SECTION 6 • APPENDIX C
Free Care for Children with Complex Medical Needs Who are Uninsured or Underinsured
Shriner’s Hospital: Orthopedic Problems or Spinal Cord Injuries
Shriner’s Hospitals for children is a network of 22 hospitals across the nation that provide free, specialized care for orthopedic conditions, burns, spinal cord injuries, and cleft lip and palate. Shriner’s Hospital in Southeastern Pennsylvania in Philadelphia offers medical and rehabilitative services for pediatric patients with orthopedic problems or spinal cord injuries. Children from infancy to their 18th birthday may be eligible for care if in the opinion of the chief of staff there is a reasonable possibility that the treatment will benefit the child and if treatment at another facility would place a financial burden on the patient’s family or guardian.
For more information, contact:
3551 North Broad Street
Philadelphia, PA 19140
Kelly Anne Dolan Memorial Fund: Grants to Help Family Members with Chronic or Terminal Illnesses
The Kelly Anne Dolan Memorial Fund offers grants to families with children suffering from a chronic or terminal illness. The goal of the fund is to “lift the spirits and decrease the burdens of families dealing with the traumas and expenses serious childhood illness brings.”
The Fund helps both low- and middle-income families and is committed by its mission to helping families who are experiencing financial challenges as a direct result of the level of care required by their child. For example, one or both parents or guardians have lost a job as a result of time off from work to care for their sick child or have had to cut back on work in order to care for their medically involved child.
The most frequently requested forms of assistance include electric and gas bills, phone bills, transportation assistance, car repairs, and child care for well siblings. Any necessity will be considered. The fund responds within one to three days to an urgent request (e.g., loss of utilities). Other types of requests are handled within one week.
- All referrals must be made by a social worker, nurse, case worker, or other health care provider currently familiar with the child and his or her illness and family situation.
- The child must have a diagnosed serious, chronic or critical illness, disability or condition currently requiring medical attention, though he or she does not need to be hospitalized at the time of the referral.
- The child must be medically involved enough that he or she is currently being followed by a health care provider who is informed about the child’s condition.
- The child must be a resident of Pennsylvania, New Jersey, or Delaware, though they may be receiving treatment in another state.
- The child must be dependent on parents or guardians.
For information contact:
The Kelly Anne Dolan Memorial Fund
580 Virginia Drive, Suite 110
Fort Washington, PA 19034
Western Association for a Serious, One-time Medical Need
If a child’s insurance will not cover a specific need or the child is not eligible for health insurance, the Western Association may be able to help the family. The Western Association provides small grants for expenses such as eyeglasses, orthodontia, or one month of home health care. The Western Association will not provide financial assistance directly to the family; a check is mailed directly to a designated provider if the application is approved.
To apply to the Western Association, a school nurse should write a letter for the family on School District letterhead describing the situation and explaining why the family cannot get help elsewhere. Include the name and address of the designated provider and the exact cost of the service. The Western Association usually responds within six weeks.
240 Chatham Way
West Chester, PA 19380
Help with Medications
Some children with private insurance may have no or inadequate coverage for prescription drugs. If you are working with a family in this situation, there are several options:
- Medical Assistance Coverage
A child can enroll in Medical Assistance even if the child has private insurance. Medical Assistance will pay for whatever the private insurance does not cover, including prescription drugs or the prescription co-pay. A family’s income must be under the Medical Assistance eligibility guidelines or the child must have a serious disability in order to qualify. For more information, call Children First 215-563-5848 x17.
- Patient Assistance Programs
Most pharmaceutical companies provide free prescription drugs to primary care providers (PCPs) whose patients could not otherwise afford them. These programs are called Patient Assistance Programs or Indigent Patient Programs. The PCP will need to write to the company and explain the situation; usually the family does not need to verify their lack of income. The pharmaceutical company may then provide the prescription directly to the PCP for a limited period of time (after which the PCP will need to reapply). Families can also go online at https://www.needmeds.org to find the pharmaceutical company that provides the drug(s) they need.
