reglab/statecodes huggingface dataset:
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part II - Public Assistance Manual › Subpart M - Home Energy Assistance › Chapter 601 - LOW INCOME HOME ENERGY ASSISTANCE PROGRAM › Subchapter A - FEDERAL LOW INCOME HOME ENERGY ASSISTANCE PROGRAM › PAYMENTS FOR CASH BENEFITS › Section 601.46 - Refunds

Current through Register Vol. 54, No. 28, July 13, 2024
Refunds of LIHEAP benefits are treated as follows:
(1)
Refunds from the
						vendor.
If the LIHEAP client changes vendors, leaves the area served
						by the vendor or dies, the vendor shall refund the unexpended portion of the
						LIHEAP benefit to the Department's Central Office. If the vendor finds it
						necessary to return a security deposit that had been paid with LIHEAP funds,
						the vendor shall refund the security deposit to the Department's Central
						Office.
(2)
Refunds to the
						client.
The Department will reissue a vendor refund of a credit
						balance or security deposit to the LIHEAP household if the following conditions
						are met:
(i) The whereabouts of the household
						are known.
(ii) The household
						continues to live in this Commonwealth.
(iii) The household continues to have a home
						heating responsibility.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part II - Public Assistance Manual › Subpart M - Home Energy Assistance › Chapter 601 - LOW INCOME HOME ENERGY ASSISTANCE PROGRAM › Subchapter A - FEDERAL LOW INCOME HOME ENERGY ASSISTANCE PROGRAM › PROVISION OF CRISIS BENEFITS › Section 601.61 - Benefit amounts

Current through Register Vol. 54, No. 28, July 13, 2024
The amount of a crisis benefit is the minimum amount
						  needed to resolve the home heating emergency, subject to a maximum of $300 for
						  the program year. The household is ineligible for a crisis benefit which, alone
						  or combined with other resources available to the household, will not resolve
						  the crisis.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part II - Public Assistance Manual › Subpart M - Home Energy Assistance › Chapter 601 - LOW INCOME HOME ENERGY ASSISTANCE PROGRAM › Subchapter A - FEDERAL LOW INCOME HOME ENERGY ASSISTANCE PROGRAM › PROVISION OF CRISIS BENEFITS › Section 601.62 - Types of crisis benefits

Current through Register Vol. 54, No. 28, July 13, 2024
An eligible household may receive crisis benefits for
						  weather-related or energy supply shortage emergencies.
(1)
Benefits for weather-related
						emergencies.
Crisis benefits for weather-related emergencies may
						include the following types of assistance if the household is without heat or
						in imminent danger of being without heat. The types of assistance may include:
(i) The purchase of a new heating system if
						the heating system cannot be repaired or repairs will correct the problem only
						temporarily.
(ii) Pipe thawing
						services if the household has a consistent problem with freezing pipes that
						cannot be repaired by a plumber.
(iii) The repair of a broken furnace, which
						may include filter replacement and chimney cleaning or repair.
(iv) The repair of a water heating system,
						including repair of water pumps and accessories, if the system is essential for
						producing home heat.
(v) The repair
						of gas or other fuel lines when the lines feed the main heating
						source.
(vi) The repair of broken
						windows.
(vii) The loan of an
						auxiliary heater.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part II - Public Assistance Manual › Subpart M - Home Energy Assistance › Chapter 601 - LOW INCOME HOME ENERGY ASSISTANCE PROGRAM › Subchapter A - FEDERAL LOW INCOME HOME ENERGY ASSISTANCE PROGRAM › PROVISION OF CRISIS BENEFITS › Section 601.63 - Number of payments

Current through Register Vol. 54, No. 28, July 13, 2024
A household may receive more than one crisis benefit
						  during the program year, subject to the $300 maximum amount for the program
						  year.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part II - Public Assistance Manual › Subpart M - Home Energy Assistance › Chapter 601 - LOW INCOME HOME ENERGY ASSISTANCE PROGRAM › Subchapter A - FEDERAL LOW INCOME HOME ENERGY ASSISTANCE PROGRAM › PROVISION OF CRISIS BENEFITS › Section 601.64 - Payees

Current through Register Vol. 54, No. 28, July 13, 2024
The Department pays crisis benefits directly to the
						  vendor, unless direct payment to a vendor cannot be made. If the Department
						  determines that crisis benefits cannot be paid directly to the vendor, the
						  Department pays the crisis benefit to the applicant.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part II - Public Assistance Manual › Subpart M - Home Energy Assistance › Chapter 601 - LOW INCOME HOME ENERGY ASSISTANCE PROGRAM › Subchapter A - FEDERAL LOW INCOME HOME ENERGY ASSISTANCE PROGRAM › INCOME DETERMINATION FOR CASH AND CRISIS BENEFITS › Section 601.81 - Income counted

