It covers topics like:
- Picking a PCP.
- Getting specialty services.
- Covered services.
- Finding a ride to a doctor’s appointment.
- Getting disease management.
- And more.
To download the ACCESS Plus Enrollee Handbook, please click here.
If you need help with this Handbook, please call our toll-free Helpline at 1-800-543-7633. We will be glad to help you!
(Downloadable file requires Adobe Acrobat Reader - Free Download)
Congratulations! You are a member of ACCESS Plus. ACCESS Plus is sponsored by the Department of Public Welfare (DPW) for people who get their health care through the ACCESS/EBT card.
As a member of ACCESS Plus you have:
- A Primary Care Provider (PCP) you can reach 24 hours a day who will provide your regular health care.
- Referrals to specialty doctors.
- Help making appointments.
- Disease management for chronic diseases (like asthma, diabetes, heart and lung diseases).
- EPSDT – check-ups for kids, teens and young adults (birth through age 20).
- A toll-free Helpline (a free call) 1-800-543-7633.
The services you can get through ACCESS Plus will depend on the benefits package you have through Medical Assistance (MA). You may also have a co-pay for some services. You can call the ACCESS Plus Helpline at 1-800-543-7633 to find out what services are covered for you by MA and whether or not you will have a co-pay for certain services.
In ACCESS Plus, your PCP may need to refer you to a specialist for a service to be covered by Medical Assistance (MA). Read this Member Guide to find out which services need a referral from your PCP.
Please know that not everyone on MA will participate in ACCESS Plus. The groups of people receiving MA who will not be enrolled in ACCESS Plus include:
- Consumers enrolled in a Voluntary Managed Care Plan.
- Consumers over the age of twenty-one (21) who are “dually eligible” (on MA and Medicare).
- Consumers enrolled in the HIPP (the Health Insurance Premium Payment Program) who have HMO coverage only.
- Consumers who reside in a nursing home.
If you need help with this Guide, or if you want the information in another format, please call ACCESS Plus toll-free Helpline at 1-800-543-7633. We will be glad to help you.
You can call us Monday through Friday from 7:00 a.m. to 8:00 p.m. and Saturdays from 10:00 a.m. to 2:00 p.m. There will be someone who can speak with you in your native language. AT&T Pennsylvania Relay Service is available for those with special needs.
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- ACCESS Plus
- A health care delivery system in which you pick a PCP. This PCP gives you most of your medical care. You will need a referral from your PCP to see some specialists. ACCESS Plus is for people who get their health care through the ACCESS/EBT card.
- Case Management
- ACCESS Plus will help you coordinate care for medical, social, educational, and other services you need. For example, ACCESS Plus will help you find transportation to your medical appointments.
- Co-pay
- Short for “co-payment.” This is a small fee that you may have to pay for some services, like prescription drugs. Your co-pays depend on your age and benefits package.
- Covered Service
- The services you can get under ACCESS Plus depend on your MA benefits package. For example, coverage for prescription drugs, medical equipment, and dental services are provided to some persons on MA but not to others. Call the ACCESS Plus Helpline at 1-800-543- 7633 to find out what services are covered for you.
- DPW (The Department of Public Welfare)
- This is the agency that runs the Medical Assistance (MA) Program.
- Disease Management
- Extra services you can get if you have a chronic disease (like asthma, diabetes, and heart disease). Extra services may include educational programs and videotapes about your disease or specialized case management to help meet all of your health care needs. These services help you manage your disease and stay as healthy as possible.
- EPSDT
- Check-ups for kids, teens and young adults (birth through age 20).
- Helpline
- The ACCESS Plus toll-free Helpline you can call from 7:00 a.m. to 8:00 p.m. Monday through Friday, and Saturday 10:00 a.m. to 2:00 p.m.
- Immunizations
- Shots that stop sickness like measles, mumps, and chicken pox.
- Lab Work
- Blood or urine tests for illness.
- Prenatal Care
- Care that is given to a pregnant woman the whole time she is pregnant. This care is important for the mom and unborn child’s health.
- Primary Care Provider or PCP
- A doctor, clinic, or other health care professional who handles all of your health care needs like a check-up, shots, blood work, and medicine when needed. The PCP will also answer medical questions. The PCP can be reached 24 hours a day, 7 days a week.
- Prior Authorization
- A process in which DPW reviews a prescription for a health service or medication and any related documents and decides whether or not to approve the prescription before the service/medication can be covered under MA.
