Medicaid Continuous Coverage Glossary
Appeal and Reconsideration Rights
Appeal rights are provided with any decision made about Medicaid (also known as Medical Assistance (MA) in Pennsylvania) coverage. Medicaid recipients have the right to ask for a hearing to appeal a decision that affects their Medicaid benefits. Information about how to appeal is included with all notices from us.
An automatic renewal occurs when our eligibility system uses information from electronic data sources to renew MA without requiring the recipient to provide their renewal packet. If we cannot renew MA with electronic data sources, we will mail a renewal packet. A mailed renewal packet MUST be completed, signed and returned to us for us to determine if MA can be continued.
Children's Health Insurance Program (CHIP) provides health coverage to children and teens (age 19 and under) who do not have health insurance and are not eligible for or already receiving Medicaid. CHIP offers high quality, affordable coverage on three tiers based on family income: full cost, low cost, and free. CHIP provides eligible children with health services such as medical, dental, vision, and behavioral health.
COMPASS is the Department of Human Services' (DHS') online portal to access many of Pennsylvania's health and human services benefits. COMPASS allows users to learn about benefits and see if they qualify. People can also apply for, renew, and manage benefits.
Continuous Coverage Period
The segment of time for which the requirement that no Medicaid enrollee have their coverage reduced or disenrolled except for a limited set of circumstances as required by the Families First Coronavirus Response Act.
County Assistance Office
County Assistance Offices (also called CAOs) are Department of Human Services offices where anyone can apply for benefits, submit verification documents, or receive help from staff. There is at least one CAO in every county and you can find them on this list of CAO locations.
Coverage refers only to health care insurance. This can include Medicaid, CHIP, insurance through Pennie, or private medical insurance. Health coverage is used to pay for personal medical expenses like doctor visits, medication, dental and vision care, and other covered medical costs.
Customer Service Center
The Statewide Customer Service Center is a point of contact for applicants and recipients to ask questions about their benefits, report changes to their information, or seek help in managing their benefits without having to go to a CAO. The Customer Service Center is available Monday – Friday 8 a.m. - 4:30 p.m. at 1-877-395-8930 or 215-560-7226 in Philadelphia.
To be disenrolled means that Medicaid or CHIP coverage has ended. Medicaid managed care coverage ends at the end of the month in which the disenrollment occurs.
In this case, eligible means that a person meets the requirements to receive Medicaid or CHIP coverage. If a person is ineligible, it means that they do not meet the requirements for Medicaid or CHIP coverage and DHS may then send information to Pennie to get health coverage through a Qualified Health Plan (QHP).
Eligibility Review Process
A CHIP applicant or enrollee may request that an impartial Eligibility Review be completed if an application or renewal determination results in an adverse action to the case.
Some people who sign up for certain coverage options through Pennie, PA’s official health insurance marketplace, may qualify for some of their insurance premium to be paid for, also known as a subsidy. This financial help lowers the individual's monthly payments and out-of-pocket costs (co-pays, deductibles, and others). The amount of financial assistance someone receives is mostly based on income and the number of people in their household. Nine out of 10 Pennie customers qualify for financial assistance.
Medical Assistance (MA)
Medical Assistance (MA) in Pennsylvania includes Medicaid, which is a federal program that provides eligible individuals with health services such as medical, vision, and dental care health coverage.
myCOMPASS PA mobile app
myCOMPASS PA is Pennsylvania's free mobile app that allows users to access their My COMPASS Account from their mobile device or smartphone and perform certain actions like changing their contact information or uploading verification documents.
Pennie® is Pennsylvania's official health coverage marketplace. Only Pennie can provide financial savings to help reduce the cost of coverage and care. Nine out of 10 Pennie customers qualify for these savings. Pennie allows people to shop for the best medical and dental coverage options for themselves and their families. In 2020, Pennie replaced HealthCare.gov (also known as Affordable Care Act (ACA) coverage) as the official health insurance marketplace for Pennsylvania. Free help is available through Pennie-certified pros. Visit pennie.com or call 1-844-844-8040 to learn more.
A premium is the amount a person pays for their health insurance every month. In addition to the premium, people usually must pay other costs when getting healthcare services, including deductibles, co-payments, and co-insurance. If you have a health plan through Pennie, PA’s official health insurance marketplace, you may be able to lower your monthly premium (and potential out-of-pocket costs) with financial savings.
Qualified Health Plan (QHP)
Any health insurance that meets the Affordable Care Act standards for comprehensive coverage. Qualifying health coverage is also referred to as Minimum Essential Coverage or MEC. All plans available on Pennie, PA’s official health insurance marketplace, must meet these standards and must cover emergency room services, doctor and hospital charges, pregnancy care, treatment for all pre-existing conditions, mental health and substance abuse services, lab work, and a list of essential health benefits. Some include dental coverage.
Reconsideration is a period when Department of Human Services can accept required documents after an individual’s Medicaid coverage has closed. If the renewal packet and/or necessary information is not returned by the renewal date, the recipient can provide the renewal packet and/or information up to 90 days after coverage closes, and Medicaid can be reopened with no gap in coverage if eligible. The recipient does not need to specifically request reconsideration for the County Assistance Office (CAO) to review for reopening Medicaid.
A renewal is the process of reviewing a person's eligibility for Medicaid (also known as Medical Assistance in Pennsylvania) or CHIP. A renewal must take place every year and includes updating information to determine if the person receiving Medicaid or CHIP still meets eligibility requirements.
A renewal packet will be mailed to every person receiving Medicaid whose renewal cannot be completed via an Automatic Renewal. These forms must be completed and returned by the due date.
An appeal made within the period of time specified on the renewal. If the appeal is made within that time Medicaid coverage may be maintained during the appeal process and until the outcome of the appeal is decided.
Verification documents are paperwork the Department of Human Services needs to show proof that the information given to us is correct. This can be identification (ID), paystubs, bank statements, financial award letters, or any other documents with the needed information.