comprises physicians, nurse practitioners, physician assistants, other clinicians, as well as hospitals and other healthcare facilities who come together voluntarily to provide high-quality, cost- efficient care to Medicare and Medicaid patients.

St. Luke’s formed its ACO in 2018 and includes more than 1,700 physicians and advanced practitioners, both employed by SLUHN and independent community offices, serving 45,000 Medicare patients who selected primary care physicians participating in the ACO.

“This much-deserved recognition and shared-savings reflects our providers’ commitment to collaboration and evidence-based medicine as we strive to provide the right care at the right cost in the right place and at the right time,” said Linda Gately, St. Luke’s vice president Quality, Performance, and Compliance.

In 2020, Medicare’s benchmark or expected cost of care of patients in the St. Luke’s network, after adjustment for the impact of the COVID-19 pandemic, was $470 million. The actual cost of care to Medicare was $451 million for a savings of more than $18 million. The network attained a perfect quality score of 100% even during the pandemic when it was difficult to maintain preventive care testing like breast cancer and colorectal cancer screenings for much of the year because of the COVID shutdown.

St. Luke’s initiatives that improved care while reducing costs include the following:

Proactive care management services driven by artificial intelligence (AI) analytical tools to identify patients at higher risk for poorer outcomes

Use of evidence-based, patient-centric clinical protocols developed by physicians and other clinical leaders across the spectrum of care including hospital, outpatient, home care, and skilled nursing facilities

Real-time clinical decision support tools in the electronic health record to aid in the ordering of the most cost-effective tests

Focus on preventive care services and other initiatives to reduce avoidable hospitalizations and readmissions

The CMS MSSP was started in 2013 to stem the continuously increasing cost of healthcare in the U.S. while maintaining a focus on the delivery of high-quality care. Benchmarks for the MSSP include both expected total cost of care, based on the complexity of the population served, and quality measures compared to peer providers.

Last year was St. Luke’s third year as a participant in the MSSP. “Our performance improved each year. In 2018, we held the total cost of care at the benchmark. In 2019, we realized savings of 1.9% or $9.5 million. Last year, our savings was almost 4 % lower than benchmark. Saving $18 million on the total cost of care and achieving high-quality outcomes is a testament to St. Luke’s focus on high-value care,” said Chris Lewis, executive director of the ACO.

According to a news release from the National Association of ACOs, Medicare Shared Savings Programs served 10.6 million seniors and saved a total of $4.1 billion nationwide in 2020, the highest annual savings to date by this program.

New CMS proposal could lead to permanent changes in telemedicine reimbursement

A dramatic increase to Medicare reimbursements for telemedicine services that allowed health care providers to receive payment for services they provide online, could continue after the public health emergency is over.

In the country’s first weeks of the pandemic, the Centers for Medicare & Medicaid Services (CMS), a federal agency that oversees Medicare and Medicaid programs across the country, rolled out a series of rule changes that opened the door to reimbursements of telemedicine that were much closer to what a provider would make during an in-person meeting.

To promote social distancing and to protect at-risk patients from contacting COVID-19, the agency also introduced leniencies on HIPAA requirements that allowed providers to use a variety of video software while conferencing with patients.

Prior to the changes, approximately 14,000 Medicare beneficiaries across the country received telehealth services in any given week. Thanks to the changes in reimbursements, CMS reported that 10 million beneficiaries received a Medicare telehealth service from mid-March through early-July.

This month, CMS announced it will propose expanding telehealth reimbursements permanently after President Donald Trump signed an executive order on Improving Rural and Telehealth Access on Aug. 3. The order outlines CMS’ recent rule changes and the impact they’ve had on Medicare beneficiaries. In the order, Trump directs Secretary of Health and Human Services Alex Azar to review the temporary measures and propose an extension to them as appropriate within the next 60 days.

While the changes in reimbursements only apply to Medicare beneficiaries, some health care providers expect that a permanent change to reimbursements could drive third-party payers to provide similar services.

