[35 Pa.B. 4811]
[Continued from previous Web Page]
BENEFITS § 1101.31. Scope.
(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 (relating to clinic and emergency room services) and in paragraph (2).
(ii) Ambulatory surgical center services as specified in Chapter 1126 (relating to ambulatory surgical center services and hospital short procedure unit services).
(iii) Psychiatric clinic services as specified in Chapter 1153 (relating to outpatient psychiatric services), 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 (relating to family planning clinic services).
(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.
FEES AND PAYMENTS § 1101.63. Payment in full.
(a) Supplementary payment for a compensable service. A provider shall accept as payment in full, the amounts paid by the Department plus a copayment required to be paid by a recipient under subsection (b). A provider who seeks or accepts supplementary payment of another kind from the Department, the recipient or another person for a compensable service or item is required to return the supplementary payment. A provider may bill a MA recipient for a noncompensable service or item if the recipient is told before the service is rendered that the program does not cover it.
(b) Copayments for MA services.
(1) Recipients receiving services under the MA Program are responsible to pay the provider the applicable copayment amounts set forth in this subsection.
(2) The following services are excluded from the copayment requirement for all categories of recipients:
(i) Services furnished to individuals under 18 years of age.
(ii) Services and items furnished to pregnant women.
(iii) Services furnished to an individual who is a patient in a long term care facility or other medical institution as defined in 42 CFR 435.1009 (relating to definitions relating to institutional status) if the individual is required as a condition of receiving services in the institution, to spend all but a minimal amount of his income for medical care costs.
(iv) Services provided in an emergency situation as defined in § 1101.21 (relating to definitions).
(v) Laboratory services.
(vi) The professional component of diagnostic radiology, nuclear medicine, radiation therapy and medical diagnostic services, when the professional component is billed separately from the technical component.
(vii) Family planning services and supplies.
(viii) Home health agency services.
(ix) Psychiatric partial hospitalization program services.
(x) Services furnished by a funeral director.
(xi) Renal dialysis services.
(xii) Blood and blood products.
(xiii) Oxygen.
(xiv) Ostomy supplies.
(xv) Rental of durable medical equipment.
(xvi) Outpatient services when the MA fee is under $2.
(xvii) Medical examinations when requested by the Department.
(xviii) Screenings provided under the EPSDT Program.
(xix) More than one of a series of a specific allergy test provided in a 24-hour period.
(xx) Targeted case management services.
(3) The following services are excluded from the copayment requirement for categories of recipients except GA recipients age 21 to 65:
(i) Drugs, including immunizations, dispensed by a physician.
(ii) Specific drugs identified by the Department in the following categories:
(A) Antihypertensive agents.
(B) Antidiabetic agents.
(C) Anticonvulsants.
(D) Cardiovascular preparations.
(E) Antipsychotic agents, except those that are also schedule C-IV antianxiety agents.
(F) Antineoplastic agents.
(G) Antiglaucoma drugs.
(H) Antiparkinson drugs.
(I) Drugs whose only approved indication is the treatment of acquired immunodeficiency syndrome (AIDS).
(4) Except for the exclusions specified in paragraphs (2) and (3), each MA service furnished by a provider to an eligible recipient is subject to copayment requirements.
(5) The amount of the copayment, which is to be paid to providers by categories of recipients, except GA recipients, and which is deducted from the Commonwealth's MA fee to providers for each service, is as follows:
(i) For pharmacy services, drugs and over-the-counter medications:
(A) For recipients other than State Blind Pension recipients, $1 per prescription and $1 per refill for generic drugs.
(B) For recipients other than State Blind Pension recipients, $3 per prescription and $3 per refill for brand name drugs.
(C) For State Blind Pension recipients, $1 per prescription and $1 per refill for brand name drugs and generic drugs.
(ii) For inpatient hospital services, provided in a general hospital, rehabilitation hospital or private psychiatric hospital, the copayment is $3 per covered day of inpatient care, to an amount not to exceed $21 per admission.
