MHAPA and other advocacy groups recently invited families of “loophole” children to fill out a survey when the passed 2011-2012 budget included projected savings that the PA Department of Public Welfare (DPW) could achieve by implementing co-pays.  See More Information below to take the survey.

Why the Loophole is Important
The “loophole” has provided medical care for 1000’s of children in Pennsylvania who would not have had access any other way. The “loophole” is not a loophole in MA regulations, despite its nickname. In the 1990s, Pennsylvania children’s advocates worked with the state to identify a process to identify children with disabilities under Medicaid’s “family of one” category. Children became eligible if they met the disability criteria, without considering their family’s income. This allowed critical medical services to be provided to children under Medicaid, including Mental Health Services that were not available under their parent’s private insurance, or were just not covered adequately.

In fact, the process was created specifically to stop the practice of giving parents/guardians having to give up custody to child welfare in order to have a child placed in a psychiatric residential treatment facility, still the process in many states. Many states now offer “Custody Diversion” processes that delay placement of children into state custody; giving families time limited access to public medical services.  Usually called “Voluntary Placement Agreements” (VPA), the family is still opened under Child Welfare, and must be supervised, but there is an “agreement” that there has been no official neglect. These diversions are often authorized for short periods, so families live on the edge hoping their child is either cured quickly, or they will be able to be eligible for extensions which are often denied. It is a get better or be taken out of the family scenario.

I will never forget helping a wealthy professional family get Pennsylvania’s loophole coverage for their teenage son. They had actually contacted my advocacy project looking for information on how to get their son open to the county Juvenile Justice System. He had serious behavioral health needs, and was engaged in many very dangerous and aggressive behaviors. They had tried to place him privately in psychiatric residential treatment, but no facilities would admit their son, because their health insurance would not pay for the placement. They begged facilities to admit their son, offering to pay the costs not covered by their insurance themselves. However, the facilities felt that was too much of a liability if the youth was admitted, and the parent’s failed to pay, but the youth was too ill to be safely discharged.

The family was so relieved  when I told them they could apply for MA and most likely, their son would be covered, allowing him to access critically needed care. And they swallowed their embarrassment, and made a successful application at their County‘s Office of Public Assistance, and joined the many families who never thought they would go through those doors, but were endlessly grateful for the help they were receiving.

Co-Pays- What’s Fair, What’s Wise?
Presently in Pennsylvania, when a family’s child qualifies as a “family of one” (PH-95 category) their private insurance is billed first, then Medical Assistance is billed.  What is not covered has to be accepted by the medical provider, sometimes causing problems for families who found that their chosen practitioner did not want to accept Medicaid and the possibility of reduced payments.

Co-pays for the amount of medical care “family of one” children need could be considerable.  Many families over the official federal poverty eligibility guidelines may be unable to meet these ongoing costs. They face the very real possibility that child welfare would take custody due to a finding of medical neglect, something that happens too frequently in many states, and which happened in PA regularly before 1993.  Or like the couple described earlier, families could be reporting their child to juvenile justice for behaviors like stealing parent’s car, cash or credit cards.

While recognizing DPW’s mandate to reduce spending, co-pays cannot be implemented in a way that puts children and their families at risk.  It is critical that implementation of a co-pay structure does not have the unintended consequence of adding costs and strains to the child welfare and juvenile justice systems when families cannot care appropriately for their children’s health needs.

Families above the federal poverty eligibility may be able to contribute more to their child’s Medicaid coverage medical care without risking hardship. But not all families will have the resources. Depending on the co-pay structure, some families face jeopardizing the needs of all family members. For example, some families have several children with serious medical needs. While a co-pay for one child may be doable, co-pays for two or more may be prohibitive. And if the State begins to charge a percentage of the services cost, psychiatric residential treatment facility and other costly services could be $1000 a month or more.

Policies Need to Penny Wise and Pound Smart
Pennsylvania should ensure that implementing co-pays does not jeopardize the families’ well-being, including the Medicaid insured child.  And no family should have to access the juvenile justice or child welfare system to access needed services.

Any new process must have a rational assessment and appeal process so the whole family situation is considered not just the family income.

More Information