reglab/statecodes huggingface dataset:
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1245 - AMBULANCE TRANSPORTATION › GENERAL PROVISIONS › Section 1245.2 - Definitions

Current through Register Vol. 54, No. 28, July 13, 2024
The following words and terms, when used in this chapter,
					 have the following meanings, unless the context clearly indicates
					 otherwise:
ALS-Advanced Life Support
-Services
					 provided for life-threatening situations.
Appropriate medical facility
-A clinic,
					 rural health clinic, hospital, skilled nursing facility or intermediate care
					 facility which participates in the MA Program.
BLS-Basic Life Support
-Services provided
					 for emergency or nonemergency situations.
Clinic
-An independent or hospital operated
					 facility enrolled in the MA Program which is designed to provide preventative
					 diagnostic, therapeutic, rehabilitative or palliative services on an outpatient
					 basis.
General public
-Patients other than MA
					 recipients.
Incapacitated
-Incapable of sitting,
					 standing or perambulating.
Medical service
-A covered service as
					 specified in Chapter 1101 (relating to general provisions).
Mileage
-The distance traveled from the
					 point of departure of the ambulance to the point of destination and the return
					 to the point of departure.
Physician's office
-A site designated for
					 the sole purpose of providing physicians' services to outpatients. This
					 includes a private physician's office located at a hospital or other medical
					 facility.
Specialized services
-Interfacility
					 transportation of critical care patients such as neonatal, prenatal or cardiac
					 patients provided by ALS units.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1245 - AMBULANCE TRANSPORTATION › COVERED AND NONCOVERED SERVICES › Section 1245.11 - Types of services covered

Current through Register Vol. 54, No. 28, July 13, 2024
MA Program coverage for ambulance transportation is limited
					 to the transportation of eligible recipients to their home, or to the nearest
					 appropriate medical facility site only when the condition of the patient
					 absolutely precludes another method of transportation, or to a nonhospital drug
					 and alcohol detoxification or rehabilitation facility from a hospital when a
					 recipient presents to the hospital for inpatient drug and alcohol treatment and
					 the hospital has determined that the required services are not medically
					 necessary in an inpatient facility.
The provisions of this §
												1245.11 amended under sections
						201(2) and 443.1(1) of the Public Welfare Code (62 P. S. §§
													201(2) and
						443.1(1)).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1245 - AMBULANCE TRANSPORTATION › SCOPE OF BENEFITS › Section 1245.21 - Scope of benefits for the categorically needy

Current through Register Vol. 54, No. 28, July 13, 2024
Categorically needy recipients are eligible for the full
					 range of covered ambulance transportation services listed in Chapter 1150
					 (relating to MA Program payment policies) and the MA Program fee schedule.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1245 - AMBULANCE TRANSPORTATION › SCOPE OF BENEFITS › Section 1245.22 - Scope of benefits for the medically needy

Current through Register Vol. 54, No. 28, July 13, 2024
Medically needy recipients are eligible for the full range
					 of covered ambulance transportation services listed in Chapter 1150 (relating
					 to MA Program payment policies) and the MA Program fee schedule.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1245 - AMBULANCE TRANSPORTATION › SCOPE OF BENEFITS › Section 1245.23 - Scope of benefits for State Blind Pension recipients

Current through Register Vol. 54, No. 28, July 13, 2024
State Blind Pension recipients are eligible for the full
					 range of covered ambulance transportation services listed in the fee schedule
					 in Chapter 1150 (relating to MA Program payment policies) and the MA Program
					 fee schedule.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1245 - AMBULANCE TRANSPORTATION › SCOPE OF BENEFITS › Section 1245.24 - Scope of benefits for General Assistance recipients

Current through Register Vol. 54, No. 28, July 13, 2024
General Assistance recipients, age 21 to 65, whose MA
					 benefits are funded solely by State funds, are eligible for medically necessary
					 basic health care benefits as defined in Chapter 1101 (relating to general
					 provisions). See § 1101.31(e) (relating to scope).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1245 - AMBULANCE TRANSPORTATION › PROVIDER PARTICIPATION › Section 1245.41 - Participation requirements

