PA Legislature gives DPW green light for copays on services for children with disabilities.

PA Legislature gives DPW green light for copays on services for children with disabilities.

 

On June 30, the PA General Assembly enacted significant changes to the Public Welfare Code which governs many of DPW’s programs, including Medical Assistance.  These were signed into law by the Governor on June 30 as Act 22 of 2011.  Generally speaking, these changes grant DPW the authority to make significant changes to Medical Assistance benefits and provider reimbursement rates without the usual oversight by the General Assembly or the Independent Regulatory Review Commission.

 

Among the changes made, was the express grant of authority to DPW to charge copays for services to some children under 18 with disabilities that are covered under Medical Assistance.  DPW will be able to require providers to charge families a copay for services their children receive under Medical Assistance.  The copays would not apply to children on SSI or families whose children receive cash assistance.  The copays could apply to children whose family income is above 200% of the federal poverty level.  Those amounts, by family size, are below:

 

 

Household	Monthly income (200% of poverty)	Annual income (200% of poverty)
2	$2,452	$29,420
3	$3,090	$37,060
4	$3,725	$44,700
5	$4,362	$52,340
6	$5,000	$59,980
7	$5,635	$67,620
8	$6,272	$75,260

 

It will now be up to DPW to make a number of crucial policy decisions in developing these copays.  Below are a few of the critical issues DPW will need to address:

 

How much will the copays be? 

Will they vary based on income? 

How will income be determined?  Gross or take home?

Will out of pocket medical costs be deducted in determining family income for copay purposes?

On which services will copays be imposed? 

Will copays be imposed on each unit of service, each hour of service, each visit, per day?

Will there be a cap on the total amount of copays?

Will copays be imposed on services authorized but not delivered?  

Who collects the copays? 

What happens if the family can’t or doesn’t pay the copay?

Will there be any exemptions, say for example, children on waivers?

 

Unfortunately, DPW will be able to make these crucial policy decisions without oversight by the legislature or the Independent Regulatory Review Commission.  It appears that DPW can avoid the regulatory process and just publish a notice in the official state publication- the PA Bulletin- that will “set forth the copayment schedule”.

 

This means that it will be absolutely essential that there be an open and inclusive process to obtain input from affected families and providers to address the issues above and others. The Health Law Project looks forward to working with family and advocacy organizations as well as providers to advocate with DPW. 

 

 

Special needs insurance doesn’t have to be complicated

It’s among the most pressing concerns that special needs families have: health insurance. I recently posted about a new healthcare plan, the Special Needs Plan, which provides other medical benefits to intellectually disabled people who are on Medicaid.

But I wanted to learn more. I talked to George Violand, an Arc board member and insurance consultant with 30 years in the business. We talked about what the Special Needs Plan is, what benefits it provides, who qualifies, what payers offer the plan, and how to enroll.

Listen to the podcast to get the scoop. If you have questions or want to learn more, feel free to contact George at gvioland@verizon.net, or Tom Dareneau, Executive Director of Arc Advocacy Services, at berksarc@aol.com. When e-mailing, be sure to include “Arc” in your subject line!

 

You might have more health insurance benefits than you think

It’s no secret medical care and treatment for those with intellectual disabilities is a large, ongoing expense, and many families are struggling to afford it. Medicare Advantage Plans have helped families shoulder this burden by providing prescription drug coverage and other benefits.

But there is a new Medicare Advantage Plan that might give families new hope. It’s called the Special Needs Plan (SNP). It provides greater access to providers and facilities, and offer dental, vision, and hearing benefits that are not part of Medicaid.

The Arc sent more information about SNPs to the community, and we’re sharing it below. If you need help in enrolling or have questions, call or e-mail Arc Advocacy Services 610-382-5805 or berksarc@aol.com.

Many service providers and advocates are unaware of the significant benefits to be derived from the Medicare Modernization Act, especially for individuals with Mental Retardation. While most people are familiar with Part D Prescription Drug coverage resulting from this legislation, few people are aware of the medical insurance benefits to be derived from Medicare Advantage for individuals who qualify for both Medicare and Medicaid.

The impetus behind the Medicare Modernization Act was to create competition in the Medicare marketplace. Part D continues to create more competition and lower costs for consumers. Medicare Advantage Plans are similarly encouraged by the Center for Medicare Services (CMS) to stimulate competition in the private sector and effectively lower insurance costs in the marketplace.

A new type of Medicare Advantage Plan is called the Special Needs Plan (SNP). Under current Medicaid law, eligible participants must seek care from a participating Medicaid provider in order to have Medicaid coverage that picks up what Medicare does not pay.

However, because of poor reimbursements and cumbersome claim filling requirements, most doctors and dentists are unwilling to participate in the state Medicaid program. As a result, many individuals have trouble seeing the doctors, dentists, and specialists that they would prefer to see. For many Medicaid recipients, their only access to healthcare is either through a clinic or through the emergency room.

The SNP attempts to correct this disparity in access to healthcare coverage by paying providers the full Medicare allowable charge or the negotiated insurance rate that the provider has agreed to! Provider participation with Medicaid is no longer a requirement, since Medicare Advantage is a Federal program! Several insurers in the five-county area and Berks County are offering provider access through their commercial insurance networks.

In addition to greater access to providers and facilities, these Special Needs Plans also offer dental, vision and hearing benefits that simply are not part of current Medicaid!

If you need help in enrolling or have questions, call or e-mail Arc Advocacy Services 610-382-5805 or berksarc@aol.com.