§ 1101.32. Coverage variations.
(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.
Source The provisions of this § 1101.32 amended September 30, 1988, effective October 1, 1988, 18 Pa.B. 4418. Immediately preceding text appears at serial pages (114356) and (117307) to (117308).
Notes of Decisions Program Exception
The Department of Public Welfare acted within its discretion in denying a claimant’s request for a Medical Assistance regulation program exception to compensate her for the expense of a special commercially processed food, where the claimant did not present any medical evidence to show that the food was medically necessary for her physical maintenance; the Department did not refuse the claimant, ‘‘the minimum necessary medical services required for the successful treatment of the particular medical condition presented,’’ as required under Title XIX of the Social Security Act (42 U.S.C.A. § § 1396a—1396i). Shappell v. Department of Public Welfare, 445 A.2d 1334 (Pa. Cmwlth. 1982).
The Department of Public Welfare’s denial of a Program Exception for over-the-counter items, where alternative items were available under the Department’s fee schedule, was not an abuse of discretion and did not offend the statutory purpose of providing minimum necessary medical services. Wengrzyn v. Cohen, 498 A.2d 61 (Pa. Cmwlth. 1985).
Cross References 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).
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