Current through Register Vol. 54, No. 28, July 13, 2024
In addition to the participation requirements in Chapter
					 1101 (relating to general provisions), ambulance transportation providers shall
					 meet the following requirements:
(1)
				  Ambulance providers that transport recipients shall be Medicare
				  certified.
(2) Ambulance providers
				  approved to provide ALS services shall submit to the Department an approval
				  letter from their regional emergency medical services council designated by the
				  Department of Health, and approved by its division of emergency medical
				  services of the Department of Health.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1245 - AMBULANCE TRANSPORTATION › PAYMENT FOR AMBULANCE TRANSPORTATION SERVICES › Section 1245.51 - General payment policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
				  Payment is made for medically necessary ambulance transportation services
				  subject to the conditions and limitations established in this chapter, and
				  Chapters 1101 and 1150 (relating to general provisions; and MA Program payment
				  policies). Payment for transportation other than by ambulance is made through
				  the MA Transportation Program, administered by the Office of Social Programs in
				  accordance with §
										175.23(b)(2) and
				  (3) (relating to requirements).
(b) Ambulance services which obtain Voluntary
				  Ambulance Service Certification (VASC) from the Department of Health will be
				  reimbursed at a higher rate than non-VASC certified services, as listed in
				  Chapter 1150.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1245 - AMBULANCE TRANSPORTATION › PAYMENT FOR AMBULANCE TRANSPORTATION SERVICES › Section 1245.52 - Payment conditions

Current through Register Vol. 54, No. 28, July 13, 2024
Payment for ambulance transportation will be made subject
					 to the following conditions:
(1)
				  Ambulance transportation is medically necessary. For ambulance transportation
				  to be considered medically necessary, one or more of the following conditions
				  shall be documented in the remarks section of the Medical Services/Supplies
				  Invoice:
(i) The patient is incapacitated as
				  the result of injury or illness and transportation by van, taxicab, public
				  transportation or private vehicle is either physically impossible or would
				  endanger the health of the patient.
(ii) There is reason to suspect serious
				  internal or head injury.
(iii) The
				  patient requires physical restraints.
(iv) The patient requires oxygen or other
				  life support treatment en route.
(v) Because of the medical history of the
				  patient and present condition, there is reason to believe that oxygen or life
				  support treatment is required en route.
(vi) The recipient requires transportation
				  from a hospital to a nonhospital drug and alcohol detoxification facility or
				  rehabilitation facility and the hospital has determined that the required
				  services are not medically necessary in an inpatient facility.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1245 - AMBULANCE TRANSPORTATION › PAYMENT FOR AMBULANCE TRANSPORTATION SERVICES › Section 1245.53 - Limitations on payment

Current through Register Vol. 54, No. 28, July 13, 2024
Payment for ambulance transportation is subject to the
					 following limitation:
(1) If more than
				  one person is transported during the same trip, either to the same destination
				  or a different destination, payment is made for the transportation of the
				  patient whose destination is the greatest distance. No additional payment is
				  allowed for the additional person.
(2) [Reserved].
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1245 - AMBULANCE TRANSPORTATION › PAYMENT FOR AMBULANCE TRANSPORTATION SERVICES › Section 1245.54 - Noncompensable services and items

Current through Register Vol. 54, No. 28, July 13, 2024
Payment will not be made for the following services and
					 items:
(1) Ambulance transportation to
				  a physician's office or group practice.
(2) Ambulance transportation for a medical
				  service which is not covered under the MA Program, except for nonhospital drug
				  and alcohol detoxification or rehabilitation facility services when a recipient
				  presents to a hospital for inpatient drug and alcohol treatment and the
				  hospital has determined that the required services are not medically necessary
				  in an inpatient facility.
(3)
				  Ambulance transportation to a clinic, rural health clinic, hospital, skilled
				  nursing facility or intermediate care facility not enrolled in the MA Program,
				  except in an emergency situation. An emergency situation is when an item or
				  service is required to sustain the life of a person or is critical to the
				  health of a person.
(4) Ambulance
				  transportation of a deceased person to a morgue or funeral parlor.
(5) Ambulance transportation from one medical
				  facility to another, unless it is for the purpose of obtaining necessary
				  medical care which is unavailable at the facility in which the recipient is a
				  patient and meets the requirements in §
										1245.52 (relating to payment
				  conditions).
(6) Ambulance
				  transportation from one long term care facility to another, unless it is for
				  the purpose of changing the patient's level of care or if the patient is
				  transferred from a facility because its provider agreement has been terminated
				  and the requirements in §
										1245.52 are met. Payment is not
				  made if the ambulance is owned by the nursing facility.
(7) Ambulance transportation out-of-State,
				  unless the nearest appropriate medical facility is located
				  out-of-State.
(8) Ambulance
				  transportation that is available from another insurance or health program of
				  public agency.
The provisions of this §
												1245.54 amended under sections
						201(1) and 443.1(1) of the Public Welfare Code (62 P. S. §§
													201(1) and
						443.1(1)).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1245 - AMBULANCE TRANSPORTATION › PAYMENT FOR AMBULANCE TRANSPORTATION SERVICES › Section 1245.55 - Billing a recipient for noncompensable ambulance transportation

Current through Register Vol. 54, No. 28, July 13, 2024
A MA client may be billed for ambulance transportation
					 services only if all of the following conditions have been met:
(1) The provider determines that ambulance
				  transportation is not covered by MA under the existing circumstances.
(2) The client or responsible party is
				  informed before the service is rendered that he must pay for the
				  service.
(3) The client or
				  responsible party consents to receive the service and be responsible for the
				  charges.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1245 - AMBULANCE TRANSPORTATION › UTILIZATION CONTROL › Section 1245.71 - Scope of claims review procedures