- Referral
- When your PCP sends you to a specialist for care.
- Specialist
- A doctor who practices a special kind of medicine like an ear, nose and throat doctor or a foot doctor.
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With ACCESS Plus, you will now have a doctor or clinic for regular health care. This doctor is called a Primary Care Doctor or PCP. The PCP will manage your care and help you maintain your health. The PCP will give you check-ups and sick care. If needed, your PCP can arrange for you to see a specialist.
There are several kinds of health care providers who may be PCPs:
- Family practice and general practice doctors (who treat adults and children).
- Internal medicine doctors (who only treat adults).
- Pediatricians (who only treat children and teens).
- Medical residents.
- Certified registered nurse practitioners.
- Certified registered midwives.
- Physician’s assistants.
- Physician specialists.
You can pick one PCP for everyone in your family who is on MA. Or, you can pick a PCP for yourself and a different one for your children. You may also be able to pick a specialist as a PCP if you already get care from them. For example, a pregnant woman may want to pick her OB/GYN as her PCP.
If you or a family member has a special need and you want to pick a PCP with that need in mind (for example, a PCP whose office is wheelchair accessible), please call the Enrollment Services Hotline at 1-800-485-5998.
The Enrollment Services Hotline can help you find a PCP. Call them at 1-800-485-5998. Once you are contacted, you have 14 days to call them and pick a PCP. If you did not pick a PCP within 14 days, ACCESS Plus will choose a PCP for you.
Remember: You can change your PCP at any time by calling the Enrollment Services Hotline.
Whenever you have a medical need, call your PCP. Your PCP will make an appointment for you or answer any questions.
Your PCP will be available to you by phone 24 hours a day, 7 days a week. Call your PCP’s office for directions on how to contact your PCP when the office is closed.
Every person in ACCESS Plus will get an ACCESS Plus ID card to be used with their ACCESS/EBT card. The ACCESS Plus ID card lists your PCP’s name, address and phone number. Show both of these cards when you go to your PCP for care.
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We want you to be happy with your PCP choice. We also hope that you keep the same PCP. This way, your PCP gets to know you and any health issues you have. But, as an ACCESS Plus member, you have the right to change your PCP.
If you want to change your PCP because you have moved, your doctor has moved, or for any other reasons, call the Enrollment Services Hotline at 1-800-485-5998. Staff will give you the names and addresses of other doctors in your area. Or, you can ask for a list of Medical Assistance (MA) providers and we will mail one to you. To get a list sent to you, call the ACCESS Plus toll-free Helpline at 1-800-543-7633. You can pick your new PCP from this list.
When you change your PCP, a new ACCESS Plus ID card will be sent to you. The new PCP will become your doctor the first day of the next month.
Your PCP may ask you to change to another doctor if you disagree with or refuse to go along with the PCP’s treatment plan, or if your PCP feels another provider could better care for you. If this happens, ACCESS Plus will contact both you and your PCP to discuss the reason your PCP is asking you to change doctors. ACCESS Plus will send you a written notice before your PCP can stop treating you. If you do not agree with the reason why your PCP is asking you to change to another doctor, you can file a complaint. You will not have to change doctors until the complaint process is finished.
You can pick a new PCP by calling the Enrollment Services Hotline at 1-800-485-5998.
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It is important that you and all your family members who are on MA go to see your new PCP(s) as soon as possible. Get to know your PCP and let him or her get to know you. This way, if you or a family member gets sick, the PCP will be able to give the best care.
If you need an interpreter, call your PCP’s office. They will help you. You can also call the ACCESS Plus toll-free Helpline at 1-800-543-7633.
ACCESS Plus is designed to give you the health care you need to stay healthy. You should see your doctor regularly – not just when you are sick. ACCESS Plus suggests that you see your doctor once a year for a check-up.
Here are some things the PCP may do when you visit:
- Check your blood pressure.
- Check your blood sugar (for diabetes).
- Provide a breast exam and PAP smear.
- Give you information on family planning and sexually transmitted diseases.
- Talk with you about substance abuse and mental health.
- Do screenings such as rectal exams for older adults, and referral for mammograms.
- Speak with you about quitting smoking, healthy eating, and other things important to your health.
Kids also need to see the doctor regularly. For more information about check-ups for kids (called EPSDT), please see the section titled EPSDT.