LVHN creates Valley Health Partners to take over community clinics

Eight clinics, located mostly at Lehigh Valley Health Network’s 17th and Chew campus in Allentown will become Valley Health Partners Community Health Center. PHOTO/SUBMITTED –


Lehigh Valley Health Network is creating a new organization to run its community clinics, most of which are located at Lehigh Valley Hospital and 17th and Chew streets.

James Demopoulos, senior vice president and COO of Lehigh Valley Physicians Group said creating Valley Health Partners Community Health Center will give the new entity access to more federal funding and enable it to serve more patients with expanded services.

“Lehigh Valley Health network made a commitment years ago to the underserved population of the Lehigh Valley, the uninsured the underinsured,” he said.

Veronica Gonzalez, who is currently in charge of such services and will now be the head of VHP, said the health network’s services, performed mostly at eight community clinics centered on the Allentown hospital campus, were already operating as health centers but were never designated as a Federally Qualified Health Center (FQHC) because they were part of a health network.

Such centers need to be independently operated to receive enhanced reimbursements from Medicare and Medicaid. The additional funding allows practitioners at the center to offer more comprehensive whole-patient care. The center will also be able to partner with other nonprofits in the community to address problems such as drug addictions or lack of access to proper nutrition that are impacting a patient’s health.

“In many ways this is the same way we have been operating, we just weren’t designated,” Gonzalez said.

However, she said, while much will stay the same, programs and staff will be added. “Our goal is to expand our care and our services, patient empowerment and engagement.”

Demopoulos said the new center will hire its own staff but will also be able to lease existing LVHN staff currently working for the center to continue working at the clinics. They will remain employees of the health network. An appealing requirement of being a Federally Qualified Health Center is that its board of directors, which will guide operations independently of LVHN, is to be made up mostly of members of the population the health center will be serving.

“They need to be consumers of these services, people who live and work in the community. That way the majority of the board will be well connected to the community we serve,” he said.

Demopoulos said with the health care industry feeling the impact of the COVID-19 pandemic, the change is coming at an optimal time. “More people unfortunately are going to have to get on the Medicaid insurance products,” he said. “It’s a benefit of what we were going to be doing, that we certainly didn’t plan for, but it will be more impactful than ever.”

The clinics that will become VHP are:

  • VHP Centro de Salud – Primary care practice dedicated to advancing the health and well-being of the Hispanic community with common health problems such as high blood pressure, diabetes, asthma and heart disease.
  • VHP Children’s Clinic – Care for children who are well, sick or have special needs including behavioral health, ADHD, asthma, obesity and more.
  • VHP Children’s Clinic at Sheridan – An extension of the Children’s Clinic, provides primary and specialty care for all Children’s Clinic patients in the Allentown School District from kindergarten through high school.
  • VHP Center for Women’s Medicine – Comprehensive health care for women and adolescent girls, including specialists who help with high-risk pregnancies, depression and more.
  • VHP Lehigh Valley Family Health Center – Community-based family medicine with an emphasis on improving and maintaining health for patients who are well, as well as those with chronic diseases.
  • VHP Lehigh Valley Physicians Practice Primary Care – High-quality, accessible, cost-effective primary health care for the Lehigh Valley’s diverse community.
  • VHP Mark J. Young Community Health and Wellness Center – Helping people learn how to take care of themselves, which is especially important for those with chronic conditions such as diabetes, asthma and obesity. Prediabetes and diabetes classes, as well as nutritional services, are offered.
  • VHP Street Medicine – Primary and urgent care for homeless people in the Lehigh Valley wherever they may live – in shelters, soup kitchens, under bridges or in the woods.

The eight community health clinics will become Valley Health Partners on July 1, continuing to treat the 60,000 patients already served.

After operating as VHP for six months, the new center will be able to apply to become qualified as a FQHC Look-Alike and will have access to the additional federal funding if approved.

Rating changes drop nursing-home quality scores

A major update to a national rating system for nursing homes has had a trickledown effect on the ratings of Pennsylvania facilities, one that could affect their ability to attract residents.

Late last month, 220 Pennsylvania nursing homes slipped in their rankings under what is known as the Nursing Home Compare Tool, compiled by the Centers for Medicare and Medicaid Services, a federal agency that oversees the Medicare program and helps states administer Medicaid.

