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State Acts to Implement PH 95 MA Co-payment
August 13, 2012

On August 11 the Department of Public Welfare (DPW) announced its intent to amend the Medicaid State Plan to apply co-payments to services provided to certain Medical Assistance (MA) eligible children with disabilities. Co-payments will be applied for MA services provided to children with disabilities whose household income is above 200 percent of the federal poverty guidelines based on family size. DPW will determine family income based on the family's gross annual income prorated for monthly periods. The total aggregate amount of the copayments will not exceed five percent of the family's gross annual income, prorated and applied on a monthly basis. The following are a sampling of key services that will not have copayments:

  • Prevention,
  • Early intervention,
  • Emergency,
  • Laboratory,
  • Medical exams for persons under 21 years of age provided through the Early and Periodic Screening, Diagnosis and Treatment Program,
  • Targeted case management,
  • School-Based Access Program,
  • Home and Community Based Waiver, and programs.

The annoucnment in the Pennsylvania Bulletin focuses primarily on the fee-for-service system and provides insight into the implementation of the co-payments in HealthChoices. The notice can be found at www.pabulletin.com/secure/data/vol42/42-32/1551.html.

All other copayments fee-for-service system  will be charged on a sliding scale based on the cost of the service. MA providers may not deny covered care or services nor may they waive or reduce the copayment because of an individual's inability to pay the co-payment amount. Providers will be advised through the eligibility verification system that the co-payment maximum has been reached and they should not collect further co-payments. The department will send a written notice to recipients subject to co-payments and issue a bulletin to providers.

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