As part of the 2011-12 state budget, the Pennsylvania Department of Public Welfare was directed to impose co-payments for Medicaid services on children with special health care needs whose family income is more than 200% of the federal poverty guidelines.  PHLP and several partners (Disability Rights Network, Mental Health Association in PA, the PA Chapter of the American Academy of Pediatrics, Pennsylvania Partnerships for Children and PA Community Providers Association) are working to ensure that this imposition does not place too great a financial and administrative burden on families.

As part of that effort, PHLP surveyed 948 families about what services they use, what out-of-pocket expenses they pay, and how Medicaid services support their children in school.
Highlights of the responses are:

• Children need services on a regular basis

933 families said that Medicaid pays for their child’s primary care.
763 families said that Medicaid pays for their child’s specialty care.
758 families said that Medicaid pays for their child’s prescriptions with almost half saying they filled prescriptions once a month.
625 families said that Medicaid pays for their child’s diagnostic tests and 405 families said that Medicaid pays for their child’s diagnostic x-rays and other radiology.
325 families said that Medicaid pays for their child’s physical therapy, 514 families said that Medicaid pays for their child’s speech therapy, and 449 families said that Medicaid pays for their child’s occupational therapy.
272 families said that Medicaid pays for outpatient behavioral health, 407 families have wraparound services and 261 families said that Medicaid pays for other behavioral therapies/psychiatrist/psychologist services.

• A significant number of families already are paying out-of-pocket for services

212 families pay for primary care, 258 families pay for specialty care, 242 families pay for medications with 34.3% paying between $100 and $200 a month.
143 families pay for diagnostic tests with 48.3% paying between $100 and $200.
71 families are paying for outpatient behavioral health with 42.3% paying between $100 and $200 per visit.

• The majority of families who answered the survey have private coverage. This means that Medicaid is the secondary payer, paying only what private insurance doesn’t cover.  75.9% (707) families are paying a premium for their child’s private health insurance with the majority paying between $100 and $200 per pay period.

• School Districts rely on Medicaid to help support the costs of a child’s Individualized Education Plan (IEP).  630 families said that their child’s school district bills Medicaid for services.

• The families who answered the survey are not wealthy; 40% make less than $60,000 a year, 60.6% make less than $80,000 a year, and 77.7% make less than $100,000 a year. Only 21.6% make more than $100,000 a year.

PHLP and its partners have developed a set of recommendations to DPW on how to best implement the co-payments and will meet with DPW staff later this month. For more information, contact David Gates.