No MA "Loophole" Premium

We, the undersigned, strenuously oppose the request of the Pennsylvania Department of Public Welfare (DPW) to impose an income-based, sliding scale Medical Assistance premium on families of children with disabilities, known as Loophole families.

Under current law, DPW must obtain and consider input from the public and the state legislature before making significant changes to Medical Assistance eligibility and services. This process is set out in a law known as The Regulatory Review Act. We oppose the attempt of DPW to gain exemption from the Regulatory Review Act, now and in the future, to impose any Loophole premium.

We realize the challenges to preserve the Medical Assistance program in the face of drastic cuts proposed at the federal level and ever-increasing enrollment. However, we believe that the legislature must exhaust all other avenues for funding and savings before looking to balance the budget on the backs of disabled children and their families.

We acknowledge that in todays reality of skyrocketing health care costs, more consumers are required to pay for a portion of their health care coverage. Many Pennsylvania legislators and DPW officials are using this Fair Share argument to justify the proposed Loophole premiums. The inherent flaw in this argument is that, unlike General Assistance consumers, most loophole families already pay costly private health insurance premiums for medically necessary services which are expressly denied to their children with disabilities, particularly autism spectrum disorder. DPW Secretary Estelle Richman has acknowledged that if children had most any other diagnosis than autism, their medical care would be a covered expense under most private health insurance plans.

We understand that DPW has an anticipated rollout date of October 2005 for the Loophole premiums to take effect. Yet, no details or specifics of the premium proposal have been finalized or presented to the public and the legislature. We believe that it would be a dereliction of your duties as state legislators to blindly approve this premium proposal. Any approval must be contingent upon the following issues being addressed in a thoughtful and factual manner:

I. Pennsylvania must join the other 49 states in the Union and impose a tax on smokeless tobacco the proceeds of which should be dedicated to funding the Medical Assistance Program

II. Pennsylvania must enact legislation similar to Kentucky regulations that mandate private insurers cover medically necessary services for individuals with autism. (KRS 304)

III. Pennsylvania must compel private insurers to release their enrollment information so that DPW may cross-reference the enrollment lists with their enrollment data to ensure that private health insurers for children with disabilities are the primary insurance billed, with Medical Assistance billed as secondary insurance.

IV. DPW must implement the recommendations of the Autism Task Force in regards to the wasteful and fraudulent practices that usurp so many needed funds from quality programs and services.

V. DPW, in conjunction with the Department of Education, must provide a formal estimate as to how much federal funding local school districts will lose if premiums are imposed. Many school districts use a "school-based Access program" to draw additional federal funding for special education for its students with disabilities. If families drop their MA coverage due to the premium, the loss of federal revenue will result in increased local school taxes or decreased services for disabled students.

VI. The state legislature must guarantee that these premiums will not increase dramatically from year to year, as has been the trend in the private insurance industry and among other states that impose premiums. How many children will fall through the cracks of the system when parents can no longer afford the premiums? What will be the long-term costs to society when these underserved children reach adulthood having not received the care and instruction they needed so desperately?

VII. In determining income levels for any premium, DPW must consider the many out-of-pocket expenses incurred by families in obtaining treatment for their disabled child. Protections for sudden and precipitous drops in income, due to death, divorce and/or loss of employment must be in place to allow DPW to immediately adjust the amount of the premium.

VIII. DPW must demonstrate the feasibility and justify the administrative costs of collecting the premiums. Currently, DPW collects premiums from about 4,000 adult workers with MA. Under this proposal, premiums would need to be collected from about 38,000 children.


We pledge to hold our legislators accountable for their consideration of the issues that we have outlined as they pertain to the development and implementation of a Medical Assistance premium for Pennsylvanias Loophole families.