Medical Assistance in Pennsylvania: FAQs
What is Medical Assistance (MA)?
Medical Assistance, or Medicaid is a public insurance system that provides free health insurance to persons who are eligible. It is jointly funded by the federal and state governments and administered by state governments. It is not "welfare"and does not provide its beneficiaries with cash assistance.
What are Access and HealthChoices?
Pennsylvania residents, depending primarily on area of residence in the state, get fee-for-service Medical Assistance or managed care medical assistance (HealthChoices). The Office of Medical Assistance Programs of the Department of Public Welfare ( DPW) administers both programs. Although fee-for-service is sometimes used interchangeably with Access, all recipients receive an Access card. Managed care recipients also receive a member card from the HMO of their choice. Occasionally a beneficiary living in a HealthChoices area will not have managed care, and some fee-for-service areas also have a managed care option. Services available under HealthChoices and Access are not identical. Consumers or providers with questions about services under HealthChoices must contact their individual health plan. Consumers or providers with questions about services under Access must call the fee for service provider line xxx-xxxx or consumer line xxx-xxxx.
Are physical and behavioral health services covered separately?
Fee-for-service MA covers physical and behavioral health services provided by any provider participating in the Medical Assistance program. In managed care, there are separate physical health and behavioral health providers. Each county chooses its own behavioral health managed care organization. However, DPW contracts with physical health managed care organizations to provide care over wider, pre-determined geographic areas. Physical health HMOs pay for all covered aspects of physical healthcare, and all pharmaceuticals including mental health drugs.
What determines Medicaid eligibility?
Eligibility is determined by being part of a particular group such as pregnant women, children, older adults, or disabled adults, and also by meeting financial and citizenship requirements. Some people are eligible because of a temporary disability, or because they are caring for a disabled family member. In this situation the physician plays an important role in helping the patient obtain MA. (see below)
The PHLP Guide for Determining Eligibility reviews all of this in detail. If a patient has no insurance and you believe they are eligible, you may refer them to the local County Assistance Office or a staff member in your office can use Quickscreen to assess eligibility for various state health care programs. If they are denied and you or they believe they may be eligible, call the Pennsylvania Health Law Project at 1-800-274-3258.
Are there special programs for specific medical conditions?
The Breast and Cervical Cancer Prevention and Treatment Program provides coverage for uninsured women with breast or cervical cancer who might not otherwise qualify for MA. Persons with disabilities who are able to work part-time can purchase MA under the MAWD program. This can be done without jeopardizing their disability income.
What are waiver programs?
Home and community based waiver services provide patients with a variety of services in the home. These services may include case management, homemaker, home health aide, transportation, and personal attendant services. Waiver services are available to patients who would otherwise require a nursing home, and who meet certain financial requirements. They are not an entitlement and there is no guaranteed entrance into a waiver. For more information about waiver services see PHLP Guide for Determining Eligibility or call the Pennsylvania long term care website or call the DPW public information Helpline at 1-800-692-7462 [note – is this the best #)
Does a physician have a role in determining eligibility?
Physicians have a key role in enabling patients to obtain Medical Assistance if:
- The patient is temporarily or permanently disabled. The provider must complete PA 1663 or the
Employability Assessment Form
The patient requires health sustaining medications in order to be employable. This includes medications for chronic conditions such as hypertension, diabetes, arthritis, or ulcers. The provider must complete PA form 1671,Health Sustaining Medication Assessment Form
The patient is the caretaker for a household member who is ill or who has a disability and there is no one else in the household to care for that person. The provider must write a letter.
The patient is an immigrant with an emergency medical condition who is not eligible for full MA due to immigrant status. The physician must write a letter.
What do I do with those forms patients bring me from the County Assistance Office?
We have provided a guide for medical providers which explains the meaning of the options on the most common forms, including the consequences to your patient depending on the answers you provide.
Can someone have medical assistance and another insurance?
Yes. A person can have Medicare and also qualify for medical assistance if they are low income. In this situation Medicare is primary insurance and MA is secondary insurance. Since Medicare does not cover prescriptions, MA pays for them. In addition, a person can qualify for medical assistance even if they are covered under commercial insurance. The commercial insurance is primary and MA is secondary. This frequently occurs with children with disabilities.
Are PACE and PACENET part of Medical Assistance?
No. Persons eligible for Medical Assistance are not eligible for these programs. PACE and PACENET ( http://www.aging.state.pa.us/aging/cwp/view.asp?a=293&Q=173876) are Pennsylvania programs which provide assistance with prescription drug coverage for patients 65 or over. They are funded by the state lottery and eligibility is based on income. Applications are available online or from any pharmacy in the commonwealth.
What if my patient is in an HMO and needs a specialist and there is no one available in the HMO network?
The HMO must have at least 2 specialists or sub-specialists who can meet the needs of an individual patient. For children with special needs, the HMO must have at least two pediatric specialists or sub-specialists. If the HMO does not meet these requirements, then the patient, or the primary care physician acting on behalf of the patient, must allow the patient to pick an out-of-network provider. You must obtain prior authorization for an out-of-network referral, unless it is for medically necessary emergency care.
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