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Section 3 Medical Insurance and Benefits
A review of medical insurance, from
private insurance to managed care programs. Explains Medical
Assistance (MA) and how to obtain an MA Access Card. Other
helpful programs and benefits highlighted include: the Health
Insurance Premium Payment Program (HIPP), the Early Periodic Screening
Diagnosis Treatment (EPSDT), the Children's Health Insurance Program (CHIP) of Pennsylvania, Social Security, and Supplemental Security Income (SSI).
Using Private Medical Insurance
Switching Insurance Coverage, and Waiting Periods for Pre-existing Conditions
Contract Renewals, Lifetime Caps, and Exclusions
Coverage for Children with Special Health Needs
Out-of-Pocket Medical Costs and Your Federal Taxes
A Look at Managed Care
The Three Most Common Managed Care Programs-HMO, POS, and PPO
Understanding Your Managed Care Plan
Consumer Safeguards for HMOs
What To Do If You Have a Problem with an HMO
Ten Patient Tips for Navigating Managed Care
Medical Assistance (MA) and the MA Access Card
Eligibility for Medical Assistance
How To Apply for Medical Assistance for Your Child
Required Documentation for a Medical Assistance Card
Additional Information on Medical Assistance May Be Obtained Through the Following Agencies
Services Covered Under Medical Assistance
Medical Assistance Options: "Straight" Medical Assistance and HealthChoices (Managed Care)
HealthChoices-New Mandatory Managed Care for MA Recipients
Using Medical Assistance and Private Insurance
The Health Insurance Premium Payment (HIPP) Program
HIPP Eligibility
Early Periodic Screening Diagnosis Treatment (EPSDT)
Wraparound Services
EPSDT Eligibility
The Children's Health Insurance Program (CHIP) of Pennsylvania
Insurers Providing CHIP Programs
Pennsylvania Department of Health, Division of Children's Special Health Care Needs
Eligibility-Open to PA Residents Who Meet the Following Criteria
Social Security Benefits for Children with Special Needs
How Social Security Determines If a Child is "Disabled"
Two Ways a Child May Be Eligible for Social Security Benefits
How Social Security Determines If an Adult is "Disabled"
Continuing Disability Reviews (CDRs)
How To Apply for Supplemental Security Income (SSI) Benefits
Frequent Obstacles to Receiving Supplemental Security Income (SSI)
Contacting Your Local Social Security Administration Office
Agencies Assisting with Medical Insurance Issues-Index
Providers of Health and Financial Benefits-Index
Using Private Medical Insurance
One major concern for families when a
child has a medical problem is the high cost of specialized health
care. For the uninsured, costs can exceed personal resources in
just a few days. For this reason, a variety of programs are in
place to help families avoid financial hardship, including Medical
Assistance, the Health Insurance Premium Payment Program (HIPP), the
Children's
Health Insurance Program (CHIP), and Social Security. All are
explained in this chapter, along with explanations of basic terminology
you may encounter.
Many people with private medical
insurance are unaware of the details of their policies, including how
much of the bill they are responsible for in a serious medical
situation.
Parents and guardians of children with special needs, however, must
become experts in health insurance and be familiar with the fine print
in their policies.
There are many different private medical insurance plans.
Co-pays, deductibles, inclusions, and exclusions can vary with each
plan - even within the same insurance company.
Study your current health insurance benefits booklet and ask your
employer for a copy of the complete contract - and the new contract
after renewal periods. (The benefits booklet issued to new employees may not
reflect changes that could occur during contract renewals.) Keep
abreast of the current status of your insurance plan and verify
anything you don't understand.
Switching Insurance Coverage, and Waiting Periods for Pre-existing Conditions
Many private health insurance providers require a waiting period before paying for services related to conditions diagnosed prior to the initial date of
coverage; policies vary in this regard. When facing a
waiting period for a pre-existing condition, remember the following
consumer safeguards ensured by Pennsylvania law:
● A waiting period cannot exceed 12 months.
● A pre-existing condition is defined as a condition for which medical advice or treatment has been
received within 90 days immediately prior to new coverage under group contracts (not individual
contracts). Therefore, if your child did not receive
care for a particular condition during the 90-day period
under a group plan, services should not be subject to a waiting period.
● The waiting period does not pertain to care for illnesses or injuries unrelated to the pre-existing
condition.
Services for these medical problems would be covered according to the
normal provisions of
the policy.
● The Health Insurance Portability and Accountability Act of 1996 (HIPAA) provides families some
protection from the waiting period when changing group insurance plans. Under HIPAA, as long as there
is no break in coverage for longer than 62 days from
one group plan to another, the insurer cannot
impose a pre-existing condition clause. HIPAA applies
only if you are moving from a group plan that had
covered you for at
least 18 months prior to your switch.
Highmark Blue Cross Blue Shield has gone one step further than HIPAA by
voluntarily agreeing not to impose a pre-existing clause if a person
moves from a group plan to an individual plan. Again, you must
have had coverage under the previous group plan for at least 18 months
prior to the switch.
If you switch jobs, your new employer may offer a plan from the same
insurance company, but the terms and conditions may be different.
For example, one plan may not charge a deductible or offer prescription
drug coverage, while another does.
The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA)
mandates that businesses that offer health insurance and have more than
20 employees continue to make coverage available at group rates for up
to 18 months for employees who retire, quit, switch from full-time to
part-time status, or are laid off. The covered individual pays
the full cost of insurance plus a two percent administration fee.
