The CAO must let the recipient know that they must get medical services from providers who are enrolled in the MA program. Most hospitals in Pennsylvania accept MA payment.
NOTE: A doctor who gives care at a hospital that is in the program may or may not accept MA payment. The CAO must let the recipient know that they will not be paid for payments made or owed to providers who are not in the program.
The recipient must use all available third-party resources to pay medical costs before DHS will pay for a service. The recipient must present other insurance cards as well as the ACCESS card when asking for or getting medical services.
The CAO may help recipients find MA providers who accept MA by giving the recipient a list of provider names and addresses. The provider search file in PROMISe lists all providers who are enrolled in the MA program. The CAO can sort the list by ZIP code, county, or specialty to meet the recipient’s needs. (See Appendix C for instructions for using the PROMISe Inquiry System.)
Each CAO will name one worker and an alternate who will help find providers for recipients.
Recipients enrolled in managed care may contact Pennsylvania Enrollment Services to find providers who participate with their managed care plan:
For HealthChoices recipients:
For an MA recipient enrolled in HealthChoices PH, refer the individual to the right PH managed care organization for information on PH providers, including dental providers.
For MA recipients who are enrolled in HealthChoices BH, refer the recipient to the BH managed care organization for BH provider information.
For MA recipients who are in the fee-for-service “window” (before the effective date for managed care enrollment), refer the individual to either (a) the Fee-For-Service Recipient Service Center at 1-800-537-8862 or (b) the Fee-For-Service Provider Physician Directory website.
NOTE: Recipients can contact the enrollment broker to find providers for each PH and BH plan by calling 1-800-440-3989 or visiting the PA Enrollment Services website (www.enrollnow.net).
For fee-for-service:
For BH provider information, refer the recipient to the county MH/MR program.
For MA recipients who are not enrolled in managed care, use PROMISe. The PROMISe worker in the CAO helps these recipients find providers who are in the program, if the recipient asks for help.
CAOs can also refer the individual to either (a) the Fee-For-Service Recipient Service Center at 1-800-537-8862 or (b) the Fee-For-Service Provider Physician Directory website
MA recipients sometimes have a copayment for medical services. Certain GA-related recipients have higher copayments than other recipients. (See Appendix D for copayment fees and exclusions.)
NOTE: Services given to recipients who are under 18 years of age, pregnant (including throughout the 12-month postpartum period), or in a nursing home are excluded from copayments.
The provider will tell the recipient the copayment amount and collect that payment. The recipient should request a receipt. MA rules do not allow MA providers to deny a service or item if the recipient cannot make the copayment. The recipient should tell their provider if they cannot afford the copayment amount at the time of service. However, the recipient is still responsible for the copayment, and the provider may try to collect the copayment from the recipient (for example, by billing the recipient for the overdue copayment amount). If the recipient believes that a provider has charged them incorrectly for copayments, the recipient must continue to make copayments unless DHS decides that the charges are wrong.
Adult General Assistance MA recipients pay a $150 deductible (the amount the recipient must pay before DHS begins to pay) each fiscal year for the following MA services:
Outpatient surgical center services
Inpatient hospital services
Outpatient hospital services
NOTE: Recipients do not have to pay a deductible for laboratory and x-ray services.
The period for the deductible is from July 1 to June 30 of the following year. Services will be provided even if the recipient cannot pay the deductible.
The Office of Administration (OA) Recipient Restriction (Lock-In) Program may decide that limits must be placed on a recipient’s MA benefits because the individual is misusing or defrauding the MA program.
Most recipients are enrolled in a managed care organization (MCO). A recipient in an MCO goes to a primary care physician, who is responsible for managing the recipient’s medical care. Each month, the DHS pays the MCO a set amount for each individual in the MCO. Under DHS rules, MCOs must provide the same medical coverage that is available to recipients under the fee-for-service Healthcare Benefits Package.
When a recipient enrolls in an MCO, they get a medical services ID card from the plan and an ACCESS card from DHS. The ACCESS card identifies the recipient for the Medical Assistance Transportation Program (MATP).
The Enrollment Assistant Program (EAP) contractor or someone who handles managed care assists the recipient in selecting a managed care plan. When a recipient enrolls in or leaves a managed care program, that information is automatically posted to eCIS.
Enrollment in an MCO is not available for recipients who are in any of the following situations or programs:
A noncontinuous eligibility (NCE) period.
NMP Spend-down, if a monthly review of eligibility is required.
Healthy Horizons Cost-Sharing (PG).
Presumptive Eligibility.- PE for Pregnant Women and Hospital Based PE.
Specified Low Income Medicare Beneficiaries (SLMB) TA/TJ 65.
Qualifying Individuals (QI-1 Buy In) TA/TJ 67.
Breast and Cervical Cancer Prevention and Treatment (BCCPT) PH/20.
Family Planning (PSF)
eCIS sets the MCO begin date based on MCO dating rules.
If a budget is closed and reopened within six months, CIS re-enrolls the budget in the MCO. The recipient can choose another provider when the budget is reopened.
The recipient may use MA for medical services from an out-of-state provider if:
The recipient needs emergency medical care while temporarily away from home.
The recipient would be risking his or her health by waiting for the service until returning home.
The trip back to Pennsylvania would endanger the recipient’s health.
It is general practice for recipients in that area of the state to use medical resources in a neighboring state.
DHS decides, on the attending practitioner’s advice, that the recipient has better access to the needed care in another state.
OMAP decides whether DHS will pay for the service. If the provider is not familiar with DHS’s billing process, the CAO refers the provider to OMAP.
Updated August 26, 2025, Replacing September 19, 2023