Current through Register Vol. 54, No. 44, November 2, 2024
(a)
Scope. The scope of benefits for which MA recipients are
eligible differs according to recipients' categories of assistance, as
described in this section.
(1) Recipients
under 21 years of age are eligible for all medically necessary
services.
(2) The benefit limits
specified in subsections (b), (c), and (e) apply only to adults, with the
exception of pregnant women, including throughout the postpartum
period.
(3) Recipients shall
exhaust other available medical resources prior to receiving MA
benefits.
(b)
Categorically needy. The categorically needy are eligible for
all of the following benefits:
(1) Inpatient
hospital services other than services in an institution for mental disease, as
specified in Chapter 1163 (relating to inpatient hospital services), including
one medical rehabilitation hospital admission per fiscal year.
(2) Up to a combined maximum of 18 clinic,
office and home visits per fiscal year by physicians, podiatrists,
optometrists, CRNPs, chiropractors, outpatient hospital clinics, independent
medical clinics, rural health clinics, and FQHCs.
(3) Outpatient hospital services as follows:
(i) Short procedure unit services as
specified in Chapter 1126 (relating to ambulatory surgical center services and
hospital short procedure unit services).
(ii) Psychiatric partial hospitalization
services as specified in Chapter 1153 (relating to outpatient psychiatric
services) up to one hundred and eighty three-hour sessions, 540 total hours,
per recipient per fiscal year.
(iii) Outpatient hospital clinic services as
specified in Chapter 1221 (relating to clinic and emergency room services) and
in paragraph (2).
(iv) Rural health
clinic services and FQHC services as specified in Chapter 1129 (relating to
rural health clinic services) and in paragraph (2).
(4) Laboratory and X-ray services as
specified in Chapter 1243 (relating to outpatient laboratory services) and
Chapter 1230 (relating to portable X-ray services).
(5) Nursing facility care as specified in
Chapter 1181 (relating to nursing facility care) and Chapter 1187 (relating to
nursing facility services).
(6)
Intermediate care.
(7) Inpatient
psychiatric care as specified in Chapter 1151 (relating to inpatient
psychiatric services), up to 30 days per fiscal year.
(8) Physicians' services as specified in
Chapter 1141 (relating to physicians' services) and in paragraph (2).
(9) Optometrists' services as specified in
Chapter 1147 (relating to optometrists' services) and in paragraph
(2).
(10) Home health care as
specified in Chapter 1249 (relating to home health agency services).
(11) Clinic services as follows:
(i) Independent medical clinic services as
specified in Chapter 1221 and in paragraph (2).
(ii) Ambulatory surgical center services as
specified in Chapter 1126.
(iii)
Psychiatric clinic services as specified in Chapter 1153, including up to 5
hours or 10 one-half hour sessions of psychotherapy per recipient in a 30
consecutive day period.
(iv) Drug
and alcohol clinic services, including methadone maintenance, as specified in
Chapter 1223 (relating to outpatient drug and alcohol clinic
services).
(12) Ambulance
services as specified in Chapter 1245 (relating to ambulance
transportation).
(13) Dental
services as specified in Chapter 1149 (relating to dentists'
services).
(14) Medical equipment,
supplies, prostheses, orthoses and appliances as specified in Chapter 1123
(relating to medical supplies).
(15) EPSDT services, for recipients under 21
years of age as specified in Chapter 1241 (relating to early and periodic
screening, diagnosis, and treatment program).
(16) Family planning services and supplies as
specified in Chapter 1245.
(17)
Drugs as specified in Chapter 1121 (relating to pharmaceutical
services).
(18) Chiropractic
services as specified in Chapter 1145 (relating to chiropractors' services)
limited to the visits specified in paragraph (2).
(19) Podiatrists' services as specified in
Chapter 1143 (relating to podiatrists' services) and in paragraph
(2).
(20) CRNP services as
specified in Chapter 1144 (relating to certified registered nurse practitioner
services) and in paragraph (2).
(c)
Medically needy. The
medically needy are eligible for the benefits in subsection (b) with the
exception of the following:
(1) Medical
equipment, supplies, prostheses, orthoses and appliances.
(2) Drugs.
(d)
State Blind Pension.
State Blind Pension recipients are eligible for the following benefits:
(1) Outpatient hospital services as follows:
(i) Psychiatric partial hospitalization
services as specified in Chapter 1153 up to 240 three-hour sessions, 720 total
hours, per recipient in a 365 consecutive day period.
(ii) Rural health clinic services and FQHC
services, as specified in Chapter 1129.
(2) Physicians' services as specified in
Chapter 1141.
(3) Optometrists'
services as specified in Chapter 1147.
