The individual must pay for services which are not included in the MA LTC rate or not covered by the individual’s MA LTC benefits. Payment for these services or items may be made by the individual, family members, or friends. When an individual requests an item that will not be included in the rate, the LTC facility must tell the individual in advance of the cost of the item and that MA LTC will not pay for it. The individual must be given the option of taking or not taking the non-covered items or services.
Services which are not covered include the following:
Medical expenses such as, but not limited to:
health insurance premiums.
visit by a non-participating physician other than one provided by the LTC facility.
emergency ambulance services, if the ambulance company does not accept MA.
over-the-counter medications which are a particular brand not supplied by the LTC facility. For example, the LTC facility must provide aspirin, but the individual may request and buy a specific brand of pain reliever, such as Excedrin PM or Tylenol.
hearing aids and batteries.
NOTE: If any of the above items are paid from the person’s income, the cost of such items is an allowable medical expense when determining the person’s payment towards the cost of care. They will be subtracted on the LTC facility’s bill to DHS. Over-the-counter medication must be prescribed by a physician in order to be considered an allowable medical expense. The LTC facility submits one claim for the cost of LTC facility services provided to the individual for the first billable day to the last day of the calendar month.
All verified medical expenses must be entered in eCIS by the CAO so that they are deducted from the individual’s payment towards the cost of care in eCIS and on the PA 162.
If the CAO notifies the LTC facility of a change in the individual’s payment towards the cost of care, the LTC facility will bill DHS based on the new amount for LTC facility services provided to the person beginning the effective date of the change.
Hair care services which are provided over and above the reasonable standard of care established by the LTC facility.
Diapers, if the individual wants a style or brand which is not provided by the LTC facility.
Clothing, cigarettes, and personal laundry. The LTC facility may provide laundry service for personal clothing, but it is not required.
Personal care items of the individual's choice if they are preferred over the items provided by the LTC facility. This includes items such as brushes, combs, toothbrushes, cosmetics, etc.
55 Pa. Code § 1181.59 applies to entire section
Updated June 13, 2024, Replacing March 12, 2012