Benefits and special services

• Covered Benefits
• Benefit Limits
• Benefit Limit Exceptions
• Medicines
• Can the Formulary Change?
• Utilization Management
• Eye Exams and Eyeglasses
• Dental Care
• Special Needs
• Mental Health, Drug and Alcohol Services
• AIR Gateway^® Asthma Program
• Help Your Heart Cardiac Program
• Healthy Returns Diabetes Program
• MOM Matters^® Program
• Women, Infants and Children (WIC) Program
• Growing Up with Gateway^SM Program
• Early Intervention Services
• Family Planning
• HIV/AIDS Services
• Chiropractic Services
• Services Not Covered

Some of the services that are covered by Gateway at no cost to you include:

• Visits to your Primary Care Physician (PCP)
• Visits to the doctor while you are pregnant
• Yearly physical examination
• Well child care, including regular check-ups and shots
• Non-emergency dental care, if eligible for non-emergency dental care under Medical Assistance.
• Braces for teeth for members under the age of 21, if medically necessary
• Eye exams
• Contraceptives (birth control), insulin, insulin syringes, vitamins and certain over-the-counter medicines when prescribed by a doctor and covered by the approved drug list
• Drugs for members under age 21 when prescribed by a doctor and covered by the approved drug list
• Orthopedic shoes and hearing aids for members under the age of 21, if medically necessary
• Emergency care 24 hours a day, 7 days a week
• 24-hour toll-free member telephone service for non-emergency and urgent needs, through Member Services
• Surgery and anesthesia, if medically necessary
• EPSDT expanded services for members under the age of 21
• Extended home nursing services for members under the age of 21, if medically necessary
• Nursing facility care (limited to 30 days), if medically necessary
• Home health care visits, if medically necessary and ordered by your doctor
• Molded shoes, if medically necessary
• Any other medical services for members under age 21 determined to be medically necessary

Some of the services that are covered by Gateway that may require you to pay a co-payment include:

• Visits to specialists with a referral from your Primary Care Physician (PCP)
• Allergy tests and shots with a referral from your Primary Care Physician (PCP)
• Drugs for members age 18 and older, if eligible for medicine coverage under Medical Assistance, prescribed by a doctor and covered by the approved drug list
• Foot care
• Hospitalization, if medically necessary, including semi-private rooms (a private room is covered if needed for a medical condition), inpatient drug and doctor services
• Laboratory tests and cardiograms, as ordered by your doctor
• X-rays, when medically necessary and ordered by your doctor
• Physical therapy, if medically necessary
• Occupational and speech therapy, if medically necessary
• On-going chiropractic services, if medically necessary

Co-payments do not apply to any member who is under age 18, in a nursing home or pregnant (plus 60-days after pregnancy ends through the end of the month the 60-days ends).

Your provider will tell you the amount of your copayment when you present your Gateway Health Plan^® ID Card and any other insurance ID cards that you may have. General Assistance (GA) recipients cannot be charged more than $180.00 worth of co-payments in a six month period and Medical Assistance (MA) recipients cannot be charged more than $90.00 worth of co-payments in a six month period. Your caseworker at your local county assistance office (CAO) determines if you are MA or GA eligible. If you have any questions about the amount of your co-payment or how to be reimbursed, talk with your provider or call Member Services at 1-800-392-1147 (TTY/TDD 1-800-654-5988).

Every six months, Gateway will review the amount of co-payments you have made. If you have paid more than the maximum amount, based on your assistance level, Gateway will send you a refund check for the amount of the excess co-payments.

You cannot be denied a service or drug if you cannot pay the co-payment. Tell your provider if you cannot afford to pay. Your provider may bill you later and has the right to collect for co-payments not paid at the time of service.

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Some members age 21 and older have limits to the services they can receive. To find out if benefit limits apply to you, talk with your physician or call Member Services at 1-800-392-1147 (TTY/TDD 1-800-654-5988).

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Benefit limits do not apply if you are under age 21 or are pregnant. If benefits limits do apply to you and you or your provider feel you need services above these limits, your provider can ask Gateway to approve additional services for you. This is called an exception.

All exception requests are reviewed for medical necessity and can be granted if:

• You have a serious chronic illness or other serious health condition and without the additional service your life would be in danger
• You have a serious chronic illness or other serious health condition and without the additional service your health will get much worse
• You would need more costly services if the exception is not granted
• You would have to go into a nursing home or institution if the exception is not granted
• You need the exception approved to agree with State regulations

Any exception request received prior to the service being provided will get a response within 21 days of the date on which Gateway received the request. Prospective urgent exception requests will receive a response within 48 hours of the date and time on which Gateway received the request.

