Current through Register Vol. 54, No. 23, June 8, 2024
Section 1101.32 - Coverage variations(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.(b)Coverage for out-of-State services. The Department pays for compensable services furnished out-of-State to eligible Commonwealth recipients if:(1) The recipient requires emergency medical care while temporarily away from his home.(2) The recipient would be risking his health if he waited for the service until he returned home.(3) The trip back to this Commonwealth would endanger his health.(4) It is general practice for recipients in an area of the Commonwealth to use medical resources in a neighboring state.(5) The Department decides, based on the attending practitioner's advice, that the recipient has better access to the type of care he needs in another state.The provisions of this § 1101.32 amended September 30, 1988, effective 10/1/1988, 18 Pa.B. 4418. This section cited in 55 Pa. Code § 1121.22 (relating to scope of benefits for the medically needy); 55 Pa. Code § 1123.22 (relating to scope of benefits for the medically needy); 55 Pa. Code § 1123.56 (relating to vision aids); 55 Pa. Code § 1123.57 (relating to hearing aids); 55 Pa. Code § 1147.21 (relating to scope of benefits for the categorically needy); and 55 Pa. Code § 1147.22 (relating to scope of benefits for the medically needy).