This chapter contains general policy on medical benefits and related Medical Assistance (MA) programs. See the Medical Assistance Eligibility Handbook for more specific policy information.
A person who is eligible for TANF receives an ACCESS card. The card is issued automatically only for persons who do not have Individual (Recipient) Numbers and for inactive persons known to the system but who have never received ACCESS cards. Eligibility for medical services runs concurrently with Cash Assistance eligibility. In other words, if a person is eligible for Cash Assistance, then he or she is eligible for medical services. A person does not have to receive a payment to be eligible for medical assistance if one of the following applies:
A budget group is not receiving a payment due to the $10 minimum payment provision.
A budget group is not receiving a payment for a month of zero cash payment.
A budget group is in benefit hold status.
A budget group meets the requirements for Cash Assistance but chooses to receive only MA benefits. Authorize medical services in the nonmoney payment (NMP) category of PC, PU. or PD.
55 Pa. Code § 101.1(e) & 55 Pa. Code § 141.71(b)
Some medical services for certain adult MA recipients are limited. See Medical Assistance Eligibility Handbook, Chapter 338, for more information.
The CAO must prepare and issue an interim medical card from the county office if a person needs medical services but does not have an ACCESS card. See Medical Assistance Eligibility Handbook, Chapter 380. Review the need for a replacement card during application and renewal interviews.
An applicant for Cash Assistance may be eligible for retroactive MA coverage for any one or all three of the calendar months preceding the month of application.
55 Pa. Code § 141.71(f) & 55 Pa. Code § 141.71(g)
The CAO must explore eligibility for retroactive medical benefits and determine NMP eligibility for each month the person incurred an unpaid expense. If the person is ineligible for NMP, determine eligibility for MNO.
See Medical Assistance Eligibility Handbook, Chapter 338.3, for details on retroactive MA authorizations.
The CAO must extend Medical Assistance coverage to certain budget groups when cash benefits are discontinued, such as when a TANF budget has closed based on earnings or receipt of child support. The budget group will receive Medical Assistance for a specified period of time as NMP.
If requirements are met, the CAO must provide Medical Assistance NMP automatically to the following:
A TANF budget group discontinued for any of the following reasons:
New employment.
Increased income from employment.
Increased hours from employment.
A TANF budget group discontinued due to support income.
A newborn whose mother is receiving TANF at the time of birth.
A pregnant woman following termination of the pregnancy.
A TANF budget group discontinued for any reason that does not affect Medical Assistance eligibility, including but not limited to:
Resources.
Support requirements.
Certain criminal history issues.
Minor parent requirements.
Failure to keep a TANF redetermination interview to establish eligibility for continued benefits.
The eligibility for this budget group continues up to 12 months from the most recent TANF authorization date or renewal date. The system will automatically open the Medical Assistance budget when TANF is closed. The system will set the Medical Assistance renewal date 12 months from the most recent TANF authorization date or renewal date.
NOTE: See Medical Assistance Eligibility Handbook, Chapter 338 and Chapter 339, for more information on automatic extensions of Medical Assistance coverage.
For Cash budgets that do not qualify for automatic Medical Assistance coverage after each closing, the CAO must review and provide ongoing Medical Assistance benefits to eligible budget members. Determine eligibility without contact with the person if all necessary information was previously provided by the person or is available in the case record or is accessible from other sources, such as BENDEX, SDX, and IEVS files.
If eligible, authorize Medical Assistance in the appropriate category (or categories) with no lapse in coverage.
Reminder: The system will set a renewal date 12 months from the Medical Assistance authorization date. The CAO must review and change this date to no later than 12 months from the most recent Cash authorization date or renewal date.
Send a Notice of Eligibility informing the household of Medical Assistance coverage.
If not eligible, send a notice of ineligibility advising the household of the determination.
As a condition of eligibility for Cash Assistance, the budget group must provide information about any third-party resources available to pay medical expenses. See Medical Assistance Eligibility Handbook, Chapter 338.
Under certain circumstances, the third-party liability (TPL) program sends a Medical Services Questionnaire, (PW 382, see Appendix A) to a recipient when a billing indicates medical services were received under a trauma-related code. The questionnaire is sent to the payment name and address to identify possible third-party coverage and includes the following information:
The name of the patient for whom the claim was paid.
The date of service.
The provider name that appears on the claim.
The patient’s 10 digit identification number.
The date the questionnaire was sent.
If the person fails to return the questionnaire within 30 days and a specific dollar threshold has been met, a second questionnaire is sent. If the person fails to respond to this second request for information and the second specific dollar threshold has been met, a third questionnaire is sent by the CAO. It is marked FINAL NOTICE and is sent with a cover letter (PW 383, see Appendix A). The cover letter explains that the person has not responded to two previous requests for information.
Upon receipt of the PW 383, the CAO must contact the person to obtain the requested information. If the CAO receives the information, it must forward the completed form to the TPL address on the PW 383.
If the person fails to respond to the CAO request, the CAO must do the following:
For all TANF and SSP-only cash categories, take action to close the cash budget, including Medical Assistance, for failure to respond or provide information.
For all SSI categories, notify the Social Security Administration (see Medical Assistance Eligibility Handbook, Section 387.1) of the noncooperation.
55 Pa. Code § 125.21(a) & 55 Pa. Code § 125.21(c)
If the CAO receives a Medical Services Questionnaire after the person’s assistance is discontinued, the CAO must make an entry in the case record and the case comments and keep the original questionnaire in the record. If the person applies for Cash Assistance or Medical Assistance in the future, he or she must complete the form during the application process and return it to DHS at the address at the top of the cover letter (PW 383).
The Medical Assistance Management Information System (MAMIS) directly pays providers enrolled in the Medical Assistance program. DHS does not reimburse the person for the cost of services or items even if a provider does not accept the ACCESS card as payment. A provider who accepts the card for payment may not bill the person for covered services.
Exception: The person is responsible for a small co-payment fee for certain services.
NOTE: The person is responsible for payment for services not covered.
The CAO must explain all services available to a person, including Early and Periodic Screening, Diagnosis and Treatment (EPSDT).
Medical transportation services are available to TANF, NMP, MNO, and SSI recipients who have no other means of transportation to necessary medical care or to obtain medication. See Chapter 138 in this handbook and Section 338.62 of the Medical Assistance Eligibility Handbook for more information on Medical Assistance Transportation Program services.
DHS receives federal funding for Medical Assistance coverage provided to pregnant TANF recipients. If the CAO learns that a recipient is pregnant, the CAO must do the following:
Request verification of the pregnancy and the expected due date.
Determine if the pregnant woman meets the requirements to receive TANF. See Chapter 105.
The pregnancy and expected date of delivery are verified; and
If born, the child would meet deprivation requirements.
If the woman qualifies for TANF (C or U), change the category for the next payment day for which the deadline can be met.
NOTE: Provide a Confirming Notice advising of the category change.
If the woman does not qualify for Cash Assistance review for Medical Assistance coverage.
55 Pa. Code § 151.43(f) 55 Pa. Code § 140.1
Reissued September 19, 2012; replacing January 31, 2012; reviewed October 7, 2013