Current through Register Vol. 54, No. 28, July 13, 2024
Claims submitted for payment under the MA Program are
					 subject to the utilization control procedures established in Chapter 1101
					 (relating to general provisions). Providers shall fully cooperate with audits
					 and reviews made by the Department for the purpose of determining the validity
					 and claims, the reasonableness and necessity of services provided and charges
					 made to the general public.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1245 - AMBULANCE TRANSPORTATION › ADMINISTRATIVE SANCTIONS › Section 1245.81 - Provider misutilization

Current through Register Vol. 54, No. 28, July 13, 2024
Providers determined to have billed for services
					 inconsistent with MA Program regulations, or to have otherwise violated the
					 standards set forth in the provider agreement, are subject to the sanctions
					 described in Chapter 1101 (relating to general provisions).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1247 - TARGETED CASE MANAGEMENT SERVICES › GENERAL PROVISIONS › Section 1247.1 - Policy

Current through Register Vol. 54, No. 28, July 13, 2024
The MA Program provides payment for targeted case
					 management services rendered to eligible recipients by case managers enrolled
					 as providers under the program. Payment for targeted case management services
					 is subject to this chapter, and Chapters 1101 and 1150 (relating to general
					 provisions; MA Program payment policies) and the MA Program Fee
					 Schedule.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1247 - TARGETED CASE MANAGEMENT SERVICES › GENERAL PROVISIONS › Section 1247.2 - Definitions

Current through Register Vol. 54, No. 28, July 13, 2024
The following words and terms, when used in this chapter,
					 have the following meanings, unless the context clearly indicates otherwise:
Case manager
-An individual approved by the
					 Department to provide targeted case management services.
Targeted case management services
-Services
					 which provide targeted MA recipients with access to comprehensive medical and
					 social services to encourage the cost effective use of medical and community
					 resources, promoting the well-being of the recipient while ensuring the
					 recipient's freedom of choice.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1247 - TARGETED CASE MANAGEMENT SERVICES › GENERAL PROVISIONS › Section 1247.3 - Target groups

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Targeted
				  case management services are provided to eligible clients with the diagnosed
				  medical conditions listed in Appendix A (relating to targeted case management
				  services-eligible target groups).
(b) The Department will announce additional
				  target groups by notice in the
Pennsylvania Bulletin
and
				  codify the target groups in Appendix A.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1247 - TARGETED CASE MANAGEMENT SERVICES › SCOPE OF BENEFITS › Section 1247.21 - Scope of benefits for the categorically needy

Current through Register Vol. 54, No. 28, July 13, 2024
Categorically needy recipients not enrolled in a hospice,
					 health maintenance or health insuring organization are eligible for targeted
					 case management services if they have a diagnosed medical condition identified
					 by the Department as belonging to a target group.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1247 - TARGETED CASE MANAGEMENT SERVICES › SCOPE OF BENEFITS › Section 1247.22 - Scope of benefits for the medically needy

Current through Register Vol. 54, No. 28, July 13, 2024
Medically needy recipients not enrolled in a hospice,
					 health maintenance or health insuring organization are eligible for targeted
					 case management services if they have a diagnosed medical condition identified
					 by the Department as belonging to a target group.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1247 - TARGETED CASE MANAGEMENT SERVICES › SCOPE OF BENEFITS › Section 1247.23 - Scope of benefits for State Blind Pension recipients

Current through Register Vol. 54, No. 28, July 13, 2024
State Blind Pension recipients are not eligible for
					 targeted case management services under the MA Program unless the recipient is
					 also categorically needy or medically needy.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1247 - TARGETED CASE MANAGEMENT SERVICES › PROVIDER PARTICIPATION › Section 1247.41 - Participation requirements

Current through Register Vol. 54, No. 28, July 13, 2024
(a) In
				  addition to the participation requirements established in Chapter 1101
				  (relating to general provisions), each case manager shall enroll in the MA
				  Program as a case manager.
(b)
				  Enrollment is open to registered nurses licensed in this Commonwealth and
				  individuals possessing, at a minimum, a bachelor's degree in one of the social
				  sciences.
(c) Case managers shall
				  maintain licensure status, if required for initial enrollment, and shall have
				  the particularized knowledge of the special needs associated with the
				  conditions of the special target group.
(d) In addition to meeting the requirements
				  of this section, out-of-State case managers are eligible for enrollment if one
				  of the following occurs:
(1) An appropriate
				  Pennsylvania-based case manager is not available within a reasonable distance
				  to provide the targeted case management services needed by members of a target
				  group.
(2) The recipient lives in
				  an area where residents generally receive health care services from providers
				  located in the area in which the case manager is situated.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1247 - TARGETED CASE MANAGEMENT SERVICES › PROVIDER PARTICIPATION › Section 1247.42 - Ongoing responsibilities of providers