Current through Register Vol. 54, No. 28, July 13, 2024
To determine the income level of an applicant household
						  for cash and crisis benefits, the LIHEAP administering agency counts the gross
						  annual income of the following persons:
(1) The household members, regardless of
						relationship.
(2) A roomer who is
						related by blood, marriage or adoption to a household member.
(3) A person who, as a member of another
						household, has already received a LIHEAP cash benefit during the program
						year.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part II - Public Assistance Manual › Subpart M - Home Energy Assistance › Chapter 601 - LOW INCOME HOME ENERGY ASSISTANCE PROGRAM › Subchapter A - FEDERAL LOW INCOME HOME ENERGY ASSISTANCE PROGRAM › INCOME DETERMINATION FOR CASH AND CRISIS BENEFITS › Section 601.82 - Gross income defined

Current through Register Vol. 54, No. 28, July 13, 2024
Gross income is the total earned and nonearned income
						  of the household and includes the following:
(1)
Employe earnings.
Employe earnings are money, including wages, salaries, bonuses, commissions and
						tips, before taxes or other deductions, that a person receives for providing
						services on behalf of an employer.
(2)
Profit from
						self-employment.
Profit of a self-employed person is gross receipts
						minus costs of operating a business or farm, practicing a profession, providing
						day care for children in an approved family day care facility, or renting
						nonresident real property.
(i) The following
						expenses are among those that are not deductible from gross receipts:
(A) Gross wages, commissions, withdrawals of
						money or loans paid to LIHEAP household members, including those paid to a
						self-employed LIHEAP client.
(B)
						Purchase of goods for personal use or gifts.
(C) Depreciation.
(D) Capital losses.
(E) Purchase costs of capital
						equipment.
(F) Personal
						entertainment and transportation expenses.
(G) Interest and payments on loans for the
						purchase of capital equipment.
(H)
						Theft and casualty losses.
(I)
						Charges for residential telephone service (even if used for business
						purposes).
(J) Mortgage
						payments.
(K) Taxes.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part II - Public Assistance Manual › Subpart M - Home Energy Assistance › Chapter 601 - LOW INCOME HOME ENERGY ASSISTANCE PROGRAM › Subchapter A - FEDERAL LOW INCOME HOME ENERGY ASSISTANCE PROGRAM › INCOME DETERMINATION FOR CASH AND CRISIS BENEFITS › Section 601.83 - Treatment of income

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The
						applicant may choose whether the time period to be used in determining gross
						annual income shall be for the 12 months or the 90 days before the date of
						application. Regardless of the selected time period, income shall be converted
						to a yearly figure.
(b) If the
						total gross annual income exceeds 150% of the poverty level for the number of
						persons who are counted as household members for the current year, the
						household is ineligible.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part II - Public Assistance Manual › Subpart M - Home Energy Assistance › Chapter 601 - LOW INCOME HOME ENERGY ASSISTANCE PROGRAM › Subchapter A - FEDERAL LOW INCOME HOME ENERGY ASSISTANCE PROGRAM › INCOME DETERMINATION FOR CASH AND CRISIS BENEFITS › Section 601.84 - Income exclusions

Current through Register Vol. 54, No. 28, July 13, 2024
The following income will not be considered when
						  determining gross yearly income for the purpose of establishing LIHEAP
						  eligibility:
(1) The portion of an
						educational loan, grant or scholarship to an undergraduate student actually
						spent for tuition, books and other required educational fees, and the amount of
						income from other sources used to pay out-of-pocket expenses for books and
						other required educational fees.
(2) Allowable costs of a student's financial
						assistance received from a program funded in whole or in part under Title IV of
						the Higher Education Assistance Act Amendments of 1986 (Pub. L. 99-498, 100
						Stat. 1268).
(3) Payments for
						services or out-of-pocket expenses to volunteers serving as foster
						grandparents, senior health aids or senior companions, and to persons serving
						in other programs under Title II of the Domestic Volunteer Service Act of 1973
						(42 U.S.C.A. §§
													5001-5024).
(4) Payments to volunteers for VISTA, Service
						Learning Programs and Volunteer Programs under Title I of the Domestic
						Volunteer Service Act of 1973 (42 U.S.C.A. §§
													4951-4994).
(5) The value of bonus coupons received by a
						participant in the Food Stamp Program.
(6) The value of donated foods-surplus
						commodities-from the United States Department of Agriculture.
(7) The value of home produce of clients for
						household consumption.
(8) Money
						received under the Senior Citizen Rebate and Assistance Act (72 P. S.
						§§
													4751-1-4751-12).
(9) Money received as incentive or
						training-related expenses provided to persons involved in a work/training
						program sponsored by a Federal, State or local government agency.
(10) Deductions for Medicare premiums
						deducted from Social Security benefit payments.
(11) Amounts received as reimbursement for
						medical costs, medical transportation and special need items as defined under
						Chapter 175 (relating to allowances and benefits).
(12) Cash or in-kind assistance with heating
						costs provided by private or public agencies or utility companies.
(13) Personal loans, bank loans or other
						noneducational loan designated for a specific purpose from an established
						financial institution.
(14) The
						portion of a Social Security lump sum death benefit designated for funeral
						expenses.
(15) Up to the first $50
						of voluntary support from legally responsible relatives or a court-ordered
						support that the household actually receives in a given month, including
						support refunded during the month by the Department.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part II - Public Assistance Manual › Subpart M - Home Energy Assistance › Chapter 601 - LOW INCOME HOME ENERGY ASSISTANCE PROGRAM › Subchapter A - FEDERAL LOW INCOME HOME ENERGY ASSISTANCE PROGRAM › VERIFICATION AND DOCUMENTATION › Section 601.101 - Verification and documentation defined

