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Acute Care Services
Long-Term Care Services


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Benefits by State: Pennsylvania (October 2008) Notes
 
 
 
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Acute Care Services

Is the Benefit Covered? Copayment Requirement Prior Approval Requirement Coverage Limitations Reimbursement Methodology Populations Covered


Institutional and Clinic Services
Clinic Services, by an organized facility or clinic not part of a hospital: Freestanding Ambulatory Surgery Center
Yes $.50-$3/service, depending on payment rate Limits vary by service Fee for service CN & MN
Clinic Services, by an organized facility or clinic not part of a hospital: Public Health and Mental Health Clinics
Yes $.50-$3/service, depending on payment rate; $.50/unit of psychotherapy service Visit limits dependent on type of service Fee for service CN & MN
Federally Qualified Health Center Services
Yes $.50-$3/service, depending on payment rate Frequency limits vary by service Provider based: prospective cost based rate/visit, Independent: prospective cost based rate/visit with ancillaries paid fee for service CN & MN
Inpatient Hospital Services, other than in an Institution for Mental Diseases
Yes $3/day up to $21/admission Specified non-emergency admissions 1 med rehab admission/year, 30 days psychiatric care/year, non-emergency weekend admissions must have procedures same or next day, medical/surgical patients limited to 2 periods of therapeutic leave/month of no more than 12 hours/day Prospective payment/discharge using DRG, rehab hospitals/units and psych units paid prospective per diem, cost based payment for alcohol detox units CN & MN
Outpatient Hospital Services
Yes $.50-$3/service, depending on payment rate Frequency limits vary by service Fee for service CN & MN
Rehabilitation Services: Mental Health and Substance Abuse
No
Rural Health Clinic Services
Yes $.50-$3/service, depending on payment rate Frequency limits vary by service Provider based: prospective cost based rate/visit, Independent: prospective cost based rate/visit with cost based payment for ancillaries CN & MN
Practitioner Services
Certified Registered Nurse Anesthetist Services
No
Chiropractor Services
Yes $.50-$3/service, depending on payment rate Frequency limits vary by service Fee for service CN & MN
Dental Services
Yes $.50-$3/service, depending on payment rate Prosthetics, crowns, multiple or surgical extractions, periodontia and endodontia CN: exam and cleaning 2/year, MN: preventive care not covered and medically necessary services limited to those provided in a hospital or ambulatory surgery center setting, CN & MN: crowns limited to 1/5 years, services in outpatient hospital or ambulatory surgery center setting limited to $500/procedure unless fee screen higher, services in inpatient hospital setting limited to $1,000/procedure unless fee screen higher Fee for service CN & MN
Medical and Remedial Care - Other Practitioners
Medical/Surgical Services of a Dentist
Yes $.50-$3/service, depending on payment rate Fee for service CN & MN
Nurse Midwife Services
Yes 12 prenatal and postpartum visits/year plus 1 postpartum visit included in delivery fee Fee for service CN & MN
Nurse Practitioner Services
Yes $.50-$3/service, depending on payment Frequency limits vary by service Fee for service CN & MN
Optometrist Services
Yes $.50-$3/service, depending on payment rate 2 vision exams/year, Fee for service CN & MN
Physician Services
Yes $.50-$3/specified service, depending on payment rate Frequency limits vary by service Fee for service CN & MN
Podiatrist Services
Yes $.50-$3/service, depending on payment rate Frequency limits vary by service; routine foot care, physical therapy, orthopedic shoes and appliances not covered Fee for service CN & MN
Psychologist Services
No
Prescription Drugs
Prescription Drugs
Yes $1/generic Rx, $3/brand Rx MN - limited to birth control drugs but long term care residents have no limitations WAC+7% for brand Rx or WAC+66% for generic, plus $4.00 dispensing fee CN & MN
Physical Therapy and Other Services
Occupational Therapy Services
No
Physical Therapy Services
No
Services for Speech, Hearing and Language Disorders
No
Products and Devices
Dentures
Yes Yes 1 full upper and/or lower denture or 1 partial denture/5 years Fee for service CN
Eyeglasses
Yes $.50-$3/service, depending on payment rate Adult coverage limited to diagnosis of aphakia Fee for service CN & MN
Hearing Aids
No
Medical Equipment and Supplies
Yes $.50-$3/service, depending on payment rate for purchased items only, not applicable to oxygen For equipment other than oxygen MN: limited to items related to family planning and to medically necessary items for beneficiaries receiving home health care Fee for service CN & MN
Prosthetic and Orthotic Devices
Yes $.50-$3/service, depending on payment rate Yes Limited to orthopedic shoe inserts and selected orthotics, specified frequency and quantity limits apply Fee for service CN
Transportation Services
Ambulance Services
Yes Fee for service CN & MN
Non-Emergency Medical Transportation Services
Yes $.50-$3/service, depending on payment See service-specific FN CN & MN
Other Services
Diagnostic, Screening and Preventive Services
Yes $1/x-ray Diagnostic services only Fee for service CN & MN
Early and Periodic Screening, Diagnosis and Treatment
See service-specific FN.
Extended Services for Pregnant Women
Family Planning Services
See service-specific FN.
Laboratory and X-Ray Services, outside Hospital or Clinic
Yes $1/x-ray Fee for service CN & MN
Targeted Case Management
Yes Varies by targeted group Fee for service CN & MN


