§ 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.
Source The provisions of this § 175.73 adopted August 4, 1977, effective August 5, 1977, 7 Pa.B. 2180.
Cross References This section cited in 55 Pa. Code § 141.81 (relating to eligibility policy for Medically Needy Only); and 55 Pa. Code § 175.84 (relating to procedures).
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