Current through Register Vol. 54, No. 28, July 13, 2024
The applicant shall provide sufficient information
						  regarding the household's circumstances to enable the LIHEAP administering
						  agency to determine LIHEAP eligibility and the amount of a LIHEAP benefit.
(1)
Verification.
The term refers to any form of convincing information, including oral
						statements or documentation.
(2)
Documentation.
The term refers to written or printed evidence,
						such as fuel bills, rent receipts or pay stubs, that is needed to determine
						LIHEAP eligibility and the type and amount of the LIHEAP benefit.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part II - Public Assistance Manual › Subpart M - Home Energy Assistance › Chapter 601 - LOW INCOME HOME ENERGY ASSISTANCE PROGRAM › Subchapter A - FEDERAL LOW INCOME HOME ENERGY ASSISTANCE PROGRAM › VERIFICATION AND DOCUMENTATION › Section 601.102 - Income

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The applicant
						shall produce documentation of the amounts and sources of income of household
						members, including related roomers, as well as that of anyone in the household
						who already received LIHEAP benefits during the current program year as a
						member of another household.
(b)
						The applicant shall report but is not required to document income of persons in
						the household who are current recipients of public assistance, food stamps or
						supplemental security income.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part II - Public Assistance Manual › Subpart M - Home Energy Assistance › Chapter 601 - LOW INCOME HOME ENERGY ASSISTANCE PROGRAM › Subchapter A - FEDERAL LOW INCOME HOME ENERGY ASSISTANCE PROGRAM › VERIFICATION AND DOCUMENTATION › Section 601.103 - Minimal or no income

Current through Register Vol. 54, No. 28, July 13, 2024
If the applicant states that the household has minimal
						  or no income, the applicant may be required, as a condition of eligibility, to
						  produce evidence that will satisfactorily explain how basic living needs of the
						  household members are meeting their financial obligations and basic living
						  needs.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part II - Public Assistance Manual › Subpart M - Home Energy Assistance › Chapter 601 - LOW INCOME HOME ENERGY ASSISTANCE PROGRAM › Subchapter A - FEDERAL LOW INCOME HOME ENERGY ASSISTANCE PROGRAM › VERIFICATION AND DOCUMENTATION › Section 601.104 - Responsibility for home heating costs

Current through Register Vol. 54, No. 28, July 13, 2024
(a) If the household pays the vendor directly
						for heat, acceptable documentation of a home heating responsibility for a cash
						benefit is a recent fuel bill or receipt from the vendor of the main fuel. A
						recent bill or receipt is one that was issued within 2 months of the date
						before application. If the household chooses to have the benefit paid to the
						vendor of its second fuel type, the applicant for a cash benefit shall provide
						documentation of a financial responsibility for both the main and second fuel
						types.
(b) The applicant for a
						crisis benefit shall prove payment responsibility for either the main or second
						fuel type of the household.
(c) If
						the household pays for heat indirectly, a written or oral statement from the
						landlord or rental agent may be acceptable verification of a home heating
						responsibility. The statement shall specify the main type of fuel used to heat
						the home of the applicant household.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part II - Public Assistance Manual › Subpart M - Home Energy Assistance › Chapter 601 - LOW INCOME HOME ENERGY ASSISTANCE PROGRAM › Subchapter A - FEDERAL LOW INCOME HOME ENERGY ASSISTANCE PROGRAM › VERIFICATION AND DOCUMENTATION › Section 601.105 - Social security numbers

Current through Register Vol. 54, No. 28, July 13, 2024
The applicant shall present proof of Social Security
						  numbers of household members. Verification of Social Security numbers is not
						  required for household members whose Social Security numbers had previously
						  been verified and are available in a LIHEAP or public assistance case record.
						  An applicant who does not have a Social Security number or refuses to disclose
						  it shall complete an energy assistance affidavit.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part II - Public Assistance Manual › Subpart M - Home Energy Assistance › Chapter 601 - LOW INCOME HOME ENERGY ASSISTANCE PROGRAM › Subchapter A - FEDERAL LOW INCOME HOME ENERGY ASSISTANCE PROGRAM › VERIFICATION AND DOCUMENTATION › Section 601.106 - Questionable information

Current through Register Vol. 54, No. 28, July 13, 2024
The LIHEAP administering agency may require the
						  applicant to verify information affecting eligibility that appears to be
						  incomplete, unreasonable or inconsistent with known facts.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part II - Public Assistance Manual › Subpart M - Home Energy Assistance › Chapter 601 - LOW INCOME HOME ENERGY ASSISTANCE PROGRAM › Subchapter A - FEDERAL LOW INCOME HOME ENERGY ASSISTANCE PROGRAM › CLIENT RIGHTS › Section 601.121 - Confidentiality

