Waste, Fraud, and Abuse: One Family’s Medicaid Re-Determination Story
Gabriel R. was born November 2, 2010, the second child of Corey R. and Shiela may T. Twelve hours after his birth, the doctors informed his parents that Gabriel has a rare and extremely complex congenital heart defect called Tetralogy of Fallot (TOF). He would require heart surgery and life-long care by a cardiologist.
Gabriel was referred to cardiology specialists at St. Christopher’s Hospital for Children in Philadelphia, where the family lives. A middle class white-collar worker, Corey is medically insured through his work. However, when he learned that the cost of Gabriel’s care would be prohibitively expensive, even with insurance, he started to research other coverage options, including CHIP.
From a co-worker, Corey learned of Pennsylvania’s “Family of One” provision or Act 95. Known as the Medicaid “loophole,” it provides Medical Assistance for thousands of children with disabilities and/or complex health care needs, regardless of their parents’ income. And it enables children to receive critical services and treatments that are not adequately covered or covered at all under their parents’ insurance.
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