HB 2128 Implementation Research

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