Behavioral health refers to treatment and services to address mental health problems or drug and alcohol abuse. Coverage depends on the type of health insurance, but accessing behavioral health services is frequently different from accessing physical health care.
Children’s Health Insurance Program (CHIP)
The Children’s Health Insurance Program (CHIP) is Pennsylvania’s health insurance program for uninsured children and teens up to age 19. CHIP provides a comprehensive array of benefits, including check-ups, dental care, therapies, prescription medications, and mental health treatment. For children in low-income families, CHIP is free. For children in higher-income families, CHIP has a sliding scale monthly premium based on household income and a requirement that the child has been without health insurance for at least six months.
Prescription Drug Access & Coverage
Many people have trouble paying for prescription drugs, either because they are uninsured, because their co-pays are too high, or because they are not aware of available help. Pennsylvania has several programs to help its residents obtain prescription drugs. All children and most adults on Medical Assistance are eligible for prescription drug coverage. Pennsylvania’s PACE and PACENET programs provide prescription assistance to individuals age 65 and older with limited income. Medicare provides prescription drugs through the Part D benefit. For those without prescription coverage, free or low-cost medications may be available through the patient assistance programs offered by drug manufacturers.
Health Care for …
Often, belonging to an identified group of people—children, people with disabilities, veterans, immigrants, persons with mental health problems, seniors, or the uninsured—affects a person’s ability to get health care. Materials in this section contain information on accessing health care for persons who might, depending on diagnoses, life circumstances, or gender, fit into a category with special rules or benefits.
President Barack Obama signed legislation known as the Affordable Care Act, or Health Care Reform, into law in March of 2010. The most sweeping domestic legislation enacted since the creation of Medicare and Medicaid, the Affordable Care Act is intended to increase access to care, bend the cost curve, and improve the care delivery system.
Long Term Care
Long term care refers to services and supports over an extended period of time that meet the medical and non-medical (personal assistance) needs of people with chronic conditions who cannot independently care for themselves. Long term care can be provided at home, in the community, or in institutions (e.g., personal care homes, assisted living facilities, or nursing homes). Home and Community Based Services are Medical Assistance programs that allow individuals at risk for institutionalization to remain in the community by providing them with extra medical and support services. Eligibility for these programs depends on income and resources, need for assistance, and the availability of funds.
Medicaid is Pennsylvania’s health insurance safety net. It provides health and long-term care services to low income children, families, persons with disabilities, and the elderly. In Pennsylvania, the Medicaid program is called Medical Assistance and is administered by the Department of Public Welfare (DPW). To qualify for Medicaid, a person must meet financial requirements and fit into a certain group or category. While children on Medicaid get all medically necessary health care benefits, the benefits available to adults vary depending on the person’s eligibility category. (Find out if you are eligible for Medical Assistance by using PHLP’s online Quickscreen tool.)
Medicare is a federal health insurance program for people who are disabled or aged 65 and older. People under age 65 have to receive Social Security Disability (SSDI) for at least two years, or have End Stage Renal Disease, to get Medicare. Medicare has three parts: inpatient hospital coverage (Part A); outpatient coverage (Part B); and prescription drug coverage (Part D). Its beneficiaries access care through either original Medicare, using their “red, white, and blue” Medicare card, or a Medicare managed care plan (also known as a Medicare Advantage Plan). Because Medicare has substantial cost-sharing, most beneficiaries obtain additional or supplemental coverage for help with out-of-pocket costs.
Currently hundreds of thousands of Pennsylvanians lack health insurance of any kind. Uninsured Pennsylvanians include the self-employed, those employed in low wage jobs or working for small companies who do not offer health benefits, those who have recently lost jobs and the insurance that came with it, persons who cannot purchase insurance because of pre-existing health conditions, and immigrants, both documented and undocumented, who are not eligible for public health insurance. The Affordable Care Act decreases the number of the uninsured by eliminating pre-existing condition requirements imposed by health plans, establishing health insurance exchanges selling affordable insurance, and expanding Medicaid. Until these reforms take effect in 2014, there is a patchwork system for the uninsured to obtain health care. This includes insurance programs and health care options like adultBasic, PA Fair Care, hospital charity care programs, pharmaceutical patient assistance programs, and Federally Qualified Health Centers.