Health Care Coverage for Thousands of Pennsylvania Children Has Changed from CHIP to Medical Assistance

Some—but not all—children who had been receiving health care through the Children’s Health Insurance Program (CHIP) will no longer be covered by CHIP, according to an email distributed to health care provider associations by the Pennsylvania Department of Human Services (DHS). As of Jan. 1, 2015, approximately 6,000 children previously covered by CHIP now receive health care under the HealthChoices program through the HealthChoices Managed Care Organizations (HC MCOs) and administered by the DHS Office of Medical Assistance Programs.

The change was made in order to ensure compliance with the Affordable Care Act (ACA). Pennsylvania was permitted to allow these children—ages 6-18 with family incomes greater than 100 percent but no greater than 133 percent of poverty—to remain with CHIP through 2014 but was required to enroll them in Medical Assistance (MA) beginning in Jan. 2015. Annual poverty guidelines are based on family size; for example, 100% of poverty in 2014 for a family of four is $23,850. Complete 2014 poverty guidelines are published by Medicaid.

Families of children affected by this change were notified in fall 2014 and provided with the option to select any of the HC MCOs that operate in their county. Children whose families did not choose an HC MCO were automatically assigned to one. Those who were automatically assigned do have the right to select an alternate HC MCO; however, changes will take two to six weeks to be effective.

Continuity of Care
The Pennsylvania DHS has confirmed that all HC MCOs will be required to honor existing prior authorizations for the children’s medically necessary covered services that were approved by their CHIP plan. DHS and the Pennsylvania Department of Insurance have worked with CHIP plans and HC MCOs to ensure that all prior authorizations are communicated to the new health plans. HC MCOs are also required to make all reasonable efforts to ensure continuity of care through steps such as ensuring timely receipt of new ID cards and actively recruiting primary care providers, specialists, and facilities who currently serve CHIP members but do not participate in the HC MCO network.

What Providers Can Do to Assist Patients or Join HC MCOs
Providers who serve children covered by CHIP and/or HealthChoices may be receiving questions about health care coverage. There are steps you can take to help ensure continuity of care. You can also participate with and become credentialed with the HC MCO that will now cover the patient.

Below you’ll find contact information provided by the DHS to assist providers and office staff:

  • Quick reference guide for providers serving children moving from CHIP to HealthChoices
  • Contact list and links organized by region for special needs unit or provider services at participating HealthChoices plans
  • HealthChoices behavioral health managed care plans contact list