Benefits Breakdown: Healthy PA Draft 115 Waiver (December 2013 vs.

February 2014 Versions)

Final Draft Waiver Application Low Risk High Risk No Limit No Limit Initial Draft Waiver Application Low Risk High Risk

Services Primary Care Provider Visits/Immunizations Routine Adult Visits Specialized Visits Certified Registered Nurse Practitioner FQHC/Rural Health Clinic Outpatient Clinic/ Independent Clinic Hearing Screening Optometrist Services Podiatrist Services Chiropractor Services

Current MA State Plan No Limit

Combined 12 visits per year 12 Visits per year (combined) 18 visits per year (combined) 18 Visits per year (combined)

Combined 18 visits per year

Not Covered Not Covered Not Covered The only key limitation is related to respite care, which may not exceed a total of 5 days in a 60day certification period. No Limits Diagnostic, preventive, restorative, and surgical dental procedures, prosthodontics and sedation. Key Limitations: Dentures 1 per lifetime, Exams/prophylaxis 1 per 180 days, Crowns, Periodontics and Endodontics only via approved benefit limit exception No limits Only to and From MA Covered Services Current Limits The only key limitation is related to respite care, which may not exceed a total of 5 days in a 60day certification period. 6 tests Diagnostic, preventive, restorative, and surgical dental procedures, prosthodontics and sedation. Key Limitations: Dentures 1 per lifetime, Exams/prophylaxis 1 per 180 days, Crowns, Periodontics and Endodontics only via approved benefit limit exception 2 visits/year Only to and From MA Covered Services Current Limits

Not Covered Not Covered Not Covered The only key limitation is related to respite care, which may not exceed a total of 5 days in a 60day certification period. 8 tests Diagnostic, preventive, restorative, and surgical dental procedures, prosthodontics and sedation. Key Limitations: Dentures 1 per lifetime, Exams/prophylaxis 1 per 180 days, Crowns, Periodontics and Endodontics only via approved benefit limit exception 4 visits/year Only to and From MA Covered Services Current Limits The only key limitation is related to respite care, which may not exceed a total of 5 days in a 60day certification period. $500 per year Diagnostic, preventive, restorative, and surgical dental procedures, prosthodontics and sedation. Key Limitations: Dentures 1 per lifetime, Exams/prophylaxis 1 per 180 days, Crowns, Periodontics and Endodontics only via approved benefit limit exception 2 visits per year The only key limitation is related to respite care, which may not exceed a total of 5 days in a 60day certification period. $750 per year Diagnostic, preventive, restorative, and surgical dental procedures, prosthodontics and sedation. Key Limitations: Dentures 1 per lifetime, Exams/prophylaxis 1 per 180 days, Crowns, Periodontics and Endodontics only via approved benefit limit exception 4 visits per year

Hospice Care

Radiology

Dentists

Outpatient Surgery Non-Emergency Medical Transport Family Planning Clinic

Renal Dialysis

Initial training for home dialysis Initial training for home dialysis Initial training for home dialysis is limited to 24 sessions per is limited to 24 sessions per is limited to 24 sessions per patient. Backup visits to the patient. Backup visits to the patient. Backup visits to the facility limited to no more than facility limited to no more than facility limited to no more than 15 per calendar year 15 per calendar year 15 per calendar year

Benefits Breakdown: Healthy PA Draft 115 Waiver (December 2013 vs. February 2014 Versions)
Final Draft Waiver Application Low Risk High Risk No Limits No Limits No Limits No Limits 2 non-emergency admits per 3 non-emergency admits per year year 1 admit per year 2 admits per year 30 days per year 30 days per year No Limits 45 days per year 45 days per year No Limits Initial Draft Waiver Application Low Risk High Risk No Limits No Limits No Limits No Limits 2 non-emergency admits per 3 non-emergency admits per year year 1 admit per year 2 admits per year 30 days per year 30 days per year No Limits 45 days per year 45 days per year No Limits

Services Emergency Room Ambulance Inpatient Acute Hospital Inpatient Rehab Hospital Inpatient Psychiatric Hospital Inpatient Drug and Alcohol Maternity Outpatient Mental Health Treatment Clinic

Current MA State Plan No Limits No Limits No Limits 1 admit per year 30 days per year No Limits No Limits 5 hours or 10 half hour sessions of psychotherapy per recipient per 30 consecutive days

30 visits per year

60 visits per year

30 visits per year

40 visits per year

Outpatient Drug and Alcohol Treatment Methadone Maintenance Clozapine Psychiatric Partial Hospital Peer Support Crisis Targeted Case Management Behavioral Health Only Prescription Drugs Nutritional Supplements Skilled Nursing Facility Home Health Care ICF/ID and ICF/ORC Durable Medical Equipment Medical Supplies

42 opiate detox visits per 365 42 opiate detox visits per 365 42 opiate detox visits per 365 days; 3 chemotherapy or drug- days; 3 chemotherapy or drug- days; 3 chemotherapy or drugfree visits per 30 days; 8 hours free visits per 30 days; 8 hours free visits per 30 days; 8 hours total psychotherapy per 30 days total psychotherapy per 30 days total psychotherapy per 30 days once/day, 7 visits/week Limited to persons with Schizophrenia 540 hours per year No Limits No Limits Limited to persons with SMI Diagnoses 6 per month No Limits No Limits 28 days unlimited, 15 days per month thereafter No Limits Orthotic devices limited to one pair every three years No Limits

30 visits per year

40 visits per year

once/day, 7 visits/week once/day, 7 visits/week 7 visits per week 7 visits per week Limited to persons with Limited to persons with Limited to persons with Limited to persons with Schizophrenia Schizophrenia Schizophrenia Schizophrenia 541 hours per year 542 hours per year 540 hours per year 540 hours per year 4 hours per day/ 900 hours per 4 hours per day/ 900 hours per 4 hours per day/ 900 hours per 4 hours per day/ 900 hours per year year year year No Limits No Limits Not Covered 6 per month No Limits 120 days per year 60 visits per pear Not Covered $1000 per year $1000 per year Limited to persons with SMI Diagnoses 6 per month No Limits 365 days per year 28 days unlimited, 15 days per month thereafter 365 days per year $2500 per year $2500 per year Not Covered 6 per month 120 days per year 60 visits per year Not Covered Limited to persons with SMI Diagnoses 6 per month 365 days per year 28 days unlimited, 15 days per month thereafter 365 days per year

$1000 per year (combined with $2500 per year (combined with Medical Supplies) Medical Supplies) $1000 per year (combined with $2500 per year (combined with DME) DME)

Benefits Breakdown: Healthy PA Draft 115 Waiver (December 2013 vs. February 2014 Versions)
Final Draft Waiver Application Low Risk High Risk Only when provided by a hospital, outpatient clinic, or home health provider $350 per year 70 per year Only when provided by a hospital, outpatient clinic, or home health provider $450 per year 70 per year $250 per year 70 per year $350 per year 70 per year Initial Draft Waiver Application Low Risk High Risk

Services

Current MA State Plan Only when provided by a hospital, outpatient clinic, or home health provider No Limits 70 per year

Therapy (Speech, Language, Hearing) Laboratory Tobacco Cessation