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PH 95 Co-payment Notices to Providers and Families
September 26, 2012

The Department of Public Welfare (DPW) issued Medical Assistance Bulletin 99-12-11 Alternative Cost Sharing for Families of Children with Disabilities with Incomes Over 200% of the Federal Poverty Income Guidelines. The bulletin states that co-payment obligations will be applied to newly enrolled children/families on October 1 and on current beneficiaries on November 1.  County Assistance Offices will perform income determinations. The scope of the bulletin includes providers in the Medicaid (MA) fee-for-service and ACCESS Plus system and the bulletin advises “providers rendering services in the MA managed care delivery system should address any questions to the appropriate managed care organization.” It is important to note that the eligibility verification system known as EVS will not display information about managed care liability and providers should contact the appropriate managed care organization for information about co-payments in HealthChoices. Community behavioral health providers should contact any behavioral health managed care organization (BH-MCO) with which they contract to determine how the BH-MCO will inform them of the copayment obligation and process for billing, collection, reporting and conflict resolution. The bulletin, is available at http://services.dpw.state.pa.us/olddpw/bulletinsearch.aspx?BulletinDetailId=4855.

PCPA has also been informed that DPW has begun to mail notices to families of children with disabilities who may be subject to the co-payment based on DPW income information. Because both the co-payment obligation and the cap on the amount of co-payment a family will have to pay depends on the amount of parental income listed in DPW records, it is essential that families check the notice to be sure that the income listed is correct.  The Pennsylvania Health Law Project reports that several families have received letters that had listed income well above actual income. If a family reports to a provider that their listed income is incorrect, the family should file an appeal.  Information is attached to the family notice about filing an appeal and calling the child’s caseworker at the County Assistance Office (not the case manager or supports coordinator) to inform them of the error reflected in the notification letter. Additional information for families needing to address errors or issues will be available through the Pennsylvania Health Law Project at www.phlp.org and the Disability Rights Network of Pennsylvania at http://drnpa.org/.

PCPA, in collaboration with consumer and provider advocates, is continuing to press DPW and the members of the General Assembly for a fair, reasonable, and cost effective application of the state’s “fair share” policy.

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