HB 2128 Implementation Research

Pennsylvania Full Premium Buy-In Program

Overview of Program Design

Feature / PA “Cover All Kids” At-Cost Program
Eligibility Level / 301% FPL and above
Program Users / Children who do not meet the SSI definition of disability. Those that do meet the SSI definition are automatically eligible for Medicaid, regardless of parental income (PH-95 category).
Premiums / According to PA CHIP rate sheet effective March 1, 2009:
  • Average premium = $195 PMPM.
  • Premiums range from $124.40 to $232.68, depending on MCO contractor.
  • No family premium cap

Cost-Sharing / Co-payments:
  • Doctor visits = $15 (waived for well-child services)
  • Brand prescriptions = $18
  • Generic prescriptions = $10
  • Specialist visits = $25
  • ER visits = $50 (waived if admitted for hospital stay)

Covered Services / Primary Services:
  • Immunizations and well-baby care
  • Routine check-ups
  • X-Rays
  • Laboratory/pathology testing
  • Emergency care, including emergency transportation
  • Emergency, preventative, and routine dental care
  • Emergency, preventative, and routine vision care
  • Prescription drugs
  • Up to 90 inpatient days hospitalization/year
Ancillary Services:
  • Maternity care
  • Mental health benefits
  • Durable medical equipment
  • Inpatient and outpatient substance abuse treatment
  • Partial hospitalization for mental health services
  • Rehabilitation therapies
  • Home health care

MCO or FFS / 8 MCO health insurance contractors
High Risk Pool / No high risk pool, but see “Program Users” box for more information on disabled children.
Eligibility /
  • Children under 19
  • Qualified aliens and citizens. Does not cover undocumented children.
  • Must be ineligible for Medicaid or CHIP
  • Must not be enrolled in employer-based or private health insurance
  • Comparable insurance must either unavailable or unaffordable

Limitations / No pre-existing condition limitation
Waiting Period /
  • Child must be uninsured for at least six months prior to application.
  • Exceptions to waiting period:
  • If child lost insurance due to a parent losing employment
  • If child is transferring from one government-subsidized health care program to another
  • If child is under age 2

Penalties / Termination for:
  • Nonpayment
  • Failure to renew annually

Start of Coverage /
  • Coverage begins at the first of the month if application receive by the 15th of the month.
  • Must pay first month’s premium prior to enrollment.
  • Can appeal if denied.

Changing Plans / Family can change at will.
Dual Enrollment / If eligible for Medicaid/CHIP, cannot enroll in at-cost program
Current Enrollment / 1,863 enrolled in at-cost program, out of 196,000 total CHIP enrollees.

Prepared by Northwest Health Law Advocates

Last Updated July 2009