(iii) For nonemergency services provided in a hospital emergency room, the copayment on the hospital support component is double the amount shown in subparagraph (vi), if an approved waiver exists from the United States Department of Health and Human Services. If an approved waiver does not exist, the copayment will follow the schedule shown in subparagraph (vi).
(iv) When the total component or only the technical component of the following services are billed, the copayment is $1:
(A) Diagnostic radiology.
(B) Nuclear medicine.
(C) Radiation therapy.
(D) Medical diagnostic services.
(v) For outpatient psychotherapy services, the copayment is 50¢ per unit of service.
(vi) For other services, the amount of the copayment is based on the MA fee for the service, using the following schedule:
(A) If the MA fee is $2 through $10, the copayment is 50¢.
(B) If the MA fee is $10.01 through $25, the copayment is $1.
(C) If the MA fee is $25.01 through $50, the copayment is $2.
(D) If the MA fee is $50.01 or more, the copayment is $3.
(6) The amount of the copayment, which is to be paid to providers by GA recipients age 21 to 65, and which is deducted from the Commonwealth's MA fee to providers for each service, is as follows:
(i) For prescription drugs:
(A) $1 per prescription and $1 per refill for generic drugs.
(B) $3 per prescription and $3 per refill for brand name drugs.
(ii) For inpatient hospital services, provided in a general hospital, rehabilitation hospital or private psychiatric hospital, the copayment is $6 per covered day of inpatient care, not to exceed $42 per admission.
(iii) When the total component or only the technical component of the following services are billed, the copayment is $2:
(A) Diagnostic radiology.
(B) Nuclear medicine.
(C) Radiation therapy.
(D) Medical diagnostic services.
(iv) For all other services, the amount of the copayment is based on the MA fee for the service, using the following schedule:
(A) If the MA fee is $2 through $10, the copayment is $1.
(B) If the MA fee is $10.01 through $25, the copayment is $2.
(C) If the MA fee is $25.01 through $50, the copayment is $4.
(D) If the MA fee is $50.01 or more, the copayment is $6.
(7) The Department calculates the amount of copayments paid by a recipient and reimburses GA recipients age 21 to 65 whose MA benefits are funded solely by State funds for copayments in excess of $180 in a 6-month period. The Department reimburses all other categories of recipients for copayments in excess of $90 in a 6-month period. This calculation is based on invoices paid by the MA Program and adjudicated between January through June and July through December of each year, which verify that the recipient paid the copayment.
(8) A provider participating in the program may not deny covered care or services to an eligible MA recipient because of the recipient's inability to pay the copayment amount. This paragraph does not change the fact that the recipient is liable for the copayment, and it does not prevent the provider from attempting to collect the copayment amount. If a recipient believes that a provider has charged the recipient incorrectly, the recipient shall continue to pay copayments charged by that provider until the Department determines whether the copayment charges are correct.
(9) A provider may not waive the copayment requirement or compensate the recipient for the copayment amount.
(10) If a recipient is covered by a third-party resource and the provider is eligible for an additional payment from MA, the copayment required of the recipient may not exceed the amount of the MA payment for the item or service.
(c) MA deductible.
(1) A $150 deductible per fiscal year shall be applied to adult GA recipients for the following MA compensable services:
(i) Ambulatory surgical center services.
(ii) Inpatient hospital services.
(iii) Outpatient hospital services.
(2) Laboratory and x-ray services are excluded from the deductible requirement.
CHAPTER 1123. MEDICAL SUPPLIES
SCOPE OF BENEFITS§ 1123.21. Scope of benefits for the categorically needy.
Categorically needy recipients are eligible for medically necessary medical supplies covered by the MA Program subject to the conditions and limitations of this chapter and Chapter 1101 (relating to general provisions). See § 1101.31(b) (relating to scope).
§ 1123.24. Scope of benefits for GA recipients.
GA recipients, age 21 to 65, are eligible for medically necessary basic health care benefits as defined in Chapter 1101 (relating to general provisions). See § 1101.31(e) (relating to scope).
PAYMENT FOR MEDICAL SUPPLIES § 1123.60. Limitations on payments.
