Health Care
From Autism Transition Handbook
Contents |
Medical Assistance
Coverage for Children up to Age 21:
Medical Assistance has the broadest coverage of medical and mental health services for persons under 21 of any insurance plan. Even if you have private medical insurance, Medicaid may be available to cover services that are not covered under your plan. For information on eligibility, click here.
- Early Periodic Screening, Diagnosis, and Treatment (EPSDT): Medical Assistance has a children’s health care benefit package called EPSDT. Under this program, children and youth receiving Medical Assistance (both fee-for-service ACCESS Plus and Managed Care Options) are entitled to regular check-ups and full physical and mental health care from birth up to age 21. Most services are covered under this program with the exception of purely educational and vocational services, habilitation, environmental modifications and respite. These non-covered items are covered under Home and Community Based Waivers such as the Person/Family Directed Support and Consolidated Waivers.
- Wrap Around Services: A Wrap Around Service is another name for Behavioral Health Rehabilitation Services (BHRS), which “wrap” around services already provided. BHRS is part of EPSDT and is a Medicaid-funded program that provides trained professional support for children under age 21 with a serious emotional or behavioral disorder to “reduce or replace problem behavior with positive, socially appropriate behavior.” BHRS services are medically necessary and not a substitute for speech and language, occupational, or physical therapies. Wrap Around services differ from education services designed to meet the goals of IDEA in that BHRS focus on community integration and skill development to increase the independence of individuals and their families. These services are defined by a Behavior Treatment Plan, or Behavior Care Plan. To access BHRS, contact the County MH/IDD office. Click on Wrap Around services for more information.
Individuals Ages 21 and Older:
- Physical Health The county in which the individual lives determines the type of Medical Assistance available. For those in a county covered by HealthChoices, individuals generally have two to three Managed Care Organizations (MCO) from which to choose. Once enrolled, the MCO can help the participant find a provider. Services will depend on what your medical provider recommends, and what the Managed Care Organization finds to be medically necessary. Fee-for-Service: Some counties pay for medical services through the Fee-For-Service option and will give you an ACCESS card to use with qualifying doctors in your area. For further information, contact your local County Assistance Office
- Behavioral Health HealthChoices Managed Care: There are differences between the physical health and mental health components provided by the HealthChoices program. Each county contracts with a Managed Care Organization, and while the participant does not have a choice of which MCO to use, he or she has choices of participating providers. Fee-for-Service: If you are eligible for services under the Fee-For-Service program, you will receive a list of Medical Assistance behavioral health providers within your county. For additional information, refer to the DPW website.
- Pennsylvania MA Medical Transportation (MATP) MATP provides transportation to medical services, providers, therapy and clinics for MA recipients who do not have transportation. Your county provides transportation either through a transportation service or from the provider. There is a one-time application that must be completed. You can contact your local County Assistance Office for your local MATP provider and an application.
Coverage if Working Puts Individual over the Medicaid Limits (MAWD)
Earning too much money can mean risking losing health care coverage. The Medical Coverage for Workers with Disabilities program (MAWD) lets individuals take a fulfilling job, earn more money and keep their full medical coverage. To be eligible for MAWD, you must:
- Be at least 16 years of age but less than 65
- Be employed and receiving compensation
- Have a disability that meets the Social Security Administration's standards (note: you do not need to be receiving SSA benefits)
- Have countable income below 250 percent of the Federal Poverty Income Guidelines
- Have $10,000 or less in countable resources (resident property and one automobile are not countable assets)
See Also:
Medicaid which includes how to apply and eligibility requirements.
Other Publicly Funded Health Care Coverage
- CHIP Program. CHIP stands for the Children's Health Insurance Program. The Children’s Health Insurance Program enables states to provide health insurance to children from working families with incomes too high to qualify for Medicaid, but too low to afford private health insurance. The program provides coverage for prescription drugs, vision, hearing and mental health services and is available in all 50 states and the District of Columbia. Your state Medicaid agency can provide more information about this program, or you can get more information about coverage for your children at www.insurekidsnow.gov on the Internet or by calling 1-877-543-7669.
See Also:
For specific information on your state's eligibility requirements for children and adults, the Kaiser Family Foundation has an excellent resource on Medicaid and CHIP coverage. The resource, which can be accessed at http://www.kff.org/medicaid/upload/8130.pdf covers Medicaid and CHIP eligibility, enrollment and renewal polices and procedures, premium and cost sharing requirements for all fifty states.
Health Insurance Finder, from Health.gov.
Health Care Coverage in Pennsylvania
- CHIP in Pennsylvania: This program provides health insurance to all uninsured children and teens up to age 19 who are not eligible for or enrolled in Medical Assistance. There is no income limit for CHIP. The cost varies from free to low monthly premiums with co-pays. You may apply on-line through ONLINE COMPASS, by phone at 1-800-986-KIDS or through a mail application which can be found at http://www.chipcoverspakids.com/apply-and-renew/apply/.
- AdultBasic Health Insurance: AdultBasic health insurance was created several years ago to cover basic healthcare needs of individuals in Pennsylvania, aged 19-64 who have no health insurance. If an adult with ASD does not meet the requirements for Medical Assistance, the Pennsylvania Department of Insurance can determine eligibility for the AdultBasic program. For more information go to http://www.portal.state.pa.us/portal/server.pt/community/health_insurance/9189/adultbasic/592645. Also you may contact them at 800-GO BASIC.
- Health Insurance Premium Program (HIPP). In this "buy-in" program, which was first implemented in 1994, the state pays the worker's share of the health insurance premium for those who are eligible for Medicaid and have access to employer-sponsored health coverage. For further information, please refer to PHLP's excellent summary at http://www.phlp.org/Website/education/hipp.html.
The Autism Insurance Act
As of January 1, 2012, 29 states have passed autism insurance reform laws. For a full list of states that have passed legislation designed to eliminate marketplace discrimination on the basis of an autism diagnosis, please refer to Autism Speaks AutismVotes.org website.
Pennsylvania's Act 62
Pennsylvania's New Act 62 requires many private health insurance companies to cover the cost of diagnostic assessment and treatment of autism spectrum disorder and services for children under the age of 21, up to $36,000 per year. If your child is under 21, and you have private medical insurance from your employer, you should contact your Human Resources department for coverage questions. If your employer has more than 50 employees, and the policy is not a "self-insured" or "ERISA" policy, this coverage may apply.
The new law also requires the Pennsylvania Department of Public Welfare, DPW, under certain circumstances to cover the cost of services for individuals who are enrolled in the Medical Assistance program, CHIP, or adultBasic and do not have private insurance coverage, or for individuals whose costs exceed $36,000 in one year. Please contact your Contact Behavioral Health Managed Care Contacts - Member Services Line
The Department of Public Welfare has an excellent informational site at www.PAAutismInsurance.org.
Private Medical Insurance
Contact your personal medical insurance plan to find out if they cover dependent children with a disability over the age of 21. Be prepared to have documentation of medical disability.
See Also:
The Pennsylvania Department of Health's Special Kids Network has a toll-free helpline for Pennsylvanians with special health care needs and their families. SKN is available Monday through Friday from 8:00am to 8:00pm, and Saturday from 9:00am to 3:00pm. Call: 1-800-986-4550, TTY 1-877-232-7640 for more information. The PA Department of Health also has an excellent handbook entitled, "Transition Health Care Checklist" that is available on their website.
The Disability Rights Network has an excellent presentation on Managed Care Medical Assistance for Children in Pennsylvania.