Of course, if you are sick or get hurt, see your PCP as soon as possible. If it is an emergency, call your PCP or go directly to the Emergency Room. If you think you may be pregnant, see your PCP or an OB/GYN right away.
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Your PCP does not know how long it will take to see each person. Please be patient if you have to wait. If you feel you have to wait too long at your PCP’s office, or if you feel you have to wait too long to get an appointment, please call the ACCESS Plus Helpline at 1-800-543-7633.
For a regular check-up, you may have to wait two to three weeks.
When you call, tell the PCP why you need to see him or her. Your PCP will decide if your need for care is urgent. If you are having an emergency, you should call your PCP or go to the Emergency Room. Please see page 11 for more information about Emergency Care.
If you are going to be late for an appointment or can not make it, call the PCP’s office so you can set a new time or day. Some offices allow “walk-in” visits. This means that you can go without an appointment and still be seen. Walk-ins may have to wait longer to see the PCP. If you want to know if your PCP allows walk-ins, ask the staff.
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Kids also need to see the doctor regularly. EPSDT is a health care program for kids, teens and young adults (birth through 20 years).
An EPSDT check-up includes:
- Complete physical exam.
- Hearing test.
- Vision test.
- Developmental screening.
- Lab work (blood and urine tests).
- Immunizations (shots that keep you from getting sick).
- Complete health history and education on staying healthy.
- Schedule an EPSDT check-up.
- Help with transportation.
- Remind you when the next EPSDT check-up is due.
If a problem is found during the EPSDT check-up, your PCP can refer you to a specialist. Those under the age of 21 may be able to get things like a hearing aid, eyeglasses, and braces for teeth.
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Call your PCP if you need medical help...24 hours a day, any day of the year. Call when you first notice a problem. Your PCP will make an appointment or answer any questions you may have. And, dealing with a problem early may prevent a trip to the emergency room.
Your PCP may say you need special medical care. When this happens, your PCP will send you to a specialist.
This is called a referral. ACCESS Plus covers health care you get from specialists when:
- The specialist who gives you care is in MA.
- And, your PCP approves care that needs a referral.
Not all specialty services need a referral from your PCP. See the information below to find out which services need a referral by your PCP in order to be covered. If you need help finding a specialist call the ACCESS Plus toll-free Helpline at 1-800-543-7633.
When your PCP sends you to see a specialist, it is called a "referral". The cost of the visit to the specialist may not be covered IF you do not call your PCP first.
If you get any of these services with a referral, you will not have to pay a bill for those services:
- Personal care (under 21 only).
- Physician services with a specialist (e.g., cardiologist, neurologist).
- Physical Therapy, Occupational Therapy, and Speech Therapy.
- Foot doctor (podiatrist) services.
- Chiropractic services.
Remember, the services MA covers depend on your MA benefit package. To find out what services are covered for you, call the ACCESS Plus Helpline at 1-800-543-7633. Children under 21 get all medically necessary services.
- Family planning.
- Pregnancy related services.
- OB/GYN treatment.
- Dental services.
- Eye exams.
- Medical services through the school.
- Mental health services.
- Drug or alcohol treatment.
- Inpatient hospital care.
- Hospice.
- Nursing home or residential care in a medical facility.
- Medical transportation or ambulance.
- Prescriptions.
- True emergency services.
- Diagnostic/laboratory services (like X-rays or blood work).
- Medical equipment.
- Help to stop smoking.
You may have to pay a co-pay even if the service is covered by MA, but you should not have to pay the entire bill if you go to a MA provider. If you get a bill for a service that you think should be covered or if you need help finding a MA provider, please call the ACCESS Plus toll-free Helpline at 1-800-543-7633.
If you have any questions about what requires a referral, please call the ACCESS Plus toll-free Helpline at 1-800-543-7633.
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Sometimes you will need to get "prior authorization." This means getting approval from DPW before you get the service. Some items and services that may need prior authorization are:
- Rental of durable medical equipment (DME).
- Purchase of DME.
- Orthotics (like back braces, leg braces, and arch supports).
- Prosthetics (such as artificial limbs).
- Surgical supplies.
- Certain medications.
- Some types of hospitalization.
In order for the item or service to be approved, it has to be "medically necessary".
See the next section for more information about medical necessity.
There is a hotline that you may call in order to check your prior authorization requests. Call the toll-free Prior Authorization Hotline at 1-800-433-1324. Hotline hours are 9:00 a.m. to 4:00 p.m. Monday through Thursday.
