338.6 Special MA Services

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.

338.61 Early and Periodic Screening, Diagnosis and Treatment (EPSDT)

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:


by one month
2 months
4 months
6 months
9 months

12 months
15 months
18 months
24 months
3 years
4 years
5 years

6 years
8 years
10 years
11 years
12 years
13 years
14 years

15 years
16 years
17 years
18 years
19 years
20 years


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:


NOTE:  It is important to update CIS. A daily file is transferred from CIS to the EPSDT provider to speed up EPSDT services.


338.62 Medical Transportation

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.           

 55 Pa. Code § 175.23(b)(2)      

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:


NOTE:  See Cash Handbook Chapter 138, Allowances and Benefits, for information on MATP services and transportation allowances offered by the CAO.

338.63 MA Targeted Case Management Program

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:


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

338.64 Special Pharmaceutical Benefits Program

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:


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:


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:


NOTE:  Applications are on the OMAP web site.



Department of Human Services
Special Pharmaceutical Benefits Program
P.O. Box 8021
Harrisburg, PA 17105-8021


NOTE:  CAO workers and providers who have questions can call the SPBP at 800-922-9384.

338.65 Hospice Services

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:


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:


The hospice provider must fill out the following forms:

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.

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.

If a recipient chooses a new hospice provider, the new provider must get this form, and the CAO must get a copy.

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:

338.651 Eligibility for Hospice Care at a Place Other than an Intermediate or Skilled Care Facility

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:


If the individual does not have MA, the CAO will:

338.652 Eligibility for Hospice Care in an Intermediate or Skilled Care Facility

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:

2. Contact the hospice provider about the MA (daily rate) for hospice services.

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.

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.

338.653 Changes in 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:

338.654 Stopping of Hospice Care

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.

338.66 Healthy Beginnings Plus

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:

The CAO will:

Updated November 8, 2016, Replacing February 14, 2012