Updating Pregnancy Screen to Ensure Medical Assistance (MA) 12-Month Continuous Postpartum Coverage, PMA 21880-338 (Published August 16, 2024)
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 individual 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.
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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.
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, including their MA Managed Care Organization (MCO). 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 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 is assigned a HealthCare Benefits Package. The package depends on the age of the recipient, and the category/program status code. MA providers use EVS to find out the recipient’s HealthCare Benefits Package. 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 or their MCO 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 MA. All MA categories EXCEPT:
Specified Low-Income Medicare Beneficiaries (SLMB - TA/TJ 65)
Qualified Individuals (QI-1 - TA/TJ 67).
Managed Care Organizations (MCOs) give ID cards to individuals enrolled in their program. Recipients should use their PA ACCESS cards as well as their MCO card when getting services.
NOTE: The ACCESS card allows some clients to use medical transportation services from the Medical Assistance Transportation Program (MATP).
Updated August 26, 2025, Replacing January 30, 2020