DHS offers special MA services that meet the needs of certain groups of recipients. Services that the CAO may need to deal with are discussed in this section.
EPSDT provides preventive medical services to individuals under age 21 who are eligible for the ACCESS card.
NOTE: Recipients enrolled in a managed care organization and ACCESS Plus receive services like those provided by EPSDT.
EPSDT services include:
26 screenings that include examinations, evaluations and certain required tests, based on the following schedule of ages.
Newborn |
12
months |
6
years |
15 years |
Follow-up care, including payment for eyeglasses, hearing aids, dental work, and braces.
Payment for tests and services needed to correct or improve illnesses or conditions found in an EPSDT screening. These tests and services are covered by EPSDT even if they are not covered under the state Medicaid plan. The services must be covered under the federal Medicaid program and must be approved in advance by DHS.
NOTE: The EPSDT program provides all benefits of the NMP program to children under age 21 who get MNO.
The CAO will do the following:
Explain the program to each eligible recipient at application and renewal, using words that the recipient understands.
Encourage the recipient to enroll family members in the program.
Answer general questions about the program.
Help the recipient schedule appointment if he or she asks for help.
In CIS, enter “Y” in the EPSDT field, and enter the medical provider name in the Medical Service Provider field.
NOTE: It is important to update CIS. A daily file is transferred from CIS to the EPSDT provider to speed up EPSDT services.
If the recipient does not want the service, make sure he or she understands the benefits of the program.
Medical transportation services are available to recipients of GA, TANF, SSI, and MA who have no other way of traveling for necessary medical care or prescription drugs.
62 P.S. 422.1
Exception: Transportation services are not available to recipients of Healthy Horizons cost-sharing benefits or the GA-MNO 30-day noncontinuous eligibility benefits used to prove disability for GA eligibility.
Coverage for transportation for medical care is available from two sources:
The Medical Assistance Transportation Program (MATP), if the county has one.
CAO payments for medical transportation costs not covered by the MATP or in counties that do not have an MATP program. Transportation costs may include the cost of meals and lodging. The CAO must approve either an advance payment or payment for money the recipient already spent.
NOTE: See Cash Handbook Chapter 138, Allowances and Benefits, for information on MATP services and transportation allowances offered by the CAO.
The MA Targeted Case Management Program provides certain MA recipients with access to complete medical and social services. The service encourages cost-effective use of medical care and community resources while making sure that the recipient has freedom of choice. Services are provided by a case manager chosen by the recipient.
Case management services are currently available to individuals who have Acquired Immune Deficiency Syndrome (AIDS) or Human Immunodeficiency Virus (HIV) with symptoms.
Case-management services through the MA Targeted Case Management Program are not available to individuals who are in an MCO or Hospice Program. individuals in those programs get similar services through the program they are in.
MA recipients from a target group can use the services of a case manager, but they do not have to. Services handled by the case manager must be a part of a medical care plan. The case manager must refer each individual to the right places to get the care needed to meet the goals of the plan.
NOTE: Case managers are enrolled as MA providers and are listed under “Provider Search” in the PROMISe Information system.
When the CAO finds out that an MA recipient as a member of a targeted group, it must take the following actions:
Tell the recipient, using words that he or she understands, about the case-management services that are available.
If the recipient requests it, give him or her a list of case managers from the PROMISe information system. (See Section 338.51, MA CARES/PROMISe.)
For questions about the program, contact:
Department of Human Services
Office of Medical Assistance Programs
Case Management Section
Room 100, Cherrywood Building
P. O. Box 8021
Harrisburg, Pennsylvania 17105
The Special Pharmaceutical Benefits Program (SPBP) provides certain drugs to people with HIV or AIDS and to mental health recipients suffering from schizophrenia who:
NOTE: Recipients of cash assistance and NMP and Blind Pension can use MA to buy needed drugs.
Important: The CAO must make sure information about SPBP applicants and recipients is kept private.
Recipients of MNO and nonrecipients must apply for the SPBP to get coverage for the drugs.
NOTE: In some other states, the HIV/AIDS part of SPBP is called the AIDS Drugs Assistance Program (ADAP).
The program provides payment for:
Certain HIV/AIDS drugs.
The drugs Abilify, Clozaril (Clozapine), Geodon, Risperdal, Seroquel, and Zyprexa for schizophrenia.
NOTE: For a list of covered HIV/AIDS drugs, call 1-800-922-9384.
NOTE: The Department of Health (DOH) provides free CD 4 + T-cell tests for individuals in SPBP. The tests are given only at certain sites. Recipients should call the AIDS Factline at 1-800-662-6080 for information and locations.