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Information
						about a LIHEAP applicant or recipient is confidential and may be disclosed for
						only the following purposes:
(1) To aid in
						the determination of LIHEAP eligibility.
(2) To aid in the investigation or
						prosecution of suspected fraud in connection with LIHEAP.
(3) To cooperate with Federal or State
						authorities regarding LIHEAP audits, reviews and
						investigations.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part II - Public Assistance Manual › Subpart M - Home Energy Assistance › Chapter 601 - LOW INCOME HOME ENERGY ASSISTANCE PROGRAM › Subchapter A - FEDERAL LOW INCOME HOME ENERGY ASSISTANCE PROGRAM › CLIENT RIGHTS › Section 601.122 - Nondiscrimination

Current through Register Vol. 54, No. 28, July 13, 2024
The Department assures that no person on the basis of
						  race, color, sex, age, handicap, religion, national origin or ancestry or
						  political belief will be excluded from participation in LIHEAP, denied LIHEAP
						  benefits or be subject to discrimination in an activity or project receiving
						  LIHEAP funds.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part II - Public Assistance Manual › Subpart M - Home Energy Assistance › Chapter 601 - LOW INCOME HOME ENERGY ASSISTANCE PROGRAM › Subchapter A - FEDERAL LOW INCOME HOME ENERGY ASSISTANCE PROGRAM › CLIENT RIGHTS › Section 601.123 - Appeals and fair hearings

Current through Register Vol. 54, No. 28, July 13, 2024
(a) An
						applicant may appeal and receive a fair hearing if the applicant believes a
						decision on eligibility for LIHEAP benefits is incorrect or unreasonably
						delayed.
(b) Client rights and
						procedures for appeals and fair hearings appear in Chapter 275 (relating to
						appeal and fair hearing and administrative disqualification
						hearings).
(c) Upon request, LIHEAP
						staff will help the client with any aspect of the appeal and fair hearing
						process.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part II - Public Assistance Manual › Subpart M - Home Energy Assistance › Chapter 601 - LOW INCOME HOME ENERGY ASSISTANCE PROGRAM › Subchapter A - FEDERAL LOW INCOME HOME ENERGY ASSISTANCE PROGRAM › OVERPAYMENTS › Section 601.141 - Overpayment defined

Current through Register Vol. 54, No. 28, July 13, 2024
An overpayment is the payment of LIHEAP funds or
						  provision of LIHEAP benefits to an agency or a person for which the agency or
						  person is either fully or partially ineligible.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part II - Public Assistance Manual › Subpart M - Home Energy Assistance › Chapter 601 - LOW INCOME HOME ENERGY ASSISTANCE PROGRAM › Subchapter A - FEDERAL LOW INCOME HOME ENERGY ASSISTANCE PROGRAM › OVERPAYMENTS › Section 601.142 - Liability

Current through Register Vol. 54, No. 28, July 13, 2024
A person or agency that receives LIHEAP funds or
						  benefits for which it is ineligible shall repay the Department for the
						  overpayment.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part II - Public Assistance Manual › Subpart M - Home Energy Assistance › Chapter 601 - LOW INCOME HOME ENERGY ASSISTANCE PROGRAM › Subchapter A - FEDERAL LOW INCOME HOME ENERGY ASSISTANCE PROGRAM › OVERPAYMENTS › Section 601.143 - Fraud

Current through Register Vol. 54, No. 28, July 13, 2024
A person who knowingly misrepresents or withholds
						  information in order to qualify anyone for a LIHEAP benefit is guilty of fraud
						  and subject to a penalty of a fine or imprisonment, or both.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part II - Public Assistance Manual › Subpart M - Home Energy Assistance › Chapter 601 - LOW INCOME HOME ENERGY ASSISTANCE PROGRAM › Subchapter A - FEDERAL LOW INCOME HOME ENERGY ASSISTANCE PROGRAM › OVERPAYMENTS › Section 601.144 - Treatment of overpayments

Current through Register Vol. 54, No. 28, July 13, 2024
(a) If an
						overpayment occurs because of suspected fraud, client error or client
						misrepresentation, the Department will refer the overpayment for collection or
						prosecution to the Office of Fraud and Abuse Investigation and Recovery (OFAIR)
						in accordance with procedures under Chapter 255 (relating to
						restitution).
(b) If a vendor has
						received an overpayment of LIHEAP funds, the Department will take progressive
						steps, if necessary, to seek repayment of the funds as follows:
(1) The Department will notify the vendor of
						the overpayment by telephone to request repayment within 10 days of the
						telephone call.
(2) If, after 10
						days of the telephone call, the vendor fails or refuses to repay the Department
						for the overpayment, the Department will send a written notice to the vendor
						requesting restitution.
(3) If,
						after 10 days from the date of the written notice, the Department has still not
						received restitution from the vendor, the Department will send the vendor a
						notice by certified mail. This notice will inform the vendor that unless
						restitution is paid within 10 days, the Department will remove the vendor from
						the list of participating LIHEAP vendors and will refer the overpayment to
						OFAIR for collection.
(4) If, after
						10 days from the date of the notice by certified mail, the vendor fails to
						return the funds, the Department will remove the vendor from the list of
						participating vendors and refer the overpayment to the Department's OFAIR for
						investigation and collection.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part II - Public Assistance Manual › Subpart M - Home Energy Assistance › Chapter 601 - LOW INCOME HOME ENERGY ASSISTANCE PROGRAM › Subchapter B - STATE EMERGENCY ENERGY ASSISTANCE FUND › Section 601.151 - Eligibility criteria

