AFTER AN APPLICATION IS APPROVED
After the application is submitted, the Medical Assistance or CHIP office will make a decision to approve or deny the application. Each office has 30 days to make a decision. This section describes the steps to take after an application is approved. (If the application is turned down, actions can be taken to get it approved. For more information, see Section 6, Appendix C – Application Denials and Due Process Rights and Appeals).
Choosing a Health Plan and Primary Care Provider
The County Assistance Office will mail an approval letter that will include information on how to choose a health plan and primary care provider (PCP) for each family member who applied. The system of health plans and PCPs is called HealthChoices. Each person enrolled in HealthChoices is called a member. A PCP can be a physician or nurse practitioner.
Families can choose a health plan and PCP through Pennsylvania Enrollment Services at www.enrollnow.net or 800-440-3989 (TTY 800-618-4225). Enrollment Services can answer questions, explain how the health plan works, provide a list of doctors and hospitals that accept each plan and describe any extra benefits that a plan offers.
The family needs to choose a health plan and PCP within 30 days, or one will be assigned to them. Families have the right to change and choose a new PCP and/or new health plan at any time.
If the child was recently enrolled in a Medical Assistance plan and had a PCP, the CAO will assign the child back to that plan and PCP. Families may always choose a different plan and PCP.
Choosing a Health Plan
If a child has a health care provider that the family would like to keep, the family should ask Enrollment Services or their provider which Medical Assistance plan(s) the provider accepts and then choose one of those plans. This ensures that the child is enrolled in a plan that will allow them to keep seeing their current provider.
The Pennsylvania Department of Human Services issues a yellow and blue ACCESS card that serves as proof of enrollment in Medical Assistance. In addition, the child’s Medical Assistance plan will send an ID card that shows the child is enrolled in that plan. Families need to show both cards when using health services.
If the child had an ACCESS card in the past, it will be reactivated and usable. If the child never had an ACCESS card, the state will mail the child’s yellow and blue ACCESS card. If the child needs health care before the ACCESS card arrives, the family can show the approval letter to the health care provider to get health care. If the ACCESS card is lost, families can get a replacement card by calling 800-692-7462.
Generally, two to three weeks after the family chooses a health plan, the health plan will send the child an identification card.
CHIP operates separately from Medical Assistance. Approval letters for CHIP come directly from the CHIP plan the family chose. If a CHIP plan was not selected on the application, one will be assigned. Families can choose a new CHIP plan if one was automatically assigned.
The approval letter will also include instructions on how to choose a PCP. There is no Enrollment Broker for CHIP. Each child becomes a member of the CHIP plan, and the parent or caregiver has to call their CHIP plan’s member services to tell them which PCP they chose.
If the child is eligible for low-cost or full-cost CHIP, the family will also receive a bill for the monthly premium that must be paid before coverage can start.
The CHIP plan will send an identification card for each child soon after the family receives the approval letter. The card will look like a typical commercial insurance card and will not be labeled “CHIP.”
Tips for Choosing a Primary Care Provider (PCP)
Enrollment in health insurance is only the first step in getting children health care. After enrolling, children need to find a primary care provider (PCP). In both Medical Assistance and CHIP, if a family does not choose a PCP, one will be automatically assigned to them by the health plan. Families can always choose a new Primary Care Provider within their plan.
If a child does not already have a primary care provider, here are some questions to consider when choosing:
- How important is location? Does the provider need to be within walking distance? Is public transportation an option to reach a provider’s office? Is a car available? (Note: A child enrolled in Medical Assistance is eligible for the Medical Assistance Transportation Program (MATP) that can provide free rides or reimburse travel expenses. Tell parents to call their health plan for more information.)
- What type of provider? Does the parent/guardian prefer a Nurse Practitioner, a Physician’s Assistant or a doctor? Does the gender of the doctor make a difference? Is there a particular language requirement? Does the child have an ongoing condition where it makes sense for the PCP to be a doctor that specializes in that area of medicine, or does the parent/guardian prefer a generalist?
- Are there any methods of medical practice that are important to the parent/guardian? How does the provider fit with these ideas? An example of this might be a parent/guardian who wants their child to see a chiropractor.
Keeping Health Insurance
Families with Medical Assistance need to report the changes below to the Customer Service Center at 215-560-7226 (for Philadelphia) or 877-395-8930 (statewide).
- Changes in income of more than $100 in earned income and more than $50 in unearned income: increase or decrease in income; changes in Social Security (not the annual Cost of Living changes); change in pension or disability income; change in self-employment income.
- Changes in family size due to marriage, divorce, birth, adoption, death.
- Change of address or phone number.
- Change in disability status.
- Gaining or losing private insurance
Medical Assistance income limits change when a child turns one and again when a child turns six. That birthday may change the child’s eligibility from Medical Assistance to CHIP even if family income did not change. The family must receive a notice ending their child’s Medical Assistance coverage. That notice should also indicate that the child’s information will be sent to CHIP for enrollment.
Families with CHIP need to report the changes below to their health plan:
- Change in address
- Gaining private insurance
Families with CHIP are not required to report a change in income or family size until renewal. However, families may report income changes if a decrease in income or increase in family size would mean new eligibility for Medical Assistance or a change in monthly CHIP premium payments.
Medical Assistance or CHIP coverage must be renewed once a year or the coverage will end. The process of renewing coverage is called re-determination.
Renewal can happen automatically through electronic data matching and the parent will receive a notice of continuing coverage. When renewal cannot be done through data matching, the parent will receive a form they must complete and return along with the requested proof.
The County Assistance Office (CAO) or the CHIP health plan will try to obtain the renewal information from a set of employment, Social Security, and tax databases. If they find the needed information, they will send a notice to the parent stating the child’s insurance has been renewed automatically.
If the CAO or CHIP health plan cannot find the information they need, they will send a renewal packet to the family. Families on Medical Assistance can renew their child’s coverage by completing the form and sending it back with the required proof. Families on Medical Assistance can also renew their coverage by completing renewal on the COMPASS website at www.compass.state.pa.us or the My COMPASS phone app.
Families on CHIP will receive a renewal packet and two reminders to complete the forms and send them back. Some CHIP health plans allow renewal over the phone.
Failure to complete renewal is the biggest reason why children lose coverage. Remind families to look for these letters, to open them and send back the form and the documents requested by the CAO or the CHIP health plan.
Families that are receiving other public benefits in addition to Medical Assistance such as Temporary Assistance for Needy Families (TANF) or SNAP may have to renew those benefits more often than once a year. Each benefit program has its own eligibility criteria and schedule of renewal.
There are no time limits on the length of time a person can be covered by Medical Assistance or CHIP; children and adults are eligible as long as they meet the eligibility requirements. Coverage can and should be renewed for eligible children until they turn 19 for CHIP or 21 for Medical Assistance.