(4) Home health care as specified in Chapter
1249.
(5) Clinic services as
follows:
(i) Psychiatric clinic services as
specified in Chapter 1153, including up to 7 hours or 14 one-half hour sessions
of psychotherapy per recipient in a 30 consecutive day period.
(ii) Drug and alcohol clinic services,
including methadone maintenance, as specified in Chapter 1223.
(6) Ambulance services as
specified in Chapter 1245.
(7)
Dental services as specified in Chapter 1149.
(8) Family planning services and supplies as
specified in Chapter 1245.
(9)
Drugs as specified in Chapter 1121.
(10) Chiropractors' services as specified in
Chapter 1145.
(e)
GA recipients. GA recipients are eligible for benefits as
follows:
(1) GA chronically needy and nonmoney
payment recipients are eligible for all of the following benefits:
(i) Up to a combined maximum of 18 clinic,
office, and home visits per fiscal year by physicians, podiatrists,
optometrists, CRNPs, chiropractors, outpatient hospital clinics, independent
medical clinics, rural health clinics and FQHCs.
(ii) Home health care as specified in Chapter
1249, up to a maximum of 30 visits per fiscal year.
(iii) Legend and nonlegend drugs as specified
in Chapter 1121 not to exceed a maximum of six prescriptions and refills per
month.
(iv) Inpatient hospital
services other than services in an institution for mental disease as specified
in Chapter 1163, as follows:
(A) One acute
care inpatient hospital admission per fiscal year.
(B) One medical rehabilitation hospital
admission per fiscal year.
(C) Up
to 30 days of drug and alcohol inpatient hospital care per fiscal
year.
(v) Outpatient
hospital services as follows:
(A) Short
procedure unit services as specified in Chapter 1126.
(B) Psychiatric partial hospitalization
services as specified in Chapter 1153, up to 180 three-hour sessions, 540 total
hours, per recipient per fiscal year.
(C) Outpatient hospital clinic services as
specified in Chapter 1221 and in subparagraph (i).
(D) Rural health clinic services and FQHC
services as specified in Chapter 1129 and in subparagraph (i).
(vi) Ambulance services as
specified in Chapter 1245, for medically necessary emergency transportation and
transportation to a nonhospital drug and alcohol detoxification and
rehabilitation facility from a hospital when a recipient presents to the
hospital for inpatient drug and alcohol treatment and the hospital has
determined that the required services are not medically necessary in an
inpatient facility.
(vii) Emergency
room care as specified in Chapter 1221, limited to emergency situations as
defined in §§
1101.21 and
1150.2 (relating to definitions;
and definitions).
(viii) Laboratory
and X-ray services as specified in Chapter 1243 and Chapter 1230.
(ix) Nursing facility care as specified in
Chapter 1181 and Chapter 1187.
(x)
Intermediate care.
(xi) Inpatient
psychiatric care as specified in Chapter 1151, up to 30 days per fiscal
year.
(xii) Clinic services as
follows:
(A) Independent medical clinic
services as specified in Chapter 1221 and in subparagraph (i).
(B) Ambulatory surgical center services as
specified in Chapter 1126.
(C)
Psychiatric clinic services as specified in Chapter 1153, including a total of
5 hours or 10 one-half hour sessions of psychotherapy per recipient in a 30
consecutive day period.
(D) Drug
and alcohol clinic services, including methadone maintenance, as specified in
Chapter 1223.
(xiii)
Physicians' services as specified in Chapter 1141 and in subparagraph
(i).
(xiv) Dental services as
specified in Chapter 1149.
(xv)
Podiatrists' services as specified in Chapter 1143 and in subparagraph
(i).
(xvi) Chiropractic services as
specified in Chapter 1145 limited to the visits specified in subparagraph
(i)
(xvii) CRNP services as
specified in Chapter 1144 and in subparagraph (i).
(xviii) Medical equipment, supplies,
prostheses, orthoses and appliances as specified in Chapter 1123.
(xix) Family planning services and supplies
as specified in Chapter 1225.
(2) GA medically needy only recipients are
eligible for the benefits described in paragraph (1) of subsection (e), with
the following exceptions:
(i) Medical
equipment, supplies, prostheses, orthoses and appliances.
(ii) Drugs.
(3) The Department will inform recipients
subject to the limits established in this subsection and medical service
providers of these limits and the recipient's current usage of limited
services. When the Department determines that a recipient's usage of services
is likely to exceed the limits established by this subsection, it will review
the case to determine whether the recipient should be referred to the
Disability Advocacy Program.
(f)
Exceptions.