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Contract Renewals, Lifetime Caps, and Exclusions
Even when your group insurance coverage is continuous through one insurer and plan, your
employer must renew the contract periodically. After contract
renewals, terms and conditions (such as exclusions for certain
services) and lifetime benefit caps may be instituted. You may
not be advised of these changes, so keep abreast of the plan's status.
Some insurance providers have lifetime caps - the maximum amount of
benefits payable in a lifetime. When an individual or family
reaches this cap, coverage is discontinued. Some policies may not
have a cap at the time you enroll but can set one when the contract is
renewed.
Benefit exclusions also may be instituted during contract
renewals. New, expensive treatments that are beginning to be used
regularly are often the subject of exclusions.
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Coverage for Children with Special Health Needs
If your child has a chronic health condition, your insurance carrier probably will assign a case manager who will oversee your child's medical expenses. If you are having trouble with insurance denials, be sure to speak directly to this person.
The Pennsylvania Department of Health, Division of Children's
Special Health Care Needs, is a program that oversees issues that can
cause families to exceed their lifetime cap, leaving them uninsurable
(CLICK HERE for information about this program).
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Out-of-Pocket Medical Costs and Your Federal Taxes
Under current tax law, the Internal Revenue Service (IRS) permits many out-of-pocket medical
and dental expenses to be deducted from your Federal Income Tax
return. You are permitted to deduct the amount that exceeds 7.5
percent of your adjusted gross income. To do so, you must itemize
your deductions on a Schedule A (Form 1040) and have receipts.
Examples of applicable expenses are insurance premiums, prescription
drugs, mileage and parking for physician appointments, wheelchairs,
hearing aids, eyeglasses, braces, and modifications to your home or
vehicle to make them accessible. In some cases, it still might be
cost-effective for you to take your standard deduction as opposed to
itemizing medical and dental costs. Individuals who are legally
blind are entitled to a higher standardized deduction.
A Look at Managed Care
By Bob Crytzer, Highmark Blue Cross Blue Shield
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The Three Most Common Managed Care Programs - HMO, POS, and PPO
Most Pennsylvanians who have enrolled
in a health insurance plan - whether a group or individual plan -
generally have either traditional coverage (also called indemnity or
fee-for-service) or managed care.
With traditional coverage, you are offered the widest choice of
physicians, services, and hospitals, and may choose any physician
(including specialists) without prior approval. The insurance
company pays a set amount per health care service performed. In
managed care programs - the fastest growing health insurance plans in
Western Pennsylvania - care is given through physicians and other
health care providers within a particular network.
The three most common managed care programs are:
● Health Maintenance Organization (HMO): With an HMO, a member selects a Primary Care Physician
(PCP) from the provider network, who coordinates the patient's care, including referrals to specialists.
Otherwise, services will not be covered.
● Point-of-Service Program (POS): POS members select PCPs from a network, as in an HMO, but also
can receive some insurance coverage for services from a non-network provider.
● Preferred Provider Organization (PPO): In a PPO members are not required to use a PCP and can
select non-network
providers for care. Benefit amounts generally are higher for care received from
network providers.
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Understanding Your Managed Care Plan
All insurance plans differ in what is covered, the maximum amount to be paid, and other potential limitations. If you have group insurance through your
employer, review your policy with your benefits administrator to glean
additional insights. If you have an individual policy, seek
professional assistance from an attorney or other person educated in
the intricacies of contracts.
Be informed about your health care coverage. Once you've
familiarized yourself with the policy, contact a customer service
representative at the insurance company and explain your child's
condition, what treatment has been rendered to date, and what treatment
might be needed in the future. Ask the representative to walk you
through the complete description of pertinent benefits, as well as
terms and conditions of coverage, and any present or future exclusions. Keep a log of phone calls or emails you've made to the insurer.
For example, if your child requires or will require hospital care,
pediatric specialists, special medications and supplies, or other
services in addition to basic primary care, find out whether your
insurance covers such treatments. Also, if your insurance
requires it, obtain necessary referrals for specialized care from your
primary care physician. It is important to remember that your
health care plan may not cover certain specialized services.
Don't
be intimidated by the term HMO or worried that your child will not
receive optimal care. Quality managed care health insurers are
focused on patient care and should pay close attention to the quality
of service rendered by physicians and other caregivers. Managed
care plans can provide more opportunities for personalized attention
for patients, as well as increased access to immunizations and
preventive and wellness services.
Also, ask the insurance representative if your policy includes case
management services for children diagnosed with life-threatening
illnesses. If so, your child could be assigned to a case manager,
who assists patients and helps physicians and other health care
providers coordinate even the most complex cases.
A case manager can:
● Become an active advocate for the child, making sure that procedures are occurring in a timely fashion
and in the correct setting.
● Guide the child's care when he or she is hospitalized.
● Help parents/caregivers decide what is the most beneficial course of action following discharge (skilled
nursing, rehabilitation, home health
care, therapies, medical equipment, nutritional counseling,
etc.).
● Help extend the life of your health care benefits through efficient, quality-focused use of the health care
system.
● Provide leads for alternative assistance to help pay for services that are not covered under your policy,
and put you in touch with a community agency that can supplement your child's care.
● Act as an ombudsman between you and your employer's benefits administrator.
