LOOPHOLE COPAYMENT FAQs

Transcription

1 LOOPHOLE COPAYMENT FAQs What is the PH-95 loophole category? A child may be eligible for the loophole category of Medical Assistance (MA) if they: Are 18 years old or younger; Meet the Social Security disability standards (SSI may deny SSI benefits to the child due to income and assets, but as long as a disability determination was made, the child can be eligible.); o Note: all other states require an institutional level of care, but PA is unique and does not require this. Are not eligible for other MA Categories (Parental income is used to review other categories of Medical Assistance, and if they are not eligible in other categories, income is disregarded for the PH-95 category.); o Note: Income and assets of the family (parent and child) do not count when applying for this category of MA. (Most other states count income and assets of the child.) What kind of benefits is a PH-95 child entitled to? They are entitled to full Medicaid benefits this will not change with this initiative. What disabilities are included? Any physical or intellectual disability that meets the SSI disability determination is included. The majority fall within the following diagnoses: Attention Deficit Hyper-activity Autistic Disorder and other Pervasive Developmental Disability Mood Disorders Organic Mental Disorders, Multiple Body Dysfunction Hearing Impairment Down Syndrome Communication Impairment associated with neurological disorder How will families know what their copayment limit is? All impacted families have been sent a notice from the Department of Public Welfare (DPW), which includes their estimated monthly copayment limit. This has been calculated for each family based on their gross family income. What if a family has more than one child on MA through the loophole category? Will their copayment limit be above 5 percent? No. The 5 percent cap on a family s copayment obligation is based on the family s gross monthly income and is capped by family, not child. If a family has more than one child on Medical Assistance, their copayment limit will be 5 percent total.

2 What will the copayments be? The following services will have a fixed copayment: Fixed Copayments MA Service Copayment Amount Diagnostic Radiology $1.00 Nuclear Medicine $1.00 Medical Diagnostic Test $1.00 Radiation Therapy $1.00 Prescription and $1.00 Generic Prescription Drug Refills $3.00 Brand Inpatient Hospital Services $20.00 per day (up to $ per stay) Outpatient Psychotherapy $.50 per unit Services For all other services, copayments will be on a sliding scale based on the MA fee for the service, as follows: Sliding Scale Copayments MA Fee for the Service Copayment Amount $ $10.00 $.65 $ $25.00 $2.00 $ $50.00 $5.00 $ $ $10.00 $ $ $20.00 $ $ $40.00 $ $ $60.00 $ $ $80.00 $ or greater $ Will copayments be assessed for all services paid for by MA? No. The following services will be exempt from copayments: Outpatient Hospital and other clinic services Other medically necessary services not otherwise specified in the plan, covered as a result of OBRA 89 Physician s services and medical/surgical services by a dentist Medical care furnished by licensed practitioners within the scope of their practice as defined by state law (Podiatrists, Optometrists, and Chiropractors) Medical supplies and equipment Physical therapy, occupational therapy and speech pathology Private duty nursing services Clinic services Dental services Physical therapy and related services

