CHAPTER 175. ALLOWANCES AND BENEFITS
ALLOWANCES AND BENEFITS PROVISIONS FOR TANF/GA
MA ALLOWANCES AND BENEFITS PROVISIONS FOR THE
CATEGORICALLY NEEDY AND SCHOOL CHILDREN WHO ARE
ONLY MEDICALLY NEEDY
MA ALLOWANCES AND BENEFITS PROVISIONS FOR THE
This chapter cited in 55 Pa. Code § 168.71 (relating to monthly payment determination); 55 Pa. Code § 171.81 (relating to policy); 55 Pa. Code § 183.101 (relating to prospective and retrospective determination); 55 Pa. Code § 183.121 (relating to incorrect payments); and 55 Pa. Code § 601.84 (relating to income exclusions).
ALLOWANCES AND BENEFITS PROVISIONS FOR TANF/GA
§ 175.21. Policy.
(a) The allowances of the Department will recognize certain amounts by family size that persons require to meet basic living requirements. The family size allowances will take into account costs for food, clothing, incidentals, shelter and utilities. These family size allowances will be used in computing the grant.
(b) The Department will also recognize that there are certain special item allowances which certain clients require under special circumstances. These are called special items as defined by § 175.23(b)(1) (relating to requirements) and are confined to transportation, clothing and personal care items for entry into a rehabilitation center, tuberculosis sanitarium or residential school, hearing aid batteries or maintenance or both and grants to decrease need for assistance.
The provisions of this § 175.21 adopted August 4, 1977, effective August 5, 1977, 7 Pa.B. 2180; amended February 9, 1979, effective March 12, 1979, 9 Pa.B. 502; amended November 16, 1979, effective January 1, 1980, 9 Pa.B. 3809. Immediately preceding text appears at serial page (39046).
§ 175.22. Definitions.
The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise:
Assistance unitDefined in § 171.22 (relating to definitions).
ClientApplicant or recipient. Special need items shall be included, when appropriate, in determining the needs of eligible applicants when initially authorizing assistance, as well as to clients in determining their ongoing needs.
Effective date of an initial grantThe effective date of an initial grant is the date on which a worker determines that the client is eligible. In cases involving eligibility of a newborn child added to an active case, the effective date is determined under § 133.23(b)(5) (relating to requirements).
Grant groupDefined in § 171.21 (relating to policy).
Tenant or tenant-boarderA lone person whose rent, or rent and board arrangements with the client are independent of other persons. Tenant group and tenant-boarder group mean two or more persons living together as a family normally would and who have a joint rent, or rent and board arrangement.
The provisions of this § 175.22 amended under sections 201 and 403(b) of the Public Welfare Code (62 P. S. § § 201 and 403(b)).
The provisions of this § 175.22 adopted August 4, 1977, effective August 5, 1977, 7 Pa.B. 2180; amended November 16, 1979, effective January 1, 1980, 9 Pa.B. 3809; amended April 12, 1991, effective May 1, 1991, 21 Pa.B. 1557; amended August 16, 1991, effective August 17, 1991, 21 Pa.B. 3699; amended February 7, 1992, effective upon publication and apply retroactively to February 1, 1990, 22 Pa.B. 590. Immediately preceding text appears at serial page (159806).
§ 175.23. Requirements.
(a) Basic allowances. Allowances used in computing the grant are dependent on the number of persons to receive assistance and the county in which they live. Each time the family size allowances are revised, the Department will announce the revised allowances by a notice submitted for publication in the Pennsylvania Bulletin and recommended codification in the Pennsylvania Code.
(Editors Note: The Family Size Allowances Table has been relocated to Chapter 183 Appendix B, Table 3. See 20 Pa.B. 554 (February 3, 1990). Immediately preceding text appears at serial page (130487).)
(b) Special items.