Services also are available for
families requiring medical assistance in addition to, or in place of, a
managed care program. These programs usually offer free or
subsidized health care for children with special needs.
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Consumer Safeguards for HMOs
Pennsylvania law requires responsibilities for HMOs and provides new rights for HMO members. The law:
● Requires HMOs to notify clients in writing about what is covered, how coverage decisions are made, and
patient appeal rights.
● Prohibits so-called "gag rules" used by some HMOs to discourage physicians from fully discussing
treatment options with patients.
The law bans HMOs from expelling physicians for expressing
disapproval over patient treatments, and prohibits
HMOs from offering physicians incentives (financial or
otherwise) to prescribe less-than-necessary care.
● Prohibits HMOs from denying emergency room coverage based on an after-the-fact look at whether such
care was necessary.
● Provides internal and external grievance procedures for members, who may appeal their disagreement
to the Pennsylvania Department of Health (current grievance procedures may be modified).
● Allows members to receive services from a medical provider for at least 60 days after the provider leaves
a managed care network.
● Gives members with disabilities direct access to specialists and the option to designate a specialist as
their primary care provider.
● Gives women direct access to obstetrical and gynecological services.
● Ensures that patients' medical histories remain confidential.
(Source: Reports to the People, Pennsylvania State Senator Jay Costa; and the Pennsylvania Department of Health)
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What To Do If You Have a Problem with an HMO
The Pennsylvania Department of Health
oversees HMO member complaints and makes sure insurance companies have
approved systems to handle complaints.
Some Common Complaints:
● Receiving a bill you shouldn't have - or that you don't understand.
● Unable to get an appointment with your primary care physician.
● Denied an authorization to see a specialist.
● Denied an authorization for a medical service, such as an emergency room visit.
Here's What To Do:
1. First, call your HMO member services department.
2. If the HMO does not resolve the problem, call again and say that you want to file a grievance. Your HMO
may ask you to write a letter or complete a
special form explaining your complaint. In the complaint, be
as specific as possible, including dates and the
names of people you spoke with about the problem.
Describe the action needed to resolve your
problem. The HMO will review your grievance and inform
you of its decision in writing.
3. If you are not satisfied with the decision, you may request another review by the HMO grievance review
committee, where you can discuss your case in person.
4. If you still are not satisfied with the decision, you may appeal to the Pennsylvania Department of Health.
Call toll-free at 888-466-2787 to begin the
process. The Department of Health will obtain the necessary
information from your HMO and conduct a full review.
HMOs may resolve grievances differently if you are:
● A federal employee or dependent enrolled in an HMO.
● A Medicare or Medicaid recipient enrolled in an HMO.
● Employed by a business that is self-funded or self-insured.
If your problem with an HMO is urgent
and you think you need medical help quickly, call the HMO member
services department and ask for assistance in filing an expedited
grievance. The Pennsylvania Department of Health has established
special procedures and shortened time frames for these types of
grievances.
HMOs are not permitted to terminate a member's coverage without prior approval of the Pennsylvania Department of Health. Involuntary termination can be appealed.
(Source: What to Do if you Have a Problem with your HMO, Pennsylvania Department of Health, Department of Managed Care.)
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Ten Patient Tips for Navigating Managed Care
1. Read And Understand Your Policy
Your health care policy represents a
contract. Read it, understand it, and ask questions before
problems
arise. Also ask about exclusions - every policy has them.
2. Don't Make Assumptions
Never assume that your policy covers something - always ask questions.
3. Understand Your Contract
A variety of policies are available, and
each is very different (HMO, PPO, indemnity). Understand what
kind of contract you have and how that impacts your coverage.
4. Do You Have Access To Specialty Care?
Check to see if your policy restricts
access to specialty hospitals or academic institutions. If it
does, talk
to your benefits manager about selecting a
plan that offers greater access to specialty care before you
need specialty care and cannot have access to it.
5. Update Your Primary Care Physician
Most plans require that your primary
care physician authorize services before they are rendered. Keep
your physician up-to-date on your
current treatment. You also might ask if the physician can
forecast or
discuss any services or treatment that
might be required in the future so that authorizations can be
requested in advance.
6. Does Your Policy Have Carve-Outs?
Some companies stipulate that certain
services be handled by specific companies. The stipulations,
called carve-outs, mean that patients
might be directed to one company for radiologic services, another
for blood services, another for prescription
drugs, and so on. Be sure to ask if your policy includes these
stipulations.
7. Do You Have A Case Manager?
Often with chronic medical conditions
patients are assigned a case manager to guide them through the
managed care system. Get to know
that person and share as much information as possible about your
current treatment and any plans for future treatment. If you don't have a case manager, get to know your
patient representative at your insurance or managed care company.
8. Authorizations Are Your Responsibility
Ultimately, it is the patient's responsibility to get authorization for treatment from his or her insurance
company before the treatment
occurs. To save time and trouble, call your insurance company
before
services are rendered to make sure that
authorization numbers have been received. Otherwise, patients
run the risk of being billed directly for services.
9. Carry Your Policy Card With You
Don't leave home without it! Also, make sure that you leave copies of it with every referring facility that
you visit. Having a copy of the card
will make it much easier for patients to get questions answered.