Current through Register Vol. 54, No. 28, July 13, 2024
Eligibility criteria and benefits for the State Emergency
						Energy Assistance Fund shall be as set forth in the Commonwealth's Federal
						Fiscal Year 2006 LIHEAP State Plan and Subchapter A (relating to Federal Low
						Income Home Energy Assistance Program).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part II - Public Assistance Manual › Subpart M - Home Energy Assistance › Chapter 601 - LOW INCOME HOME ENERGY ASSISTANCE PROGRAM › Subchapter B - STATE EMERGENCY ENERGY ASSISTANCE FUND › Section 601.152 - Sunset date

Current through Register Vol. 54, No. 28, July 13, 2024
This subchapter will sunset on June 30,
						2006.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part II - Public Assistance Manual › Subpart M - Home Energy Assistance › Chapter 601 - LOW INCOME HOME ENERGY ASSISTANCE PROGRAM › Subchapter B - STATE EMERGENCY ENERGY ASSISTANCE FUND › Appendix A - HEATING REGIONS

Current through Register Vol. 54, No. 28, July 13, 2024
State Heating Region
Counties
1
Bradford, Cameron, Clearfield, Elk,
								Forest, Lackawanna, Luzerne, McKean, Potter, Sullivan, Susquehanna, Tioga,
								Wayne, Wyoming
2
Blair, Cambria, Carbon, Centre, Clarion,
								Clinton, Columbia, Crawford, Erie, Jefferson, Lycoming, Monroe, Pike,
								Schuylkill, Somerset, Venango, Warren
3
Armstrong, Beaver, Bedford, Butler,
								Huntingdon, Indiana, Lawrence, Mercer, Montour, Northumberland, Westmoreland
4
Adams, Allegheny, Berks, Bucks, Dauphin,
								Fayette, Franklin, Fulton, Greene, Juniata, Lebanon, Lehigh, Mifflin,
								Northampton, Perry, Snyder, Union, Washington
5
Chester, Cumberland, Delaware, Lancaster,
								Montgomery, Philadelphia, York
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1101 - GENERAL PROVISIONS › PRELIMINARY PROVISIONS › Section 1101.11 - General provisions

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
Scope.
This chapter sets forth the MA regulations and policies
				  which apply to providers. Regulations specific to each type of provider are
				  located in the separate chapters relating to each provider type.
(b)
Legal authority.
The MA
				  Program is authorized under Article IV of the Public Welfare Code
				  (62
				  P. S. §§
											401-488) and is
				  administered in conformity with Title XIX of the Social Security Act
				  (42 U.S.C.A. §§
											1396-1396q) and regulations issued
				  under it.
This section cited in 55 Pa. Code §
												1130.51 (relating to provider
						enrollment requirements).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1101 - GENERAL PROVISIONS › DEFINITIONS › Section 1101.21a - Clarification regarding the definition of "medically necessary"-statement of policy

Current through Register Vol. 54, No. 28, July 13, 2024
A service, item, procedure or level of care that is
					 necessary for the proper treatment or management of an illness, injury or
					 disability is one that:
(1) Will, or
				  is reasonably expected to, prevent the onset of an illness, condition, injury
				  or disability.
(2) Will, or is
				  reasonably expected to, reduce or ameliorate the physical, mental or
				  developmental effects of an illness, condition, injury or disability.
(3) Will assist the recipient to achieve or
				  maintain maximum functional capacity in performing daily activities, taking
				  into account both the functional capacity of the recipient and those functional
				  capacities that are appropriate of recipients of the same age.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1101 - GENERAL PROVISIONS › BENEFITS › Section 1101.31 - Scope

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
Scope
. The scope of benefits for which MA recipients are
				  eligible differs according to recipients' categories of assistance, as
				  described in this section.
(1) Recipients
				  under 21 years of age are eligible for all medically necessary
				  services.
(2) The benefit limits
				  specified in subsections (b), (c), and (e) apply only to adults, with the
				  exception of pregnant women, including throughout the postpartum
				  period.
(3) Recipients shall
				  exhaust other available medical resources prior to receiving MA
				  benefits.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1101 - GENERAL PROVISIONS › BENEFITS › Section 1101.32 - Coverage variations

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
Expanded coverage.
Expanded coverage benefits include the
				  following:
(1)
EPSDT.
Recipients under age 21 are entitled to benefit coverage for preventive health
				  screening and vision, dental, and hearing problems. The basis for this coverage
				  is the EPSDT. The Department will pay for scheduled periodic health screening
				  services for categorically needy and medically needy individuals. Clients may
				  receive these benefits at approved screening centers. If requested, the CAO
				  will assist clients in making an appointment. Recipients under age 21 are also
				  entitled to necessary vision care by a doctor of optometry or a physician
				  skilled in the diseases of the eye, hearing and dental exams and treatment
				  covered in the State Plan by virtue of being screened under EPSDT. A child need
				  not be screened first if an existing vision problem can be diagnosed and
				  treated by an appropriate specialist. Medically needy children referred from
				  EPSDT are not eligible for pharmaceuticals, medical supplies, equipment or
				  prostheses and orthoses.
(2)
School medical program.
A medically needy school child is
				  eligible for benefits available to categorically needy recipients if the
				  benefits are required to treat a health problem noted in his school medical
				  record. The school nurse or doctor refers the child to the provider by
				  completing a School Medical Referral Form. Payment for services provided under
				  this program shall be subject to this chapter and the applicable provider
				  regulations.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1101 - GENERAL PROVISIONS › BENEFITS › Section 1101.33 - Recipient eligibility