(1) General. Special items generally will conform with the following:
(i) Appropriate allowances for special items will be included in computing the grant for any client whose circumstances are as defined in this section. A recurring allowance for any of these items may be included in the regular grant. When a recurring allowance is included in the regular grant, the special allowance and need must be explained as set forth in § 227.24(d)(2) (relating to procedures) on every Form PA 122 authorizing changes to that case during the entire period the special allowance is included in the grant. This will include those changes that may not affect the grant such as change of name or address.
(ii) One-time grants will be authorized for all nonrecurring allowances in accordance with § 227.24(d). A one-time grant may be a prepayment or may be authorized after the item or service has been received and the correct amount determined, whichever method better suits the individual case. When authorizing a one-time grant, an explanation of the special allowance as set forth in § 227.24(d)(2) must also be included on the Form PA 122 or Form PA 122-E authorization and every future one-time grant for that case during the entire period the special allowance will be included in the regular grant.
(iii) Individuals have a right to receive corrective payments when they have been underpaid due to agency error or delay. In cases, corrective payment shall be made promptly, so that the client will receive the check for the corrective payment within 30 calendar days from the date of verification of the underpayment.
(v) In most instances, as specified in this section, these allowances must be approved by the Executive Director or his delegate before the Form PA 122 or Form PA 122-E is authorized. In districted counties the District Director is considered a delegate. If the Executive Director must delegate this authority, it should be to an immediate assistant, but no lower than a second level supervisor.
(vi) It is essential that County or District Offices have approval procedures that insure a prompt review and decision for all one-time grants requiring prior approval.
(2) Transportation for necessary medical care or to obtain prescription drugs.
(i) Ambulance services. For ambulance service see Chapter 1245 (relating to ambulance transportation).
(ii) Nonemergency transportation to medical care for prescription drugs. Services are available to clients who have no other means of transportation to or from a source of necessary medical care or to obtain prescription drugs through counties and prime contractors funded by the Public Assistance Transportation Block Grant. See Chapter 2070 (relating to eligibility for services funded through the public assistance transportation block grant).
(3) Other special transportation needs. Actual minimum cost of transportation and necessary related expenses which cannot be met from other resources will be authorized as a one-time grant or included in the computation of the grant if one or more of the following circumstances exist:
(i) A client who has not received a moving allowance for any reason within the previous 12 months and must move due to a verified health hazard, such as but not limited to unsanitary plumbing conditions, exposed wiring, Department of Environmental Resources certification of polluted drinking water, rat infestation, as confirmed by a housing inspector, IMU worker observation of the condition of the home or other documentation. The client must provide verification, on a document provided by the Department, from a physician which clearly states the client must move because the current residence which is unfit for habitation is contributing to or causing specific health problems. The moving allowance must be approved by the Executive Director or his delegate before the Form PA 122 or Form PA 122-E will be authorized as set forth for SSI clients in § 297.3(1) (Reserved). Note: For purposes of determining eligibility for a transportation allowance, a rent escrow account refunded to a recipient shall be regarded as a resource available to meet the cost of transportation and necessary related expenses. Allowance for transportation will conform with the following:
(A) The cost of transportation includes transportation of clients and their household effects, not storage, to their new residence and any necessary expenses related to transportation enroute. The most acceptable method of determining actual minimum cost of transportation is to have the client secure bids from Pennsylvania Public Utility Commission licensed moving companies. Only two bids are required.
(B) Payment of a moving allowance is limited to no more than once in a 12-month period and shall not exceed $200 and is used to cover transportation and labor.
(C) Payment for transportation will not be made for moves by unlicensed moving companies, except in the following situations:
(I) Moves out of this Commonwealth applicable only to individuals relocating to accept gainful, permanent employment under subsection (c).
(II) Moves by bona fide associations of their members.
(III) Moves by household members.
(D) For the client who prefers to rent a truck and move himself with the assistance of friends or relatives, the following conditions apply:
(I) The truck must be leased from a commercial rental organization such as U-Haul or Ryder.