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Ongoing responsibilities of providers are
				  established in §
										1101.51 (relating to ongoing
				  responsibilities of providers).
(b)
				  In addition to the requirements set forth under subsection (a), a case manager
				  shall comply with the following recordkeeping requirements:
(1) A case manager shall maintain an activity
				  log on each recipient that includes, at a minimum:
(i) The case manager's name.
(ii) The recipient's name and MA
				  identification number.
(iii) The
				  time, date, place and a description of each targeted case management
				  service.
(iv) Information relating
				  to the services provided.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1247 - TARGETED CASE MANAGEMENT SERVICES › PAYMENT FOR TARGETED CASE MANAGEMENT SERVICES › Section 1247.51 - General payment policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
				  The Department pays a predetermined fee for targeted case management services
				  provided to eligible recipients by participating case managers subject to the
				  conditions and limitations established in this chapter.
(b) Payment is made for targeted case
				  management services provided in 15-minute units.
(c) The Department will determine the target
				  groups eligible for targeted case management services.
(d) The Department will determine the
				  geographic areas covered by targeted case management services.
(e) Targeted case management services are
				  optional services available to eligible recipients.
(f) Recipient access to targeted case
				  management services is as follows:
(1)
				  Recipients may access targeted case management services through self-referral
				  or referral by a physician, advocacy group, the local county assistance office
				  or other person/agency acting on behalf of the recipient.
(2) Recipients may apply for a change in case
				  managers by submitting a written request to the Department. Reassignment to
				  another case manager takes effect 30 days from the date on which the request is
				  received by the Department contingent upon the availability of an appropriate
				  case manager.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1247 - TARGETED CASE MANAGEMENT SERVICES › PAYMENT FOR TARGETED CASE MANAGEMENT SERVICES › Section 1247.52 - Payment criteria

Current through Register Vol. 54, No. 28, July 13, 2024
The Department will establish maximum fees for case
					 managers based on the criteria established in §
										1150.6 (relating to payment
					 levels), and included in the MA Program Fee Schedule.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1247 - TARGETED CASE MANAGEMENT SERVICES › PAYMENT FOR TARGETED CASE MANAGEMENT SERVICES › Section 1247.53 - Limitations on payment

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The
				  Department's coverage for targeted case management services is limited to a
				  specified number of hours per 30-day period as determined by the Department as
				  appropriate for the specific target group, and included in the MA Program Fee
				  Schedule.
(b) Payment will be made
				  for targeted case management services provided by only one MA case manager per
				  recipient for a given period of time, which will be determined by the
				  Department.
(c) Coverage for
				  targeted case management services is limited to recipients identified by the
				  Department as belonging to a group targeted for case management
				  services.
(d) The Department
				  reserves the right to limit a case manager MA caseload.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1247 - TARGETED CASE MANAGEMENT SERVICES › PAYMENT FOR TARGETED CASE MANAGEMENT SERVICES › Section 1247.54 - Noncompensable services

Current through Register Vol. 54, No. 28, July 13, 2024
Payment will not be made to a case manager for the
					 following:
(1) Targeted case
				  management services that are available through other public agencies, private
				  insurance plans and State or Federal programs.
(2) Targeted case management services
				  provided to recipients who reside in a geographic area excluded from the
				  program for that target group or who do not otherwise qualify as members of a
				  target group.
(3) Targeted case
				  management that is provided as an integral part of another covered MA
				  service.
(4) Services provided for
				  purposes other than to assist the recipient to gain access to medical and
				  social services related to a targeted illness. These services include
				  institutional discharge planning and outreach activities for the purpose of
				  seeking potential recipients of targeted case management services.
(5) Services other than those defined by the
				  Department as targeted case management services.
(6) Direct patient care services other than
				  those provided for under this chapter.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1247 - TARGETED CASE MANAGEMENT SERVICES › UTILIZATION CONTROL › Section 1247.71 - Scope of claim review procedures

Current through Register Vol. 54, No. 28, July 13, 2024
Claims submitted for payment under the MA Program are
					 subject to the utilization review procedures established in Chapter 1101
					 (relating to general provisions).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1247 - TARGETED CASE MANAGEMENT SERVICES › ADMINISTRATIVE SANCTIONS › Section 1247.81 - Provider misutilization

Current through Register Vol. 54, No. 28, July 13, 2024
Providers determined to have billed for services
					 inconsistent with this part, to have provided services outside the scope of
					 customary standards of practice, or to have otherwise violated the standards in
					 the provider agreement, are subject to the sanctions described in Chapter 1101
					 (relating to general provisions).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1247 - TARGETED CASE MANAGEMENT SERVICES › ADMINISTRATIVE SANCTIONS › Appendix A - TARGETED CASE MANAGEMENT SERVICES-ELIGIBLE TARGET GROUPS