Requests received after the service has been rendered will receive a response within 30 days of the date on which Gateway received the request. A retrospective request for an exception must be submitted no later than sixty (60) days from the date that Gateway rejects a claim due to a service being over the benefit limit. Retrospective exception requests made after sixty (60) days will be denied.

If your exception request is denied, you or your doctor may appeal the denial.

Your doctor may not bill you for services over the limits unless both of the following conditions are met:

• Your doctor has requested an exception to the limit and Gateway denied the request
• Your doctor told you before the service was provided that you are responsible for payment if the exception is not granted

To ask for an exception, you or your doctor can call Member Services at 1-800-392-1147 (TTY/TDD 1-800-654-5988).

You and your doctor will receive written notice of the approval or denial of the request for exception. For prospective exception requests, if you or your doctor are not notified of the decision within 21 days the request is received, the decision will be automatically granted.

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If you are under 21, or age 21 or over and eligible for drug coverage, your prescriptions can be filled at any pharmacy (drug store) that is part of Gateway’s pharmacy network. Members that are not eligible for drug coverage can get contraceptives (birth control) and vitamins. Diabetic members that are not eligible for drug coverage from Medical Assistance can get insulin and syringes (needles) from Gateway. Members must get prescriptions from their Primary Care Physician (PCP) for insulin, syringes, contraceptives, and vitamins. The prescription may be taken to a pharmacy in Gateway’s network. You may be charged a co-payment depending upon your eligibility and the prescription being filled. If you need help finding a pharmacy that is in the network or have questions on drug coverage, please call Member Services at 1-800-392-1147 (TTY/TDD 1-800-654-5988).

Gateway uses an approved drug list, called a drug formulary, to determine if your drug is covered. The drug formulary has FDA approved products from every major drug category, including vitamins and all over-the-counter medicines covered by Medical Assistance.

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Gateway may make certain changes to our formulary during the year. These changes must first be approved by the Department of Public Welfare. Changes in the formulary may affect which drugs are covered and how much you will pay when filling your prescriptions. The kinds of formulary changes we may make include:

• Adding or removing drugs from the formulary
• Adding prior authorizations (prior approval), quantity limits (limits the amount of drug you can have filled), and/or step-therapy restrictions (you must try certain drugs before you can fill a prescription for some drugs) on a drug

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Gateway has additional requirements for coverage or limitations of certain formulary drugs. Our formulary book will tell you which drugs may have any additional requirements or limits on them. These requirements and limits help us be sure that our members use these drugs in a safe and effective manner while helping to control drug plan costs. A team of doctors and/or pharmacists work to develop these requirements and limits for Gateway to help provide quality coverage to our members. The requirements for coverage or limits on certain drugs are listed as follows:

• Prior Authorization: Gateway requires prior authorization (prior approval) for certain drugs. Some drugs on the formulary require additional information from your doctor to make sure the drug is being used safely and will work well in treating your condition. This means that your doctor will need to get approval from Gateway before you fill your prescription. If they don’t get prior approval, Gateway will not cover the drug.
• Quantity Limits: For certain drugs, Gateway has established quantity limits that the FDA has approved to be safe and effective. A quantity limit is the maximum amount of the drug Gateway will cover per prescription of over a defined period of time. For example, we will provide up to 28 tablets per prescription for the antibiotic, ciprofloxacin, every 30 days.
• Step Therapy: Some medications on Gateway’s formulary require specific drugs to be tried before you can receive a step therapy medication that treats your medical condition first. For example, if Drug A and Drug B both treat your medical condition, we may require your doctor to prescribe Drug A first. If Drug A does not work for you, then we will cover Drug B.
• Generic Substitution: When there is a generic version of a brand-name drug available, Gateway requires the generic drug be given to you. If your doctor prescribes a brand name drug, our network pharmacies will automatically give you the generic version. If your doctor feels you must take the brand name drug, he or she must contact Gateway’s pharmacy services to have that request reviewed.

If you would like a copy of the approved drug formulary, or have any questions on drug coverage, please call Member Services at 1-800-392-1147 (TTY/TDD 1-800-654-5988). Members can also notify Gateway if they feel a new drug should be placed on the formulary.