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
Verification of eligibility.
The County Assistance Office
				  determines whether or not an applicant is eligible for MA services. If the
				  applicant is determined to be eligible, the Department issues Medical Services
				  Eligibility (MSE) cards that are effective from the first of the month through
				  the last day of the month. Providers are responsible for checking the effective
				  dates on the MSE card and for making sure that services are furnished to a
				  person named on the card. The Department may not pay providers for services the
				  provider rendered to persons ineligible on the date of service unless there is
				  specific provision for the payment in the provider regulations. If the provider
				  notes any discrepancies, he should call the recipient's County Assistance
				  Office to verify eligibility.
(b)
Services restricted to a single provider.
Providers are
				  responsible for checking the recipient's MSE card and other forms of
				  notification sent to the provider by the Department, to verify that the
				  recipient has not been restricted to obtaining the service from a single
				  provider. The Department may not pay for a restricted service rendered by a
				  provider other than the one to which a recipient has been restricted unless it
				  was furnished in response to an emergency situation. Reference should be made
				  to §
										1101.91(b)
				  (relating to recipient misutilization and abuse).
(c)
Other resources.
The MSE
				  card lists any other medical coverage a recipient has of which the Department
				  may be aware. However, the provider has the responsibility of attempting to
				  identify and utilize all of the recipient's medical resources before billing
				  the Department as described in §
										1101.64 (relating to third-party
				  medical resources (TPR)).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1101 - GENERAL PROVISIONS › PARTICIPATION › Section 1101.41 - Provider participation and registration of shared health facilities

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Any physician,
				  dentist, optometrist, podiatrist, chiropractor, pharmacy, laboratory, nursing
				  facility, hospital, clinic, home health agency, ambulance service, health
				  establishment, State Mental Retardation Center or medical supplier in this
				  Commonwealth or another state may apply to participate in the MA
				  Program.
(b) Shared health
				  facilities shall register and sign a shared health facility agreement with the
				  Department and meet the requirements set forth in Chapter 1102 (relating to
				  shared health facilities).
(c) Each
				  provider who renders services in a registered shared health facility shall
				  enroll in the program and meet §
										1102.41 (relating to provider
				  participation and enrollment).
This section cited in 55 Pa. Code §
												1121.41 (relating to participation
						requirements); 55 Pa. Code §
												1123.41 (relating to participation
						requirements); 55 Pa. Code §
												1127.41 (relating to participation
						requirements); 55 Pa. Code §
												1128.41 (relating to participation
						requirements); 55 Pa. Code §
												1141.41 (relating to participation
						requirements); 55 Pa. Code §
												1142.41 (relating to participation
						requirements); 55 Pa. Code §
												1143.41 (relating to participation
						requirements); 55 Pa. Code §
												1144.41 (relating to participation
						requirements); 55 Pa. Code §
												1149.41 (relating to participation
						requirements); and 55 Pa. Code §
												1251.41 (relating to participation
						requirements).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1101 - GENERAL PROVISIONS › PARTICIPATION › Section 1101.42a - Policy clarification regarding physician licensure-statement of policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a) To participate
				  in the MA Program, a physician shall have and maintain a current license.
(1) Services rendered, ordered, arranged for
				  or prescribed for MA recipients by a physician whose license to practice
				  medicine has expired are not eligible for payment under the MA
				  Program.
(2) Refer to §
											1101.42 (relating to prerequisites
				  for participation) and 49 Pa. Code Chapters 16, 17 and 25 (relating to State
				  Board of Medicine-general provisions; State Board of Medicine-medical doctors;
				  and State Board of Osteopathic Medicine) for additional requirements.
(3) The Department intends to periodically
				  monitor the expiration of medical licenses to ensure compliance with MA
				  regulations.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1101 - GENERAL PROVISIONS › PARTICIPATION › Section 1101.42b - Certificate of Need requirement for participation-statement of policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Effective
				  December 19, 1996, the Department will not enter into a provider agreement with
				  an ICF/MR, nursing facility, an inpatient psychiatric hospital or a
				  rehabilitation hospital unless the Department of Health issued a Certificate of
				  Need authorizing construction of the facility or hospital in accordance with 28
				  Pa. Code Chapter 401 (relating to Certificate of Need program) or a letter of
				  nonreviewability indicating that the facility or hospital was not subject to
				  review under 28 Pa. Code Chapter 401 dated on or before December 18,
				  1996.
(b) The Department will
				  consider exceptions to subsection (a) on a case-by-case basis. Exceptions
				  requested by nursing facilities will be reviewed under §
										1187.21a (relating to nursing
				  facility exception requests-statement of policy).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1101 - GENERAL PROVISIONS › RESPONSIBILITIES › Section 1101.51 - Clarification of the term ''within a provider's office''- statement of policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
Recipient freedom of choice of providers.
A recipient may
				  obtain services from any institution, agency, pharmacy, person or organization
				  that is approved by the Department to provide them. Therefore, the provider
				  shall not make any direct or indirect referral arrangements between
				  practitioners and other providers of medical services or supplies but may
				  recommend the services of another provider or practitioner; automatic referrals
				  between providers are, however, prohibited.
(b)
Nondiscrimination.
Federal regulations require that programs receiving Federal assistance through
				  HHS comply fully with Title VI of the Civil Rights Act of 1964 (42 U.S.C.A. §
											§
											2000d-2000d-4) , Section 504 of the
				  Rehabilitation Act of 1973 (29 U.S.C.A.
				  §
											794) , and the Pennsylvania Human
				  Relations Act (43 P. S. §
											§
											951-963). Providers are prohibited from
				  denying services or otherwise discriminating against an MA recipient on the
				  grounds of race, color, national origin or handicap.
(c)
Interrelationship of
				  providers.
Providers are prohibited from making the following
				  arrangements with other providers:
(1) The
				  referral of MA recipients directly or indirectly to other practitioners or
				  providers for financial consideration or the solicitation of MA recipients from
				  other providers.
(2) The offering
				  of, or paying, or the acceptance of remuneration to or from other providers for
				  the referral of MA recipients for services or supplies under the MA
				  Program.
(3) [Reserved].
(4) The solicitation or receipt or offer of a
				  kickback, payment, gift, bribe or rebate for purchasing, leasing, ordering or
				  arranging for or recommending purchasing, leasing, ordering or arranging for or
				  recommending purchasing, leasing or ordering a good, facility, service or item
				  for which payment is made under MA. This does not preclude discounts or other
				  reductions in charges by a provider to a practitioner for services, that is,
				  laboratory and x-ray, so long as the price is properly disclosed and
				  appropriately reflected in the costs claimed or charges made by a
				  practitioner.
(5) A participating
				  practitioner or professional corporation may not refer a MA recipient to an
				  independent laboratory, pharmacy, radiology or other ancillary medical service
				  in which the practitioner or professional corporation has an ownership
				  interest.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1101 - GENERAL PROVISIONS › FEES AND PAYMENTS › Section 1101.61 - Reimbursement policies

