Medical Insurance &
Medical Assistance (MA) (Also called Medicaid or ACCESS)
In Pennsylvania, Medical Assistance (MA) provides free medical and behavioral health coverage to people with low incomes or with disabilities. A Medical Assistance ACCESS Card is issued to people on Medical Assistance.
Medical Assistance does not have a lifetime cap on benefits and does not exclude pre-existing conditions.
Children under 21 on Medical Assistance are entitled to all medically necessary health care services and treatment, including:
- Inpatient and outpatient hospital and clinical care, including care in the patient's home if medically needed.
- Care by the following practitioners: physician, chiropractor, optometrist, podiatrist, dentist, or home-care nurse.
- Laboratory work and X-rays.
- Shift nursing and home health care.
- Some formulas and nutritional supplements.
- Medical equipment and supplies.
- Medications, both prescription and many over-the-counter medications (if prescribed)
- Vision care and eyeglasses.
- 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 and orthodontia
- Transportation to and from medical appointments (see “Medical Assistance Transportation Program” in this section of the Guide)
Eligibility for Children on the Basis of Disability or Special Health Care Needs (PH-95)
A child may qualify for Medical Assistance if he or she has a disability (see definition below) or special health care needs, regardless of the parental income. This eligibility is called “PH-95 -- Children with Special Needs” and is informally referred to as the “Loophole Category.”
To be eligible in the "PH-95-Children with Special Needs" category, the child must meet the Social Security Administration 's definition of disabled and have an income of no more than $903 per month in his/her name.
The Social Security Administration definition of disability for children:
- Physical or mental condition(s) that very seriously limit the child’s activities
- The condition(s) must have lasted, or be expected to last, at least 1 year or result in death.
Examples of a child's income counted towards MA eligibility include Social Security Disability Income (SSDI), interest or dividends on bank accounts, stocks or bonds in the child’s name, and earnings from a child’s job.
If the child's monthly income exceeds $903, monthly medical expenses can be used to meet a deductible (referred to as a “spend down”), which will then allow the child to obtain MA coverage for the rest of the month.
How to Apply for MA on the Basis of a Child’s Disability or Special Health Care Needs
The applicant may be a parent, a medical provider, a representative of a hospital or institution, a child welfare agency for a foster child, or any person acting on behalf of the child.
A SIMPLIFIED APPLICATION for applying for Medicaid on behalf of a child (called “PA600-CH Application for Health Care Coverage”) is available by calling 800-842-2020 or 800-692-7462 or visiting any Allegheny County Assistance Office. (For a list of Allegheny County Assistance Offices, call 412-565-2146)
Required documentation for the application:
- Birth certificate.
- Social Security number.
- Proof of other health care insurance, is any.
- Proof of income in the child's name, if any.
Section V of the SIMPLIFIED APPLICATION (PA600-CH) has questions for those applying on behalf of a child with a disability or special health care need. You should submit proof of the child's disability (e.g. medical records; names, addresses and phone numbers of physicians; and information about how the disability affects the child's function at home). A letter from a physician explaining the child’s disability or special health care need is recommended.
The completed application can be mailed or hand-delivered to an Allegheny County Assistance Office.
If the MA application for the child is approved, coverage can be retroactive for up to three months prior to the month of application. If you wish to receive retroactive coverage to cover outstanding medical bills, use Form PA600 form and complete the section regarding “unpaid medical bills.” The PA 600 form is available at a local County Assistance Offices, by calling 412-565-2146, or by downloading it here. ” Include photocopies of the unpaid bills with your application. Alert your health care providers that the application is pending.
Medical Assistance Plan Options: “Fee for Service” and HealthChoices (Managed Care)
"Fee for Service" Plan
With ”Fee-for-Service” health coverage, you can choose any health care provider and facility that are registered as a Medicaid provider with the Pennsylvania Department of Public Welfare.
HealthChoices (Managed Care)
In Allegheny County, Medical Assistance has an HMO (managed care) model of service delivery called HealthChoices for most MA recipients. Enrollees are asked to choose a Medical Assistance HMO. If you do not choose an HMO, one will be chosen for you. A list of current Medical Assistance HMO providers in Allegheny County.
Medical Assistance offers new enrollees an Independent Enrollment Assistance (IEA) Program to assist in the selection of an HMO (also known as a Physical Health Managed Care Organization, or PH-MCO). To enroll in a Medical Assistance HMO, contact the Pennsylvania Enrollment Services Consumer Support Center, 800-440-3989.
Medical Assistance HMOs are required to cover the same services available under the MA “Fee for Service” program. Each HMO is required to provide an adequate provider network, a directory of providers, and a case manager to all enrollees with special needs. Upon request, case managers can serve as health care representatives on interagency teams for a child's Individualized Education Plan (IEP) and Individual Family Support Plan (IFSP).
Medical Assistance HMOs are required to maintain Special Needs Units for their 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:
- Educates HMO staff and network providers about special needs populations,
- Assists enrollees in obtaining timely authorizations for needed items or services,
- Recruits health care providers with experience serving special needs patients, thereby providing enrollees with adequate choices.
- Assists with health-related issues such as lack of transportation.
When an individual enrolls in a Medical Assistance HMO, he or she is automatically enrolled in a Behavioral Health HMO (called a BH-MCO, or Behavioral Health Managed Care Organization). Coordination of care for the enrollee is required between the Physical Health HMO and the Behavioral Health HMO.
A Behavioral Health HMO oversees behavioral health care (mental health and drug and alcohol services) for individuals with autism, serious emotional disturbances, mental illness, or addictive diseases. Only one Behavioral Health HMO is designated for these services within each county. In Allegheny County, it is Community Care Behavioral Health Organization - 800-553-7499.
If Your Application for Medical Assistance is Denied
If your application is denied, the reason will be stated on the denial notice. Information about how to appeal the decision and a form to do so will be included in the notice. You may also send a letter of appeal.
See the Disabilities and the Law in the Family Support section of this guide for information about legal representation in an appeal.
Using Medical Assistance AND Private Insurance
Having private health coverage does not affect a child’s 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 the “payer of last resort” and can only be billed 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.
Also, MA covers co-pays and deductibles not covered by private insurance only if the provider is in your Medical Assistance HMO network or registered as an MA provider with the Pennsylvania Department of Public Welfare (if you are in a Medical Assistance “Fee for Service” Plan).
Health care providers who accept MA sign an agreement with the Pennsylvania Department of Public Welfare 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 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.
It is your responsibility to verify that your child's physician will accept both your private insurance AND Medical Assistance. 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