If you are on a drug that is not on Gateway’s approved drug formulary, talk to your doctor to see if your drug can be switched to a drug from the formulary that has the same or similar effect. If your doctor feels that the drug you take now is medically necessary and cannot be switched, your doctor can call Gateway to request an exception. If the exception is approved, Gateway will cover your current drug. Gateway will approve for your pharmacy to give you enough of the drug for 72 hours if a decision on the exception cannot be made within 24 hours, and you need the drug.

You have the right to appeal any decision made about your drug coverage. Call Member Services toll-free at 1-800-392-1147 (TTY/TDD 1-800-654-5988), 24 hours a day, 7 days a week.

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Regular eye exams are very important. That is why Gateway gives this benefit to all Gateway members. Each Gateway member is eligible for eye examinations every calendar year (there are no benefit limits for members under age 21, if medically necessary). There is no waiting period to get your vision benefit.

You must go to an eye doctor who is part of Gateway’s vision network. You do not need a referral. Be sure to show your Gateway Health Plan^® ID card and say that you are a Gateway Health Plan^® member.

Members age 21 and older will also be covered for one pair of standard eyeglasses (frames and lenses) or contact lenses per calendar year. Members under age 21 are eligible for two standard pairs of eyeglasses (frames and lenses) and one pair of contact lenses from within Gateway’s network each calendar year, as well as replacement pairs, if medically necessary. Some examples of covered lenses would be:

• Single Vision lenses (standard, plastic, glass or oversize)
• Bifocal lenses (standard, plastic, glass or oversize)
• Trifocal lenses (standard, plastic, glass or oversize)
• Aphakic/Lenticular lenses (standard, plastic, glass or oversize)
• Contact lens Prescription and Fitting
• Standard Contact Lenses (two lenses) (such as daily wear/spherical)
• Disposable/Replacement contacts - $75.00 member credit
• Polycarbonate lenses for members under 21 years of age

Designer Frames from the Davis Vision Collection are covered in full or you may receive a $20.00 retail allowance for a provider supplied frame. You will be responsible for the amount over $20.00.

If you have a medical condition such as cataracts, you will also be covered for glasses or contacts to treat your condition.

If you choose value-added options for your lenses that are beyond the standard eyeglass lenses, such as tinting or special coatings, you may be charged an additional fee which may not be covered by Gateway. Some examples of options and services that are not covered are:

• Special lens designs or coatings other than those described in the benefit plan
• Non-prescription (Plano) lenses
• Two pair of eyeglasses in lieu of bifocals for members age 21 and over
• Materials and services not specified in the benefit design
• Contact lenses and eyeglasses in the same benefit cycle for members age 21 and over
• Replacement of lost/stolen eyewear if not authorized by Gateway
• Any refractive surgical procedures, including Lasik
• Medical treatment of eye disease or injury
• Low vision aids
• Low vision devices
• Visual Therapy
• Services not performed by licensed personnel

You can call Member Services at 1-800-392-1147 (TTY/TDD 1-800-654-5988) for a list of participating eye doctors or if you have questions about your vision benefits.

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All Gateway members may get the following dental services each year from any Gateway participating dentist:

• One exam
• Two (2) Cleanings
• X-rays

Children under the age of 21 are eligible to receive all medically necessary complete dental services. Your child can go to any dentist that is a part of Gateway’s network. You can find a dentist in your area by using our online provider directory or by calling Gateway Member Services at 1-800-392-1147 (TTY/TDD 1-800-654-5988). Your child does not need a referral for a dental visit. However, your child’s PCP may refer children age 3 and above to a dental home as part of their regular EPSDT well child screens.

Dental services that are covered for children under the age of 21 include the following, when medically necessary:

• Anesthesia
• Orthodontics (braces)*
• Check-ups (two per year)
• Periodontal services
• Cleanings (two per year)
• Fluoride Treatments
• Root canals
• Crowns
• Sealants
• Dentures
• Dental surgical procedures
• Dental emergencies
• X-rays
• Extractions (tooth removals)
• Fillings

* If braces were put on before the age of 21, services will be covered, until they are completed, or age 23, whichever comes first, as long as the patient remains a member of Gateway.

For more information on your child’s dental benefits, please call Gateway Member Services at 1-800-392-1147 (TTY/TDD 1-800-654-5988).

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If you have a special healthcare need, the Care Management Department can help. Nurses, social workers, and other healthcare staff help to make sure you get the medical care that you need. They can assist you with any problems you have in getting your care.

