The Children with Special Needs category is authorized only after eligibility for all other MA categories has been explored. It is a category of last resort for medical coverage.
The CAO will determine eligibility for Children with Special Needs using the following criteria:
The child is under 18 at the time of requested MA coverage.
The child meets the SSA’s disability standards. The disability requires verification from SSA or DHS’s MRT. Supplemental Handbook Chapter 820, Disability Advocacy Program.
NOTE: If the child has been denied SSI or RSDI for a non-medical reason and SSA completed the medical evaluation, an MRT referral is not required.
Review for all MA categories using the parents’ and the child’s income.
If ineligible for other categories of MA review for the Children with Special Needs category using only the child’s countable income.
For households with more than one child with special needs determine eligibility for each child individually.
Calculate total income for the child only. Apply the Healthy Horizons income deductions.
Retroactive coverage can be authorized when medical documentation (either by SSA or MRT) confirms the disability existed in the retroactive period. There is no presumptive eligibility to qualify for MA in the retroactive period for Children with Special Needs category.
Medical expenses are not considered for eligibility for the Children with Special Needs category. Therefore, there is no patient pay liability or spend down provision.
Determine the total net countable income of the child for the calendar month and compare it to 100% of the Federal Poverty Income Guideline (FPIG).
If the total net countable income of the child is equal to or less than 100% of the FPIG for one person, authorize eligibility in the Children with Special Needs category “PH,” with program status code “95.” Generate a notice of eligibility per Chapter 377, Notices.
If the total net countable income of the child exceeds 100 percent of the FPIG, deny eligibility for the Children with Special Needs Category. Generate a notice of ineligibility per Chapter 377, Notices.
The individual is notified that the denied application, income, resource and household composition information is automatically forwarded to the Children’s Health Insurance Program (CHIP) for an eligibility determination.
55 Pa. Code §§ 140.601 140.603
Some children currently covered by CHIP may meet SSA disability criteria, making them eligible for MA coverage under the PH95 category. If a child is eligible for MA, the child is ineligible for CHIP. It is a Federal requirement that CHIP coverage may be provided only if the child is ineligible for MA.
To ensure that children who are potentially eligible for MA are enrolled in MA, a process was implemented to send referrals from CHIP to MA for children with special health care needs. During this process, CHIP insurance coverage continues until MA eligibility is established.
Prior to sending a referral, the CHIP contractor will do the following:
Confirm the child is under age 18.
Confirm citizenship and identity.
Confirm the child appears to meet the financial requirements for PH95.
Make three telephone attempts to notify families the child is being referred to DHS for an eligibility determination; and follow up with a letter to the family which includes a Release Form to be signed and returned.
Contact the medical provider and send the provider a Physician Certification for Child with Special Needs form, to be returned to the CHIP contractor.
Make two follow-up attempts with the medical provider. The follow-up period is 20 days or until the Physician Certification form is received, whichever is earlier.
Upon completion of the follow-up period, the CHIP Insurance Contractor forwards the packet to the Central Unit (CU). A completed packet includes:
PH95 Referral Cover Sheet
CAPS Summary
Physician Certification for Child with Special Needs Form
Signed Release Form
NOTE: See Appendix A, CHIP to PH-95 Referral for a copy of these forms.
The CHIP contractor will fax referrals to the CU for review using the PH95 Referral Cover Sheet. Most referrals will be processed and maintained by the CU; however, if a referral is received and the case is open for any other benefits (Cash, MA or SNAP) for anyone in the family, the CU will forward the referral to the CAO for processing.
NOTE: The CU is responsible for appeals on any referral they authorize or reject.
To process a CHIP referral, the CU or CAO will take the following steps:
Review the referral packet received from the CHIP contractor.
Request the signed release form, if not included, from the family.
If there is no Physician Certification form, the CU will send the family a blank form for the physician to complete.
Before the eligibility determination, the CU will send an email with scanned copies of the cover sheet, Physician Certification form and signed release form to the Bureau of Managed Care Operations (BMCO) and Office of Mental Health and Substance Abuse Services (OMHSAS) contacts to ensure continuity of care.
Determine MA eligibility within 30 days of receipt of the referral packet.
An MRT referral and disability determination is needed for this process.
NOTE: The Physician Certification form is used only for the CHIP/DHS referral process. It is not considered acceptable documentation of disability for the MRT.
If the child appears to be eligible for SSI or RSDI, the family must be referred to SSA for the appropriate determination.
Authorize MA eligibility in the electronic Client Information System (eCIS).
The effective date is the date the case is processed in eCIS. The CAO will update the MA begin date on the Program Request screen to reflect the case processing date.
Enter the PID Provider Number (P1712002) on the Provider screen to ensure the CHIP contractor receives a copy of the eligibility notice.
Issue a PA ACCESS card, even if the child previously received one.
If the case is processed by the CAO, complete and return the PH95 referral cover sheet to the CU. The CU will follow up with the CAO if necessary.
The CU will notify CHIP, BMCO and OMHSAS of the eligibility decision via the PH95 referral cover sheet.
If found eligible, the child will be disenrolled from CHIP using the usual CHIP disenrollment process, including sending advance notice to the family.
NOTE: Once PH95 is authorized, a new application is not required if a category change is needed.
If the Physician Certification form has not been provided, and 30 days have passed since the packet was received, determine whether the diagnosis listed on the PH95 referral cover sheet is on the Priority Diagnosis List (see Appendix A ).
If the child has a priority diagnosis, authorize PH95 presumptively and set an alert to review the case in 45 days.
If the Physician Certification form has not been returned after 45 days, send a follow-up email to BMCO and OMHSAS with the child’s name, county and record number to inform them that the form has not been returned and the case has been opened presumptively for 45 days. Set a new alert for 45 days, and continue to attempt to verify ongoing eligibility.
After the second 45-day alert:
If the case was opened presumptively and the family has cooperated, but the physician has not returned the Physician Certification form, close the case using reason code 042; make a note on the PH95 referral cover sheet that the family has cooperated; and refer the child back to the CHIP contractor to ensure continuity of care.
If the Physician Certification form indicates the child is not disabled, review eligibility for all MA categories using the parents’ and the child’s income. If ineligible for other categories, the case is closed, and the child is referred to CHIP. The CU will inform BMCO, Fee-For-Service, Intensive Care Management Unit and OMHSAS if the child is determined no longer eligible for MA.
If the child does not have a priority diagnosis, determine whether the family is cooperating with the verification process.
If the family has not cooperated with completing the verification process, reject the application using reason code 042; the child will be disenrolled from CHIP.
If the family has cooperated, but the physician has not returned the Physician Certification form, reject the application using reason code 042; make a note on the PH95 referral cover sheet that the family has cooperated; and refer the child back to the CHIP contractor to ensure continuity of care.
Updated April 12, 2018, Replacing February 14, 2012