Current through Register Vol. 54, No. 28, July 13, 2024
The Department will only pay for medically necessary
					 compensable services and items in accordance with this part and Chapter 1150
					 (relating to MA Program payment policies) and the MA Program fee schedule.
This section cited in 55 Pa. Code §
												1181.542 (relating to who is
						required to be screened).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1101 - GENERAL PROVISIONS › FEES AND PAYMENTS › Section 1101.62 - Maximum fees

Current through Register Vol. 54, No. 28, July 13, 2024
The Department's maximum fees or rates are the lowest of
					 the upper limits set by Medicare or Medicaid, or the fees or rates listed in
					 the separate provider chapters and fee schedules or the provider's usual and
					 customary charge to the general public. For the purpose of establishing the
					 usual and customary charge to the general public, the provider shall permit the
					 Department access to payment records of non-MA patients without disclosing the
					 identity of the patients.
This section cited in 55 Pa. Code §
												1143.51 (relating to general
						payment policy); and 55 Pa. Code §
												1143.58 (relating to
						noncompensable services and items).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1101 - GENERAL PROVISIONS › FEES AND PAYMENTS › Section 1101.63a - Full reimbursement for covered services rendered-statement of policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Section 1406(a)
				  of the Public Welfare Code (62 P. S. §
											1406(a)) and MA regulations
				  in §
										1101.63(a) 
				  (relating to payment in full) mandate that all payments made to providers under
				  the MA Program plus any copayment required to be paid by a recipient shall
				  constitute full reimbursement to the provider for covered services
				  rendered.
(b) A provider who seeks
				  or accepts supplementary payment of another kind from the Department, the
				  recipient or another person for a compensable service or item is required to
				  return the supplementary payment.
(c) A provider may bill an MA recipient for a
				  noncompensable service or item if the recipient is told before the service is
				  rendered that the program does not cover it.
This section cited in 55 Pa. Code §
												1187.158 (relating to
						appeals).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1101 - GENERAL PROVISIONS › FEES AND PAYMENTS › Section 1101.64 - Third-party medical resources (TPR)