If you would like information about programs in your community such as food banks or HIV programs, the Care Managers will help you. Call Member Services at 1-800-392-1147 (TTY/TDD 1-800-654-5988) if you would like to talk to a Care Manager.

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Services for mental health care such as depression, or drug and alcohol abuse are available to you. Please see the last page of the member handbook for the phone numbers for your county.

If you need help accessing these services, you can call Member Services at 1-800-392-1147 (TTY/TDD 1-800-654-5988).

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Gateway has a program for members between the ages of 2 years and 56 years with asthma called AIR Gateway^®. This program will help you understand how to take care of your asthma. Your asthma can be managed and should not be stopping you from doing things you like. As part of the program, a specially trained asthma care manager may call you on the telephone. The care manager will help you understand the difference between your long term control medicine and rescue medicine. The care manager will help you understand peak flow monitoring and how to use an asthma action plan. You will also receive information on asthma in the mail.

Here are a few reminders for managing your asthma:

• Take your long term control medicine every day as your doctor tells you even when you feel good
• The quick relief medicine helps you when you are having trouble breathing. This medicine should not be used everyday. If you are using them everyday, call your doctor.
• Visit your doctor at least twice a year. Your doctor needs to see you to make sure your asthma is in control so you can do things you like to do.
• Stop smoking and avoid second-hand smoke. Get help to quit smoking by calling 1-800-QUIT-NOW (1-800-784-8669).

If you would like more information on AIR Gateway^®, call 1-800-642-3550 and press #3. The care managers are available Monday through Friday between 8:30 a.m. and 4:30 p.m. by phone.

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If you are a Gateway Health Plan^® member age 21 or older who has congestive heart failure, or had a heart attack, stents or bypass surgery you might like to join the Help Your Heart Cardiac Program. This program helps you understand how to take care of your heart so you can live a healthy life. This program has specially trained care managers available by phone between 8:30 a.m. and 4:30 p.m. The care managers help you understand what has happened to your heart. They will teach you about a proper diet, exercise and how to take your medicines. They will teach you warning signs to look out for.

Here are a few reminders for managing your heart problems:

• Take your medicine the way your doctor ordered. If you can’t, call the office and tell them. Wait to hear from the office before you stop taking your pills.
• Some heart pills have to be stopped over several days. Do not just stop taking a pill. You can have complications if you do. Follow your doctor’s directions.
• Make sure you visit your doctor at least twice a year for a check up. If you are admitted to the hospital make an appointment to see your doctor within 2 weeks of discharge.
• Ask your doctor which lab tests you need to control your heart disease
• Stop smoking and avoid second-hand smoke. Get help to quit smoking by calling 1-800-QUIT-NOW (1-800-784-8669).

If you would like more information on the Help Your Heart Cardiac Program, call 1-800-642-3550 and press #3. The care managers are available Monday through Friday between 8:30 a.m. and 4:30 p.m. by phone.

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If you are a Gateway Health Plan^® member with diabetes, you might want to join the Healthy Returns Diabetes Program. Diabetes can cause problems for your heart, eyes, kidneys and circulation before you even know it. Diabetes can lead to heart failure. It is also the leading cause for amputations. Many people who are getting kidney dialysis are diabetics. Gateway offers a diabetic program that teaches you what symptoms to look for. As part of this program, specially trained nurses may call you on the telephone. The nurses teach you about the simple blood and urine tests you should have that warn you of some of the problems BEFORE you even know they are a problem!

The nurses are available all day long, seven days a week for this program. Monday through Friday between 8:30 a.m. and 4:30 p.m. dieticians and pharmacists are able to talk to you about your diet and medicines.

Here are a few reminders about managing your diabetes:

• Take your blood sugar readings the way your doctor ordered them
• Make sure you get these tests at least every year and more often if the doctor tells you to: HbA1c, LDL-c, urine test and have your blood pressure taken. These will help to show kidney or heart problems.
• Go to your eye doctor and tell them you are a diabetic. You need a dilated retinal eye exam at least every year. Your doctor can tell if diabetes is damaging your eyes during this test. Glasses cannot fix all eye problems caused by diabetes.
• Ask your doctor which lab tests you need to keep your diabetes under control
• Stop smoking and avoid second-hand smoke. Get help to quit smoking by calling 1-800-QUIT-NOW (1-800-784-8669).

If you would like to learn more about how to care for your diabetes, please call the Gateway Healthy Returns Diabetes Program twenty-four hours a day at 1-866-366-9415.

