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Medicaid in Pennsylvania

Medicaid in Pennsylvania

Medicaid is Pennsylvania’s health insurance safety net. It provides health and long-term care services to low income children, families, persons with disabilities, and the elderly. In Pennsylvania, the Medicaid program is called Medical Assistance and is administered by the Department of Public Welfare (DPW). To qualify for Medicaid, a person must meet financial requirements and fit into a certain group or category. While children on Medicaid get all medically necessary health care benefits, the benefits available to adults vary depending on the person’s eligibility category.

Medical Assistance Eligibility for a Child (under 18) with a Severe Disability, Behavioral or Autism Spectrum Disorder under the PH-95 Category (“Loophole”) in Pennsylvania

Many children in Pennsylvania with disabilities can generally qualify for Medical Assistance, regardless of their parent’s income.

A child can qualify even if they have other health insurance (though the other insurance needs to be billed first). The assets of the parents, guardian, and the child (money in bank accounts, stocks, bonds, etc) do not count in determining eligibility for this type of Medical Assistance eligibility. The income of caregivers and guardians, other than parents, do not count. The income of the parents is also not considered if the child’s condition meets certain disability standards. Requirements for eligibility include:

  • Child must be under the age of 18.
  • Child must meet the Social Security Disability Guidelines.
  • Resources (assets) of the child/parent are not counted.
  • Income of the child generally is counted. Income of the parent and caregivers is not.

An application can be made to the Pennsylvania Department of Public Welfare.

Wraparound Services in Pennsylvania

Everyone on Medical Assistance (MA) in Pennsylvania has an ACCESS card. Most people on MA now receive mental health and drug & alcohol services from a Behavioral Health Managed Care Organization (MCO).

Wraparound Services, also referred to as Behavioral Health Rehabilitative Services (BHRS), are individualized mental health services provided in the home, school, or community to help keep a child at home. These services are also used in school or daycare settings to help keep a child in a regular classroom instead of a more restrictive classroom setting. Wraparound services should be designed to meet the specific needs of your child. The services are provided by trained staff working one‐on‐one with your child to help with emotional or behavioral problems such as poor anger management or trouble getting along with other children. The staff also teaches children, their parents, and others (teachers or educational aides) new ways of dealing with problem behaviors that are keeping kids from having success in coping with their feelings and relationships. Children or adolescents may need wraparound services if they have Autism, Pervasive Developmental Disorder, drug or alcohol problems, serious emotional problems, or mental illness that gets in the way of “normal” day to day functioning with family, friends, in school, or in the community.

The standard wraparound package usually consists of the services of three staff people:

Therapeutic Staff Support (TSS)

The TSS provides most of the BHRS services, by working to redirect the child to more appropriate behaviors or responses, working on behavioral modification, or whatever else is called for in the treatment plan.

Mobile Therapist (MT)

The Mobile Therapist provides individual therapy to the child—discussing emotions and problems the child is having—but not in a traditional office setting. Instead, therapy is provided at home or in some other community setting.

Behavioral Specialist Consultant (BSC)

The BSC is not supposed to provide direct service to the child. The BSC’s role is to write the treatment plan and work with the Mobile Therapist and TSS to implement the treatment plan and make changes to the plan as needed. The BSC is also responsible for making sure that the treatment plan is carried out as written and intended.

A psychologist (or sometimes a psychiatrist) must evaluate your child to determine if he or she needs wraparound services. The written evaluation must specify the type of service your child needs (TSS, Mobile Therapist, and/or BSC) and the number of hours needed each week. The evaluation must also explain why these services are medically necessary in the amount prescribed. The evaluation should also specify where the services are to occur (i.e. 15 hours per week of TSS in school and 10 hours per week of TSS in the home & community) and over what timeframe they are to occur.

The psychologist who makes the prescription for wraparound services must be “in the network” of the Behavioral Health Managed Care Organization (MCO) that serves your county. If necessary, you can get permission to see a psychologist or psychiatrist out of the MCO’s network, but you must get permission from your MCO before you see that person. Some MCO’s require that the evaluator/prescriber is an independent provider from the wraparound provider agency. Check with the MCO to find out their requirement before scheduling your child’s evaluation.


HealthChoices is what the Pennsylvania Department of Public Welfare (DPW) calls mandatory managed care for Medicaid (also referred to as “Medical Assistance” in Pennsylvania) consumers. Under HealthChoices, Pennsylvania Medical Assistance (MA) consumers must enroll into a managed care plan and get all their care through that plan unless they fall into an exempt group. As a MA consumer, you have the right to choose your physical health plan. In addition, you will be enrolled in a behavioral health plan that is selected by your county.

HealthChoices consumers receive all physical health care and all prescription medications through their physical health managed care plan. When you go to the hospital, doctor, or pharmacy, you will show them your insurance card provided by the plan you have selected. You must get all of your services from in-network providers for them to be paid by your plan. As a result, it is important to pick the plan that will work best for you.

Under HealthChoices, you are enrolled in a separate behavioral health managed care plan to cover the behavioral health services you may need. You will access all mental health and drug and alcohol services through providers in your behavioral health plan network. Unlike the physical health side of managed care, you cannot choose your behavioral health plan. Instead, your county has selected the plan that will provide behavioral health care to its residents.

Medical Assistance for Workers with Disabilities in Pennsylvania

Medical Assistance for Workers with Disabilities (“MAWD”) is a state health insurance program for individuals who have chronic health problems and are working.

MAWD is often a good option for low-income and middle-income individuals who need health insurance. Compared to other medical assistance programs, MAWD has high income and resource limits. It also has flexible work and disability requirements. To qualify for MAWD, the individual must be:

  • Be between the ages of 16 and 65
  • Be disabled and working
  • Have an income under 250% of the Federal Poverty Level, and
  • Have less than $10,000 in resources.

Under MAWD, disability is not defined as an inability to work. Individuals who have a long lasting health condition, and meet the program requirements, should apply for MAWD. Because the disability standard is complicated, you should not try to predict whether your health conditions would meet the standard.

An application can be made to the Pennsylvania Department of Public Welfare.

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Disclaimer: Meeting Life’s Challenges, LLC is a not for profit corporation that provides without charge confidential social services resources, information and networking opportunities. If you have legal questions you should consult an attorney of your own choosing. The web site and the resources and information provided are not offered in lieu of medical advice, diagnosis, or treatment. Always consult a physician for diagnosis and treatment of any medical condition or for any questions you may have regarding a health concern.