(a) Under no circumstances may the provider be paid an amount that exceeds the price the provider currently charges the self-paying public.
(b) Payment will be made for either orthopedic shoes or orthotic devices but not both.
(c) Payment for orthopedic shoes and orthotic devices is subject to the following limitations:
(1) Four pairs of orthopedic shoes, either with or without an attached leg brace per year for those eligible recipients 20 years of age or younger.
(2) One pair of orthotic devices every 3 years for those eligible recipients 16 years of age or older. These are not compensable, however, if the recipient has received orthopedic shoes in the 365 days prior to provision of the orthotic device.
(3) Four pairs of orthotic devices every 3 years for those eligible recipients under 16 years of age. These are not compensable, however, if the recipient has received orthopedic shoes in the 365 days prior to provision of the orthotic device.
(d) Contact lenses are compensable only when prescribed as prostheses, that is, to replace the lens of the eye.
(e) Payment for durable medical equipment and surgical supplies is limited to a maximum of $600 unless prior authorized by the Department as specified in § 1101.67 (relating to prior authorization).
(f) Unless a shorter period is specified on the MA Program fee schedule, payment for rental of durable medical equipment is limited to 6 months after which time prior authorization is required from the Department as specified in § 1101.67.
(g) Payment for prescribed or ordered medical supplies shall be limited to those items in the MA program fee schedule.
(h) Only one eyeglass fitting fee will be paid per recipient per year.
(i) Prostheses and orthoses shall be prior authorized as specified in § 1101.67.
CHAPTER 1149. DENTISTS' SERVICES
GENERAL PROVISIONS§ 1149.2. Definitions.
The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise:
Approved institution--A university, college or hospital whose dental school program is approved by the American Dental Association or a Canadian university whose dental school program is recognized by the American Dental Association.
Board certified or Board eligible orthodontist--A dentist who has successfully completed the full curriculum of advanced education in orthodontics at an approved institution or an orthodontic hospital residency program which is accredited by the Commission on Accreditation of Dental and Dental Auxiliary Education Programs of the American Dental Association.
Dental laboratory--A laboratory, comprised of dental technicians, and engaged in the business of constructing, altering, repairing or duplicating dentures, plates, partial plates, bridges, splints and orthodontic or prosthetic appliances.
Dental technician--An individual not licensed to practice dentistry in this Commonwealth but engaged in the business of constructing, altering, repairing or duplicating dentures, plates, partial plates, bridges, splints and orthodontic or prosthetic appliances from a prescription by a dentist.
Dentist--An individual licensed under the laws of the Commonwealth to practice dentistry within the scope of The Dental Law (63 P. S. §§ 120--130g).
Oral and maxillofacial surgeon--A dentist who limits his practice to the part of dental care which deals with the diagnosis, the surgical and adjunctive treatment of diseases, injuries and defects of the oral and maxillofacial region.
Pedodontist--A dentist who limits his practice to the diagnosis and treatment of conditions of the teeth and mouth in children.
SCOPE OF BENEFITS § 1149.21. Scope of benefits for the categorically needy.
Categorically needy adult recipients are eligible for all medically necessary dental services, subject to the conditions and limitations established in this chapter, Chapters 1101 and 1150 (relating to general provisions; and MA Program payment policies) and the MA Program fee schedule. Categorically needy recipients under 21 years of age are eligible for all medically necessary dental services.
§ 1149.22. Scope of benefits for the medically needy.
Medically needy adult recipients are eligible for medically necessary dental services only when provided in an inpatient, ambulatory surgical center, or short procedure unit setting, and subject to the conditions and limitations established in this chapter and Chapters 1101 and 1150 (relating to general provisions; and MA Program payment policies) and the MA Program fee schedule. Medically needy recipients under 21 years of age are eligible for all medically necessary dental services.
§ 1149.23. Scope of benefits for State Blind Pension recipients.
(a) Except as noted in subsection (b), State Blind Pension recipients are eligible for all medically necessary dental services, subject to the conditions and limitations established in this chapter, Chapters 1101 and 1150 (relating to the general provisions; and MA Program payment policies) and the MA Program fee schedule.