When you call the hotline, you may have to leave a message and someone will call you back in 2-3 business days. You should be ready to give your name, your recipient number, the type of service requested, the date of the request, and the prior authorization number if you know it.
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A service or item is “medically necessary” if:
- It is covered by MA.
- It is needed for the proper treatment or management of an illness, injury, or disability.
- And, it is prescribed, provided, or ordered by an appropriate licensed provider in accordance with accepted standards of practice.
DPW will determine if the care and services are medically necessary. To do this, your PCP or specialist must give DPW all needed information in writing.
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An emergency is a health problem that is life threatening or one that will seriously affect your health if not treated right away. It can result from an accident or sudden illness and puts you in danger of death or severe harm. If you have an emergency, approval for care is NOT needed. Call 9-1-1 or go to the nearest emergency room.
Some examples of emergencies are:
- Chest pain.
- Poisoning.
- A serious accident.
- Severe burns.
- Damage to your eyes.
- Broken bone(s).
- Throwing up blood.
- Sudden loss of feeling or not being able to move.
- Severe pain in your stomach area.
- Fainting or a severe dizzy feeling.
- Severe wound or heavy bleeding.
- Choking or being unable to breathe properly.
- Severe shortness of breath.
- Miscarriage (when a pregnant woman loses her baby).
- Strong feeling you might kill yourself or another person.
If you are not sure whether you have an emergency, you should call your PCP.
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ACCESS Plus provides family planning services and supplies. This includes counseling and birth control. You can get this care from your PCP, an MA family planning provider, or any doctor or clinic that takes MA. You do not need a referral from your PCP.
If you need help finding family planning services, call the toll-free ACCESS Plus Helpline at 1-800-543-7633.
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The health services that a woman gets from a doctor, nurse, or nurse midwife before the birth of a baby are known as "prenatal care". Prenatal care is very important. It is a way of seeing how well the pregnancy is going and if there are any problems. Even if a woman has been pregnant before, prenatal care is important.
If you think you are pregnant and need a pregnancy test, see your PCP or an MA family planning provider.
If you are pregnant you can:
- Call or visit your PCP, who will help you find a prenatal care provider.
- Visit an MA OB/GYN or nurse midwife on your own.
- Visit an MA health center that offers family planning services.
The ACCESS Plus Provider Directory lists OB/GYNs, nurse midwives and family planning centers that take MA. To get a copy of this list, or if you need more help finding an OB/GYN or making an appointment, please call the toll-free ACCESS Plus Helpline at 1-800-543-7633.
It is best for you to get care as soon as you think you might be pregnant.
You should also talk with your PCP when you find out you are pregnant. Your PCP may have information about your health that your prenatal care provider needs to know.
Getting regular prenatal care throughout your pregnancy is best.
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WIC is a special program that helps you and your baby eat well. WIC starts when you are pregnant and goes until your child is five years old. It is important that babies and young children eat right. This helps them grow up healthy and strong. WIC can teach you about good nutrition and provide you with coupons to buy food.
For more information about WIC, ask your PCP or call the toll-free ACCESS Plus Helpline at 1-800-543-7633.
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The Commonwealth of Pennsylvania has programs and services for babies to school-age children who have developmental delays or disabilities. It is best to get involved as soon as you think your child may have a physical or emotional developmental problem. Early intervention may make a difference.
If you have any questions or concerns about your child’s development (physical, emotional, or other), please talk with your child’s PCP about them.
If you want more information about early intervention services or need help getting these services, call the toll-free ACCESS Plus Helpline at 1-800-543-7633.
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MA covers all medically necessary dental services for enrolled children from birth through age 20. This includes:
- Teeth cleaning.
- X-rays.
- Cavity fillings.
- Crowns.
- Other services.
Whether or not adults on MA have dental services covered by ACCESS Plus depends on their MA benefits package and their medical need for the services. You can find out whether MA covers dental services for you by calling the ACCESS Plus toll-free Helpline at 1-800-543-7633.
If you have dental coverage, you can visit any MA dentist. For help finding a dentist or making an appointment, call the ACCESS Plus toll-free Helpline at 1-800-543-7633.
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ACCESS Plus enrollees are eligible for vision services. These services depend on your MA benefits package.
All ACCESS Plus members may get eye exams. You do not need a referral for eye exams. You can make an appointment with any MA vision care provider.