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
General.
Other private
				  or governmental health insurance benefits shall be utilized before billing the
				  MA Program. Providers shall make reasonable efforts to secure from the
				  recipient sufficient information regarding the primary coverages necessary to
				  bill the insurers or programs. The medical resources which are primary third
				  parties to MA include Medicare; CHAMPUS (Civilian Health and Medical Programs
				  of the Uniformed Services); Blue Cross, Blue Shield or other commercial
				  insurance; VA benefits; Workman's Compensation; and the like. The information
				  needed to bill third parties includes the insurer's name and address, policy or
				  group I.D. number, and the patient's or the patient's employer's address. When
				  the total amount of payment by the third-party resource is less than the
				  Department's fee or rate for the same service, the provider may bill the
				  Department for the difference by submitting an invoice with a copy of the third
				  party's statement of payments attached. If a third-party resource refuses
				  payment to the provider based on coverage exclusions or other reasons, the
				  provider may bill the Department by submitting an invoice with a copy of the
				  third party's refusal advisory attached.
(b)
Persons covered by Medicare and
				  MA.
If a MA recipient also has Medicare coverage, the Department may
				  be billed for charges that Medicare applied to the deductible or coinsurance,
				  or both. Payment will be made in accordance with established MA rates and
				  fees.
This section cited in 55 Pa. Code §
												1101.33 (relating to recipient
						eligibility); 55 Pa. Code §
												1140.54 (relating to
						noncompensable services and items); 55 Pa. Code §
												1142.55 (relating to
						noncompensable services); 55 Pa. Code §
												1144.53 (relating to
						noncompensable services); 55 Pa. Code §
												1155.31 (relating to general
						payment policy); 55 Pa. Code §
												1187.155 (relating to exceptional
						DME grants-payment conditions and limitations); and 55 Pa. Code §
												6100.482 (relating to
						payment).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1101 - GENERAL PROVISIONS › FEES AND PAYMENTS › Section 1101.65 - Method of payment

Current through Register Vol. 54, No. 28, July 13, 2024
The Department makes direct payments to enrolled providers
					 for medically necessary compensable services and items furnished to eligible
					 recipients. The MA Program does not reimburse recipients for their
					 expenditures. To be reimbursed for an item or service, the provider shall be
					 eligible to provide it on the date it is provided, and the recipient shall be
					 eligible to receive it on the date it is furnished unless there is specific
					 provision for such payment in the provider regulations. Providers are
					 prohibited from factoring, assigning, reassigning or executing a power of
					 attorney for the rights to any claims or payments for services rendered under
					 the program except as provided in paragraphs (1) and (3).
(1)
Reassignment of payment.
The Department will not make payment to a collection agency or a service bureau
				  to which a provider has assigned his accounts receivable; however, payment may
				  be made if the provider has reassigned his claim to a government agency or the
				  reassignment is by a court order.
(2)
Payment through business
				  agents.
The Department will not make payment to a provider through a
				  billing service or accounting firm that receives payment in the name of the
				  provider.
(3)
Payment
				  through employers.
Payment may be made to practitioners' professional
				  corporations or partnerships if the professional corporation or partnership is
				  composed of like practitioners. Payment is made directly to practitioners if
				  they are members of professional corporations or partnerships composed of
				  unlike practitioners. The Department will not make payment to a shared health
				  facility for services rendered by a practitioner practicing at the shared
				  health facility.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1101 - GENERAL PROVISIONS › FEES AND PAYMENTS › Section 1101.66 - Payment for rendered, prescribed or ordered services

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The Department pays for compensable
				  services or items rendered, prescribed or ordered by a practitioner or provider
				  if the service or item is:
(1) Within the
				  practitioner's scope of practice.
(2) Medically necessary.
(3) Not in an amount that exceeds the
				  recipient's needs.
(4) Not ordered
				  or prescribed solely for the recipient's convenience.
(5) Ordered with the recipient's
				  knowledge.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1101 - GENERAL PROVISIONS › FEES AND PAYMENTS › Section 1101.66a - Clarification of the terms "written" and "signature"-statement of policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The term
				  "written" in §
										1101.66(b) 
				  (relating to payment for rendered, prescribed or ordered services) includes
				  orders and prescriptions that are handwritten or transmitted by electronic
				  means.
(b) Written orders and
				  prescriptions transmitted by electronic means must be electronically encrypted
				  or transmitted by other technological means designed to protect and prevent
				  access, alteration, manipulation or use by any unauthorized person.
(c) The term "signature" in §
										1101.66(b)(2)
				  includes a handwritten or electronic signature that is made in accordance with
				  the Electronic Transaction Act (73 P. S. §§
											2260.101-2260.5101).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1101 - GENERAL PROVISIONS › FEES AND PAYMENTS › Section 1101.67 - Prior authorization

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
				  This section does not apply to noncompensable items or services. Medical
				  services and items that require prior authorization are designated in Chapter
				  1150 (relating to MA Program payment policies) and the MA Program Fee Schedule
				  and may also be addressed in the specific provider chapters. Providers shall
				  follow the instructions in the provider handbook for processing prior
				  authorization requests. Services and items that require prior authorization
				  shall be prescribed or ordered by a licensed practitioner.
(b) If a recipient is not notified of a
				  decision on a request for a covered service or item within 21 days of the date
				  the written request is received by the Department, the authorization is
				  automatically approved.
(1) For services prior
				  authorized at the State level, the 21 day time period will be satisfied if the
				  Department mails to the recipient, the recipient's practitioner or provider, a
				  notice of approval or denial of prior authorization request on or before the
				  18th day after receipt of the request at the address specified in the handbook.
				  If the notice is not mailed within 18 days from the date of receipt at the
				  address specified in the handbook, the request is automatically
				  authorized.
(2) The Department
				  will, if necessary, ask the practitioner for additional information to assist
				  the Department's medical consultants to reach a decision. If the practitioner
				  fails to provide the additional information in sufficient time for the
				  Department to consider it before the time for the Department's acting on the
				  request expires, prior authorization will be denied.