A individual who is not a recipient of MNO may be eligible for special pharmaceutical benefits if he or she meets the following conditions:
The individual’s yearly gross income is equal to or less than $30,000 plus $2,480 for each family member.
The individual lives in Pennsylvania.
The individual is not in an institution.
The individual is being treated for HIV, AIDS, or schizophrenia and needs covered drugs that have been prescribed by a physician.
NOTE: Medical insurance is counted as a resource, but other resources are not counted
.
Eligible people will get an SPBP card, which must be shown at a pharmacy that is enrolled in the MA program. If a individual has medical insurance that pays for prescriptions, the program will pay for the amount that is not covered by the insurance, up to the MA maximum fee for that drug.
When the CAO finds out that an MNO recipient or a nonrecipient has the need for one of the drugs covered by the SPBP, the CAO will do the following:
Explain the benefits of the program and let the individual know that all information will be kept private, using words that the individual understands.
Give the individual an SPBP application—either an SPBP (effective 03/12) for HIV/AIDS drugs or an MA 442 (dated 08/03) for Abilify, Clozaril, Geodon, Risperdal, Seroquel, or Zyprexa. Help the individual fill out the application if he or she asks for help.
NOTE: Applications are on the OMAP web site.
Tell the individual to attach the following papers to the application:
A copy of the prescription for each item needed.
Proof of Pennsylvania residency.
A copy of his or her Social Security card.
Proof of income
Tell the individual to send the completed application and papers to the following address:
Department of Human Services
Special Pharmaceutical Benefits Program
P.O. Box 8021
Harrisburg, PA 17105-8021
Tell applicants they can send questions by e-mail to SPBP@state.pa.us or call the SPBP toll free at 1-800-922-9384.
Tell the applicants the SPBP coordinator will let them know if they are eligible. If so, they will get an SPBP card, which they must show to the pharmacy whenever they go to fill a prescription for covered drugs.
Tell the applicants if they become eligible for MA drug coverage in the future, they will not keep using the SPBP card
NOTE: CAO workers and providers who have questions can call the SPBP at 800-922-9384.
Hospice services are available to recipients of MA who are dying. The recipient must get services from a hospice that is certified by Medicare and enrolled in MA. (See PROMISe for a list of certified hospices.)
The goal of hospice services is to make a dying individual as physically and emotionally comfortable as possible. The recipient can receive hospice services in a hospice or at any of the following locations:
At home.
The home of a friend.
The home of a relative.
A hotel.
A individual care home.
A domiciliary care facility.
An intermediate care facility.
A skilled nursing facility.
A hospital.
NOTE: A hospital, domiciliary care facility, intermediate care facility, or skilled nursing facility must be approved by OMAP to provide hospice services.
If the individual who is requesting hospice services does not have MA, the CAO applies MA rules as it would for any other applicant. If the individual is getting hospice services in an intermediate or skilled nursing care facility, the CAO takes the actions listed in Section 338.652, Eligibility for care provided in an intermediate or skilled care facility.
A hospice provider must let the CAO known within 7 days when a individual:
Chooses hospice care.
Cancels hospice care.
Moves to another hospice facility.
Dies.
The hospice provider must fill out the following forms:
Certification of Terminal Illness (MA 372)
The hospice provider has the form signed by the attending physician and hospice medical director every 60 days. An illness is considered terminal if the individual is expected to live six months or less. The CAO does not need a copy of this form.
Election of Hospice Care (MA 373)
This form is signed by the individual to confirm that he or she wants to get hospice care. The hospice provider gives the CAO a copy of the form when a individual is applying for MA or when a individual moves to another hospice facility.
Change of Hospice Provider (MA 374)
If a recipient chooses a new hospice provider, the new provider must get this form, and the CAO must get a copy.
Revocation of Hospice Care (MA 375)
This form shows that the recipient decided to cancel hospice services. The CAO must get a copy.
When the CAO gets the MA 373, the CAO will:
Make sure all needed information is on the form.
Check line 17 for a change of address. If there is an address change, take the right action. The CAO changes the address in CIS. Proof is only needed if there is a question or a conflict. If the individual moves out of state, they are not eligible for MA in PA.
Check line 10 for the patient’s signature. If there is no signature, check line 15 for the name of the appointed legal representative. If no legal representative is listed, return the MA 373 to the provider and point out that the information is missing.
Check to see if the individual is getting hospice care in an intermediate or skilled care facility.
If the individual is getting care in a place other than an intermediate or skilled care facility, see Section 338.651.
If the individual is getting care in an intermediate or skilled care facility, see Section 338.652.