To see an eye specialist (called an ophthalmologist) because of eye disease or eye injury, you do need a referral from your PCP.
If you need help finding an eye doctor, or if you have any questions, please call the ACCESS Plus toll-free Helpline at 1-800-543-7633.
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If you have HIV or AIDS, and you are eligible, you may get one or more of the following:
- Targeted Case Management to help you get medical and social support services.
- The AIDS Waiver Program to help you stay at home and out of a hospital or nursing home.
- The Special Pharmaceutical Benefits Program to help pay for specific HIV/AIDS treatment drugs.
Please call the ACCESS Plus toll-free Helpline at 1-800-543-7633 if you want to know more about these services or if you need help with making an application for these services.
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If it is hard for you to get to your medical appointments either because you do not have an available vehicle or because you cannot afford the gas, your county’s Medical Assistance Transportation Program (MATP) can help you get a ride to your doctor/clinic or pay you for your travel. To qualify, call the office listed below for your county.
| County |
Phone Number |
County |
Phone Number |
| Bedford |
(814) 623-2002 |
Luzerne |
(800) 679-4135 |
| Blair |
(814) 695-3500 |
Lycoming |
(800) 222-2498 |
| Bradford |
(800) 242-3484 |
McKean |
(866) 282-4968 |
| Cambria |
(800) 647-4814 |
Mercer |
(800) 222-8797 |
| Cameron |
(866) 282-4968 |
Mifflin |
(800) 348-2277 |
| Carbon |
(800) 990-4287 |
Monroe |
(888) 955-6282 |
| Centre |
(814) 355-6807 |
Montour |
(570) 271-0833 |
| Clarion |
(800) 372-7116 |
Northumberland |
(570) 644-4463 |
| Clearfield |
(800) 822-2610 |
Pike |
(570) 775-5555 |
| Clinton |
(800) 206-3006 |
Potter |
(800) 800-2560 |
| Columbia |
(888) 868-2320 |
Schulkill |
(888) 656-0700 |
| Crawford |
(800) 210-6226 |
Snyder |
(877) 877-9021 |
| Elk |
(866) 282-4968 |
Somerset |
(800) 452-0241 |
| Erie |
(814) 456-2299 |
Sullivan |
(570) 888-7330 |
| Forest |
(800) 222-1706 |
Susquehanna |
(800) 323-2051 |
| Franklin |
(800) 548-5600 |
Tioga |
(800) 242-3484 |
| Fulton |
(888) 329-2376 |
Union |
(877) 877-9021 |
| Huntingdon |
(814) 641-6408 |
Venango |
(877) 836-4699 |
| Jefferson |
(800) 648-3381 |
Warren |
(877) 723-9456 |
| Juniata |
(800) 348-2277 |
Wayne |
(800) 662-0780 |
| Lackawanna |
(570) 963-6482 |
Wyoming |
(570) 288-8420 |
Please, try to call at least two weeks before the appointment.
If you need help contacting your county’s MATP or scheduling transportation with them, or if you want to find out about other transportation options please call the ACCESS Plus toll-free Helpline at 1-800-543-7633.
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If prescription drugs are covered by your MA benefits package, you can get your prescriptions filled through ACCESS Plus. Children (under 21) are covered for all medically necessary prescription drugs. Adults on MA may or may not have prescription coverage, depending on their benefits package. In addition, some MA recipients must pay a co-pay on their medications. If you want help determining whether or not MA will cover your drugs or whether or not you will have to pay a copay, call the ACCESS Plus toll-free Helpline at 1-800-543-7633.
To obtain your medications through ACCESS Plus you will need a prescription from your PCP or MA specialist. Many over-the-counter drugs may also be covered as long as you have a prescription. Your benefits package will determine if you have a co-pay or not. It will also determine the number of prescriptions you can get filled. Call the ACCESS Plus toll-free Helpline at 1-800-543-7633 if you need help finding a pharmacy or if you have any other questions.
Note: Brand name drugs need prior authorization from DPW (see page 10). Your PCP or specialist will call for prior authorization. DPW will make a decision within 24 hours of receiving the prior authorization request. If the authorization is approved, your doctor will put the authorization number on the prescription. If the authorization is denied, you have 30 days to file an appeal.
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ACCESS Plus is only for your physical health care. If you need mental health treatment, you should get in touch with your county’s MH/MR program. If you need drug or alcohol treatment, you should get in touch with your county’s Drug and Alcohol Program.
