Maintaining Medical Assistance (MA) Coverage with Buy-In Terminations during the Coronavirus (COVID-19) Emergency, PMA 20725-338 (Published October 21, 2021)
HealthChoices Intranet Site, PMA19508338 (Published June 26, 2019)
Third Party Liabilities (TPLs) and Children's Health Insurance Program (CHIP) Referrals, PMA19106338 (Published September 17, 2018)
Minimum Essential Coverage (MEC) Reporting to the Internal Revenue Service (IRS) and Individuals, OPS161201 (Published December 6, 2016)
When an individual is eligible for Medical Assistance (MA), the Department of Human Services (DHS) issues a Pennsylvania ACCESS card. The medical provider uses the card to confirm the recipient’s eligibility on the Eligibility Verification System (EVS) and to get information to bill DHS for medical services or items.
NOTE: The ACCESS card does not say whether the recipient is eligible or which medical benefits are approved. Medical providers use the card to get into EVS to find out these things.
The provider must be enrolled in the MA program to bill DHS
.
The CAO and enrolled providers must have an MA Program Fee Schedule. The schedule provides a list of services and items that may be covered under the MA program. There is a maximum fee for each item. The provider is responsible for finding out whether a service or item is covered.
NOTE: A covered service or item may be called compensable. Some compensable items require approval in advance before the provider can receive payment. (See Section 338.53, Prior Authorization (Advance Approval)) Items that are not compensable may be paid in some situations; however, a special request must be submitted and approved. (See Section 338.54, Administrative Waiver Requests (Program Exception).)
Payment is made by the Provider Reimbursement and Operations Management Information System (PROMISe) directly to the provider. DHS does not reimburse the recipient for the cost of services or items.
An enrolled provider must accept the MA fee for an item or service and may not bill the recipient for any amount over that. If payment by a third party such as Medicare is more than the MA fee, the third-party payment is considered payment in full. The provider may bill DHS for the difference between the MA fee and the third-party payment if the third-party payment is less than the MA fee.
Exception: The recipient is responsible for a small copayment for certain services. (See Section 338.52, Copayment.)
NOTE: The provider can bill the recipient for a non covered service or item if the recipient is told, before the service is provided, that the MA program does not cover it.
When there is need for a medical service or item, the recipient must present the ACCESS card before each service is provided. The recipient must also give information to the provider about any other insurance or coverage that may be available to pay for the cost of care. The recipient may have to pay a copayment and a deductible for certain medical services. (See Appendix D and Section 338.521.)
An applicant for cash or MA may be eligible for MA to cover an unpaid medical bill for services or items in the retroactive period. The retroactive period begins the first day of the third calendar month before the month of application and ends the day before the date of application.
When approved for MA, each recipient has a HealthCare Benefits Package. The package depends on the age of the recipient, the category, program status code and/or the qualification code. (The qualification code is used only for GA cash assistance.) MA providers use EVS to find out the recipient’s HealthCare Benefits Package number. MA providers have full information about available medical services and limits on those services.
A description of the HealthCare Benefits Package can be found in Appendix A.
The CAO should tell recipients to contact providers for details on coverage and medical benefits. The CAO should tell recipients they can access their "My COMPASS" accounts.
The CAO must approve MA and review the need for ACCESS cards for people who are found eligible for the following programs:
TANF or GA cash payment.
This includes the following budget groups:
A budget group eligible for TANF or GA but not getting a monthly assistance payment because the payment is less than $10.
A cash budget group that is in “Benefit Hold” status in the Client Information System (CIS).
Nonmoney Payment (NMP) MA (PC/PU).
This includes the following budget groups that are not eligible for TANF:
A budget group getting four months of extended MA after an increase in support for TANF.
A budget group not eligible for TANF but can get TANF-related NMP using TANF deductions plus a deduction for child care expenses.
A budget group whose TANF was closed because of voluntary withdrawal to save TANF time.
Nonmoney Payment (NMP) MA.
This includes the following:
A budget group that meets the rules for TANF or GA cash payments but chooses only MA benefits
Disabled adult child and other groups in Chapter 387.6, Extended NMP Special Circumstances
NOTE: Certain GA recipients age 21 and older get MNO-level benefits.
State Blind Pension.
Healthy Horizons Cost-Sharing.
MA clients in:
HealthChoices, Mandatory Managed Care, Voluntary Managed Care, or ACCESS Plus.
Managed Care Plans and ACCESS Plus give ID cards to individuals enrolled in their program. CAOs will tell clients to ask questions of the programs in which they are enrolled. Clients should use their PA ACCESS cards as well as program cards when getting services.
NOTE: The ACCESS card allows some clients to use medical transportation services from the Medical Assistance Transportation Program (MATP).
Under Act 42 of 2005, MA program rules were changed as of August 29, 2005, to provide certain benefit limits for adult MA and adult general assistance (GA) MA recipients. This includes recipients who get cash benefits under TANF, SSI, or GA. It includes adult MA recipients approved for MAWD, BCCPT, or MA Home and Community Based Services (HCBS) Waivers. These changes limit certain medical services. (See Appendix G.)
The MA benefit limits do not apply to the following recipients:
Any individual under 21 years of age.
Pregnant women, including during the pregnancy through the last day of the month in which the 60th day after the end of the pregnancy falls.
State Blind Pension recipients.
MA recipients who get Medicare Parts A and B.
MA recipients who get only Medicare Part B.
NOTE: An MA recipient who has only Medicare Part A falls under these benefit limits.
NOTE: The benefit limits in Appendix G will be in effect for the ACCESS Plus enhanced primary care case management program and the MA Fee-For-Service program. HealthChoices mandatory managed care organizations (MCOs) and contracted voluntary MCOs may choose whether to use any or all of the benefit limits described in Appendix G.
As required by Act 42, DHS has set up a process to allow payment for services beyond the benefit limits described in Appendix G. DHS is allowed to give exceptions to the benefit limits in any of the following situations:
The recipient has a serious illness or other serious health condition that, without the exception, might cause the individual to get worse or die.
Giving the exception would save the MA program money.
Federal law says that the exception must be given.
The provider or the recipient can request an exception by writing, phoning, or faxing DHS. The request may be made before or after the service. The recipient may need to contact the provider for medical records and other papers to support the request.
DHS will evaluate and respond to exception requests as follows:
Before the service: Within 21 days after getting the request, or within 48 hours if the provider needs a quick response.
After the service: Within 30 days after getting the request. If a provider submits a claim and DHS rejects the claim because it is over the benefit limit, the provider must submit an exception request within 60 days of the rejection. If this is not done, the request will be denied.
The CAO will send written notices to the recipient and the provider about the approval or denial of the exception request.
NOTE: Some exceptions are always approved. Visits to the recipient’s primary care practitioner (PCP) and most visits to specialists referred by the PCP after the 18-visit limit.
Updated January 30, 2020, Replacing September 19, 2018