(II) The original lease for the transportation must be between the client or a member of the clients immediate household and the rental organization.
(III) The role of friends and relatives or any other unlicensed persons will be limited to providing labor for moving.
(IV) The cost for moving the client will be limited to the actual costs of truck rental and labor subject to a single maximum grant of $200 in a 12-month period.
(V) If the total cost for this method is less costly than by a moving company, it will be accepted as meeting the minimum cost. It will not be necessary to secure bids for this method.
(ii) A client requires transportation to apply for or accept employment, or as part of a plan for decreasing his need for assistance, subject to a maximum of $250 per month. This allowance must be approved by the Executive Director or a delegate before the Form PA 122 or PA 122-E will be authorized and may not exceed 1 month unless reapproved. For an allowance for other expenditures related to the purposes of this subparagraph, reference should be made to subsection (c).
(iii) A client needs transportation to get to the place where he is to have medical or psychological examination the Department is requiring of him. The method of payment may be by payment of invoice as well as by Central Office or county disbursement.
(iv) A client is applying for the admission of his dependent child to a secondary vocational school, which is not part of the public or parochial school system, and a required trip is part of the application procedure.
(v) An AFDC dependent unemancipated minor, reasonably expected to complete the program before age 19, must provide and pay for transportation to attend a secondary school or an equivalent vocational or technical training school which is not part of the public or parochial school system.
(vi) A client needs transportation which is not covered in subparagraph (ii).
(A) This transportation must be to a source of necessary medical care which, because of very unusual circumstances, requires an exceptional transportation service, as defined in § 2070.4 (relating to definitions), not covered by the Public Assistance Transportation Block Grant.
(B) This transportation must be part of an agencys or institutions plan for treatment of the recipient, his spouse, parent, substitute parent or child.
(C) This allowance must be approved by the Executive Director or his delegate before the Form PA 122 or Form PA 122-E is authorized and must not exceed 1 month unless reapproved.
(vii) A client is a member of a Citizens Advisory Committee, CBA or State, and money is needed for any of the following expenses to enable him to attend committee meetings, in which case this allowance must be approved in advance by the Executive Director or his delegate. If circumstances are such that the client needs ready cash, this allowance may be paid from the Petty Cash Fund as set forth in § 229.24(e)(9) (relating to procedures). This allowance must be approved by the Executive Director or his delegate before the Form PA 122 or PA 122-E is authorized. The following is a list of allowable expenses:
(D) Child care for children less than 14 years of age.
(ix) Transportation allowance for children to participate in Outreach Screening, according to Financial Code 112 or 113.
(4) Clothing and personal care items. If a client who is to be admitted to a rehabilitation center, tuberculosis sanatorium or residential school does not have the initial supply of specified clothing and personal care items required as a condition of admission, a one-time grant will be made. The amount will be determined as follows:
(i) Identify the items, and the required number of units of each such item that the client must buy and take with him at the time of admission.
(ii) For those identified items shown on the following list, total the prices for the required number of units.
(iii) For the purpose of meeting the cost of incidental items not included on the following list, add $1 for a child under 16 years of age entering a tuberculosis sanatorium or residential school, or $2 for another person entering a sanatorium, rehabilitation center or residential school.