Don't Be Afraid To Ask Questions
If you aren't able to resolve an insurance or managed care question, or a patient doesn't feel that his or her
case has been treated fairly, don't be afraid to ask questions. Consider calling the State Department of Health for information or assistance (in Pennsylvania, the number is 412-880-0251).
(Source: H. Lee Moffitt Cancer Center & Research lnstitute, 813-972-4673.)
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Medical Assistance (MA) and the MA Access Card
In Pennsylvania, Medical Assistance (MA) provides free medical care to people in low-income families and to those who are severely disabled. The MA ACCESS Card is used by persons on Medical Assistance.
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Eligibility for Medical Assistance
Under current state law, all children who meet the Social Security Administration's definition of disabled and have an income of no more than $670 per month (in the child's name) are eligible for Medical Assistance, regardless of parental income. This is sometimes called the MA Loophole.
Examples of a child's
income counted towards MA eligibility include: Child Support,
Social Security Disability Income (SSDI), and interest received from
savings accounts. Trusts that are not available to the child
until adulthood are not considered income. If the child's
income exceeds $670, monthly medical expenses can be subtracted from
this amount (referred to as spend downs) to bring the child's income within eligibility limits.
If a family's
income exceeds the limit for Medical Assistance and the child does not
qualify under the MA Loophole, a child may qualify for Medical
Assistance under the Healthy Beginnings program. Healthy
Beginnings is a state-supported Medical Assistance program with more
lenient income guidelines.
Healthy Beginnings is open only to pregnant women, and children born
after September 30, 1983. Apply for this program at your local
Public Assistance Office.
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How to Apply for Medical Assistance for Your Child
Contact your social worker, county
Public Assistance Office, or call 717-236-6310 to receive an
application form. Instead of the standard form (which is 12 pages
long) request the Teddy Bear Form, which is only four pages long.
Your medical provider can complete the
application and mail it (signed by the parent) to the Public Assistance
Office in the child's county of residence. The parent also may apply by mail directly.
To expedite the application process using the Teddy Bear Form, check
only the Medical Assistance box, and apply only for your disabled
child. To expedite your application using the standard 12-page
form, write in large block letters on the top of the form MA for
disabled child. These actions will alert the caseworker that
verification of parental income will not be required.
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Required Documentation for a Medical Assistance Card:
● Birth certificate.
● Social Security number.
● Proof of other health care insurance.
● Proof of income in the child's name, if any.
● Proof of child's
disability (medical records; names, addresses and phone numbers of
physicians; and
evidence of how the disability affects the
child at home).
Benefits can be retroactive for 90
days from the date of application. If you wish to receive
retroactive benefits, complete the section of the application titled
Unpaid Medical Bills and present photocopies of these bills with your
application. Alert your health care providers that the
application is pending and contact them when you are notified of
approval.
Instead of mailing the application, you also may apply in person at
your local Public Assistance Office. Call for an appointment or
visit the office and wait for an opening. If you bring all the
necessary documentation, your child may be found eligible and receive
an interim MA ACCESS card that day.
For further information on an interim MA ACCESS card, consult the MA
Handbook, sections 305.26 and 380.4. For a copy of the book, call
717-236-6310.
Should the caseworker insist on considering parental income for your child's application, refer the caseworker to the MA Handbook sections 355.4 and 355.2.
If your application is denied, ask for a clear explanation of the reason. The reason for denial may be as simple as insufficient information. (Consider obtaining copies of medical records or other necessary documents and hand-delivering them to the caseworker.)
If you decide to appeal the denial, ask the caseworker for the appropriate form. If the appeal is successful, services rendered 90 days prior to the date of application are covered.
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Additional information on Medical Assistance May Be Obtained Through the Following Agencies:
Social Security
Offices...............................................................................................................................
800-772-1213
Allegheny County Department of Human Services "Allegheny Link"......................................... 1-866-730-2368 or
.................................................................................................................. TTY 412-350-5205, www.alleghenylink.com
Consumer Health Coalition......................................................... 412-456-1877, www.consumerhealthcoalition.org
Department of Public Welfare, Medical Assistance Office, Allegheny County Assistance
Office
.......................................................................................................................................................................
412-565-2146
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Services Covered Under Medical Assistance
The MA ACCESS card covers services
that are not covered by a private insurer, along with co-pays required
by your private insurer.
Coverage can include:
● Inpatient and outpatient hospital and clinical care, including care in the patient's home under the
supervision of the hospital.
● Care
by the following practitioners: physician, chiropractor, optometrist,
podiatrist, dentist, or home-care
nurse.
● Laboratory work and X-rays.
● Nursing home care.
● Some formulas and nutritional supplements.
● Medical equipment and supplies.
● Prescribed drugs.
● Prostheses.
● Eye care.
● Limited psychiatric care in clinic and hospital.
● Medical services to treat conditions discovered in school examinations.
● Diapers for children ages three years and older who have a diagnosis of developmental delay.
● Dental Care
Medical Assistance does not have a lifetime cap on benefits and does not exclude pre-existing conditions.
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Medical Assistance Options: "Straight" Medical Assistance and HealthChoices(Managed Care)
In Pennsylvania, Medical Assistance has an HMO (managed care) model of service delivery called HealthChoices for enrollees who do not
have a primary private insurer. Enrollees will be asked to choose
a specific Medical Assistance HMO. If you do not choose an HMO,
one will be appointed for you. A list of current Medical
Assistance HMO providers is available from your local MA office.