Current through Register Vol. 54, No. 28, July 13, 2024
Target groups eligible for targeted case management
					 services are those eligible clients with the diagnosed medical conditions
					 listed as follows:
Acquired Immune Deficiency Syndrome (AIDS) or Symptomatic
					 Human Immunodeficiency Virus (HIV).
This appendix cited in 55 Pa. Code §
												1247.3 (relating to target
						groups).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1249 - HOME HEALTH AGENCY SERVICES › GENERAL PROVISIONS › Section 1249.1 - Policy

Current through Register Vol. 54, No. 28, July 13, 2024
The MA Program provides payment for specific medically
					 necessary home health services rendered to eligible recipients by providers
					 enrolled under the program. Payment for home health services is subject to this
					 chapter, Chapter 1101 (relating to general provisions) and the limitations
					 established in Chapter 1150 (relating to the MA Program payment policies) and
					 the MA Program fee schedule.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1249 - HOME HEALTH AGENCY SERVICES › GENERAL PROVISIONS › Section 1249.2 - Definitions

Current through Register Vol. 54, No. 28, July 13, 2024
The following words and terms, when used in this chapter,
					 have the following meanings, unless the context clearly indicates
					 otherwise:
Home health agency
-A public or private
					 agency or organization, or part of an agency or organization that is licensed
					 by the Commonwealth and certified for participation in Medicare. The agency
					 shall be staffed and equipped to provide skilled nursing care and at least one
					 therapeutic service-physical therapy, occupational therapy or speech
					 pathology-or home health aides to a disabled, aged, injured or sick recipient
					 on a part-time or intermittent basis in his residence.
Home health services
-Nursing services,
					 home health aide services, physical therapy, occupational therapy or speech
					 pathology and audiology services provided by a home health agency and medical
					 supplies, equipment and appliances suitable for use in the home. For the
					 purpose of this chapter, medical supplies, equipment and appliances do not
					 include dentures, prosthetic devices, orthoses or eyeglasses.
Residence
-A place where the recipient
					 makes his home.
(i) The term includes
				  a personal care home, a hospice, a relative's home or a friend's
				  home.
(ii) The term does not
				  include a hospital, skilled nursing facility or intermediate care
				  facility.
Usual charge
-A home health agency's most
					 frequent charge to the general public within the same calendar month.
Visit
-A personal contact in the
					 recipient's residence made for the purpose of providing a covered service by a
					 health care worker on the staff of the home health agency or by others under
					 contract or arrangement with the home health agency.
The provisions of this §
												1249.2 amended under sections
						403(a) and (b), 443.2(2) and 509 of the Public Welfare Code (62 P. S.
						§§
													403(a) and (b),
						443.2(2) and
						509).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1249 - HOME HEALTH AGENCY SERVICES › SCOPE OF BENEFITS › Section 1249.21 - Scope of benefits for the categorically needy

Current through Register Vol. 54, No. 28, July 13, 2024
Categorically needy recipients are eligible for medically
					 necessary home health services covered by the MA Program subject to the
					 conditions and limitations established in this chapter.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1249 - HOME HEALTH AGENCY SERVICES › SCOPE OF BENEFITS › Section 1249.22 - Scope of benefits for the medically needy

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Medically needy recipients are eligible
				  for medically necessary home health services covered by the MA Program subject
				  to the conditions and limitations established in this chapter.
(b) Although medical supplies, equipment and
				  appliances are not ordinarily included in the scope of benefits for the
				  medically needy, medical supplies, equipment and appliances suitable for use in
				  the home are covered for the medically needy if they are provided in
				  conjunction with nursing or home health aide services and are part of the
				  treatment plan of the physician. Payment for medical supplies, equipment and
				  appliances is made only to participating medical suppliers and is subject to
				  Chapter 1123 (relating to medical supplies).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1249 - HOME HEALTH AGENCY SERVICES › SCOPE OF BENEFITS › Section 1249.23 - Scope of benefits for State Blind Pension recipients

Current through Register Vol. 54, No. 28, July 13, 2024
(a) State Blind Pension recipients are
				  eligible for medically necessary home health services covered by the MA Program
				  subject to the conditions and limitations established in this
				  chapter.
(b) Medical supplies are
				  not covered for State Blind Pension recipients.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1249 - HOME HEALTH AGENCY SERVICES › SCOPE OF BENEFITS › Section 1249.24 - Scope of benefits for General Assistance recipients

