State Budget Alert:

PA Legislature Gives DPW Green Light for Copays, Including Services for Children with Disabilities

On June 30, the General Assembly enacted significant changes to the statute known as the Public Welfare Code, 62 P.S. § 101 – 1503, which governs many of Department of Public Welfare’s programs, including Medical Assistance. These were signed into law by the Governor on June 30 as Act 22 of 2011. These changes grant DPW the authority to make significant changes to Medical Assistance benefits and provider reimbursement rates without the usual oversight by the General Assembly or the Independent Regulatory Review Commission.

Among the changes made is the express grant of authority to DPW to charge copays, including copayments for services to some children under 18 with disabilities that are covered under Medical Assistance. DPW will be able to require providers to charge families a copay for services their children receive under Medical Assistanceand to refuse services if the family doesn’t pay the copay. The copays would not apply to children on SSI or families whose children receive cash assistance. The copays could apply to children whose family income is above 200% of the federal poverty level. Those amounts, by family size, are below:

 

Household Monthly income (200% of poverty) Annual income (200% of poverty)
2 $2,452 $29,420
3 $3,090 $37,060
4 $3,725 $44,700
5 $4,362 $52,340
6 $5,000 $59,980
7 $5,635 $67,620
8 $6,272 $75,260

It will now be up to DPW to develop and implement a copay policy. Below are a few of the critical issues DPW will need to address:

 

How much will copays be?

On which services will copays be imposed?

Will copays be imposed on each unit of service, each hour of service, each visit, per day?

Will copays be based on income? How will income be determined? Will out of pocket medical costs be deducted from family income for copay purposes?

Will there be a limit on the total amount of copays?

Will copays be imposed on services authorized but not delivered?

Will there be any exemptions (for example children on Medical Assistance waivers)?

Will managed care organizations (HMOs & BHMCOs) be able to set their own copay amounts or exemptions?

Will copays be required for special education services that school districts would usually bill to Medical Assistance under the School Based Access Program? If so, would the school be able to bill School Based Access if the family exercised their rights under IDEA to refuse to pay the copay for services listed in the child’s IEP?

Will copays be required for services under the birth to age three Early Intervention (EI) waiver? If so, would EI providers be able to bill the waiver if the family refused to pay the copay for services listed in the child’s IFSP?

DPW will be able to make these crucial decisions without oversight by the legislature or the Independent Regulatory Review Commission. It appears that DPW can avoid the regulatory process and just publish a notice in the official state publication, the Pennsylvania Bulletin, which will “set forth the copayment schedule”.

 

In the weeks and months ahead, an open and inclusive process that includes input from affected families and providers is essential. The Pennsylvania Health Law Project looks forward to working with family and advocacy organizations as well as providers on these polices and their implementation.

For more information contact David Gates at (717) 236-6310 or DGates@phlp.org.

 

 

 

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