On July 14, the Department of Human Services (DHS) reconvened their H.R. 1 Stakeholder Work Group to discuss Pennsylvania’s plan to implement the changes coming to the Medicaid program based on information released in the June 1 Interim Final Rule (IFR). The slides from the meeting are available
here.
DHS presented communication pathways for pre-implementation correspondence, as well as the communication cadence for both new and current Medicaid enrollees. Pre-implementation initial outreach will begin August–September 2026 and will take place over four mailings as well as texts and phone calls to recipients who have shared their phone numbers.
The slides also explain eligibility pathways and potential exclusions based on the CMS IFR that was published earlier this summer, with the steps both the State and enrollees will have to take to maintain compliance for continued coverage. Key DHS decisions regarding the IFR include:
- DHS will accept attestation of applicants/recipients where permissible until required to verify as of January 1, 2028.
- DHS will accept income as hours by proxy when lower than the $580 threshold.
- DHS will offer hardships as an additional category of exclusion from the community engagement requirements (CER).
- DHS will ex-parte review expansion recipient cases for continuing eligibility. If there is no ability to continue eligibility based on this review, DHS will issue a Notice of Noncompliance with the renewal packet affording the household 35 days to complete the renewal as well as demonstrate exception, exclusion, compliance, or request a hardship where applicable.
In addition, DHS updated their approach to medical frailty, as the IFR unexpectedly changed to requirements with consideration of the extent to which a condition impairs an individual’s ability to comply with CERs. The new approach groups conditions into three categories:
- Category 1: Medically frail based on the presence of a high-risk, severe condition.
- Category 2: Medically frail based on the presence of a chronic condition with additional supporting evidence of severity, complexity, treatment burden, functional impairment, or overall worse health.
- Includes severity indicators consisting of high acuity or high frequency utilization, treatment that is high-risk or requires frequent monitoring, services that directly reflect functional limitations, and risk factors for impairment or mortality.
- Category 3: Medically frail based on the presence of a significant acute or temporary condition.
RCPA continues to remain engaged with DHS and other stakeholders as H.R. 1 implementation begins to ensue. Please contact your respective Policy Director with any questions. Questions or concerns can also be submitted to DHS
via email.
With the new information provided by DHS, RCPA will be updating its H.R. 1 Medicaid Resource Guide. Questions for the FAQ section of the guide may be forwarded to
Emma Sharp.
