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.
Medical transportation services are available to recipients of 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 (PG), Specified Low-Income Medicare Beneficiaries (SLMB, TA/TJ 65) and Qualified Individuals (QI-1, TA/TJ 67).
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.
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 338.632, Eligibility for care provided in an intermediate or skilled care facility.
A hospice provider must let the CAO know 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 they want 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, No vember 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 they 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: A recipient recieved 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 the recipient changed their hospice to Hometown. After Hometown Hospice delivers services to the recipient for 21 days, the CAO receives an MA 374 on January 30 that says the recipient decided to return to Hospice of PA.
The recipient was able to make both changes, because each occurred in a separate 60-day period. If the recipient wants to make another change, they 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 they are 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 MA.
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 H.
Updated August 26, 2025, Replacing November 8, 2016