- Community Health Centers
Community health centers provide some free prescription drugs. Contact information for the Community Health Centers is in Section 5 of this manual. Note: A child must be a registered patient at the Community Health Center and the medication must be prescribed by a provider at the Health Care Center in order to get the medication.
Application Denials and Due Process Rights and Appeals
All applicants for Medical Assistance and CHIP must receive a decision in writing. This is called a notice. The notice must include a decision for each person who applied. Each person must also be allowed to appeal a decision. These are call Due Process Rights.
If Coverage Has Been Denied for Medical Assistance
The notice must include who has been turned down for coverage and the reason why.
If the child is denied because of missing information:
The notice may list the information that is missing, such as proof of income. If the notice does not state the missing information, the parent or guardian can contact the Customer Service Center at 215-560-7226 in Philadelphia and 877-395-8930 statewide to find out what documentation is missing.
Missing information can be uploaded to the COMPASS application online, uploaded through MyCOMPASS account, mailed to the caseworker, or dropped off at the CAO.
If the missing information is sent to the caseworker within 60 days, the application can be reconsidered, and coverage would be retroactive back to the date of the application.
If the parent made a good faith effort to obtain the information/documentation but was unsuccessful, the parent should contact the CAO and tell them that his/her efforts were unsuccessful and request assistance from the CAO in obtaining the information.
If the child is denied because they are eligible for CHIP:
The caseworker will deny coverage and send a notice explaining that the child is not eligible for Medical Assistance but appears eligible for CHIP. The application and assessment of eligibility is sent to the CHIP Central Eligibility Unit. The Central Eligibility Unit will then forward it to a CHIP health plan for enrollment.
If the child is denied because they were not found to be disabled:
The family can appeal the decision and present additional medical evidence of disability. For assistance in presenting stronger medical evidence, call the PA Health Law Project at 800-274-3258.
If the child is denied because the County Assistance Office does not find the child to be lawfully present, and this finding is incorrect, the family should call the Customer Service Center to find out what proof is needed. This can be uploaded to the COMPASS application online, through the MyCOMPASS app, or mailed to the CAO. For help with these cases, call the PA Health Law Project at 800-274-3258.
To file an appeal:
To appeal a denial of enrollment decision, use the appeal form that is part of the written denial notice. The notice tells the applicant they have 30 days from the date on the decision to appeal. The appeal should be sent to:
Bureau of Hearings & Appeals
2330 Vartan Way, 2nd Floor
P.O. Box 2675
Harrisburg, PA 17110
The person will be entitled to a hearing in front of an Administrative Law Judge, which can be in person or via teleconference (whatever the parent chooses). The parent will have a chance to say why they think the decision was wrong and to submit any documentation to support their case. The parent can bring someone to the hearing with them (another family member, a friend, or an attorney or paralegal.) The judge will issue an appeal decision in writing within 90 days of receiving the appeal request.
If Coverage for CHIP Has Been Denied:
If the child has been denied because of missing information:
The notice should list the information that is missing. The parent can contact the CHIP health plan to provide the missing information. There is a 30-day time limit for providing the needed information. The missing information can be faxed or mailed to the health plan. In some instances, the missing information can be emailed. Contact the CHIP health plan that sent the denial notice.
If the child is denied because they are eligible for Medical Assistance:
If the child was denied enrollment in CHIP, it may be because the family’s income is below the CHIP eligibility guidelines. The family should receive a denial notice from the CHIP health plan that states the income used to make the decision and that the application and assessment of eligibility has been sent to the relevant County Assistance Office. The family should then receive a decision and notice from the CAO. Coverage in Medical Assistance will be retroactive to the date of the application.
If the family believes there has been an error in determining their income or immigration status:
The family should contact the CHIP health plan by phone or through other contact information provided in the denial notice. Often the disagreement can be resolved. If they cannot resolve the issue with the insurance company, then they can appeal the decision by requesting a review from the Pennsylvania Insurance Department. They should send a copy of the denial letter along with a request for an Eligibility Review (a model letter can be found here) explaining why they think the decision was made in error. Send the letter within 30 days to:
CHIP Eligibility Review Unit
303 Walnut St. 6th Floor
P.O. Box 2675