(b) State Blind Pension recipients are not eligible for radiological services or inpatient dental services. State Blind Pension recipients are eligible for radiological services and inpatient surgical procedures and emergency dental services if they qualify as categorically needy or medically needy recipients.
§ 1149.24. Scope of benefits for GA recipients.
(a) GA chronically needy and nonmoney payment recipients, age 21 to 65, are eligible for medically necessary dental services subject to the conditions and limitations established in this chapter, Chapters 1101 and 1150 (relating to general provisions; and MA Program payment policies) and the MA Program fee schedule.
(b) GA medically needy only recipients, age 21 to 65, are eligible for medically necessary dental services only when provided in an inpatient, ambulatory surgical center, or short procedure unit setting, and subject to the conditions and limitations established in this chapter and Chapters 1101 and 1150 (relating to general provisions; and MA Program payment policies) and the MA Program fee schedule.
CHAPTER 1151. INPATIENT PSYCHIATRIC SERVICES
GENERAL PROVISIONS§ 1151.2. Definitions.
The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise:
Acute psychiatric services--Psychiatric services rendered in response to a severe psychiatric condition requiring intervention to bring the patient's symptoms under control.
Certified day--A day of inpatient hospital care approved by the Department under this chapter.
Day of inpatient hospital care--Room, board and professional services furnished to a patient on a continuous 24-hour-a-day basis in a semiprivate room of a hospital. The term includes items and services ordinarily furnished by the hospital for the care and treatment of inpatients provided in an institution other than one maintained primarily for treatment and care of patients with tuberculosis.
Emergency admission--The unscheduled admission of a person with a severe mental disability who requires immediate treatment, to an inpatient psychiatric facility.
Fiscal year--A period of time beginning July 1 and ending June 30 of the following year.
General hospital--A facility licensed as a hospital under 28 Pa. Code Part IV, Subpart A (relating to general and special hospitals) which provides equipment and services primarily for inpatient care to persons who require treatment for injury, illness, disability or pregnancy. The term does not include public or private psychiatric hospitals, general nursing facilities, county-operated nursing facilities, intermediate care facilities for the mentally retarded or psychiatric transitional facilities.
Inpatient psychiatric facility--The term refers to private psychiatric hospitals and distinct part psychiatric units of general hospitals.
Patient pay amount--Income or assets that the CAO has determined to be available to a recipient to meet the cost of medical care. The recipient, not the MA Program, pays this amount toward the cost of care.
Private psychiatric hospital--An institution, other than a general hospital, not directly operated or controlled by the Department that is engaged in providing acute short-term psychiatric services on an inpatient basis.
Public psychiatric hospital--An institution, other than a general hospital, controlled, operated and funded directly by the Department and engaged in providing long-term and short-term inpatient psychiatric services for the diagnosis, treatment and care of individuals with mental diseases.
Recipient under 21 years of age--A recipient who is one of the following:
(i) Under 21 years of age.
(ii) Age 21 and was receiving inpatient psychiatric services in a psychiatric hospital the day preceding the date the recipient reached age 21. This recipient continues to be recognized as a recipient under 21 years of age until the earlier of the date the recipient either:
(A) No longer requires inpatient psychiatric facility services.
(B) Reaches age 22.
Therapeutic leave--A period of absence by a patient from the inpatient psychiatric facility directly related to the treatment of that patient's illness.
SCOPE OF BENEFITS § 1151.21. Scope of benefits for the categorically needy.
Categorically needy recipients under 21 years of age as defined in § 1151.2 (relating to definitions) or 65 years of age or older are eligible for medically necessary inpatient psychiatric services provided by a participating inpatient psychiatric facility, subject to this chapter and Chapter 1101 (relating to general provisions).
§ 1151.22. Scope of benefits for the medically needy.
Medically needy recipients under 21 years of age as defined in § 1151.2 (relating to definitions) or age 65 or older are eligible for medically necessary inpatient psychiatric services provided by a participating inpatient psychiatric facility, subject to this chapter and Chapter 1101 (relating to general provisions).