If you are using Medical Assistance in addition to a private insurer
(whether an HMO or fee-for-service provider), you will not be asked to
enroll in the MA managed care service option. HIPP (Health
Insurance Premium Payment) program participants also are exempt (CLICK
HERE for more information on HIPP).
HealthChoices has three components:
1. Independent Enrollment Assistance (IEA) Program
This program educates and assists MA enrollees
in selecting an HMO. Assistance is provided by mail,
telephone, or in person (based on consumer preference).
2. Physical Health Managed Care Organization (PH-MCO)
Consumers can select from several HMOs;
otherwise, one will be chosen for them. Direct selling to a
consumer is forbidden. HMOs will be
required to cover the same services available under the MA fee
for-service program. Benefit packages will
be based on individual qualifications and needs. Each HMO
will be required to provide an adequate provider network, a directory of providers, and a caseworker to
all enrollees with special needs. Upon
request, caseworkers can serve as health care representatives
on interagency teams for a child's Individualized Education Plan (IEP) and Individual Family Support
Plan (IFSP).
3. Behavioral Health Managed Care Organization (BH-MCO)
This program oversees behavioral health care
(mental health and drug and alcohol services) for
individuals with serious emotional disturbances, mental illness, or addictive diseases. Only one HMO
will be designated for these services within each county, and it will be a separate insurer from other
Medical Assistance HMOs. When an individual
enrolls in a Medical Assistance HMO, he or she will
automatically be enrolled in the Behavioral HMO.
Coordination of care is required between the main
and Behavioral HMO.
The Behavioral HMO must provide members with a contact person who can explain services and assist in
obtaining them.
HealthChoices is required to maintain Special Needs Units for its
enrollees. The purpose of the Special Needs Unit is to ensure
that enrollees with special needs receive timely access to appropriate
primary care specialists, prescription drugs, and community
services. The Special Needs Unit serves individuals who require
care and services of a type or amount that is beyond what is typically
required.
Responsibilities of the Special Needs Unit include:
● Guiding enrollees through the process of choosing an HMO.
● Educating other HMO staff and network providers about special needs populations, and assisting
enrollees in obtaining timely authorizations for needed items or services.
● Recruiting health care providers with experience serving special needs patients, thereby providing
enrollees with adequate choices.
The Special Needs Unit will help families identify physicians who
have experience with specific special needs.
● Assisting with health-related issues such as lack of transportation.
For more information on Allegheny County HealthChoices, Inc., (ACHI), call 412-325-1100.
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Using Medical Assistance and Private Insurance
Having private health coverage does
not affect eligibility for Medical Assistance, but does affect the
amount of coverage provided by MA. Health care providers must
first bill a private health insurance plan for services. MA is
billed only for co-pays, deductibles, and items not covered by your
private insurance.
MA will cover co-pays and deductibles
as long as the terms and conditions of the private insurance carrier
are met. For example, if the private insurer requires you to
choose a provider from a certain list or to get authorization for
services and you do not, MA will not cover the expenses.
Health care providers who accept MA sign an agreement with the
Department of Public Welfare (DPW) to accept payments that are less
than the standard fees. Therefore, if your private insurance
imposes a co-pay, MA will pay it only if the health care provider
accepted the lower-than-standard fee from the primary insurance
carrier. Health care providers who accept the MA card are not
permitted to bill you for any co-pays or deductibles not paid for by MA
- even if it means a loss in revenue.
You must verify that your child's
physician will accept your private insurance as well as MA - or you
will be held responsible for the expenses. You must also make
sure that all necessary authorizations and referrals are
obtained. It is advisable to keep a log of these authorization
numbers and referrals.
When health care services are covered by your private insurer as a
Major Medical expense (where you are expected to pay the bill, file an
insurance claim, and wait for reimbursement), the health care provider
is required to bill MA for the full amount. For example, if your
prescription drug plan requires you to pay the pharmacist and then
submit a claim form for reimbursement, your pharmacist is required to
bill MA for the full amount. You will not be expected to use
private insurance for this service.
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The Health Insurance Premium Payment (HIPP) Program
The HIPP program, operated by the
Pennsylvania Department of Public Welfare (DPW), helps Medical
Assistance clients pay for private health insurance when it is available through an employer and is determined by DPW to be
cost-effective. HIPP is not a health insurance provider but a
service that helps qualifying families pay for their own health
insurance.
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HIPP Eligibility
Pennsylvania residents receiving
Medical Assistance who have a medical, developmental, or behavioral
condition are eligible for HIPP. Qualifying conditions include
HIV or AIDS, severe burns,
blood disorders, cancer, cerebral palsy, developmental disability,
heart disease, kidney disease, multiple sclerosis, respiratory disease,
and spina bifida.
HIPP recipients must use their private health insurance as the primary
payer for all health services, and Medical Assistance as the secondary
payer. HIPP clients cannot enroll in an MA HealthChoices program
for managed care. Instead, they are enrolled under "straight MA."
To apply for HIPP, call 800-684-7730.
Your child's
physician will be asked for supporting documentation, and your employer
will be contacted in order to determine the amount of reimbursement to
which you are entitled. Only those premiums paid for by the
family are reimbursed. The method of reimbursement is determined
by the employer - either by mailing a check to your employer or to you.