Current through Register Vol. 54, No. 28, July 13, 2024
General Assistance recipients, age 21 to 65, whose MA
					 benefits are funded solely by State funds, are eligible for medically necessary
					 basic health care benefits as defined in Chapter 1101 (relating to general
					 provisions). See § 1101.31(e) (relating to scope).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1249 - HOME HEALTH AGENCY SERVICES › PROVIDER PARTICIPATION › Section 1249.41 - Participation requirements

Current through Register Vol. 54, No. 28, July 13, 2024
In addition to the participation requirements established
					 in Chapter 1101 (relating to general provisions) home health agencies shall be
					 certified by the Department of Health as meeting the requirements for Medicare
					 home health agencies.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1249 - HOME HEALTH AGENCY SERVICES › PROVIDER PARTICIPATION › Section 1249.42 - Ongoing responsibilities of providers

Current through Register Vol. 54, No. 28, July 13, 2024
Ongoing responsibilities of providers are established in
					 Chapter 1101 (relating to general provisions). The home health agency shall:
(1) Have written policies concerning
				  the acceptance of recipients and the feasibility of meeting the recipient's
				  needs in the home care setting, which include, but are not limited to:
(i) An evaluation visit in the recipient's
				  residence to consider the physical facilities available, attitudes of family
				  members and the availability of family members to help in the care of the
				  patient.
(ii) Assessment and
				  documentation of the need for home health agency services.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1249 - HOME HEALTH AGENCY SERVICES › PAYMENT FOR HOME HEALTH SERVICES › Section 1249.51 - General payment policy

Current through Register Vol. 54, No. 28, July 13, 2024
Payment is made for compensable home health services
					 provided by participating home health agencies subject to the conditions and
					 limitations established in §§
										1249.52-1249.59 and Chapters 1101 and 1150
					 (relating to general provisions; and MA Program payment policies) and the MA
					 Program Fee Schedule.
The provisions of this §
												1249.51 amended under sections
						403(a) and (b), 443.2(2) and 509 of the Public Welfare Code (62 P. S.
						§§
													403(a) and (b),
						443.2(2) and
						509).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1249 - HOME HEALTH AGENCY SERVICES › PAYMENT FOR HOME HEALTH SERVICES › Section 1249.52 - Payment conditions for various services

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Home health agencies are reimbursed for
				  services furnished to MA recipients within the MA Program Fee Schedule limits
				  if the following conditions are met and documented in the recipient's medical
				  record:
(1) The services are ordered by and
				  included in the plan of treatment established by the recipient's attending
				  physician.
(2) The attending
				  physician certifies that the recipient requires care in the home and one of the
				  following conditions exist:
(i) The specific
				  home health services would avoid or delay the need for treatment in a hospital
				  or other institutional setting for the condition being treated.
(ii) The recipient has an illness, injury or
				  mental health condition that justifies providing the services at the
				  recipient's residence instead of a physician's office, clinic or other
				  outpatient setting.
(3)
				  The attending physician certifies that the recipient requires the skilled
				  services of a nurse, physical therapist, occupational therapist or speech
				  therapist or the services of a home health aide.
(4) A change in the treatment plan is made in
				  writing and signed by the physician, or if given orally, is put in writing and
				  signed by the health care professional receiving the oral order on behalf of
				  the agency. The order shall be countersigned by the physician within 30 days of
				  the physician's order. The following health care professionals may receive oral
				  orders from the physician:
(i) Registered
				  nurses.
(ii) Licensed practical
				  nurses.
(iii) Physical therapists,
				  occupational therapists and speech therapists. These health care professionals
				  may only receive oral orders that pertain to these specialties.
(5) The plan is reviewed by the
				  attending physician, in consultation with agency professional personnel at
				  least every 60 days. The review of the recipient's plan must contain the
				  signature of the attending physician and the date the review was
				  performed.
(6) The Department has
				  prior authorized the services.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1249 - HOME HEALTH AGENCY SERVICES › PAYMENT FOR HOME HEALTH SERVICES › Section 1249.53 - Payment conditions for skilled nursing care

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Skilled nursing care is a covered home
				  health service and is reimbursable under the MA Program if the following
				  conditions are met:
(1) The services are
				  ordered by and included in the plan of treatment established by the recipient's
				  attending physician.
(2) The
				  services are performed by a registered nurse or a licensed practical nurse. A
				  home health agency is not reimbursed for personal care services performed by a
				  registered nurse or licensed practical nurse if not provided in conjunction
				  with skilled services.
(3) The
				  services are reasonable and necessary to the treatment of an illness or injury.
				  To be considered reasonable and necessary, the services furnished shall be:
(i) Consistent with the recipient's
				  particular medical needs as determined by the recipient's attending
				  physician.
(ii) Consistent with
				  accepted standards of medical practice.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1249 - HOME HEALTH AGENCY SERVICES › PAYMENT FOR HOME HEALTH SERVICES › Section 1249.54 - Payment conditions for home health aide services

