MA ALLOWANCES AND BENEFITS PROVISIONS FOR THE
CATEGORICALLY NEEDY AND SCHOOL CHILDREN WHO ARE
ONLY MEDICALLY NEEDY
§ 175.71. Policy.
(a) The Department of Human Services will pay for those types of medical and allied services given in the home, office, clinic or hospital that are generally recognized as necessary treatment of illnesses.
(b) It will be the intention of the Department of Human Services to pay for adequate medical care, in accordance with accepted standards of good medical practice, to achieve the purposes set forth in this chapter.
(c) There will be no intention to pay for extravagant or superfluous medical care, or care that would be beyond the means of the average family of moderate income. Nor will the Department of Human Services pay for new and expensive medication or treatment that is still in the experimental stage.
(d) The Department of Human Services will expect that the professional participants, in giving services and prescribing supplies within the scope of the program, may not exceed in an individual instance what is essential for adequate medical care for that individual.
(e) The fees paid by the Department of Human Services will be in full payment of services given. A practitioner who seeks or accepts additional remuneration of any kind from the patient, or another person, shall be considered as violating the regulations of the medical care program and will be subject to disciplinary action.
(f) The program of medical care will include physicians’, clinic, and dental services, medications, medical goods and supplies, ambulance service, inpatient hospital care, hospital-home care, nursing care in the home, public nursing home care, private nursing home care, care in a mental institution and medical-social services, in accordance with the regulations and fees established by the Department.
(g) The program of medical care will be supplemental to other existing resources for medical services or supplies, and presupposes full use of other tax-supported or voluntary agencies or facilities for meeting medical needs.
(h) It will be the responsibility of a County Assistance Office to be aware of the resources in the area and to see that these are fully used in meeting the medical needs of assistance recipients and others who apply for medical assistance.
(i) The Department should be charged only for services that are not available through another existing tax-supported or voluntary facility. It is recognized that the services of many facilities are limited in scope and availability. However, some are available throughout the Commonwealth. The Department will not pay for or duplicate services that are available from these statewide facilities and agencies. They include treatment for rabies, which is available through County Authorities, vaccinations, which is available through local school districts or facilities of the State Department of Health or local boards of health, physicians’ services to assistance recipients in hospitals, medical care for recipients certified for medical services under the Workmen’s Compensation Act (77 P. S. § § 1—1031) or the Occupational Disease Act (77 P. S. § § 1201—1603), services for handicapped children, which are provided by the State Department of Health, treatment for tuberculosis or venereal diseases, which is the responsibility of State Health Clinics. Since the diagnosis of tuberculosis and venereal disease may not be known to the patient when he first seeks medical care, the Department will pay for the initial visit to a private physician or a hospital clinic when necessary to establish a diagnosis. This will not be paid for a school child who is only medically needy, since diagnostic service is provided in the course of the school health examination.
(j) The program of medical care as defined in regulations is designed to provide treatment for the usual medical needs arising from illness, disability or infirmity, and for certain needs associated with restoration to self-support. Specific situations may arise in which adequate medical care requires unusual or exceptional types of treatment, medication or supplies that are not specified in the public assistance regulations and are not available from any other source. In these cases, at the request of the practitioner, transmitted through the County Assistance Office, the State Office of Public Assistance will review the circumstances and approve and preauthorize the service when it is deemed necessary to meet adequately the needs of the eligible patient.
Source The provisions of this § 175.71 adopted August 4, 1977, effective August 5, 1977, 7 Pa.B. 2180.
Notes of Decisions Since a hospital patient was eligible for both MA benefits and no-fault motor vehicle insurance benefits, the allegations of the patient that the hospital exercised unreasonable care in seeking no-fault insurance benefits for his expenses instead of MA benefits set forth a valid claim. Harleysville Mutual Insurance Co. v. Yocolano, 9 Pa. D. & C.3d 226 (1978).
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