3 Dentures, prosthetic devices and eyeglasses Other diagnostic and rehabilitative services Certified Registered Nurse Practitioner (CRNP) services Personal care services How will the provider know what the copayment should be? Will DPW be able to implement copayments? DPW has been applying copayments for almost 30 years to other segments of the MA population. In fact, there are currently copayments for services that are applied to individuals well below 200 percent FPL. DPW has established the systems and procedures to ensure that families will not pay beyond their monthly copayment limit. Providers will have real time access to the Eligibility Verification System (EVS), which will inform them of any MA Fee-for-Service copayment obligations, which providers do today for other Medicaid populations. Are MA managed care plans required to implement the copayments? MA physical health and behavioral health Managed Care Organizations (MCOs) may implement the copayments, but are not mandated to do so. MCOs that choose to implement the copayments will need to determine and develop the process for how copayments will be assessed, collected, tracked, and turned off (if the family reaches their copayment cap). MCOs may also apply the copayments in a less restrictive manner, i.e. a lesser copayment amount for the same service(s) than applied by the Department. Additionally, MCOs must provide proper notice to their network providers and members prior to implementing the copayments. How will this change impact local school districts? Will local taxpayers be required to pick up the cost for services provided in schools to children on MA? School districts will not be on the hook for paying copayments. Services provided in schools through the school based access program are exempt from the copayments. Some services may be provided in schools but are not part of the school based program, such as Therapeutic Staff Support (TSS). These services are not provided by the schools or school districts and are currently paid for by Medical Assistance through a Behavior Health Managed Care Organization or the fee-for-service program, and will be assessed a copayment. When determining the copayment amount, is the sliding scale applied to the unit rate or the amount paid for that day for a specific service? For example, for an individual with 5 hours (or 20 units of service) of TSS per day, will the copayment be applied to each 15 minute unit of service separately, or will it be applied to the entire 5-hour block of time? In the MA fee-for-service program, the copayment is applied to TSS based on the unit rate, multiplied by the number of units indicated on the claim line for services rendered that day or during that span of days; the MA Billing Guides for TSS instructs TSS providers how units of services and span periods should be reflected in their MA claims. The sliding scale will be applied on a per claim basis. In this example, the copayment will be calculated for that day based on the cost of 5 hours of TSS services. Copayments for TSS services provided to individuals over 18 years of age are currently applied this way.

4 Why didn t the copayments go through the Independent Regulatory Review Commission? Act 22 of 2011 gave DPW the express authority to establish cost sharing for families applying for assistance in this category. The law specifically states that DPW will establish copayment rates through the issuance of a bulletin and specifically does not require regulations to be promulgated. Isn t private insurance supposed to pay for autism services based on the Act 62 mandate? What Act 62 requires is often misunderstood. Just because a family has private insurance does not mean that the policy is required to provide coverage for autism spectrum disorders under Act 62. If the child s coverage is under an individual policy or coverage is provided through an employer sponsored plan that is either a fully insured small group plan (less than 51 employees) or a self-insured plan, the requirements of Act 62 do not apply. Act 62 is an insurance coverage mandate that requires private health insurance policies (for groups of 51 or more employees), the Children s Health Insurance Program (CHIP) and MA to cover the costs of diagnostic assessments for autism and for certain treatment services for individuals with autism who are under the age of 21. What should I do if my private health insurance denies a claim for diagnosis or treatment of autism? It is the parent s responsibility to appeal denials and file complaints with the Pennsylvania Insurance Department if they feel an insurer is not covering what is required under the law. In the almost three years since enactment of Act 62, only 28 complaints or appeals were submitted to the Pennsylvania Insurance Department. If your insurer denies a claim for services related to the diagnosis or treatment of autism, you may follow these steps to protect your right to get full coverage under your policy: Step 1: Review the coverage (benefits) section in your benefits guide to determine if the services are a covered benefit. Step 2: After confirming the services are a covered benefit, review the appeals section in your benefits guide to determine how you may dispute the insurer s initial decision to deny services. If you have time before the deadline for filing an appeal, you may find it useful to contact the insurer and your medical provider and attempt to resolve the dispute informally. Step 3: If the informal process does not resolve the issue, you should file an appeal with your insurer (follow the process outlined in your benefits guide or call the insurer and ask how to file an appeal of a claim denial). Act 62 provides a more generous appeal process than other types of covered benefits. Families, or their authorized representative, can appeal any denial of an autism diagnostic or treatment service to the insurer and are entitled to an expedited internal review followed by an expedited independent external review. Their insurer will tell them how. At any time in the process, you may contact the Pennsylvania Insurance Department (PID) to ask a question. You have three ways to file a complaint with the PID: 1. Online: Visit our online consumer services portal ( and follow the instructions on how to file a complaint.

5 2. In writing: Download a complaint form (same web address as above) and send it in by fax or mail to: Pennsylvania Insurance Department 1209 Strawberry Square Harrisburg, PA Fax: (717) By telephone: Toll-free: ; TTY/TDD: (717)