Medical assistance concerns 2012

THE DEPARTMENT OF PUBLIC WELFARE has announced changes in Medical Assistance for children with disabilities effective January 3, 2012....

1. The reviews of Medicaid eligibility that started this past summer have particularly affected children. As discussed in previous newsletters, DPW officials ordered local County Assistance Offices to process a backlog of Medicaid cases that were overdue for renewal resulting in more than 700,000 eligibility reviews.

Medicaid enrollment data for children shows a drop of 88,000 –half of that in December alone – since August 2011. These numbers do not include an additional 23,000 children whose benefits
were cut but eventually restored retroactively. Given that virtually all Pennsylvania children without insurance are eligible for either CHIP or Medicaid, it is particularly troubling that the CHIP enrollment did not see a corresponding increase. According to program rules and procedures, when a child’s family income is too high for Medicaid, they are automatically referred to the CHIP program.

However, even as 88,000 children lost Medicaid coverage, CHIP program enrollment remained virtually flat, growing by only 309 children in the same August to December 2011 period.
Social service agencies, healthcare providers and legal aid programs across the Commonwealth all report an increase in individuals terminated from Medicaid due to alleged failure to furnish renewal documents. Many of those terminated not only continued to be eligible for Medicaid, but turned in the required paperwork in a timely fashion and had proof that they faxed, mailed or hand delivered the requested documents. However, their paperwork was apparently lost or was not properly attached to their case record by the County Assistance Office, and their benefits ended.

Individuals who receive MA termination notices and think they are still eligible can contact our
Helpline for assistance at 1-800-274-3258.
REMINDER:
The CAOs are required to send individuals a 15-day advance written notice before closing a Medicaid case. If individuals receive a termination notice but believe they might still be eligible for Medicaid, they should file an appeal within 15 days of the mailing date on the notice.

2.
DPW announced that it plans to ask families with children under age 18 on Medicaid due to their disability, and whose family income is more than 200% of the federal poverty guidelines ($44,700 for a family of four), to pay part of the cost of services starting September 2012. These co-pays are a result of the state budget cost-savings mandated by Act 22 of 2011 and will affect approximately 38,000 children. The Office of Medical Assistance Programs (OMAP) is in the process of finalizing policies and procedures regarding the co-pays. Notices will be sent to affected families 30 days prior to implementation.

Medical providers will be responsible for collecting co-payments and may do so at the time of service or make other arrangements for payment. The total amount of co-payments for all Medical Assistance services the child (or children, if more than one child in the family is on Medical Assistance) receives can not exceed the federal legal limit of five percent of the family's income, counted on a monthly or quarterly basis. So, for example, if the family’s income is $48,000 a year, the total amount of all Medical Assistance copays for which they would be responsible could not exceed $200 a month ($4000 a month income x5%) or $600 for three months if DPW decides to calculate this quarterly. Each copay can not be in excess of 20 percent of the cost of the service. Reportedly, co-payments will not be applied to school-based services,
preventative services, and other items or services that are currently excluded from MA co-payment under federal rules.

It is not known whether DPW will deduct a family’s current out-of-pocket costs for their child’s health care when calculating family income. Other questions include: how will DPW track their co-pays paid to all providers to determine when a family can stop paying co-pays? How will DPW notify providers when the family no longer has to pay co-pays?

It is unclear whether providers will be required to provide services if the co-payment is not paid. More clarity will be needed, as these rules are under the Deficit Reduction Act, which is different from co-payments under traditional Medicaid rules.

PHLP will continue updates as new information is received.

3.PLease visit http://www.phlp.org/home-page/about to learn more about Pennsylvania Health Law Project or call 1-800-274-3258.

PHLP is a nationally recognized expert and consultant on access to health care for low-income consumers, the elderly, and persons with disabilities. For more than two decades, PHLP has engaged in direct advocacy on behalf of individual consumers while working on the kinds of health policy changes that promise the most to the Pennsylvanians in greatest need.
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