ACCESS Plus case managers are available to help you access behavioral health services and to coordinate the care you get through ACCESS Plus with any care you get from behavioral health providers. For help getting any of these services call the ACCESS Plus toll-free Helpline at 1-800-543-7633.
In addition, if you receive behavioral health services you should tell your PCP. Your PCP must coordinate the care they give you with the care you get from your behavioral health providers including sharing clinical information, providing health records when requested, and being available to consult with your behavioral health providers.
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ACCESS Plus has case management services available to help you if you or any of your children have special needs. You are considered to have “special needs” if, for example, you:
- Require extensive health care or services.
- Need special equipment or services.
- Need language, communication or mobility accommodations.
If you tell us about your special need, a case manager will contact you directly to see that your special needs are addressed. These are some of the things our case managers can do to help you:
- Help you get Disease Management Services if you need them (see below).
- Help you contact the Medical Assistance Transportation Program and arrange transportation to your appointments
- Help you contact and arrange for interpreters if you are deaf/hard of hearing or if you do not speak or understand English
- Help you locate providers who are physically accessible/able to address your special needs
If you need help with your special needs call the ACCESS Plus toll-free Helpline at 1-800-543-7633.
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If you have been diagnosed with one of these diseases, you will be able to get “disease management” services:
- Asthma.
- Diabetes (sugar).
- Chronic Obstructive Pulmonary Disease (COPD).
- Coronary Artery Disease (CAD).
- Congestive Heart Failure (CHF).
Disease management helps you best manage your disease and stay as healthy as possible.
Consumers who are eligible for Disease Management can be identified:
- Through the ACCESS Plus enrollment process;
- Through a referral from their medical provider; or
- Through calling the ACCESS Plus toll-free Helpline and identifying themselves.
Once you have been identified, we will mail you information about the Disease Management Program for your condition. You will be contacted to participate in the Program. Your participation in Disease Management is voluntary.
If you agree to participate in Disease Management, ACCESS Plus will work with you to develop an individual care plan depending on your needs. These are some of the services you can get through Disease Management:
- Treatment support and follow up to remind you to make and keep medical appointments or re-fill your prescriptions.
- Help coordinating your care if you are hospitalized or if you need to go into a nursing home or rehabilitation facility.
- Educational materials/programs/videos to help you understand and manage your disease.
Call the ACCESS Plus toll-free Helpline at 1-800-543-7633 if you want to know more about Disease Management.
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If your PCP or specialist recommends that you have non-emergency surgery, you have the right to get a second opinion from another doctor. To get a second opinion, call your PCP or the ACCESS Plus toll-free Helpline for a referral at 1-800-543-7633.
Through a second opinion, you should get the information you need to decide whether or not to have the surgery. The second opinion should also give you information about other treatments and the pros and cons of those treatments.
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You have the right to make medical care decisions even when you can’t speak for yourself. You should have an Advance Directive. Your physician will know what you want done or not done if you can’t talk. An example of an Advance Directive is a living will.
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ACCESS Plus wants you to get the best possible service. When something goes wrong, we want to know.
| Step 1 |
If you have a problem or complaint about your PCP, Disease Management, or ACCESS Plus or about the service you have received, you can call the ACCESS Plus toll-free Helpline at 1-800-543-7633 and tell us or you can put your complaint in writing to us at: |
| Step 2 |
ACCESS Plus 9370
McKnight Road, Suite 300
Pittsburgh, PA 15237
We will make a record of your complaint. We will have someone not involved with the matter you are complaining about review your complaint and try to find a solution. Your satisfaction is important to us.
|
| Step 3 |
We will then send you a written response within 30 days of receiving your complaint. If you are not satisfied with the answer, you may write to:
Department of Public Welfare
ACCESS Plus
P.O. Box 2675
Harrisburg, PA 17105-2675
Someone from DPW will review the matter and follow up with you directly.
|
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If you have a problem with a denial, reduction or termination of a health care service, you may appeal to DPW and request a Fair Hearing. Your appeal must be in writing. DPW must get your appeal within 30 days of the date of the notice about the denial, approval of a different service, or decrease in services.
If services you are already getting are being reduced, denied or approved for a different service, you may want to have the services continue during your appeal. To do this, you must file your appeal to within 10 days from the date on the notice from which you are appealing.