If the individual is getting hospice services at a place other than a nursing home, the CAO will find out whether the individual has MA.
If the individual has MA, the CAO will:
Change the address, if needed.
Enter facility code 39 (Hospice care not received in a nursing facility).
File the MA 373 in the case record.
If the individual does not have MA, the CAO will:
Decide whether the individual can get MA, following the same rules for any other MA applicant. Consider categories PH, PA/TA, and PJ/TJ.
If MA eligible, enter facility code 39 (Hospice care not received in a nursing facility).
File the MA 373 in the case record.
PMA18243338 Hospice Care in a Nursing Facility, November 11, 2016
Hospice services may be given by a hospice provider to a recipient who is living in an intermediate or skilled care facility. Services are provided under a special room and board plan.
The CAO determines cost of the MA payment for hospice service as follows:
1. Determine the amount the recipient must pay toward the cost of care, using these guidelines:
Determine the recipient’s category of MA as if he or she were applying for nursing home care.
Do not allow deductions for medical expenses for items or services that are related to the terminal illness and that are given by the hospice provider.
Allow deductions for paid medical expenses that are not related to the terminal illness. Deduct the expenses only in the month they are paid.
2. Contact the hospice provider about the MA (daily rate) for hospice services.
Include the amount charged to the hospice provider by the facility for room and board.
Ask the provider to send in a written statement of the costs.
3. Use the number of days in the calendar month that the recipient got hospice service in the facility.
4. Multiply the MA (daily rate) by the number of days in the month hospice services were provided to determine the cost of hospice care for the calendar month.
5. Compare the cost of care for the month with the amount the individual is expected to pay.
If the individual’s share is equal to or more than the cost of care, DHS will not pay toward the cost of care.
If the individual’s share is less than the cost of care, subtract that amount from the total cost to determine what DHS will pay towards the cost of care.
Send the applicant a PA/FS 162 to tell the individual whether the individual can get an MA payment. If the individual is not eligible, tell the individual that the hospice must not charge a daily rate that is more than the MA rate.
Send notices to both the provider and the nursing home telling them what the recipient is expected to pay toward the cost of hospice care.
The recipient may change hospice providers once during the 60-day period set by the MA 372.
Example: Mr. Weber got MA hospice services from Hospice of PA for 40 days, beginning on December 1. On January 9, the Hometown Hospice sent a copy of an MA 374 to the CAO to let the CAO know that Mr. Weber changed his hospice to Hometown. After Hometown Hospice delivers services to Mr. Weber for 21 days, the CAO receives an MA 374 on January 30 that says Mr. Weber decided to return to Hospice of PA.
Mr. Weber was able to make both changes, because each occurred in a separate 60-day period. If Mr. Weber wants to make another change, he must wait until April 1 (60 days from the last change).
When a provider change is made, the CAO must get a completed MA 374 from the new provider. The CAO must review the information to see whether any changes in CIS or the case are needed and keep the form in the case record.
If the recipient moves from one hospice location to another, the new hospice provider must fill out an MA 373 and send a copy to the CAO within seven calendar days.
When it learns of a change in a hospice address, the CAO must take the following actions:
Change the address in CIS.
If the recipient has moved from a nursing home hospice facility, determine MA eligibility, using the same rules as for a individual who is not in a nursing home.
If the recipient has moved into a hospice located in a nursing home, determine the MA payment toward the cost of care. See Section 338.652, Eligibility for Hospice Care in an Intermediate or Skilled Care Facility.
A recipient may stop hospice service at any time for any reason. If the recipient stops hospice care while he or she is in a nursing home, the CAO will determine MA eligibility for the required level of care.
If the recipient no longer wants hospice care, the hospice provider must fill out an MA 375 and send a copy to the CAO within seven calendar days.
If the MA recipient wants hospice care again, the new provider must complete an MA 373 and send a copy to the CAO.
Healthy Beginnings Plus provides more maternity care to pregnant women who are already getting cash assistance or MA.
NOTE: The program is not limited to people who get Healthy Beginnings.
Healthy Beginnings Plus is a joint effort between DHS and the Department of Health (DOH) to provide complete care. The program offers the following services:
Basic medical care.
High-risk medical care.
Special services, such as:
Social services.
Obstetrical care.
Home nursing care.
Homemaker services.
Substance abuse identification and counseling.
Urgent transportation.
Counseling.
The CAO will:
Identify MA recipients who are pregnant.
Explain the benefits of the Healthy Beginnings Plus program.
Tell women who are interested in the program that they can call the Healthy Beginnings Plus Program Hotline at one of the numbers listed in Appendix J.
Updated November 8, 2016, Replacing February 14, 2012