What is Medical Assistance (MA)?
Medical Assistance (also known as Medicaid) is a public insurance system with eligibility mainly based on income. 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 is HealthChoices?
Pennsylvania residents, depending primarily on area of residence in the state, access their Medical Assistance (MA) benefits through either fee-for-service or Medicaid managed care. Most MA recipients in managed care are in a mandatory managed care “HealthChoices” zone. Regardless of their delivery of care system, all recipients receive an ACCESS card. Those in fee-for-service use this ACCESS card as their insurance card.
Managed care recipients 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 voluntary managed care options. Services available under HealthChoices and fee-for-service 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 fee-for-service must call the MA provider line (1-800-537-8862) or MA consumer line (800-692-7462; TDD 800-451-5886). The Department of Human Services has a web page with links to its important provider information.
Are physical and behavioral health services covered separately?
Physical health services are covered by managed care in five HealthChoices zones – Southeast, Southwest, New West, Lehigh/Capital, and New East. In addition, HealthChoices plans are responsible for all medication coverage for physical and behavioral health in HealthChoices zones. All behavioral health services are covered under managed care. The managed care provider varies by county. For more information see the DHS website
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 Medical Assistance. (see below)
If a patient has no insurance and you believe they are eligible, you may refer them to the local County Assistance Office. If they are denied and you or they believe they may be eligible, call the Pennsylvania Health Law Project at 1-800-274-3258.
By 2014, the Patient Protection and Affordable Care Act of 2010 will generally expand Medicaid eligibility to cover everyone at or below 133% of the Federal Poverty Level.
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 Medical Assistance under the MAWD program (Medical Assistance for Workers with Disabilities) and can have much higher income limits than basic Medical Assistance.
What are waiver programs?
Home and community based waiver programs 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 persons who require assistance with activities of daily living and others who meet certain functional requirements (people with AIDS, people on home ventilators, persons with autism, and others) who also 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 our waiver guide or the Pennsylvania Long Term Care website or call the DHS public information Helpline at 1-866-286-3636.
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 or has a chronic medical condition.
- The provider must complete form PA 1663, available here. How the provider completes this form has important implications for the patient’s ability to obtain Medical Assistance. See our brochure.
The patient has a chronic medical condition and is working.
- The provider must provide some verification of the medical condition and can use the PA 1663. See our letter.
The patient requires health sustaining medications in order to work.
- This includes medications for chronic conditions such as hypertension, diabetes, arthritis, or ulcers. The provider must complete PA form 1671, available here. See our brochure.
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; click here for a template.
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 in order for the patient to obtain medical assistance emergency coverage. Click here for a template for a letter (.doc).
What do I do with those forms patients bring me from the County Assistance Office?
We have provided a guide for medical providers that explains the meaning of the options on the most common forms, including the consequences to your patient depending on the answers you provide.
How long does the state have to process an application for Medical Assistance?
Normally, thirty days. This timeframe is shortened to five days when an applicant has an “urgent medical need.” Practitioners can help their patients by writing a short note on letterhead or prescription pad listing the patient’s diagnosis and stating that the patient has an “urgent medical need.”
Can someone have medical assistance and another insurance?
Yes. For example, a person can have Medicare and also qualify for Medical Assistance if they are low income. In this situation Medicare is primary insurance and Medical Assistance is secondary insurance. 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 are Pennsylvania programs that 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 on the PACE/PACENet website or from any pharmacy in the commonwealth.
What if my patient is in a Medical Assistance 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. These practitioners must have appointments available for routine care within 10-15 days. If the HMO does not meet these requirements, then the patient, or the primary care physician acting on behalf of the patient, can request an out-of-network authorization. The HMO must allow the patient to pick an out-of-network provider in these circumstances.