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Gateway has a special program for pregnant women called MOM Matters^®. This program provides education and support to help you have a healthy pregnancy. You should try to remain with Gateway throughout your pregnancy to get the most of this program. Specially trained care managers can answer your questions or concerns about your pregnancy. The care managers can also help with community service referrals. You will also receive information on pregnancy and baby care in the mail.

Here are some helpful tips for your pregnancy:

• Keep all of your prenatal appointments. If you miss an appointment, call your doctor to reschedule. Do not wait until your next visit.
• Take the prenatal vitamins prescribed by your doctor. Prenatal vitamins are an important part of your prenatal care for both the health of you and your baby. There are many prenatal vitamins available that Gateway pays for.
• Avoid alcohol, illegal drugs and smoking. Second-hand smoke can harm you and your unborn child. Get help to quit smoking by calling 1-800-QUIT-NOW (1-800-784-8669).
• Never take any medicines without checking with your doctor first. This includes prescription medications and over the counter medications like aspirin, Tylenol and cough syrup.
• Eat at least 3 meals a day and choose healthy foods like fruit, meat, milk, vegetables, breads and cereals
• Avoid foods like coffee, soda pop, fast foods, candy and doughnuts
• Drink at least 6 to 8 glasses of water every day. Juice and milk are also healthy choices.
• Keep your teeth and gums healthy by brushing and flossing daily. Gum infections can increase the risk of preterm labor.
• Wear your lap and shoulder belts when you are in a car. The lap portion should be low under your belly and touching your thighs.

If you would like more information about the MOM Matters^® Program, call 1-800-642-3550 and press #2. The care managers are available Monday through Friday between 8:30 a.m. and 4:30 p.m. by phone.

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WIC is a program that provides food vouchers, nutrition education and counseling, and referrals to health and other social services to pregnant women, post partum mothers, breastfeeding mothers and children under age five who are at nutritional risk, at no charge.

In addition to the foods normally available such as milk, eggs, cheese, cereal and juices, WIC may provide families with vouchers redeemable for many other nutritious foods, including whole wheat breads/rolls, brown rice, oats, whole wheat/corn soft tortillas, soymilk, tofu, fresh fruits/vegetables, jarred baby foods, canned beans, pink salmon or sardines.

Many grocery stores accept WIC food vouchers

You can apply for WIC by calling 1-800-942-9467 or 1-800-WIC-WINS.

If you would like more information about WIC, call our Care Management Department at 1-800-642-3550 and press #2. The care managers are available Monday through Friday between 8:30 a.m. and 4:30 p.m. by phone.

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Members under age 21 are eligible for a special program called Growing Up with Gateway^SM. Growing Up with Gateway^SM includes all of the services recommended by the Pennsylvania Department of Welfare’s Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program. The purpose of the Growing Up with Gateway^SM program is to find children’s health problems early and to keep checking to be sure that children stay healthy.

Your child’s Primary Care Physician (PCP) will check on many areas of health during EPSDT exams and screenings. The doctor will check on your child’s heart, lungs, eyesight, hearing and teeth. If you child’s doctor finds areas of concern, your child’s doctor will make a referral for other tests or to a specialist as needed. The doctor may refer children age 3 and above to a dental home as part of their regular EPSDT well child screens. For the EPSDT visit, the doctor could also give your child shots (immunizations) or ask about the child’s nutrition or diet. The doctor will also check other areas that are important to your child, by testing the child’s urine or testing the child’s blood for anemia and lead levels. The doctor will also ask questions about your child’s mental health, speech, social actions and behavior – the way your child relates to other kids their age. Finally, the doctor will ask questions to put together a family medical history.

During your child’s EPSDT exam the PCP will identify if your child is due for a dental referral based on his/her age. The PCP will advise you if the child is need of a referral. The PCP will also notify Gateway of the need for a dental referral as part of the Growing Up with Gateway^SM Program. Gateway has Preventive Health staff that will contact you and offer assistance in setting up dental appointments if needed. Please remember dental health is very important even with very young children. Talk to your PCP about your child’s dental health at each EPSDT visit.

It is very important that you keep your EPSDT appointments with the doctor. These physical exams can sometimes be used as the exam your child needs to get into Head Start, or for school, or for a driver’s license physical.

Your child’s doctor may find that your child needs a medically necessary service or a piece of equipment to treat a problem found during a screening visit. If so, your child’s doctor can call Gateway to ask for the service or equipment, and it will be reviewed for approval.

