SECTION 2

HEALTH INSURANCE ELIGIBILITY IN SPECIAL SITUATIONS

Medical Assistance for Children with Special Needs

Many children and teens have serious, ongoing physical and/or behavioral health care needs such as vision problems, hearing loss, serious diabetes, depression, anxiety, and substance use disorder. Serious conditions can exhaust the benefits provided by private, commercial insurance. Medical Assistance, because it covers all medically necessary services, can assure that their complex health care needs are met.

Some children and teens with complex health care needs live in families with smaller incomes who meet the income eligibility rules for Medical Assistance. But some children live in families above the income levels. For those families, Pennsylvania offers the Children with Special Needs program, also known as PH-95.

PH-95 does not count parents’ income, making many children and teens eligible. PH-95 is available to children with private insurance as well as to children without any insurance. Medical Assistance, through PH-95 or through the usual income rules, can always act as secondary insurance, covering what private insurance does not.

Medical Assistance supports children in school settings, providing mobile behavioral health therapy, health aides, physical, occupational and speech therapy, and Applied Behavioral Analysis. School districts can bill Medical Assistance for some school-based services.

To be eligible for this Medical Assistance program, a child must be disabled as defined by the Social Security Administration (SSA). The SSA considers a child disabled if he or she has a physical or mental impairment, which results in notable and severe functional limitations. The disability must be expected to last at least 12 months from its start (or result in death).

Generally, a child is considered disabled by Social Security if s/he has a condition that limits the child’s functioning in a way that interferes with day-to-day tasks that are age appropriate for that child. This can include not being able to focus on or complete typical school tasks. Social Security’s “Listing of Impairments” is available online at http://www.socialsecurity.gov/disability/professionals/bluebook/ChildhoodListings.html

Some diagnoses such as Down Syndrome or blindness immediately qualify a child for PH-95. For other conditions, such as Autism, the family will have to show how and to what extent the condition affects the child’s age-appropriate functioning. Most often, families will have to gather medical records and letters from the child’s providers as proof of the child’s special health care need.

Schools can play a role in supporting the family’s application for PH-95. While an IEP alone is not enough verification of a child’s condition, it can describe a child’s ability or inability to function in a school setting in an age-appropriate manner.

Importantly, behavioral health conditions, including mental health and substance abuse disorder, often meet the criteria for PH-95. Some behavioral health issues can seriously interfere with day-to-day functioning for children and adolescents and require ongoing treatment that may exceed benefit limits in private health insurance or CHIP.

To assist a parent to apply for Medical Assistance for a child with a disability and what proof will be needed, see the parent handout in Section 6, Appendix B – Applying for Medical Assistance for Children with Special Health Care Needs – Category PH-95.

Children Being Raised by Grandparents or Other Caregivers:
Guardian and Kinship Care

Children being raised by grandparents, other family members, friends, or other caregivers are eligible for Medical Assistance. The person applying for a child does not need to have legal custody of the child.

Children being raised by non-parent caregivers are an exception to the standard Medical Assistance income rules, so the caregivers’ income does not count. In most instances, this means the children will be eligible for Medical Assistance.

Generally, Medical Assistance and CHIP use tax rules to decide which members of the household to include in the application and whose income will count. Each member of the household will be evaluated separately. However, for children who are not living with a parent, there is an exception. Under that exception, the income of the guardian or caregiver is not counted. While that income should still be listed on the application, only the non-Social Security income of the child and any siblings under 19 who live with the child is counted.

Children who are Immigrants: Emergency Medical Assistance and More

Eligibility

In general, in Pennsylvania, children who have an immigration document from the United States Citizenship and Immigration Services (USCIS) or a foreign passport and current visa are eligible for either Medical Assistance or CHIP. A child with immigration documents is considered to be “lawfully present.” Even children with temporary immigration statuses such as student visas, dependent visas, or medical visas are eligible – but there are two exceptions. Children with Deferred Action for Childhood Arrivals (DACA) status or tourist visas cannot receive Medical Assistance or CHIP.

Language Translation and Interpretation

All families are entitled to appropriate language translation and interpretation services in Medical Assistance and CHIP under the Civil Rights Act.  Applications for Medical Assistance are available in five languages: Spanish, Russian, Vietnamese, Cambodian, and Chinese. CHIP applications are available in English and Spanish.

Additionally, language line services or in-person translation must be provided by all County Assistance Offices, customer service lines for Medical Assistance and CHIP, and many health delivery sites. The service is provided for free, and no one should be asked to provide their own interpreter. This requirement also applies to American Sign Language (ASL).

Immigration Status of a Child’s Parent, Caregiver or Other Household Members

Some families have members with mixed immigration status: some have immigration documents and some do not.  These families can apply for the people who are citizens or who have immigration documents without jeopardizing their other family members. All family members should be listed on the application, but immigration or citizenship status is only required for the people who are applying for coverage. The immigration status of  non-applicants cannot be used in deciding whether or not an applicant is eligible.  A parent or other head of household is not required to provide his or her social security number when applying on behalf of a child. It is helpful but not required.

Emergency Medical Assistance for Children and Teens without Immigration Documents

If a student in your school does not have immigration documents, he or she will not be eligible to enroll in Medical Assistance or CHIP.  However, they may be eligible for Emergency Medical Assistance (EMA). EMA is temporary Medical Assistance for children (and adults) who have an emergency or a dangerous ongoing medical condition that requires treatment quickly. The child must still meet all the other eligibility criteria for Medical Assistance, such as household income and age, to be eligible for EMA. EMA also covers labor and delivery.

EMA is temporary coverage. It covers the urgent or emergency treatment necessary to stabilize the child’s health, not ongoing medical care. An urgent or emergency condition can include behavioral health issues. Hospitals will often help families apply for EMA.
For more information, see Section 6, Appendix B – Applying for Emergency Medical Assistance.

Free and Low-Cost Health Care for Children Who are Undocumented Immigrants

Even without coverage, health care services are available to families across Southeastern PA for free or sliding scale fees. See the free and low-cost health care resources for Bucks, Chester, Delaware, Montgomery, and Philadelphia counties in Section 5. For children with more extensive medical conditions, see also Section 6, Appendix C – Free Care for Children with Complex Medical Needs who are Uninsured or Underinsured.

Getting Care in an Emergency for Children Who are Undocumented Immigrants

Hospitals are required by law to take patients in emergency situations and at least stabilize their medical condition, regardless of their immigration or insurance status. Don’t hesitate to take children to the ER if they don’t have insurance. Hospitals will likely apply for Emergency Medical Assistance to cover the cost of the hospital care. For more information about Emergency Medical Assistance, see Section 6, Appendix B – Applying for Emergency Medical Assistance.

Children in the Juvenile Justice System

Children and teens involved with the juvenile justice system who are in their parents’ custody can remain on their current insurance. In some instances, the probation system will ask the family to apply for Medical Assistance to obtain needed behavioral health services not typically covered by private insurance or CHIP. If the family’s income is above the income limits, these children and teens will likely qualify under the Children with Special Needs category.  To assist a parent to apply for Medical Assistance for a child with a disability and what proof will be needed, see the parent handout in Section 6, Appendix B – Applying for Medical Assistance for Children with Special Health Care Needs – Category PH-95. 

Children and teens who are placed in a juvenile justice facility or an out-of-home placement generally have their health services, including behavioral health, covered by that facility.