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PARENTS EXCHANGE PHLP CHIPIssues regarding CHIP for children with special health care needs
As the State considers how to best use the new federal funds available
to provide health insurance for uninsured children, it is important to
examine how our existing Children's Health Insurance Program ("CHIP")
needs to be improved to serve children with special health care needs
(unless the State chooses to use the new federal funds to expand
Medical Assistance). Below are a list of services not covered by CHIP
as administered by the Caring Foundation of Central PA (Blue
Cross/Blue Shield) as well as some issues regarding a family's right
to appeal a denial of service by insurer.
Physical health services limited or not covered:
Home health care is limited to 30 visits in 90 days.
Personal assistance service are not covered.
Physical therapy, occupational therapy & speech therapy are only
covered for up to 60 days from initiation of treatment per condition,
per lifetime and then only if the HMO believes the therapy will
"result in significant improvement"
Medical supplies are not covered
except for needles & syringes
Durable medical equipment and
prostheses are not covered
Hospice care is not covered
Mental health and related services not covered:
Mental health "wraparound" services are not covered
Services for the treatment of autism and "nueropschiatric (sic)
disorders"- presumable pervasive developmental delay and Tourette
Syndrome- are not covered
"Chronic" mental health care ("services
for the seriously mentally ill as defined by DPW") is not covered
Treatment in a non-hospital residential treatment facility is not
Treatment for drug abuse is not covered in any setting
Issues concerning Grievance rights:
No right to continued coverage of ongoing treatment or therapy
following an appeal
For appeals from denial of urgent services, the HMO has 15 days to
render a decision. The DoH policy statement requires a decision in 48
hours in "medically pressing cases".
For appeals from denial of
emergency or urgent services, the HMO's medical director decides the
appeal. If the Medical Director denies the appeal, the family can
appeal to a "Medical Review Committee". However, it is the Medical
Director, who denied the appeal, that presents the family's case to
the Medical Review Committee.
For appeals from denials of mental
health services, families are instructed to file a grievance with the
mental health management contractor rather than with the HMO through
which they have coverage which is in violation of the Department of
Health's policy. (DoH has already written a letter to Keystone HMO
informing them that this was a violation of their policy)