Appendix C: Desk Reference for Medical Assistance (MA) LTC Applications and Renewals

The information in this desk reference is to be used when determining eligibility for categorically needy nonmoney payment (NMP) spend-down and medically needy only (MNO) Medical Assistance benefits.

PART A identifies the medical services and items covered under Pennsylvania's Title XIX State Plan and, where applicable, general limits on services covered by the Title XIX State Plan.

PART B identifies the medical and remedial care recognized under Pennsylvania State law but not covered under the Title XIX State Plan.

Part A: Medical Services Covered Under the Title XIX State Plan

Services	Limits
Inpatient hospital services	(a) 3 pints of whole blood, except for hemophiliacs (b) 2 periods of therapeutic leave during one period of hospitalization (c) No payment for cosmetic surgery, sterilizations for persons under age 21, abortions except for reasons of life, rape, and incest. (See Chapter 1163 of the OMA Manual.)
Outpatient hospital services (Includes services provided in clinics, emergency rooms, lab tests and x-rays.)	12 prenatal visits per pregnancy
Rural health clinic services	No limitation.
Laboratory and x-ray services (Furnished by other than a hospital)	Refer to fee schedule.
Nursing facility services	No limitation.
Intermediate care facility services (Includes intermediate care for the mentally retarded.)	No limitation.
Early and periodic screening and diagnosis of persons under age 21 and treatment of conditions found	No limitation.
Family planning services and supplies for persons of child- bearing age	Refer to fee schedule.
Physicians' services	Refer to fee schedule. (a) 2 inpatient consultations per hospitalization. (b) 1 pair of eyeglasses per year. (c) 4 vision examinations and 2 refractions per year.
Podiatrists' services	Refer to fee schedule. (a) Routine foot care is not covered. (b) Treatment of flat feet is not covered.
Optometrists' services	Refer to fee schedule. (a) 1 pair of eyeglasses per year (b) 4 vision examinations and 2 refractions per year
Chiropractors' services	Refer to fee schedule.
Home health agency services	Refer to fee schedule.
Medical supplies, equipment and appliances	Refer to fee schedule. Medically Needy Only (MNO) not eligible unless receiving home health services at the time the equipment is prescribed or person is under age 21.
Clinic services, other than those provided by a hospital (Includes independent medical/surgical clinics, psychiatric clinics, drug and alcohol clinics, Methadone maintenance clinics, and psychiatric partial hospitalization services.)	No limitation.
Dental services	Refer to fee schedule. MNO persons age 21 and older not eligible. Complete and partial dentures/5 years or under age 21. Orthodontic Treatment under age 21. Cleft Palette Services under age 21. Periodontics not covered.
Prescribed drugs	MNO persons under age 21, persons in an Intermediate Care Facilities/Mental Retardation, or county or private nursing facility and persons eligible only for family planning purposes.
Prosthetic or orthotic devices	Refer to fee schedule MNO persons not eligible except for family planning purposes or unless the person is under age 21.
Services for persons age 65 and older in institutions for mental diseases (Includes inpatient hospital services, skilled nursing services, and intermediate care services.)	No limitation.
Inpatient psychiatric facility services for persons under age 22	No limitation.
Nurse-midwife services	Refer to fee schedule.
Ambulance transportation	Refer to fee schedule.
Birth center services	No limitation.
Renal dialysis services	Federal categories only.

Part B: Medical and Remedial Care Recognized by State Law but Not Covered under the Title XIX State Plan

Private duty nursing services.
Any preventive, diagnostic, therapeutic, rehabilitative, or palliative clinic services organized to provide medical care, but not qualifying as a medical/surgical clinic, psychiatric clinic, or drug and alcohol clinic.
Physical therapy provided by an independent, practicing therapist.
Occupational therapy provided by an independent, practicing therapist.
Services for individuals with speech, hearing, and language disorders, including necessary supplies and equipment.

NOTE: Individuals under age 21 are eligible for audiology testing and hearing aids.

Services of Christian Science nurses.
Services in Christian Science sanitariums.
Personal care services in a recipient's home.
Acupuncture.
Biofeedback.
Medical supplies, equipment, and appliances, including prosthetics and orthotics not listed on the fee schedule.
Medical, surgical, and diagnostic procedures not listed on the fee schedule.
Psychologists' services.
Respiratory therapy provided by an independent, practicing therapist.

Updated March 12, 2012, Replacing December 2, 2005