If you need more information about the Growing Up with Gateway^SM program, please call the Preventive Health Department at 1-800-642-3550, Option 4 (TTY/TDD 1-800-654-5988). Preventive Health staff can also help you set up an appointment for your child, assist you with dental appointments or help you get a ride for these appointments.

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Gateway participates in Early Intervention Services by identifying infants, toddlers and preschool children who have special needs due to developmental delays or disabilities. Primary Care Physicians (PCP) and school districts may also help identify members in need of Early Intervention Services. When a member is identified, the parent is contacted and given the CONNECT Helpline at 1-800-692-7288. The CONNECT staff will answer questions and refer a family to the appropriate local agency for a developmental assessment.

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Family planning (birth control) services are available to Gateway Health Plan^® members. You do not need a referral from your Primary Care Physician (PCP) for family planning services. You can see any doctor that offers family planning. If you would like more information on a doctor in Gateway’s network, please call 1-800-392-1147 (TTY/TDD 1-800-654-5988). However, you may choose to use a family planning clinic that is not part of Gateway’s network. There is no cost for these services. When you go to a family planning provider, just show your Gateway Health Plan^® ID card.

Treatment for infertility (cannot have a baby) is not covered by Gateway Health Plan^®.

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If you have HIV/AIDS you can call Gateway’s Care Management Department, 1-800-642-3550, Option 1 to discuss services and resources that are available for you.

You may be eligible for additional home and community based services if you have AIDS or symptomatic HIV. Services include additional nursing and home health aide visits, homemaker services, nutritional supplements, nutritional consultations, and medical supplies.

To get services, your doctor will need to write an order. Prior authorization is required for some services. Your doctor’s office can call Gateway’s Utilization Management Department at 1-800-392-1146 to obtain prior authorization.

If you need help finding a PCP or specialist to treat you, call Gateway’s Member Services Department at 1-800-392-1147.

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Gateway Health Plan^® members can get chiropractic care. You may go to a chiropractor from Gateway’s list of doctors on your own for the first visit, or your Primary Care Physician (PCP) can call Gateway before you go. After your first visit, the chiropractor must talk to a Gateway nurse about your treatment plan, and the nurse may approve more visits, if medically necessary.

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There are some services not covered by Gateway. Limitations and most exclusions do not apply to members under age 21. Services not covered include:

• Braces for teeth (called orthodontics) for members age 21 or older
• Cosmetic Surgery (also called plastic surgery), unless medically necessary
• Custodial care including Personal Care Homes
• Experimental procedures, unless prior approval from Gateway is received
• Nursing home care for more than 30 days. If you need to stay in a nursing home for more than 30 days, you will be switched back to the traditional Medical Assistance Fee for Service Program (also called ACCESS).
• Personal items or services such as television or a telephone while you are in the hospital.
• Prescription drugs for members age 21 and older that are not eligible for Medical Assistance drug benefits (other than vitamins, insulin, syringes, and birth control)
• Prescription drugs not listed on the approved drug list, unless an exception is made
• Drugs designated as less than effective by the Food and Drug Administration (FDA). This area also known as DESI for the Drug Efficacy Study Implementation drugs.
• Drugs prescribed for the treatment of erectile dysfunction
• Treatment for infertility (cannot become pregnant)
• Home modifications
• Respite care
• Services that are not covered by the Medical Assistance program
• Non-medical items or services
• Surgery, medication or any other medical procedures or services related to sex-change

Shift nursing services are not covered for members age 21 and older. This applies to members who began receiving these services when they were under age 21. You may be eligible for a Home and Community Based Waiver through Medical Assistance to provide shift nursing services beyond the age of 21. If you are interested in obtaining information regarding Home and Community Based Waivers, please call 1-800-642-3550, Option 1.

There may be other services that are not covered by Gateway. If you are not sure if the service you need is covered, call Member Services at 1-800-392-1147 (TTY/TDD 1-800-654-5988). Some services, such as transportation and Behavioral Health services, are not covered by Gateway but may be covered by your ACCESS card. You may have to pay for services that are not covered by Gateway or your ACCESS card or for services not provided by a Pennsylvania Medical Assistance participating provider. A Care Manager will provide you with information regarding waivers and important phone numbers that you will need. If you are interested, the Care Manager can also send you “The Transition to Adulthood“ brochure that includes information about various aspects of transitioning to adulthood, and services that are available.

Remember, in most cases, Gateway will only cover those services that are ordered by your Primary Care Physician (PCP), except in a medical emergency.

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