When an individual applies for Medical Assistance (MA) the County Assistance Office (CAO) will inform the individual of their rights and responsibilities (things an individual must do). The CAO worker can give the individual the rights and responsibilities 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 they request one.
To have anyone they chooses look over the case or represent them 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 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.
To receive a notice that explains an eligibility decision or a change in benefit.
To be treated with dignity and respect.
To receive services without any form of discrimination.
To have medical records and information provided to the CAO kept private.
To appeal and request a fair hearing if (a) they are not satisfied with anything done by the CAO, (b) if the individual feels that they have been discriminated against or (c) if the individual is denied a covered MA service.
To look over the case record and DHS regulations and procedures.
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 accept MA, who accept new patients covered by MA, and who will get paid for medical services by DHS.
To be told in advance by the medical provider if a service that they asked for is not covered by MA.
To receive medical services for which they are 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).
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 they can, and say that all the answers are true.
Give true and complete information about everything that may affect their eligibility.
Provide all needed information for eligibility and confirm as best they 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.
Provide proof of U.S. citizenship (if necessary).
Cooperate with quality control and audit reviews of eligibility.
Inform the CAO and medical providers about any available medical coverage or medical resources.
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 provided by the CAO.
Cooperate with DHS and allow request for payment from any third party 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.
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 DHS 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.
Give individuals the opportunity 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.
Provide information about services from DHS and other agencies, including the following:
Teen parenting and pregnancy programs.
Area Office for the Aging.
Medical Assistance Transportation Program (MATP) www.matp.pa.gov/
Respect each individual’s dignity and right to privacy.
Give medical providers proof that an individual is eligible, to be helpful in the billing process.
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.
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.
Give each individual the chance to have an appeal and fair hearing if they are not satisfied with any CAO action.
Updated April 24, 2025, Replacing June 4, 2024