The declines were not the fault of the nursing homes, but instead a symptom of what may be the largest update to the comparison tool since it was created in 2012.

The Centers for Medicare and Medicaid Services, or CMS, ranks nursing homes based on staffing levels, health inspections and quality of care. Nursing homes get between one and five stars, with the rating made public on CMS’ website and used by consumers, providers and hospitals to find the best nursing homes in a region.

A CMS spokesperson said the department continues to make changes to the five-star rating system in an effort to incentivize facilities to continue to improve the quality of care they offer.

“In order to continue to improve quality, we need to constantly evaluate and enhance our expectations, so that facilities continue to strive to achieve better performance and higher ratings, thereby improving quality and outcomes for residents,” said the spokesperson, who wished to remain anonymous.

To alert consumers of the change, CMS has emphasized the update on the Nursing Home Compare website and has alerted other agencies that work with seniors looking for care.

Critics, however, said the most recent update could still confuse consumers, who may not understand that a nursing home dropped in rating not because of a change in quality but because the goalposts were moved.

“These changes would indicate that 33 percent of Pennsylvania nursing homes became worse overnight,” said Zach Shamberg, president and CEO of the Pennsylvania Health Care Association, a Harrisburg-based group representing providers of senior care. “The data tells a different story: Nursing homes have made significant improvements in quality of care and staff have never been more dedicated to their residents.”

Consumers themselves have been quiet over the change, according to Robyn Grant, director of public policy and advocacy for the National Consumer Voice for Quality Long-Term Care, a consumer advocacy group in Washington, D.C.

That silence could mean they have not noticed the changes, according to Grant.

“My sense is that consumers research the ratings of a facility at the time they are looking for a facility, but don’t necessarily go back after that and would, therefore, not see that the ratings had changed,” she said.

Nonetheless, the group supports updates to the rating system as a way to ensure the ratings remain helpful to consumers, she said.

The ratings slide has been a nationwide problem, with a third of the county’s nursing homes losing a star overnight, according to Lori Mayer, vice president of investor relations, brand management and marketing communications at Genesis HealthCare, a senior care provider based in California. The company operates homes in the Philadelphia area as well as the Hamilton Arms Center senior home in Lancaster Township, Lancaster County.

“We are disappointed that recent changes to the Five-Star Rating System by CMS have resulted in many centers receiving a lower star rating — even though nothing has changed in terms of the quality of care provided,” Mayer said. “That’s confusing for families and residents who need simple, clear information.”

Changes to the CMS rating system included enacting separate measures for short-term and long-term residents, rather than one rating for both. CMS also reduced the number of days that a facility’s registered nurse can be off the premises.

In addition, the agency tweaked its formula for awarding stars, making it harder for nursing homes to earn the same number as before. The changes are based on overall quality improvements at nursing homes nationwide.

The last tweak was in 2015. But going forward, the agency will make changes every six months, steadily raising the bar for nursing homes so they show consistent improvement, according to the CMS spokesperson.

The ratings are an important tool for senior homes and have an effect on many facets of senior care, including contracts with insurance companies and recommendations from hospitals. Shamberg said that the associations’ members fear the ratings change could cause insurers and hospitals to refer patients to other facilities with better ratings.

“For our membership this is worrisome and can have a real effect on their ability to admit residents,” he said.

CMS said the website for the rating system also contains inspection reports for each facility. The agency noted that hospitals and insurers should review the reports to see if a rating change was the result of an inspection or an update to the system.

Crafting a system to accurately rate the quality of nursing homes is challenging, according to Douglas Motter, president of East Hempfield Township-based Homestead Village, a senior living facility with 495 residents and five stars on Nursing Home Compare.

Motter said that while five-star ratings are usually indicative of a high-quality home, minor problems in a facility’s annual inspection or changes to the system can keep a quality facility at three stars.

The ratings also don’t take into account the experiences of consumers, according to Motter.

“The challenge is that the consumers don’t have a voice,” he said. “It’s based on annual inspection and self-reported data. It doesn’t measure the taste of food, how caring the staff is or friendliness of the home.”