Long-Term Care Services

Community Based Care
Home and Community Based Services Waiver
Yes Services for the following populations: 1, 2, 4, 5, 6 & 8 - See service-specific FN Dependent upon the services provided CN & MN
Home Health Services, includes nursing services, home health aides, and medical supplies/equipment
Yes Specified services, medical equipment and supplies Multiple staff/visit counts as 1 visit, 15 visits/month after first 28 days of care, 2 postpartum visits/pregnancy Fee for service CN & MN
Hospice Care
Yes Prospective rates based on Medicare methodology CN & MN
Personal Care Services
No
Private Duty Nursing Services
No
Program of All-Inclusive Care for the Elderly
Yes See service-specific FN Capitated payment CN & MN
Institutional Care
Inpatient Hospital, Nursing Facility and Intermediate Care Facility Services In Institutions for Mental Diseases, age 65 and older
Yes 15 hosp leave days/hospitalization, 30 therapeutic leave days/year Per diem using case-mix payment system, hosp leave days paid at 1/3 of nursing facility's rate and therapeutic leave days paid at full rate CN & MN
Inpatient Psychiatric Services, under age 21
Yes Admission to residential treatment facility Two periods of therapeutic leave up to 12 hours each per month Prospective cost based per diem CN & MN
Intermediate Care Facility Services for the Mentally Retarded
Yes 15 hosp leave days/hospitalization, 75 therapeutic leave days/year Prospective cost based per diem with limits CN & MN
Nursing Facility Services, other than in an Institution for Mental Diseases
Yes 15 hosp leave days/hospitalization, 30 therapeutic leave days/year Per diem using case-mix payment systemic, hosp leave days paid at 1/3 of nursing facility's rate and therapeutic leave days paid at full rate CN & MN
Religious Non-Medical Health Care Institution and Practitioner Services
No


Notes: This State’s covered services for the Medically Needy (MN) population are more restrictive than for the Categorically Needy (CN) population. Major differences are identified on the tables. The State’s Medicaid program includes an eligibility category called “General Assistance” (GA) for single adults unable to work due to a temporary or permanent disability, are awaiting eligibility determination for Supplemental Security Income (SSI) benefits, are blind or fit into other specified categories including victims of domestic violence. Any identified copayment requirements are applicable to beneficiaries age 18 and older. The copayment amount appearing for Laboratory and X-Ray Services is also applicable to such services rendered in a clinic, physician office or outpatient hospital setting and may be collected in addition to a copayment required for other services provided. Although GA beneficiaries receive generally the same benefits as other Medicaid beneficiaries, with the exception of prescription drugs they are required to pay copayment amounts twice the value appearing on the tables for other Medicaid beneficiaries. The State has added the optional Medicaid buy-in group of disabled adults permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA) in a program called Medical Assistance for Workers with Disabilities. These beneficiaries are allowed to continue Medicaid coverage, and receive benefits available for the MN population, if their income is at or below 250 percent of the federal poverty level (FPL). Beneficiaries in this group pay a monthly premium equal to 5 percent of income except premiums under $10 are not collected.
 
 
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