Pennsylvania Code › Title 55 - HUMAN SERVICES › Part II - Public Assistance Manual › Subpart D - Determination of Need and Amount of Assistance › Chapter 175 - ALLOWANCES AND BENEFITS › MA ALLOWANCES AND BENEFITS PROVISIONS FOR THE CATEGORICALLY NEEDY AND SCHOOL CHILDREN WHO ARE ONLY MEDICALLY NEEDY › Section 175.73 - Requirements

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
Services paid for.
The following services will be paid for in
					 accordance with the following requirements:
(1)
Physicians' services.
Physicians' services will be paid for in accordance with the following:
(i) In accordance with the specific
					 regulations governing physicians' services, the Department will pay for office
					 and home calls for chronic or acute illness. Home calls will be paid for only
					 when it is situationally impossible or medically inadvisable for the patient to
					 go to the physician's office.
(ii)
					 In cases of acute illness the Department will pay for the minimum number of
					 calls deemed necessary by the physician for adequate medical care in each
					 individual instance.
(iii) In
					 chronic illness, payment will be limited to a maximum of three calls per month.
					 It will not be expected, however, that this maximum will be charged in
					 instances where one or two calls would have been sufficient.
(iv) Obstetrical care and minor surgery,
					 performed in the home or office, will be paid for.
(v) X-ray study in the physician's office, if
					 necessary for diagnosis, may be paid only for persons receiving public
					 assistance money payments. The Department will not pay for diagnostic
					 laboratory tests and x-rays provided in the course of the school health
					 examination.
(vi) The services of a
					 physician for a complete physical examination may be paid if needed to
					 determine the condition of a recipient or the eligibility of an applicant for
					 assistance, for the annual general medical examination of public assistance
					 recipients in private nursing homes and for other needed special medical
					 examinations. Prior authorization will be required.
(vii) On written prescription by the
					 physician, payment will be made for drugs included in the Drug Formulary.
					 Payment for drugs on one prescription will be limited to a 45-day supply. If
					 the charge for the medication is more than $10 or if the physician plans to
					 prescribe the same medication in an amount likely to exceed $35 per month,
					 prior authorization through the County Assistance Office will be
					 required.
(viii) Medication
					 dispensed by a physician during a home or office call may be paid for if the
					 medication costs the physician $2 or more. Prior authorization will be required
					 if the charge is more than $10.
(ix) In addition to the physicians' services
					 in subparagraphs (i)-(vii), the Department also will pay for eye examinations
					 and refractions, eye glasses, and surgeon's fees for certain specified
					 operations for an eligible child.
(x) For a patient who is receiving a public
					 assistance payment for nursing home care, the Department will not pay for
					 medical services given by a physician who owns that institution in whole or in
					 part, has a financial interest in it, operates it or is acting in another
					 capacity that indicates he is not an independent contractor.