(1) The Department is authorized to grant
exceptions to the limits specified in subsections (b) and (e) when it
determines that one of the following criteria applies:
(i) The recipient has a serious chronic
systemic illness or other serious health condition and denial of the exception
will jeopardize the life of or result in the serious deterioration of the
health of the recipient.
(ii)
Granting the exception is a cost-effective alternative for the MA
Program.
(iii) Granting the
exception is necessary in order to comply with Federal law.
(2) The process for requesting an
exception is as follows:
(i) A recipient or a
provider on behalf of a recipient may request an exception.
(ii) A request for an exception may be made
to the Department in writing, by telephone, or by facsimile.
(iii) A request for an exception may be made
prospectively, before the service has been delivered, or retrospectively, after
the service has been delivered.
(iv) The Department will respond to a request
for an exception no later than:
(A) For
prospective exception requests, within 21 days after the Department receives
the request.
(B) For prospective
exception requests when the provider indicates an urgent need for quick
response, within 48 hours after the Department receives the request.
(C) For retrospective exception requests,
within 30 days after the Department receives the request.
(v) A retrospective request for an exception
must be submitted no later than 60 days from the date the Department rejects
the claim because the service is over the benefit limit. Retrospective
exception requests made after 60 days from the claim rejection date will be
denied.
(vi) Both the recipient and
the provider will receive written notice of the approval or denial of the
exception request. For prospective exception requests, if the provider or
recipient is not notified of the decision within 21 days of the date the
request is received, the exception will be automatically granted.
(vii) Departmental denials of requests for
exception are subject to the right of appeal by the recipient in accordance
with Chapter 275 (relating to appeal and fair hearing and administrative
disqualification hearings).
(viii)
A provider may not hold a recipient liable for payment for services rendered in
excess of the limits established in subsections (b) and (e) unless both of the
following conditions are met:
(A) The
provider has requested an exception to the limit and the Department has denied
the request.
(B) The provider
informed the recipient before the service was rendered that the recipient is
liable for the payment as specified in §
1101.63(a)
(relating to payment in full) if the exception is not
granted.
The provisions of this §1101.31 amended under sections
201(2), 403(b), 443.1, 443.3, 443.6, 448 and 454 of the Public Welfare Code
(62
P.S. §§
201(2),
403(b), 443.1, 443.6, 448 and
454).
This section cited in 55 Pa. Code §
1121.24 (relating to scope of
benefits for GA recipients); 55 Pa. Code §
1123.21 (relating to scope of
benefits for the categorically needy); 55 Pa. Code §
1123.24 (relating to scope of
benefits for GA recipients); 55 Pa. Code §
1126.24 (relating to scope of
benefits for General Assistance recipients); 55 Pa. Code §
1127.24 (relating to scope of
benefits for General Assistance recipients); 55 Pa. Code §
1128.24 (relating to scope of
benefits for GA recipients); 55 Pa. Code §
1129.24 (relating to scope of
benefits for General Assistance recipients); 55 Pa. Code §
1130.23 (relating to scope of
benefits for General Assistance recipients); 55 Pa. Code §
1141.24 (relating to scope of
benefits for General Assistance recipients); 55 Pa. Code §
1142.24 (relating to scope of
benefits for General Assistance recipients); 55 Pa. Code §
1143.24 (relating to scope of
benefits for General Assistance recipients); 55 Pa. Code §
1144.24 (relating to scope of
benefits for GA recipients); 55 Pa. Code §
1145.24 (relating to scope of
benefits for General Assistance recipients); 55 Pa. Code §
1147.24 (relating to scope of
benefits for General Assistance recipients); 55 Pa. Code §
1151.24 (relating to scope of
benefits for General Assistance recipients); 55 Pa. Code §
1151.43 (relating to limitation on
payment); 55 Pa. Code §
1163.24 (relating to scope of
benefits for General Assistance recipients); 55 Pa. Code §
1163.424 (relating to scope of
benefits for General Assistance recipients); 55 Pa. Code §
1181.25 (relating to scope of
benefits for General Assistance recipients); 55 Pa. Code §
1221.24 (relating to scope of
benefits for General Assistance recipients); 55 Pa. Code §
1223.24 (relating to scope of
benefits for General Assistance recipients); 55 Pa. Code §
1225.24 (relating to scope of
benefits for General Assistance recipients); 55 Pa. Code §
1230.24 (relating to scope of
benefits for General Assistance recipients); 55 Pa. Code §
1243.24 (relating to scope of
benefits for General Assistance recipients); 55 Pa. Code §
1245.24 (relating to scope of
benefits for General Assistance recipients); 55 Pa. Code §
1249.24 (relating to scope of
benefits for General Assistance recipients); and 55 Pa. Code §
1251.24 (relating to scope of
benefits for General Assistance
recipients).