The HIPP program will continue to pay your premiums as long as your
child is eligible for Medical Assistance, and as long as payment is
determined by DPW to be cost-effective. HIPP will review your
case regularly. You are responsible for notifying HIPP about
changes in your private insurance policy, such as when premiums
increase. For more information, call 800-684-7730.
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Early Periodic Screening Diagnosis Treatment (EPSDT)
To apply for EPSDT, call 800-543-7633.
The EPSDT program provides children
with free preventive health care, including referrals and assistance in
scheduling physical exams, hearing and vision testing, immunizations,
growth and developmental assessments, dental exams, routine lab tests,
and transportation assistance to and from appointments. The
program also can provide free eyeglasses, hearing aids, braces and
assistive technology devices, and oversee that all children receive
follow-up care.
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Wraparound Services
EPSDT provides Wraparound Services to address the needs of children and adolescents
with complex mental health needs. The wraparound process is based
on a philosophy of providing highly individualized services to meet the
needs of children and families. In this process, a facilitator
(i.e., case manager) works with families to discover their strengths,
set goals, determine major needs, and develop options.
Wraparound Services are community-based in the least restrictive
environment, responsive to cultural differences, and based on family
strengths. The wraparound process includes natural community
supports as well as the following EPSDT Services: Therapeutic Staff
Support (TSS), Mobile Therapists (MT), Behavior Specialist Consultants
(BSC), Family-Based Mental Health (FBMH) services, Resource
Coordination (RC), and Intensive Case Management (ICM).
Families may call their Mental Health/Mental Retardation Base Service Units for information on accessing EPSDT services.
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EPSDT Eligibility
Children under age 21 who receive Medical Assistance are eligible for EPSDT. When you apply, have your child's
MA ACCESS card handy. You will be assigned a caseworker who will
refer you to appropriate services at the appropriate times. To
apply or for more information, call 800-543-7633.
The Children's Health Insurance Program (CHIP) of Pennsylvania
CHIP is a state-subsidized free and
low-cost health insurance program for children up to age 18 years from
uninsured, low-income families who do not meet the income guidelines
for Medical Assistance or Healthy Beginnings. Applicants are
enrolled in an HMO and receive coverage for services, which include
physician visits; dental, vision and hearing care; prescription drugs
(with a co-pay); and mental health care. With proper referral and
pre-authorization, most specialist, surgical, and outpatient care is
covered, as well as inpatient hospital care up to 90 days a year.
Some exclusions apply, such as orthodontia. To obtain benefits
for hospitalization, you must complete an application for MA Spend Down
(see page 37).
When applying for CHIP, you will need to submit proof of Pennsylvania
residency and income. Approval is based on availability. If
no openings are available at the time you apply, your name will be
placed on a waiting list.
As of (DATE), a family of three earning less than $_____ is eligible
for free coverage; a family of three earning less than $________ is
eligible for low-cost coverage.
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Insurers Providing CHIP Programs:
Aetna/U.S. HealthCare CHIP and CHIP
Plus........................................................................................
800-822-CHIP
Highmark Blue Cross Blue Shield - BlueCHIP and the Caring Program for Children..................... 800-543-7105
Pennsylvania Department of Health, Division of Children's Special Health Care Needs
The Pennsylvania Department of Health, Division of Children's Special Health Care Needs,
provides health insurance for children with chronic medical conditions
that may place severe financial burdens on the family. Children
who qualify are those who do not meet the Medical Assistance definition
of disability and those who exceed the financial cap of their private insurer.
Coverage is limited to specific medical expenses. For example, if
a child qualifies because of a cardiac condition, only medical care
directly related to the heart condition is covered. Well child
care, sick visits, and other non-related care would not be
covered. Even complications related to the qualifying condition
may not be covered. Coverage is secondary to private insurance,
as well as to Medical Assistance. Patients must use health care
providers from an approved list.
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Eligibility - Open to PA Residents Who Meet the Following Criteria:
● Children and adults with cystic fibrosis, spina bifida, or hemophilia.
● Children up to age 21 with a cardiac condition, orthopedic disorder, or cleft palate.
● Children with a hearing or speech impairment (eligible up until the time the child enters a public school
system).
Parental income determines final
eligibility and deductibles. If a child has more than one
qualifying diagnosis, he or she must be enrolled under each diagnosis
to receive coverage for all conditions. Applicants must submit a
copy of their latest federal income tax return and have their
application signed by the child's physician.
For more information about the PA Department of Health, Division of Children's Special Health Care Needs, call ________.
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Social Security Benefits for Children with Special Needs
The Social Security Administration (SSA) of the U.S. Department of Health and Human Services has nine offices in Allegheny County (call toll-free 800-772-1213 for the office nearest you).
Social Security benefits can help families who suffer a loss in income because of their child's
health condition. In many cases, one parent takes an extended
leave of absence from work or resigns to assist with the child's
illnesses, physician visits, therapies, medical procedures, and
hospitalizations. In addition, the family may have additional
expenses related to the child's
care that are not covered by medical insurance, such as parking,
modifications to the home, and specially adapted toys. Although
Social Security benefits cannot cover all of these losses, they can
alleviate the impact.
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How Social Security Determines If a Child is "Disabled"
Social Security's definition of childhood
disability is: A physical or mental condition (or a combination
of conditions) that results in marked and severe functional
limitation. The condition must last or be expected to last at
least 12 months or be expected to result in the child's death.