You must send your DPW Fair Hearing Appeal to:
Department of Public Welfare
ACCESS Plus
P.O. Box 2675
Harrisburg, PA 17105-2675
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As long as you live in an ACCESS Plus county, you must be enrolled in ACCESS Plus. You will get your care through that program unless you fit into one of the groups that is exempt from ACCESS Plus.
MA recipients are exempt from ACCESS Plus if you are:
- Enrolled in a Medical Assistance Voluntary Managed Care Plan.
- Over the age of twenty-one (21) and are “dually eligible” (on Medicaid and Medicare).
- Enrolled in the HIPP (the Health Insurance Premium Payment Program) and have HMO coverage only.
- Reside in a nursing home.
If you move, but still live in an ACCESS Plus county, you must stay in ACCESS Plus.
If you have any questions, call the ACCESS Plus toll-free Helpline number at 1-800-543-7633.
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At ACCESS Plus, we are committed to keeping your "protected health information" private. Some examples of protected health information are:
- Your Name (and the names of your children or other household members on MA).
- Your Telephone Number.
- Your Address.
- Your DPW Recipient Number.
- Your Date of Birth.
- Your Social Security Number.
- Your Admission/Discharge Date.
- Your Medical Procedure Code.
- Your Diagnostic Code.
There are times that ACCESS Plus will need to share your protected health information with other persons who are responsible for your care. Some examples of when we can share information are:
- To help you get medical care.
- To arrange payment for your care and services.
- For operating ACCESS Plus (such as using the information to remind you about an appointment).
- If we are required by law.
For more information on ACCESS Plus privacy practices, please call the ACCESS Plus toll-free Helpline at 1-800-543-7633.
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As a member of ACCESS Plus you have the right to:
- Be treated with respect and regard for your dignity and privacy.
- Receive the names, addresses and telephone numbers of PCPs in your service area, to know what languages are spoken by those PCPs, and to know which PCPs are physically accessible.
- Know which PCPs are taking new patients and which are not.
- Pick a new PCP once every 30 days for any reason.
- Be able to call your PCP and get help 24 hours a day, 7 days a week.
- Know that your medical records and any talks with your PCP are private.
- Ask for and get a copy of your medical records from your providers, and ask that they be corrected if necessary.
- Have your PCP explain your treatment, your choices for treatment and any follow-up that is needed in a way that makes sense to you.
- Have your PCP coordinate your care with any care you may be getting from behavioral health providers.
- Make decisions about the care you get, and that includes saying “no” to any care you don’t want.
- Ask questions and have them answered by your PCP.
- Receive case management services from ACCESS Plus if you need them.
- Get help with coordinating your care if you are someone with special needs.
- Tell ACCESS Plus or DPW about any complaints or problems you have with how you are treated by ACCESS Plus or with the care you get by writing a letter or calling.
- Appeal in writing from any decision to deny, reduce or terminate health care services and have a DPW Fair Hearing.
- Exercise your rights without fear of retaliation by your PCP or other health care providers.
- Get information in a different language or in a different way at no cost to you. This includes relay services, oral interpreters for all non-English languages or other ways if you are visually impaired or if you or your family cannot read. The information should also tell you how your PCP will help you get these services.
- Be told of any change made by the Department of Public Welfare to ACCESS Plus at least 30 days before the change takes place.
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You have the responsibility to:
- Learn your rights as an ACCESS Plus member.
- Carry your ACCESS Plus Member ID card at all times.
- Keep all your scheduled appointments and cancel all appointments you cannot keep in advance.
- Treat your PCP with respect.
- Tell your PCP about your health care needs and about any other health care services you are receiving.
- Keep up-to-date on immunizations (shots).
- Contact your PCP first for care that is not an emergency.
- Get a referral from your PCP before getting care that requires a referral.
- Tell your PCP about other services you access that do not require a referral.
- Let ACCESS Plus know about important changes (such as changes in your name, address, phone number, income, or family size) by calling the ACCESS Plus tollfree Helpline.
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Please call the toll-free ACCESS Plus Helpline at 1-800-543-7633. Our phone staff will be happy to help you:
- Access services.
- Identify MA providers in your region.
- Identify MA providers who are handicapped accessible.
- Determine what services are and are not covered by your MA benefits package.
- Get disease management services.
- If you have any special needs.
- Help you contact the Medical Assistance Transportation Program and help arrange transportation to your medical appointments.
- Update your contact information.
- File a complaint.
- Answer your questions.
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