When an individual applies for Medical Assistance (MA) the County Assistance Office (CAO) will inform the individual of his or her rights and responsibilities (things an individual must do). The CAO worker can give the individual the last two pages of the printed application. For a COMPASS application, the worker can print the information and then give it to the individual. 55 Pa. Code § 125.74(a) 55 Pa. Code § 125.84(d)
An individual who applies for MA has the following rights:
To receive and file an application the same day that he or she request one.
To bring anyone he or she chooses to interviews.
To have anyone he or she chooses look over the case or represent him or her at a hearing.
To have an application completed by a friend, relative or official of a hospital, institution or agency providing service if the individual is ill, weak or physically or mentally handicapped.
To have a face-to-face interview if the individual request one.
NOTE: Face-to-face interviews may be required for Long-Term Care (Nursing) and Waiver categories only.
To register to vote (see the Supplemental Handbook, Chapter 980, Voter Registration)
To have an eligibility decision within 30 days or be told in writing that the CAO cannot make a decision within 30 days and is extending the period to 45 days. 55 Pa. Code § 125.84(d)
Exception: A nursing home application may take up to 120 days if a bed is not available.
To receive a notice that explains an eligibility decision or a change in benefit.
To be treated with dignity and respect. 55 Pa. Code § 121.1(b)(2)
To receive services without any form of discrimination. 55 Pa Code § 107.1
To have a home visit if he or she cannot come to the CAO and another individual cannot come to the CAO to apply for him or her. 55 Pa. Code § 125.24(a)
To have medical records and information provided to the CAO kept private. 55 Pa. Code § 105.1(e)
To appeal and request a fair hearing if (a) he or she is not satisfied with anything done by the CAO, (b) if the individual feels that he or she has been discriminated against or (c) if the individual is denied a covered MA service. 55 Pa. Code § 275.1(a)
To look over the case record and DPW regulations and procedures. 55 Pa. Code § 105.5(a)
NOTE: An individual can look over forms like the Medical Assessment Form (PA 635) and the Report of Physical/Mental Examination (PA 586) only with the permission of the doctors who completed the forms. Some other restrictions may apply to other information in the case record. See the Supplemental Handbook, Chapter 930, Safeguarding Information.
To choose any doctor, hospital or other provider who is enrolled in the MA program.
Exception: Services may be restricted. See Chapter 338, Medical Assistance Benefits.
To receive help from the CAO in finding medical providers who take people who get MA and who will get paid for medical services by DPW.
To be told in advance by the medical provider if a service that he or she asked for is not covered by MA.
To receive medical services for which he or she is eligible at no cost.
Exception: For some services, the individual must pay a copayment. See Chapter 338, Medical Assistance Benefits, Section 338.52 MA Copayments.
To participate in a Managed Care Organization (MCO), if one is available in the county.
To receive help right away if there is a medical emergency.
An individual who applies for MA must do the following:
Answer all questions on the application as best he or she can and say that all the answers are true. 55 Pa. Code § 201.1
Give true and complete information about everything that may affect his or her eligibility. 55 Pa. Code § 125.24
Provide all needed information for eligibility and confirm as best he or she can that all of it is true.
Report any changes by the tenth day of the month following the change.
Provide a Social Security number for each individual who applies for benefits. 55 Pa. Code § 155.2
Provide proof of U.S. citizenship (if necessary).
Apply for any benefits that they may be eligible for, such as Social Security,that would bring in income to lower the need for MA. 55 Pa. Code § 181.1(d)
Cooperate with quality control and audit reviews of eligibility. 55 Pa. Code § 111.4(b)5)
Inform the CAO and medical providers about any available medical coverage or medical resources. 55 Pa. Code § 141.21(k)
Show the ACCESS card before getting medical services, and use the card only for eligible recipients and only for services that are really needed.
Stop using the ACCESS card when the recipient is no longer eligible for MA.
Make no changes to any cards or documents given by the CAO.
Cooperate with DPW and allow request for payment from any third party, such as Blue Cross, that is responsible for paying for medical expenses.
55 Pa. Code § 125.74 55 Pa. Code § 125.84(c)
NOTE: If the individual has insurance, it is considered a third-party resource. The individual must use that insurance before using MA. If the individual does not follow these rules, then he or she needs to pay the medical bill, because MA will not make the payment.
NOTE: If an individual has insurance but cannot use it (for example, a mother and child move from another state and their insurance is not accepted in Pennsylvania), it is not considered a third-party resource, and the individual could get coverage under MA.
Agree to let MA payments be made directly to providers.
Give DPW the right to inspect, review and copy any and all medical records for services paid through the MA program.
The CAO will do the following:
Make sure that application forms and information about online processes are available to anyone who wants to apply. 55 Pa. Code § 121.3
Give individuals the chance to register to vote when they apply, reapply or change their address. (See the (Supplemental Handbook, Chapter 980, Voter Registration.)
Provide help as needed to complete the application process. 55 Pa. Code § 125.24(c)(7)(i)
Provide information about services from DPW and other agencies, including the following: 55 Pa. Code § 121.3(a)(2)
Early and Periodic Screening, Diagnosis, and Treatment (EPSDT).
SelectPlan for Women Program.
Teen parenting and pregnancy programs.
Area Office for the Aging.
Medical Assistance Transportation Program (MATP) www.matp.pa.gov/
Department of Health (DOH).
Respect each individual’s dignity and right to privacy. 55 Pa. Code § 101.1(c)
Give medical providers proof that an individual is eligible, to be helpful in the billing process. 55 Pa. Code § 105.1(e)
Decide whether an individual is eligible within 30 calendar days of the date of application or let the applicant know in writing why it will take up to 45 days. 55 Pa. Code § 125.84(e)
Explain the benefits of each program that an individual is eligible for and allow the individual to choose which program is best for him or her.
Give the applicant a Lifeline Flyer /Enrollment Form. The form to enroll is PA 1799.
Provide a written notice of any eligibility decision. 55 Pa. Code § 125.24(c)(6)
Give each individual the chance to have an appeal and fair hearing if he or she is not satisfied with any CAO action. 55 Pa. Code § 275.1 (a)
The CAO will not take any of the following actions:
Enter a home by force, without permission or under false pretenses. 55 Pa. Code § 121.1(b)(3)
Search a home, rooms, closets, drawers or papers to look for clues of possible lies.
Ask an individual questions that are based on the idea that he or she is guilty of a crime.
Visit an individual’s home without letting him or her know in advance.
Exception: Staff can visit an individual’s home without advance notice if the visit is approved by a supervisor, manager or Executive Director to get information that may not be available if the individual knew that the visit would take place. This includes times when the CAO suspects fraud or believes false proof has been submitted (such as for why a parent continues to be absent).
Disclose private information about an individual in an improper way.
Updated August 13, 2012, Replacing February 14,2012