§ 1151.24. Scope of benefits for GA recipients.
(a) GA recipients, age 21 to 65, are eligible for medically necessary inpatient psychiatric services as described in Chapter 1101 (relating to general provisions). See § 1101.31(e) (relating to scope).
(b) Inpatient psychiatric services are subject to this chapter and Chapter 1101 (relating to general provisions).
PAYMENT FOR INPATIENT PSYCHIATRIC SERVICES § 1151.43. Limitations on payment.
(a) For adult recipients, payment for inpatient psychiatric hospital services in a private psychiatric hospital or a distinct part of a psychiatric unit of a general hospital is limited to 30 days per fiscal year.
(b) A recipient is limited to two periods of therapeutic leave per calendar month. Neither of these periods of therapeutic leave may exceed 12 hours in a calendar day.
(c) The Department is authorized to grant an exception to the limits specified in subsection (a) as described in § 1101.31(f) (relating to scope).
CHAPTER 1153. OUTPATIENT PSYCHIATRIC SERVICES
PAYMENT FOR OUTPATIENT PSYCHIATRIC CLINIC AND OUTPATIENT PSYCHIATRIC PARTIAL HOSPITALIZATION SERVICES§ 1153.53. Limitations on payment.
(a) Payment is subject to the following limitations:
(1) For recipients 21 years of age or older, 180 three-hour sessions, 540 total hours, of psychiatric partial hospitalization in a fiscal year per recipient, except for State Blind Pension recipients, for whom payment is limited to 240 3-hour sessions, 720 total hours, of psychiatric partial hospitalization in a consecutive 365-day period per recipient.
(2) At least 3 hours but no more than 6 hours of psychiatric partial hospitalization per 24-hour period.
(3) Two outpatient psychiatric evaluations in psychiatric clinics per patient per year.
(4) For recipients 21 years of age or older, a total of 5 hours or 10 one-half hour sessions of psychotherapy per recipient per 30-consecutive day period, except for State Blind Pension recipients, for whom payment is limited to a total of 7 hours or 14 one-half hour sessions of psychotherapy per recipient per 30-consecutive day period. This period begins on the first day that an eligible recipient receives an outpatient psychiatric clinic service listed in the MA Program Fee Schedule. Psychotherapy includes the total of individual, group, family, collateral family psychotherapy services and home visits provided per eligible recipient per 30-consecutive day period.
(5) Three psychiatric clinic medication visits per patient per 30-consecutive days in psychiatric outpatient clinics.
(6) One outpatient comprehensive diagnostic psychological evaluation or no more than $80 worth of individual psychological or intellectual evaluations in psychiatric clinics per patient per 365 consecutive days.
(7) The partial hospitalization fees listed in the MA Program Fee Schedule include payment for all services rendered to the patient during a psychiatric partial hospitalization session. Separate billings for individual services are not compensable.
(8) Partial hospitalization facilities licensed for adult programs will be reimbursed at the adult rate, regardless of the age of the client receiving treatment.
(9) Partial hospitalization facilities licensed as children and youth programs will be reimbursed at the child rate only when the client receiving treatment is 14 years of age or younger.
(10) Family psychotherapy and collateral family psychotherapy are compensable for only one person per session, regardless of the number of family members who participate in the session or the number of participants who are eligible for psychotherapy.
(11) Psychiatric clinic clozapine monitoring and evaluation visits are limited to five visits per patient per calendar month.
(12) Any combination of psychiatric clinic medication visits and psychiatric clinic clozapine monitoring and evaluation visits is limited to five per patient per calendar month.
(b) The Department is authorized to grant an exception to the limits specified in subsection (a)(1) and (4) as described in § 1101.31(f) (relating to scope).
[Pa.B. Doc. No. 05-1586. Filed for public inspection August 26, 2005, 9:00 a.m.]
No part of the information on this site may be reproduced for profit or sold for profit.This material has been drawn directly from the official Pennsylvania Bulletin full text database. Due to the limitations of HTML or differences in display capabilities of different browsers, this version may differ slightly from the official printed version.
