September Implementation of Act 22 Co-Payments

Act 22 of 2011 provides the Department of Public Welfare (DPW) the 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. The Office of Medical Assistance Programs (OMAP) has announced that this co-payment for services will be implemented in September. It will affect approximately 38,000 children with disabilities living in a family with income in excess of 200 percent of the federal poverty level. OMAP is in the process of finalizing plans. Notices will be sent to affected families 30 days prior to implementation.

Providers will be responsible for collection of co-payments and may do so at the time of service or set other arrangements for payment. The yearly cost of co-payments for service may not exceed five percent of the family’s income and may not be in excess of 20 percent of the cost of the service. The MA claims processing system will be used to regulate the family income cap so that the ceiling of five percent on a monthly or quarterly basis is not exceeded. Co-payments will not be applied to school-based services, preventative services, and other items or services that are currently excluded from MA co-payment. It is unclear whether providers will be required to provide services if the co-payment is not paid. MA representatives have stated that the law does not establish an exception process for co-payments.

PCPA will continue to update members as new information is received.

Changes to Medical Assistance Prescription Coverage

Changes are being made to the Medical Assistance/ ACCESS program regarding prescription coverage. The links below contain valuable and helpful information if you or a loved one are affected by these changes.

 

Medical Assistance Bulletin from the PA Department of Public Welfare

Medical Assistance Prescription Coverage Limit Fact sheet