The following benefits are covered by Medicaid under federal law:
- Inpatient hospital services
- Outpatient hospital services
- EPSDT: Early and Periodic Screening, Diagnostic, and Treatment Services
- Nursing facility services
- Home health services
- Physician services
- Rural health clinic services
- Federally qualified health center services
- Laboratory and X-ray services
- Family planning services
- Nurse midwife services
- Certified Pediatric and Family Nurse Practitioner services
- Freestanding Birth Center services (when licensed or otherwise recognized by the state)
- Transportation to medical care
- Tobacco cessation counseling for pregnant women
States may choose to cover the following services:
- Prescription drugs
- Clinic services
- Physical therapy
- Occupational therapy
- Speech, hearing and language disorder services
- Respiratory care services
- Other diagnostic, screening, preventive and rehabilitative services
- Podiatry services
- Optometry services
- Dental services
- Chiropractic services
- Private duty nursing services
- Personal care
- Case management
- Services for Individuals Age 65 or Older in an Institution for Mental Disease (IMD)
- State Plan Home and Community Based Services- 1915(i)
- Self-Directed Personal Assistance Services- 1915(j)
- Community First Choice Option- 1915(k)
- TB Related Services
- Inpatient psychiatric services for individuals under age 21
- Health Homes for Enrollees with Chronic Conditions – Section 1945
As a Gateway Member, you have the right to:
- To be treated with respect, recognizing your dignity and need for privacy, by Gateway staff and network providers.
- To get information in a way that you can easily understand and find help when you need it.
- To get information that you can easily understand about Gateway, its services, and the doctors and other providers that treat you.
- To pick the network health care providers that you want to treat you.
- To get emergency services when you need them from any provider without Gateway’s approval.
- To get information that you can easily understand and talk to your providers about your treatment options, risks of treatment, and tests that may be self-administered without any interference from Gateway.
- To make all decisions about your health care, including the right to refuse treatment. If you cannot make treatment decisions by yourself, you have the right to have someone else help you make decisions or make decisions for you.
- To talk with providers in confidence and to have your health care information and records kept confidential.
- To see and get a copy of your medical records and to ask for changes or corrections to your records.
- To ask for a second opinion.
- To file a grievance if you disagree with Gateway’s decision that a service is not medically necessary for you.
- To file a complaint if you are unhappy about the care or treatment you have received.
- To ask for a Department of Human Services (“DHS”) Fair Hearing.
- To be free from any form of restraint or seclusion used to force you to do something, to discipline you, to make it easier for the provider, or to punish you.
- To get information about services that Gateway or a provider does not cover because of moral or religious objections and about how to get those services.
- To exercise your rights without it negatively affecting the way DHS, Gateway, and network providers treat you.
- To create an advance directive.
- To make recommendations about the rights and responsibilities of Gateway’s members.
As a Gateway Member you have a responsibility to:
- Provide, to the extent you can, information needed by your providers.
- Follow instructions and guidelines given by your providers.
- Be involved in decisions about your health care and treatment.
- Work with your providers to create and carry out your treatment plans.
- Tell your providers what you want and need.
- Learn about Gateway’s coverage, including all covered and non-covered benefits and limits.
- Use only network providers unless Gateway approves an out-of-network provider or you have Medicare.
- Get a referral from you Primary Care Physician (“PCP”) to see a specialist.
- Respect other patients, provider staff, and provider workers.
- Make a good-faith effort to pay your co-payments.
- Report fraud and abuse to the DHS Fraud and Abuse Reporting Hotline.
Si desea una copia de los derechos y responsabilidades de los miembros del Plan de Salud Gateway, llame al 1-800-392-1147.
Derechos y Responsabilidades de las Miembros Declaracion.
For our Medicaid members, help is always just a phone call away. Call 1-855-805-9408 with your questions about:
- A recent diagnosis, treatment options or surgery
- Current symptoms
- Medication side effects
- Self-care home treatments
- When to go to the doctor
- When to go to the Urgent Care Center or Emergency Room
- Preventive care and lab tests
A professional nurse is available 24 hours a day, 7 days a week. If you experience an emergency, please call 911.
Also available to all our Medicaid members, is our wellness coaching program. You have access to several wellness coaches, including:
- Certified Rehabilitation Counselor - Help prevent or reduce falls. This Wellness Coach will ask some questions about your risk for falling and do a home safety checklist. Your coach will also give you tips to help your balance and strength.
- Registered Dietitian Nutritionist - Get answers to your questions about healthy eating from a food expert. This Wellness Coach will work with you to help manage any medical conditions or your overall health.
- Certified Diabetes Care and Education Specialist - Take control of your diabetes. This Wellness Coach will help you learn about taking medicines and lowering your risk of diabetes-related complications. You can set goals for moving more. If you are looking for help with food and nutrition information only, reach out to our Registered Dietitian Nutritionist Wellness Coach!
When you make the right choices, you deserve a reward. Healthier lifestyle decisions are no exception. The Goodness Rewards Programs gives Gateway Health members a reloadable gift card, good at over 100 locations. Every time you complete an eligible health activity, you get a reward!
Contact Goodness Rewards for more information.
Review Frequently Asked Questions here.
Monday - Friday, 7 a.m. to 7 p.m.
We have a special program for pregnant women called MOM Matters®. This program gives you the education and support to help you have a healthy pregnancy. Our Maternity Team members are here to answer questions and help you every step of the way. They can help you:
- Find a doctor and set up your appointments for prenatal care. Call us as soon as you find out you are pregnant!
- Answer questions, direct you to community services, and guide you throughout your pregnancy.
- Arrange a home visit by a nurse when needed.
- Provide resources for transportation to and from important doctor appointments.
- Connect you to the smoking quit line at 1-800-784-8669 or 1-800-QUIT-NOW.
- Earn rewards for going to all your prenatal and postpartum care doctor visits!
Enrolled in Boys & Girls Clubs Teen Workforce Academy or want to enroll? You can have the cost of monthly membership dues and monthly Workforce Academy dues paid for by Gateway Health. We have partnered with the Boys and Girls Clubs at the Duquesne/West Mifflin, Shadyside/East Liberty, Millvale Western PA locations to provide our Gateway Health members with this value added benefit. We will provide the $40 per month regular Clubs membership dues plus the $40 per month Workforce Academy dues.
IN ORDER TO QUALIFY FOR THIS VALUE ADDED BENEFIT, YOU MUST BE:
- A current Gateway Health member
- Between the ages of 14-24 years
- Enrolled in the Boys & Girls Club Teen Workforce Academy program or meet the requirements to enroll in the Teen Workforce Academy
- Meet the program criteria and located within Allegheny County Teen Workforce Academy locations: Duquesne/West Mifflin, Millvale, Shadyside/East Liberty
- Teen Workforce Development Academy application form completion, including a short essay and submission of grades/progress report, cannot be more than 3 grades behind in school
For more information about this value added benefit, please call Member Services.
IN ORDER TO QUALIFY FOR THIS VALUE ADDED BENEFIT, YOU MUST:
- Be a current Gateway Health member
- Be at least 17 years old
- Be a PA resident
- Not enrolled in any other school program
Many jobs now require a high school diploma or GED and getting your GED gives you the chance to earn at least $9,000 more a year! Don’t miss the opportunity to take your GED test at NO COST.
Request your GED Benefit Now