Health Care for CHILDREN
There are several free and low cost health insurance or health coverage options for children in Pennsylvania. Pennsylvania's state Medicaid program, called Medical Assistance, offers some of the best coverage possible, and should be the first program for which children are evaluated. It is important to know that Federal Law has a requirement known as EPSDT (“Early Periodic Screening Diagnosis and Treatment”) which requires that children under the age of 21 enrolled in Medical Assistance must receive all health care that is “medically necessary”.
Health Insurance Coverage through Medical Assistance
As a general rule, Medical Assistance is free for children whose families are within the income and asset limits. For children with disabilities, only the child's income must meet the applicable income limits as the family's income does not count.
Healthy Beginnings
Medical Assistance's program for children, called “Healthy Beginnings”, can cover children from birth until they turn 21 years old. However, there are differences in eligibility requirements for Healthy Beginnings depending upon age, disability, and a few other factors.
Children under age 1 are eligible for Healthy Beginnings if their family earns less than 185% of the Federal Poverty Income Guidelines (FPIG) ( $3,184/ monthor $38,208/year for a family of 4 – in 2007). Children from age 1 to 6 are eligible if their family earns less than 133% of the FPIG ($2,289/ month or $27,468/year for a family of 4 – in 2007). Children age 6 and older born after 9/30/83 are eligible if their family earns less than 100% of the FPIG ( $1,721/ month or $20,652/year for a family of 4 – in 2007). These income limits change each year and are never applicable when the applicant is a child with a disability.
For families coming off of cash assistance/TANF support, special rules apply. See our publications page for information regarding families coming off welfare.
Children with Disabilities
Children with disabilities who qualify for SSI, based on their families income and assets, will automatically be enrolled in Medical Assistance. For children with disabilities who do not qualify for SSI, the state of Pennsylvania also has a special category of eligibility through which they can get Medical Assistance.
Through a Medical Assistance category called “PH-95”, the Medical Assistance program will not consider parental income in the application of a disabled child. Therefore, a disabled child will only be over the income limits if he/she has money or income in his/her own name. Social Security Survivor's Benefits and Child Support payments do not count as the child's income.
It is important to note that disability includes mental and behavioral health conditions, depending on factors such as age, severity, etc. For information about disability standards for children with mental health or bio-neurological disorders, see our guide. Also see our page on Mental Retardation as well as a guide to family support services for MR. For further information about behavioral health treatment for children, see our page on Behavioral Health.
For children applying under the PH-95 category, there are some important differences in the Medical Assistance application process. See our manual on MA for a child with a severe disability for more information on how to apply for PH-95. For information on submitting parental income information under the loophole catagory, please see our flyer on reporting parental income. When ready to apply, families must complete the PA-600CH application or submit their application online through the COMPASS tool.
Health Insurance Coverage through Children's Health Insurance Program (CHIP)
Cover All Kids Takes Effect on March 1, 2007
On March 1, 2007, Pennsylvania expanded its CHIP program to make health insurance available to virtually all children who are citizens or in a qualified immigrant status. CHIP provides free or low-cost comprehensive health insurance through private insurance companies to children under age 19 whose families have low-income but do not qualify for Medical Assistance. The initiative is called Cover All Kids.
Here's how it works :
• Children in families under 200% of the Federal Poverty Limits (about $41,300 for a family of 4) will qualify for CHIP with no monthly premiums. These children will also have no copays for services.
• Children in families from 200% to 300% of the Federal Poverty Limits (about $41,300 to $61,950 for a family of 4) will qualify for CHIP with a monthly premium from $38 to $60 per month. These children will have reduced-cost copays (such as $6 for a generic medication and $10 for a specialist visit).
• Children in families over 300% of the Federal Poverty Limits (about $61,950 for a family of 4) will still qualify for CHIP for a monthly premium of $150, if they do not have other coverage which is affordable and available. These children will have copays (such as $10 for a generic medication and $25 for a specialist visit).
CHIP offers extensive coverage, including prescriptions, check-ups, immunizations, emergency care, hospitalizations, specialists, dental, vision, and more!
Here's how to apply :
• Go to the CHIP website and complete an on-line application: www.chipcoverspakids.com
Or
• Call the CHIP Helpline at 1-800-986-KIDS and enroll over the phone
Or
• Call the CHIP Helpline at 1-800-986-KIDS and request CHIP send you an application you can submit by mail
If you have problems applying or for further information contact the PA Health Law Project Helpline at 1-800-274-3896
Accessing Services through Medical Assistance
For children under 21, Federal EPSDT law requires that they have access to all healthcare services that are medically necessary for them. Demonstrating the medical necessity of a service may require documentation or supportive letters from a prescriber. The process can be different depending on whether the child gets their services through HealthChoices (the managed care program) or Access Card (the fee-for-service program). For more information on accessing services in either program, see our publications page.
All children who have special needs can get help with their Medical Assistance program form the Special Needs Unit. For more information, see a portion of the state's Request For Proposal (Medical Assistance contract with health plans) about Special Needs Units. For special issues regarding children in substitute care, see our flyers (1) (2) (3) on children in substitute care.
If you are having trouble getting services approved through HealthChoices or the Access Card, contact the Pennsylvania Health Law Project at 800-274-3258/ 866-236-6310 TTY.
Accessing Services through CHIP
Children enrolled in CHIP will receive services through a health insurance company that has contracted with the Pennsylvania Insurance Department to administer the CHIP benefits. To find out the names of the CHIP contractors available in your county, check the Pennsylvania Insurance Department page of local contractors.
Children enrolled in CHIP can not claim the Federal EPSDT laws mentioned above (see Accessing Services through Medical Assistance), but there are formal CHIP procedures which are regulated the Pennsylvania Insurance Department. In addition, your particular CHIP contractor may have review procedures. If you are having trouble with enrollment or needed services in the CHIP program, please contact the Pennsylvania Health Law Project at 800-274-3258/ 866-236-6310 TTY.
