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PH 95 Co-pay Recommendations
November 1, 2011

Act 22 of 2011 provides the Department of Public Welfare (DPW) authority to address current fiscal challenges and budgetary limitations by imposing a co-payment on services for certain children enrolled in the Medical Assistance (MA) program. These are children with disabilities living in a family with income in excess of 200 percent of the federal poverty level. PCPA has collaborated with a group of interested organizations to consider possible models and approaches to implementing a co-payment system. PCPA and several other organizations recently met with the Office of Medical Assistance Programs (OMAP) to present those recommendations.

At the core of the administrative recommendations is the conclusion that the best approach will be for OMAP to directly manage the collection and aggregation of consumer encounter data as provided by physical and behavioral health managed care organizations. Only OMAP has the capacity and authority to collect and aggregate encounter data, apply the determined co-payment, monitor payment thresholds, bill, and collect for co-payments in an efficient and cost effective manner. A point-of-service collection of co-payments would be an untenable model accompanied by extraordinary costs and cash management risks would have a significant negative impact on clinical care and outcomes.

Among key recommendations are that:

  • OMAP establish an administrative approach that is uniform and centralized;
  • The co-payment system be based on and driven by data that demonstrates cost-effectiveness at every level, especially within the managed care delivery system;
  • MA co-payments should be minimized and the fiscal benefit to the MA system maximized; and
  • No reductions should be made in the per-member per-month payments to managed care organizations or counties and no rate reduction is made by managed care organizations.

PCPA was pleased to work in close collaboration with the Pennsylvania Health Law Project, Pennsylvania Partnerships for Children, Disability Rights Network, Mental Health Association in Pennsylvania, and the Pennsylvania Chapter of the American Academy of Pediatrics in crafting recommendations to the state.

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