Clothing and Personal Care Items For A Person To Be Admitted to A
Rehabilitation Center, Tuberculosis Sanatorium or Residential School
Men Item Unit Price(in dollars) Bathrobe 7.00 Belt or Suspenders 2.00 Gloves - Work .50 Handkerchief .30 Jacket or Coat (Winter) 19.00 Jacket or Coat (Summer) 9.00 Overcoat 33.00 Pajamas 4.00 Rubbers 2.20 Shirt - Short Sleeve 1.90 Shirt - Street 3.00 Shirt - Work 2.20 Shoes - Street 8.00 Slacks or Pants - Street 8.80 Slacks or Overalls - Work 2.90 Slippers - Bedroom 3.00 Slippers - Shower 1.40 Socks .40 Sweater 6.00 T-Shirt .90 Undershirt .60 Undershorts .80 Dentifrice .50 Face Cloth .20 Laundry Bag 1.00 Razor 1.00 Razor Blades .30 Toothbrush .30 Towel .80
Women Item Unit Price (in dollars) Bathrobe or Housecoat 4.80 Bedjacket 3.00 Blouse 3.00 Brassiere 3.00 Coat 28.00 Dress - House 3.00 Dress - Street 7.00 Garters .50 Girdle or Corset 6.00 Gloves 2.00 Handkerchief .30 Nightgown - Cotton 2.80 Pajamas 4.00 Panties .60 Rubbers 2.50 Shoes - Street 7.00 Skirt 5.00 Slacks, Shorts or Pedal Pushers 3.20 Slip - Cotton 2.00 Slippers - Bedroom 2.00 Slippers - Shower 1.90 Socks - Cotton .50 Stockings - Nylon .90 Sweater 5.50 Brush 1.00 Comb .30 Dentifrice .50 Face Cloth .20 Laundry Bag 1.00 Toothbrush .30 Towel .80
Children Under 16 Years of Age
Boys Item Unit Price (in dollars) Bathing Trunks $1.80 Bathrobe 4.80 Cap - Wool 2.00 Dungarees 2.20 Galoshes 4.80 Gloves 2.80 Gym Suit (Shorts and Sweatshirt) 2.40 Handkerchief .30 Jacket - Cotton Twill 2.80 Mackinaw or Peacoat 9.00 Pajamas 2.20 Shirt 2.00 Shirt - Polo 1.10 Shoes 7.70 Shorts - Cotton 1.70 Slacks - Cotton 2.90 Slacks - Corduroy 4.40 Slippers 3.40 Sneakers or Sandals 3.80 Socks .60 Sweater - 8-18 3.80 Undershirt .50 Undershorts .50 Dentifrice .50 Face Cloth .20 Laundry Bag 1.00 Toothbrush .30 Towel .80
Girls Item Unit Price (in dollars) Bathrobe $ 3.90 Bathing Suit 4.00 Blouse 1.90 Boots 4.80 Brassiere 1.00 Coat - (Winter, Tailored-type) 22.60 Dress - Cotton 4.00 Dress - Rayon, Dress-Up 7.40 Dungarees 2.60 Garter Belt 1.20 Gym Suit 2.70 Gloves 1.80 Handkerchief .30 Nightgown 1.90 Pajamas 2.50 Panties .50 Playsuit 2.80 Shoes - Oxfords 5.70 Skirt 4.80 Slip - Cotton 1.90 Slip - Nylon Tricot 2.90 Slippers 2.80 Sneakers or Sandals 3.60 Socks .50 Stockings, Nylon .90 Sweater, Under size 12 2.80 Sweater, Size 12 and up 3.80 Vests .60 Brush - Hair 1.00 Comb .30 Dentifrice .50 Face Cloth .20 Laundry Bag 1.00 Toothbrush .30 Towel .80
(5) Medical and surgical supplies. Generally, payment for medical and surgical supplies will be made to the vendor by the invoice method as set forth in § 175.74 (relating to procedures). However, if an individual has a recurring need for hearing aid batteries, or if the cost of servicing or maintaining a hearing aid can be determined on a recurring basis, the actual minimum cost may be included in computing the grant.
(c) Grants to decrease need for assistance. A grant to decrease need for assistance shall conform with this subsection. General grant requirements are as follows:
(1) To qualify for a grant to decrease need for assistance, the client shall be receiving a Cash Assistance grant or meet the eligibility requirements to receive one.
(2) This grant may not be used to provide for an item that is available from another public source, such as the State Bureau of Vocational Rehabilitation.