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Home health aide service is a covered
				  home health service and is reimbursable under the MA Program if the following
				  conditions are met:
(1) The services of a home
				  health aide are given in conjunction with skilled care or, when skilled care is
				  not needed, when personal care services are medically necessary.
(2) The recipient record contains
				  documentation that, at least every 2 weeks, there has been communication
				  between the home health aide and a supervisory nurse regarding the
				  recipient.
(3) The assignment of a
				  home health aide to a case shall be made in accordance with a written plan of
				  treatment established by the recipient's attending physician. The plan shall
				  indicate the recipient's need for personal care services. The specific personal
				  care services to be furnished by the home health aide shall be determined by a
				  registered nurse and not by the home health aide. If skilled care is not
				  required, the recipient's attending physician shall certify that the personal
				  care services furnished are medically necessary.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1249 - HOME HEALTH AGENCY SERVICES › PAYMENT FOR HOME HEALTH SERVICES › Section 1249.55 - Payment conditions for medical supplies

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Home health agencies are reimbursed for
				  medical/surgical supplies listed in the MA Program Fee Schedule. These supplies
				  shall be prescribed by the attending physician and used by the recipient on an
				  ongoing basis.
(b) Home health
				  agencies are not reimbursed for supplies routinely needed as part of furnishing
				  home health care services. Payment for these supplies is included in the
				  comprehensive fee. Examples of the supplies are:
(1) Blood pressure equipment.
(2) Tubes for blood.
(3) Enemas.
(4) Soap.
(5) Steri-towels.
(6) Gauze roll and pads.
(7) Adhesive tape.
(8) Gloves, sterile and nonsterile.
(9) Tongue depressors.
(10) Cotton balls.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1249 - HOME HEALTH AGENCY SERVICES › PAYMENT FOR HOME HEALTH SERVICES › Section 1249.55a - Use of the Medicare Form HCFA-485-statement of policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Home health agencies may use Form
				  HCFA-485 as verification of the physician's prescription for medical/surgical
				  supplies.
(b) The requirement that
				  medical/surgical supplies must be ordered by the attending physician on the
				  physician's prescription pad has not changed. See Medical Assistance Bulletin
				  No. 23-88-02, effective September 1, 1988, and §
										1249.2a (relating to clarification
				  of conditions under which MA recipients may be considered homebound-statement
				  of policy).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1249 - HOME HEALTH AGENCY SERVICES › PAYMENT FOR HOME HEALTH SERVICES › Section 1249.56 - Payment conditions for physical therapy, occupational therapy, speech pathology and audiology services

Current through Register Vol. 54, No. 28, July 13, 2024
Home health agencies are reimbursed for physical therapy,
					 occupational therapy, speech therapy and audiology services if the following
					 conditions are met:
(1) The service is
				  prescribed by the recipient's attending physician.
(2) The service is performed by a physical
				  therapist, occupational therapist, speech therapist or audiologist currently
				  licensed to practice in this Commonwealth.
(3) The service is reasonable and necessary
				  for the treatment of the recipient's illness or injury. To be considered
				  reasonable and necessary, the services furnished shall be:
(i) Consistent with the recipient's
				  particular medical needs as ordered by the recipient's attending
				  physician.
(ii) Consistent with
				  accepted standards of medical practice.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1249 - HOME HEALTH AGENCY SERVICES › PAYMENT FOR HOME HEALTH SERVICES › Section 1249.57 - Payment conditions for maternal/child services

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
Maternal/child services
.
				  Home health agencies are reimbursed for maternal/child services if the
				  following conditions are met:
(1) The service
				  is prescribed by the recipient's attending physician.
(2) The services are reasonable and necessary
				  to the treatment of the pregnancy, illness or injury. To be considered
				  reasonable and necessary, the services furnished must be consistent with:
(i) The recipient's particular medical needs
				  as ordered by the recipient's attending physician.
(ii) Accepted standards of medical
				  practice.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1249 - HOME HEALTH AGENCY SERVICES › PAYMENT FOR HOME HEALTH SERVICES › Section 1249.58 - Payment conditions for travel costs

Current through Register Vol. 54, No. 28, July 13, 2024
A separate rate per mile will be paid, in addition to the
					 visit fee, to cover the cost of travel to and from a recipient's home when the
					 distance from the agency exceeds 5 miles, if transportation costs are not
					 included in the agency's usual charge to the general public. The first 5 miles
					 of travel cost from the agency to and from a recipient's home is included in
					 the comprehensive per visit fee.
The provisions of this §
												1249.58 issued under sections
						403(a) and (b), 443.2(2) and 509 of the Public Welfare Code (62 P. S.
						§§
													403(a) and (b),
						443.2(2) and
						509).
This section cited in 55 Pa. Code §
												1249.51 (relating to general
						payment policy).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1249 - HOME HEALTH AGENCY SERVICES › PAYMENT FOR HOME HEALTH SERVICES › Section 1249.59 - Limitations on payment

