Current through Register Vol. 54, No. 44, November 2, 2024
(a)
Expanded coverage. Expanded coverage benefits include the
following:
(1)
EPSDT.
Recipients under age 21 are entitled to benefit coverage for preventive health
screening and vision, dental, and hearing problems. The basis for this coverage
is the EPSDT. The Department will pay for scheduled periodic health screening
services for categorically needy and medically needy individuals. Clients may
receive these benefits at approved screening centers. If requested, the CAO
will assist clients in making an appointment. Recipients under age 21 are also
entitled to necessary vision care by a doctor of optometry or a physician
skilled in the diseases of the eye, hearing and dental exams and treatment
covered in the State Plan by virtue of being screened under EPSDT. A child need
not be screened first if an existing vision problem can be diagnosed and
treated by an appropriate specialist. Medically needy children referred from
EPSDT are not eligible for pharmaceuticals, medical supplies, equipment or
prostheses and orthoses.
(2)
School medical program. A medically needy school child is
eligible for benefits available to categorically needy recipients if the
benefits are required to treat a health problem noted in his school medical
record. The school nurse or doctor refers the child to the provider by
completing a School Medical Referral Form. Payment for services provided under
this program shall be subject to this chapter and the applicable provider
regulations.
(b)
Coverage for out-of-State services. The Department pays for
compensable services furnished out-of-State to eligible Commonwealth recipients
if:
(1) The recipient requires emergency
medical care while temporarily away from his home.
(2) The recipient would be risking his health
if he waited for the service until he returned home.
(3) The trip back to this Commonwealth would
endanger his health.
(4) It is
general practice for recipients in an area of the Commonwealth to use medical
resources in a neighboring state.
(5) The Department decides, based on the
attending practitioner's advice, that the recipient has better access to the
type of care he needs in another state.
This section cited in 55 Pa. Code §
1121.22 (relating to scope of
benefits for the medically needy); 55 Pa. Code §
1123.22 (relating to scope of
benefits for the medically needy); 55 Pa. Code §
1123.56 (relating to vision aids);
55 Pa. Code §
1123.57 (relating to hearing
aids); 55 Pa. Code §
1147.21 (relating to scope of
benefits for the categorically needy); and 55 Pa. Code §
1147.22 (relating to scope of
benefits for the medically needy).
