The Medical Assistance (MA) Program provides quality medical and dental services to individuals who are eligible for:
Cash assistance.
The Department of Human Services (DHS) makes direct payments to health professionals and vendors for services, medications and medical supplies.
DHS generally does not pay for new and expensive medicine or for experimental treatment.
An MA identification card called the “Pennsylvania ACCESS card” is issued to each eligible individual. The ACCESS card is used by medical providers to get information from the Eligibility Verification System (EVS). This information is needed for medical providers to bill DHS directly for services. An individual who has other medical coverage may also be eligible for and use MA for services not covered by other insurance. (Examples of other medical coverage are Medicare and private insurance)
It is the County Assistance Office’s (CAO) job to explain the available MA programs and provide the best coverage possible. The CAO gives brochures with information about MA programs and other medical services that are available in the community to anyone who applies for MA.
The CAO will explain that only medical providers who are in the plan can use the ACCESS card as proof that an individual is eligible for medical services. The CAO must also explain that only medical providers who are in the plan can be paid by the DHS for medical services.
NOTE: The CAO can use the MAPPER system, MA CARES, to identify enrolled providers for the individual. (See Chapter 338, Medical Assistance Benefits.)
A medical emergency is when a physician or another medical professional under the physician’s supervision (for example, a physician’s assistant or certified nurse practitioner) tells an individual that the individual has a problem that can cause serious injury or death. Proof of an emergency medical condition can be:
A statement on a prescription pad or on the provider’s letterhead.
Completed DHS forms.
A phone call from the provider.
When an individual applies for MA and says that he or she has an emergency medical condition, the CAO will take the following actions:
Speed up the processing of the application.
Request proof of income and resources.
Request other needed information, such as proof of citizenship and identity.
Request proof of the emergency medical condition from the medical provider.
Call the individual right away if more information or proof is needed.
If the individual cannot be reached by phone, send a letter to the individual asking for the needed information or proof. The letter should go out on the same day the application comes in.
Help the individual if he or she cannot provide the needed information or proof.
If all needed information and proof is received and the individual meets all the requirements, allow him or her to get MA.
Inform the individual whether he or she can get MA.
Send a notice telling the individual whether he or she can get MA.
NOTE: If the individual is not allowed to get MA, the CAO will give a detailed explanation.
When taking applications for MA to cover an emergency, CAO staff should know the following:
Staff will process an application as soon as possible, within five business days after the date of request.
NOTE: If the application shows that it is an emergency, the date stamp is considered the date of request. If the individual contacts the CAO either in individual or by phone, the contact date is the date of request.
If staff has all proof needed for deciding on eligibility for the individual with an emergency, they will make the decision. Staff will not hold back the decision while waiting for proof for any other household members who are applying.
Example: Mr. James submits an application for MA for himself and his son. Mr. James indicates on his application that he has an emergency medical situation and provided all needed proof for himself. For his son’s MA, Mr. James is trying to get his son’s proof of child support from his ex-wife. The CAO finds Mr. James eligible and approves benefits before it gets the proof for his son.
The applicant’s medical condition may make it hard for him or her to get needed proof. Staff will assist the individual whenever possible, but they will not allow MA without all needed proof.
The CAO will have a way to identify every emergency MA application so that it can process the application as quickly as possible. If the CAO is not sure a individual’s case is an emergency, it will process the application as if it were an emergency. If the CAO finds out the case is not an emergency, it can treat the application as a normal one.
Aliens without documentation and temporary aliens can be reviewed for emergency MA eligibility.
Mr. Jones submits an application on Wednesday, January 2nd. He provides verification from a doctor that he has surgery scheduled for Thursday, January 10th, to correct a medical condition. The medical condition is not life threatening now, but it will become so if it is not treated. His surgeon refuses to perform the surgery without proof that Mr. Jones has medical coverage.
The CAO caseworker contacts Mr. Jones by telephone on January 2nd and requests proof of Mr. Jones’s income and resources. Mr. Jones turns in the proof on January 3rd. The CAO worker processes the application and sends Mr. Jones a notice of eligibility for MA on January 3rd. The worker also calls Mr. Jones to tell him of the decision the same day.
Updated February 14, 2012, Replacing September 6, 2008