To determine if a child is disabled, a Social Security disability evaluation specialist checks to see if the child's
disability is listed in specific regulations. These listings are
descriptions of symptoms, signs, or laboratory findings of physical and
mental problems, such as cerebral palsy, mental retardation, or
muscular dystrophy, that are severe enough to disable a child.
If a disability cannot be established using the listing criteria, then a disability evaluation team assesses the child's
ability to function in everyday life. Taken into account are
reports from parents, physicians, teachers, therapists, and other
professionals. If the team is unable to make a decision based on
these reports, it may ask the parent to take the child for a special
examination paid for by the SSA.
The disability evaluation process generally takes several months.
In cases of severe disabilities and very limited parental income and
assets, benefits can be received while the formal disability decision
is being made.
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Two Ways a Child May Be Eligible for Social Security Benefits
1. Supplemental Security Income (SSI)
Supplemental Security Income (SSI)
benefits are monthly benefits payable to children under the age of 18
years who have disabilities, limited income and assets, or come from a
home with limited income and assets. Children also must meet
Social Security's definition of disability.
Income Eligibility for
Children Under 18: Most children under the age of 18 do not have
their own
income or many assets. When children live at home,
however, or are away at school but return home
occasionally and are
subject to parental control, Social Security considers the parents' income and
assets.
Income Eligibility for
Children 18 and Older: When children turn 18, Social Security no
longer
considers the parents' or guardians' income and assets. Children who were not eligible for SSI before
their 18th birthday because family income or assets were too high may
now be eligible.
2. Social Security Disability Insurance (SSDI)
There are two ways to obtain SSDI:
1. Social Security Dependents' Benefits
These are
benefits payable to children under age 18 (dependents) on the record of
a parent who is
collecting retirement or disability benefits from the
SSA, or a parent who has died. A child can receive
benefits until
age 19 if he or she is a full-time student who has not yet graduated
from high school.
Children with disabilities can receive the
benefits indefinitely
2. Social Security Benefits for Adults Disabled Since Childhood
Social Security
dependents' benefits usually stop when a child reaches age 18 (or 19
fortime students).
However, benefits can continue into adulthood
if the child is disabled. To qualify, an individual must
have had
the disability prior to the age of 22, and be the son or daughter of
someone receiving Social
Security retirement or disability benefits or
someone who had received Social Security but is now
deceased. If
an individual is receiving SSDI, and his income and assets still are
within the eligibility
guidelines for SSI, that person can receive both
SSDI and SSI.
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How Social Security Determines If an Adult is Disabled
Social Security's definition of adult
disability is: A physical or mental impairment, or combination
of impairments, that is expected to keep a person from doing any "substantial" work for at least a year or is expected to result in death.
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Continuing Disability Reviews (CDRs)
The Social Security Administration conducts Continuing Disability Reviews (CDRs) at least every three years for recipients under age 18 whose conditions are likely to improve.
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How To Apply for Supplemental Security Income (SSI) Benefits
To apply for SSI, call your local
Social Security office and set up an interview (call toll-free
800-772-1213 for the office nearest you). Be prepared to answer
questions as specifically and thoroughly as possible at the
interview. Have the following documents and information
ready:
● Child's Social Security number and original birth certificate (not a photocopy).
● Records that show your income and assets, and your child's income and assets (e.g., tax returns; pay
stubs; insurance policies; all statements showing interest income from savings accounts; certificates of
deposits (CDs); IRAs; and other investments).
● Medical records for your child or the address where they can be obtained. Bring names,
addresses, and
phone numbers of physicians, hospitals, clinics, and
specialists your child has visited - and dates of
visits to physicians
and hospitals.
● Be prepared to explain how your child's disability affects his or her everyday life at home, school and
elsewhere.
● Names, addresses, and phone
numbers of individuals who have observed how your child functions in
everyday life (e.g., teachers, day care providers, family members).
● Copies of your child's school records.
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Frequent Obstacles to Receiving SSI
Denial of Benefits
If you are denied SSI benefits, you
may request a reconsideration by letter or by completing an appeals
form (SSA-561), which can be obtained at your local SSI office.
You have the right to submit this form even if your SSI representative
discourages it. If the benefit decision is reversed, you will be
paid retroactively to the date you first applied. The involvement
of an attorney often can help you obtain SSI benefits. Try to
find a lawyer who works on a contingency basis, meaning one who will
agree to represent you at no cost unless you win, rather than one who
charges an hourly fee. By law, attorney fees cannot exceed 25
percent of your retroactive payments.
Notice of Reduction in Benefits
After qualifying for SSI, you may receive a notice stating that your
benefits are being reduced and why. If you disagree, you have the
right to request reconsideration by letter or appeals form (SSA-561).
Notice of Overpayment in Benefits
After qualifying for SSI, you may receive a notice from SSI advising
you that you were overpaid. For example, overpayment may occur if
your rate of pay varies in ways that you cannot predict. If you
disagree with the determination of overpayment, you can request a
reconsideration by letter or appeals form (SSA-561). If you agree
that you were overpaid but can't
afford to send a refund check, write to request a waiver or complete
form SSA 632. You must be prepared to show that overpayment was
not your fault (e.g., if you notified SSI of an increase in your family
income, bring proof of that notification). Also, be prepared to
explain why paying back the overpayment would be a hardship (e.g., you
need the money to meet your everyday living expenses).