Current through Register Vol. 54, No. 28, July 13, 2024
The following limits apply to payment for covered services:
(1) Only one fee will be paid per
				  home health agency visit. Payment for a visit pertains to a separate service,
				  by a separate caregiver, to a recipient. More than one visit can be billed to
				  the same recipient on the same day but only for separate care.
(2) After the first 28 days of unlimited home
				  health care, payment is limited to the number of home visits specified on the
				  MA Program Fee Schedule. A new period of unlimited care begins following
				  hospitalization, the onset of a new primary diagnosis or the exacerbation of an
				  existing diagnosis which causes a change in the recipient's condition and
				  requires a change in the plan of treatment, subject to §
										1249.52(a)(4) 
				  (relating to payment conditions for various services).
(3) For prenatal and postpartum care, the
				  following limits apply:
(i) Payment for
				  prenatal care is limited to the number of visits specified on the MA Program
				  Fee Schedule. Complications of pregnancy are not counted as prenatal care but
				  are classified for invoicing purposes as acute illness.
(ii) Payment for a postpartum visit includes
				  payment for care provided the newborn child.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1249 - HOME HEALTH AGENCY SERVICES › UTILIZATION CONTROL › Section 1249.71 - Scope of claims review procedures

Current through Register Vol. 54, No. 28, July 13, 2024
Claims submitted for payment under the MA Program are
					 subject to the utilization review procedures established in Chapter 1101
					 (relating to general provisions).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1249 - HOME HEALTH AGENCY SERVICES › ADMINISTRATIVE SANCTIONS › Section 1249.81 - Provider misutilization

Current through Register Vol. 54, No. 28, July 13, 2024
Providers determined to have billed for service
					 inconsistent with MA Program regulations, to have provided services outside the
					 scope of customary standards of medical practice, or to have otherwise violated
					 the standards set forth in provider agreement, are subject to the sanctions
					 described in Chapter 1101 (relating to general provisions).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1251 - FUNERAL DIRECTORS' SERVICES › GENERAL PROVISIONS › Section 1251.1 - Policy

Current through Register Vol. 54, No. 28, July 13, 2024
The Department provides payment for funeral directors'
					 services rendered to eligible deceased recipients by funeral directors who are
					 enrolled as providers under the program. Payment shall be subject to this
					 chapter and Chapters 283 and 1101 (relating to payment for burial and
					 cremation; and general provisions).
The provisions of this §
												1251.1 amended under sections
						201(2) and 403(b) of the Public Welfare Code (62 P. S. §§
													201(2) and
						403(b)).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1251 - FUNERAL DIRECTORS' SERVICES › SCOPE OF BENEFITS › Section 1251.21 - Scope of benefits for the categorically needy

Current through Register Vol. 54, No. 28, July 13, 2024
Categorically needy recipients who were receiving a money
					 payment at the time of their death as set forth in §
										283.4 (relating to assistance
					 status of deceased) are eligible for funeral directors' services listed in
					 Chapter 1150 (relating to MA Program payment policies) and the MA Program fee
					 schedule hereto subject to the conditions and limitations of this chapter and
					 Chapter 283 (relating to payment for burial and cremation).
The provisions of this §
												1251.21 amended under sections
						201(2) and 403(b) of the Public Welfare Code (62 P. S. §§
													201(2) and
						403(b)).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1251 - FUNERAL DIRECTORS' SERVICES › SCOPE OF BENEFITS › Section 1251.22 - Scope of benefits for the medically needy

Current through Register Vol. 54, No. 28, July 13, 2024
Medically needy recipients are not eligible for funeral
					 directors' services.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1251 - FUNERAL DIRECTORS' SERVICES › SCOPE OF BENEFITS › Section 1251.23 - Scope of benefits for State Blind Pension recipients

Current through Register Vol. 54, No. 28, July 13, 2024
State Blind Pension recipients are eligible for funeral
					 directors' services subject to the conditions and limitations of this chapter
					 and Chapter 283 (relating to payment for burial and cremation).
The provisions of this §
												1251.23 amended under sections
						201(2) and 403(b) of the Public Welfare Code (62 P. S. §§
													201(2) and
						(403(b)).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1251 - FUNERAL DIRECTORS' SERVICES › SCOPE OF BENEFITS › Section 1251.24 - Scope of benefits for General Assistance recipients

Current through Register Vol. 54, No. 28, July 13, 2024
General Assistance recipients, age 21 to 65, whose MA
					 benefits are funded solely by State funds, are eligible for medically necessary
					 basic health care benefits as defined in Chapter 1101 (relating to general
					 provisions). See § 1101.31(e) (relating to scope).