Let’s Tell the Truth: PH95 is Not a “Loophole”

Medical Assistance (Medicaid) Category PH95 was created by an act of the PA legislature in the late 1980s. Just like the legislatures in thirty-two other states, Pennsylvania’s elected representatives decided that the 14th Amendment, the one that established the right to “equal protection under the law”, applies to children with disabilities, regardless of their parents’ incomes. That some self-proclaimed advocates, especially those touting “decades” of experience, would call for the elimination of the PH95 category of Medical Assistance in Pennsylvania is not surprising. The same group came out to support Act 62, requiring a license from the Board of Medicine for some supervisors of Autism treatment, which has crippled the ability of most providers of Behavioral Health Rehabilitation Services (BHRS) to deliver quality, essential treatment to children with Autism Spectrum Disorders.

The sponsors of Act 62 misguidedly confused “credentials” with “competence” (as if the acquisition of a paper certificate would somehow bestow competence on practitioners, or that the lack of that magical piece of paper could somehow revoke the competence that providers had been demonstrating for months, if not years, prior to the stillbirth of Act 62. The State Medicaid Agency backed Act 62 in Pennsylvania, just like the State Medicaid Agencies did in thirty other States, because it would drive kids with Autism Spectrum Disorders off the Medicaid roles.  Employees of the State Medicaid Agency in Pennsylvania and their fellow “advocates” have been calling for the repeal of PH95 for decades, referring to it (in official, written documents no less) as a “loophole” — as if that is an appropriate term for an act of the Pennsylvania legislature.

My decades of experience supports the sensibility, humanitarian necessity, and fiscal responsibility of allowing people who have incomes “above the Federal Poverty Level” to receive Medical Assistance benefits if they are under the age of 21 and disabled. By giving those kids access to treatment, the State and Federal government are making a bet that treatment early in life will result in a lower need for treatment in the remainder of life. That’s a terrific bet, and explains why the legislature in thirty-three states, including Pennsylvania, decided to make that bet, despite the pleadings of others who didn’t do the math and think that this fiscally responsible and humanitarian gesture somehow entitles thousands of people to get what they don’t deserve.

The fact is, most affluent people don’t get Medical Assistance benefits because they don’t need it. Most “poor” people don’t need it, either. Children with disabilities desperately need it and it’s morally and fiscally misguided, at least, to think that taking away Medical Assistance eligibility from the few who qualify under PH95 will have more than a superficial impact on Medicaid in Pennsylvania. How about looking at the hundreds of millions of dollars that have been swallowed up by schools in Pennsylvania, over $150 million last year alone, without the slightest oversight by the Managed Care Organizations or other apparent controls. If saving Medicaid money is your big concern, take it from the schools — there’s so much more available there. Over $50 Billion nationwide in the last decade alone but that’s unthinkable.

It should be just as unthinkable to take Medicaid money from your neighbors whose family income rises above the Federal Poverty Level (hint: it’s less than $2,500 monthly for a family of four). Sure, there are a few families with high incomes who are taking advantage of the system, but their children are no less impaired than their poorer neighbors’ kids. The altruism of PH95 is a virtue that we should be able to afford, no matter how much or how little we make individually and we surrender it for no good reason.

You can learn the truth about PH95, Medicaid, the EPSDT benefit as a Civil Right for children enrolled in Medicaid, Autism, ADHD treatment and much more at the website of The Institute for Behavior Change, an organization I founded in 1997 to recruit, train, deploy and monitor the performance of new professionals treating children with mental illness symptoms in their homes, schools and communities:  www.ibc-pa.org


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