November 2006

MANAGED CARE MEDICAL ASSISTANCE FOR CHILDREN IN PENNSYLVANIA: AN OVERVIEW

Prepared by: Disability Rights Network of Pennsylvania

www.drnpa.org 1414 N. Cameron Street, Suite C

Harrisburg, PA 17103 1-800-692-7443 [Voice] 1-877-375-7139 [TTY]

717-236-0192 [Fax]

November 2006

What Children Are Eligible For Medical Assistance?

• Medical Assistance (MA), also known as Medicaid, is a low-income program, but:

• For children with significant disabilities, in Pennsylvania, parental income does not count. (Child support is parental income.) As a result, almost all children with disabilities in Pennsylvania are eligible for Medical Assistance.

• Income in the child’s name (e.g., trust income in many cases) does count.

• SSDI benefits will not count.

• Having private insurance does not make a child ineligible for Medical Assistance, but the child must use private insurance first.

November 2006

What Is Covered?

• Early and Periodic Screening, Diagnosis and Treatment (EPSDT)– All children on Medical Assistance are entitled to

EPSDT. Children on fee-for-service Medical Assistance, including ACCESS and ACCESS Plus, and children in Medical Assistance managed care health plans are entitled to EPSDT.

– EPSDT includes virtually all medical services that are necessary to treat an illness, condition, or defect.

– Not all services are considered “medical services.” But most are, including:

November 2006

Examples of Covered Services

• Physicians, hospitals, therapies, and lab work• Personal care/home health services/skilled nursing• Diapers for children over age three (or who have

extraordinary needs)• Prescription medication and nutritional

supplements• Augmentative communication devices and FM

listening systems • Wheelchairs and eyeglasses• Case management

November 2006

What Is Not Covered?

• Services not covered under EPSDT are few, but include:

– Purely educational services – Purely vocational services – “Habilitation” (training) services (as opposed to

rehabilitation services, which are covered) – Home and vehicle modifications (as opposed to

home equipment, which is covered)– Respite (as opposed to home health services

or personal care services, which are covered)

November 2006

Medicaid Home and Community Based Waivers

• Some children, particularly those with mental retardation, are also eligible for Medicaid Home and Community Based Waivers, which generally cover those services or items described above that are not otherwise covered by Medical Assistance (e.g., respite and habilitation services).

• Waivers have caps on the number of individuals

accepted and on the amount of money that can be spent.

• There can be long waiting lists.

November 2006

What Is HealthChoices?

• Most children in certain areas of Pennsylvania who apply for Medical Assistance must choose a Medical Assistance managed care physical health plan and are automatically enrolled in their county’s Medical Assistance managed care behavioral health plan.

– They must use the provider networks from those plans whenever possible, and they must get prior authorization for most services or items.

• Each of the Medical Assistance managed care physical

health plans has a Special Needs Unit, from which families should be able to get help with service access issues related to their child’s disability or other needs.

November 2006

What Is the Process for Requesting Physical Health Services?

• In addition to a prescription, doctors should send a Letter of Medical Necessity to the Medical Assistance managed care physical health plan to explain the need for the treatment, service, or item.

– The Letter of Medical Necessity should:

• Explain the child’s medical conditions and functional limitations (in both clinical and lay-person terms)

• Describe the purpose of the treatment and the consequences of not providing it, and

• Explain why any obvious, less expensive measures are inadequate.

November 2006

What About School or Early Intervention Services?

• Medical Assistance services may not be denied on the basis that the school or Early Intervention program should be providing the services. Services may be denied if the school or Early Intervention program is already fully meeting the child’s medical needs.

• If the child is receiving some of the same or similar services from the school or Early Intervention program (e.g., if the child gets group speech therapy at school but needs one-on-one, gets one hour a week of physical therapy at school but needs three hours, or gets services during the school year but not in the summer), the Letter of Medical Necessity should acknowledge what services the child is already getting and explain why something more or different is needed.

November 2006

What If…..?

• Medical Assistance managed care physical health plan doctors will sometimes contact treating doctors to try to convince them that less is needed.

• Treating doctors should always clearly ask for what they think the child really needs. Compromise is not the doctor’s role.

• As long as a doctor continues to prescribe the service or item, the family can appeal any denial. Without the doctor’s prescription, the family has no rights.

November 2006

What Is the Process for Requesting Behavioral Health Services?

• Families can call the Medical Assistance managed care behavioral health plan for help in finding an in-network provider to provide the evaluation or service requested. Children should be able to get an evaluation or see an outpatient clinician within seven days of this request.

• For many services, the provider must conduct an evaluation and convene an interagency team meeting—including the family, school, and other agencies involved in the child’s care or treatment—before submitting a request for services to the Medical Assistance managed care behavioral health plan. These requested services, if authorized, should be provided within 60 days of the family’s first call to request help.

November 2006

What If Behavioral Health Services Are Not Available?

• If families cannot access Medical Assistance behavioral health evaluations or services in a timely manner, they can complain to:

– the Medical Assistance managed care behavioral health plan

– the county Office of Mental Health, and then

– Pennsylvania Office of Mental Health and Substance Abuse Services.

• Let the Disability Rights Network of Pennsylvania know of your complaint: (800) 692-7443 (voice) or 877-375-7139 (TTY).

November 2006

When Must A Medical Assistance Managed Care Health Plan

Authorize Services?

• The HealthChoices managed care health plan (physical and behavioral health) must authorize a covered service or item prescribed by a treating professional if the service or item is medically necessary.

– The plan’s doctor has the authority to disagree with the child’s treating professional.

November 2006

What Rules Must Be Followed to Deny Authorization?

• If, after physician review, the plan denies authorization for the service or item, the plan must notify the family in writing of the reason for its decision. “Not medically necessary” is not an adequate explanation.

• The plan’s decision should be made within two (2) business days of the receipt of all necessary documentation (24 hours for medication). If there is no written denial within 21 days of the request, the service or item is automatically approved.

November 2006

How Can I Appeal A Denial of Authorization for Physical or Behavioral Health Services?

• All denial notices from a Medical Assistance managed care health plan must inform the family of the process and deadline for filing an appeal.

• Appeals can be made to the Medical Assistance managed care health plan, to the Department of Public Welfare (DPW), or to both.

• Note: Pre-existing services will continue during the appeal process if the appeal is postmarked within 10 days of the notice of termination or reduction.

November 2006

Will There Be A Hearing on My Appeal?

• If you appeal to the Medical Assistance managed care health plan, there are two internal levels of review. You have a right to attend at each level.

• If you are still not satisfied after the second level review, you can request that a paper review be done by an independent “external review committee” approved by the Department of Health.

• If you appeal to the Department of Public Welfare within 30 days of the denial, or within 30 days of a first or second level decision by the plan, you will get a Fair Hearing by phone, or, if you request it, in person.

November 2006

Who Should I Bring to A Hearing?

• You may bring a lawyer or advocate to a hearing.

• If you are low income, you can contact your local legal services office for assistance.

• It is strongly recommended that a doctor or other practitioner be available to explain the medical need.

• Doctors and other witnesses are usually permitted to participate by phone, if necessary.

• Also, bring all documentation (and two copies) necessary to prove your case.