55 Pa. Code § 175.73 - Requirements
(a)
Services paid for. The following services will be paid for in
accordance with the following requirements:
(1)
Physicians' services.
Physicians' services will be paid for in accordance with the following:
(i) In accordance with the specific
regulations governing physicians' services, the Department will pay for office
and home calls for chronic or acute illness. Home calls will be paid for only
when it is situationally impossible or medically inadvisable for the patient to
go to the physician's office.
(ii)
In cases of acute illness the Department will pay for the minimum number of
calls deemed necessary by the physician for adequate medical care in each
individual instance.
(iii) In
chronic illness, payment will be limited to a maximum of three calls per month.
It will not be expected, however, that this maximum will be charged in
instances where one or two calls would have been sufficient.
(iv) Obstetrical care and minor surgery,
performed in the home or office, will be paid for.
(v) X-ray study in the physician's office, if
necessary for diagnosis, may be paid only for persons receiving public
assistance money payments. The Department will not pay for diagnostic
laboratory tests and x-rays provided in the course of the school health
examination.
(vi) The services of a
physician for a complete physical examination may be paid if needed to
determine the condition of a recipient or the eligibility of an applicant for
assistance, for the annual general medical examination of public assistance
recipients in private nursing homes and for other needed special medical
examinations. Prior authorization will be required.
(vii) On written prescription by the
physician, payment will be made for drugs included in the Drug Formulary.
Payment for drugs on one prescription will be limited to a 45-day supply. If
the charge for the medication is more than $10 or if the physician plans to
prescribe the same medication in an amount likely to exceed $35 per month,
prior authorization through the County Assistance Office will be
required.
(viii) Medication
dispensed by a physician during a home or office call may be paid for if the
medication costs the physician $2 or more. Prior authorization will be required
if the charge is more than $10.
(ix) In addition to the physicians' services
in subparagraphs (i)-(vii), the Department also will pay for eye examinations
and refractions, eye glasses, and surgeon's fees for certain specified
operations for an eligible child.
(x) For a patient who is receiving a public
assistance payment for nursing home care, the Department will not pay for
medical services given by a physician who owns that institution in whole or in
part, has a financial interest in it, operates it or is acting in another
capacity that indicates he is not an independent contractor.
(2)
Pharmaceutical
services. Pharmaceutical services will be paid for in accordance with
the following:
(i) The Drug Formulary of the
Department will list the medications and medical supplies included in the
program, and the charge the Department will pay for the item.
(ii) If the charge for an item is more than
$10 for one prescription, the Department will pay the pharmacist only if he has
written authorization from the County Assistance Office before filling the
prescription.
(iii) Payment for a
prescription will be limited to a 45-day supply.
(iv) For a person in a nursing home for whom
the Department is making a nursing home care payment, payment will not be made
for any services, medications and supplies included in the public assistance
definition of nursing home care.
(3)
Clinic services.
Clinical services will be paid in accordance with the following:
(i) Payment may be made for prenatal care and
treatment for chronic and acute illness, with limits on the number of
chargeable visits, as outlined above under physicians' services, and x-ray
studies for diagnosis or definition, with the exception outlined in this
section under physicians' services. For the eligible school child, payment may
be made for eye examinations and refractions.
(ii) Clinic pharmacies will be expected to
fill prescriptions written by clinic physicians. Payment will not be made for
drugs and supplies that are ordinarily dispensed without charge to
nonassistance patients who are unable to pay.
(4)
Dental services. Dental
services will be paid for in accordance with the following:
(i) In line with the intent of the Department
to provide adequate, but not extravagant or superfluous care, priorities for
dental treatment have been established as a basis for restrictions on services.
(ii) To receive payment from the
Department for full and partial dentures, and major denture repairs, the
dentist or dental clinic must have written authorization from the County
Assistance Office before providing these services.
(iii) Payment may be made for dental x-rays
and medications prescribed by dentists, in addition to other dental
care.
(5)
Ambulance services and other types of transportation. Payment
may be made for necessary ambulance services if they are not available without
charge to other needy persons in the community.
(6)
Nursing care in the
home. Nursing care in the home will be paid for in accordance with the
following:
(i) Payment may be made for the
initial visit of the nurse on the request of the patient or any interested
person. Subsequent visits will be paid for only if made on the written order of
the attending physician.
(ii) The
Department will pay for nursing service for chronic or acute illness, maternity
service or instruction of the patient in accordance with the public assistance
regulations and the fee schedule.
(7)
Inpatient hospital care.
Payment may be made for inpatient hospital care.
(8)
Hospital-home care.
Payment may be made for hospital-type care in the home provided by the hospital
as an uninterrupted continuation of inpatient hospital care.
(9)
Skilled nursing or intermediate
care in public or private facilities. Skilled nursing or intermediate
care in public or private facilities will be paid in accordance with the
following:
(i) Payment may be made for
nursing home care in a public nursing home for persons found to be
categorically needy, including children up to 21, and specified relatives 21
years and over, but excluding persons who meet the definitive conditions of
GA.
(ii) Payment may continue for
as long as the need and eligibility continue.
(10)
Care in a mental
institution. Payment may be made for service in an institution for
mental diseases for a person under 21 or over 65.
(11)
Medical-social
services. Medical-social services will be provided in accordance with
the following:
(i) A broad range of social
services, including specific services related to illness, will be provided as
needed to persons applying for or receiving public assistance money payments.
The objective will be to enable them to attain or retain independence or
self-care or both.
(ii) Specific
social services related to illness will be provided as needed in relation to a
school child for whom an application is being made for medical assistance, or
who is receiving medical assistance. This will include social services in
medical emergencies.
(b)
Benefit period. The
benefit period will include the following:
(1)
Inpatient hospital care. Reference should be made to Chapter
1163 (relating to inpatient hospital services).
(2)
Hospital-home care.
Reference should be made to Chapter 1249 (relating to home health agency
services).
(c)
Eligibility of school children. Eligibility of school children
for medical care will be determined as follows:
(1) A school child shall be eligible for
medical care if any of the following occurs:
(i) He is categorically needy.
(ii) He has been certified as medically
needy.
(iii) The referral to public
assistance has been made by the School Nurse.
(2) A school child will include attending, or
scheduled to enter within the current year, a public or private Commonwealth
elementary, grade or high school, or kindergarten that is an integral part of a
local school district.
(3) A
summary of the services and eligibility conditions for medical assistance for
school children is given in Leaflet No. 5 available from the County Board of
Assistance, or from the Department of Human Services, Harrisburg.
(d)
Professional
participation. Professional participation in the Public Assistance
Medical Care Program shall be as follows:
(1)
The Public Assistance Medical Care Program, operating on a voluntary
participation basis, will be open to a practitioner of medicine, osteopathy or
dentistry; a clinic, pharmacist, nursing home, hospital, clinic or vendor of
medical supplies in the Commonwealth or in another state who meets the
requirements described under the regulations for each of the participating
professions. The practitioner or vendor who participates in the program, giving
services, thereby signifies his agreement to comply with the regulations and
intent of the program.
(2) Subject
only to the willingness of the practitioner, vendor or institution to
participate in the program and abide by the regulations, the patient will have
the right of free choice of practitioner, vendor or institution.
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