Social workers and parent advocates also can assist you in handling SSI
issues. You may want to try their help before hiring an attorney.
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Contacting Your Local Social Security Administration Office
To contact the Social Security Administration Office nearest you, call toll-free: 800-772-1213 (TDD: 800-325-0778).
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Agencies Assisting with Medical Insurance Issues-Index
Allegheny County Bar
Association...........................................................................................................
412-261-6161
920 City County Bldg., Pittsburgh, PA 15219
Provides referrals to lawyers handling SSI, insurance cases, and other related matters.
Disabilities Lawyer Referral
Service........................................................................................................
888-712-0128
Provides referrals to lawyers handling SSI, ADA, and other issues.
United Way
HelpLine.................................................................................................................................
412-578-2450
Call for your free copy of "A Guide to Primary Health Care."
Neighborhood Legal
Services..................................................................................................................
412-255-6700
928 Penn Ave., Pittsburgh, PA 15222
Provides free assistance on legal matters. Eligibility based on income.
Pennsylvania Department of Health, Bureau of Managed
Care..........................................................
888-466-2787
Rm. 1030 Health & Welfare Bldg.,
PO Box 90, Harrisburg, PA 17108-0090
Settles grievances between consumers and HMOs.
Pennsylvania Department of Public Welfare, Allegheny
County........................................................
412-565-2146
300 Liberty Ave., Pittsburgh, PA 15222
Offers assistance on HMO and other insurance grievances to MA recipients.
Pennsylvania State Insurance
Department..............................................................
412-565-5020 or 877-881-6388
304 State Office Bldg., 300 Liberty Ave., Pittsburgh, PA 15222
Provides assistance on insurance grievances not related to HMOs or MA.
Pennsylvania Health Law
Project............................................................................................................
800-274-3258
Suite 97, 931 N. Front St., Harrisburg, PA 17102
Pittsburgh
Office.....................................................................................................................................
412-434-5779
Gives
assistance and information on health-related issues to those with
disabilities.
Pittsburgh Consumer Health
Coalition....................................................................................................
412-456-1877
Provides referrals and information on free and low-cost insurance programs available to families.
University of Pittsburgh School of Law, Family Support Legal
Clinic.................................................
412-648-1082
3900 Forbes Ave.,
Pittsburgh, PA
15260...........................................................................................
412-648-2656
Offers assistance on
SSI, insurance, and other matters. Eligibility based on income.
A helpful guide to free or low-cost health care is HelpLine's A Guide
to Primary Health Care.
Call 412-578-2450 for your free copy.
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Providers of Health and Financial Benefits-Index
(Recipients must meet eligibility requirements)
Allegheny County Health
Department......................................................................................
412-687-ACHD (2243)
Infectious Diseases (Free
immunizations).........................................................................................
412-578-8060
Women, Infants, and Children (WIC) Program (Food
vouchers).........................................................
412-350-2750
American Cancer Society, Southwest Regional
Office.........................................
412-261-4352 or 800-ACS-2345
(Medications, nutritional supplements, hospital equipment, transportation)
American Lung Association of Western
PA............................................................................................
800-220-1990
(Grant for
medications)..........................................................................................................................
714-772-1750
Arthritis Foundation, Western PA
Chapter..............................................................................................
800-522-9900
(Used
equipment)...................................................................................................................................
412-566-1645
Leukemia Society of America, Inc., Western PA and West Virginia
Chapter....................................
800-726-2873
(Funding for outpatient expenses,
transportation
expenses)..........................................................
412-395-2873
UPMC Mercy
Hill-Burton
Act.........................................................................................................................................
412-232-5660
Muscular Dystrophy Association (MDA) of Southwesternand Midwestern PA,
MDA Clinic, Children's Hospital of
Pittsburgh...................................................................................
412-823-4094
National Kidney Foundation of Western PA (Free medical alert
jewelry)..........................................
412-261-4115
Family
Links..................................................................................................................
412-344-7645 or 412-661-1800
(Funds for respite care, sitting, in-home
support and therapies,
recreational activities, special adaptive
equipment)
Rheumatoid Society, Inc. (Financial aid for equipment and
services)................................................
412-371-8108
Rx Council of Western PA (Prescription
assistance)...........................................................................
412-664-1320
Sickle Cell Society, Inc. (Sickle Cell
Network).........................................................
412-371-0628 or 412-692-7192
(Assistance
with medical expenses)
Three Rivers Center for Independent
Living............................................................................................ 800-633-4588
................................................................................................................................................................... 412-371-7700
.......................................................................................................................................................... TDD 412-371-6230
Ventilator Assisted Children/Home Program
Children's Hospital of
Pittsburgh...........................................................................
412-692-6494 or 412-692-6495
(Funding for
respiratory equipment, supplies, respite
care)............................................................
412-692-6495
Washington County Day Care
Services...................................................................
888-619-9908 or 724-228-6969
YWCA of Greater
Pittsburgh......................................................................................................................
412-391-5100
Child Care Partnerships (Child care
subsidy)........................................................................................
412-255-1281
(Source: This chapter was compiled by Jeanne McMullen.
Information came from various sources, including First Steps, Jewish
Care Coordination Program; the National Information Center for Children
and Youth with Disabilities (NICHCY); the Pennsylvania Department of
Public Welfare; the Pennsylvania Health Law Project; Community
Organized Representatives for Education (CORE); and the Social Security
Administration)
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