(3) If a recurring allowance is included in the regular grant, it may not exceed the categorical time limits in § 133.23(a) (relating to requirements) without approval.
(d) Grants to relocate minor parents. A grant to relocate the minor parent and the dependent child may be provided if the following requirements are met:
(1) The minor parent does not meet an exception under § 141.21(q) (relating to policy).
(2) The parent, legal guardian or other adult relative lives at another location within the State or in another state.
(3) The minor parent and dependent child are not being forced to return to living conditions that are not in their best interest. Payment will not be authorized until the minor parent verifies she has permission to reside in the parents, legal guardians or other adult relatives home.
(4) The allowance for transportation is for the most economical and practical means of travel required to meet the minor parents and dependent childs needs.
(5) Another allowance for transportation has not been issued within the last 12-month period.
(e) Grant reduction. The family size allowance, plus special need allowance, shall be reduced by the amounts obtained by cashing an assistance check at a gambling casino, racetrack, bingo hall or other establishment that derives more than 50% of its gross revenues from gambling.
The provisions of this § 175.23 issued under sections 201(2) and 403(b) of the Public Welfare Code (62 P. S. § § 201(2) and 403(b)); amended under section 403(b) of the Public Welfare Code (62 P. S. § 403(b)).
The provisions of this § 175.23 adopted August 4, 1977, effective August 5, 1977, 7 Pa.B. 2180; amended May 5, 1978, effective August 6, 1977, 8 Pa.B. 1286; amended May 19, 1978, effective May 20, 1978, 8 Pa.B. 1412; amended February 9, 1979, effective March 12, 1979, 9 Pa.B. 502; corrected March 2, 1979, effective March 12, 1979, 9 Pa.B. 744; amended July 11, 1980, effective September 10, 1980, 10 Pa.B. 2981; amended October 17, 1980, effective December 17, 1980, 10 Pa.B. 4098; amended January 23, 1981, effective March 25, 1981, 11 Pa.B. 412; amended July 9, 1982, effective July 10, 1982, 12 Pa.B. 2173; amended September 10, 1982, effective November 1982, 12 Pa.B. 3093; amended November 19, 1982, effective July 1, 1982, 12 Pa.B. 3975; amended April 8, 1983, effective April 9, 1983, 13 Pa.B. 1259; amended September 23, 1983, effective October 1, 1983, 13 Pa.B. 2876; amended August 31, 1984, effective August 30, 1984, 14 Pa.B. 3159; corrected August 5, 1988, effective November 8, 1986, 18 Pa.B. 3432; amended August 26, 1988, effective November 1, 1988, 18 Pa.B. 3921; amended April 12, 1991, effective May 1, 1991, 21 Pa.B. 1557; amended October 2, 1992, effective upon publication and apply retroactively to October 1, 1989, 22 Pa.B. 4875; amended August 14, 1998, effective immediately and apply retroactively to March 3, 1997, 28 Pa.B. 3939; amended July 28, 2000, the provisions under Act 35, effective retroactive to June 17, 1996, 30 Pa.B. 3779. Immediately preceding text appears at serial pages (252582) and (247313) to (247320).
(Editors Note: The amendment made to this section at 21 Pa.B. 1557 (April 13, 1991) was promulgated under section 6(b) of the Regulatory Review Act (71 P. S. § 745.6(b)).)
Notes of Decisions
Fact that DPW characterized its transportation allowances as medical transportation was not determinative of the legal issue as to whether the allowance was required under subsection (b)(2) rather than subsection (b)(3); therefore, the issue on appeal was not whether petitioner was entitled to medical transportation reimbursement, but whether petitioner was entitled to any transportation reimbursement under subsection (b)(3). Ricci v. Department of Public Welfare, 477 A.2d 925 (Pa. Cmwlth. 1984).
Supplemental Security Income recipients are entitled to medical transportation benefits under this section. Kniepkamp v. Department of Public Welfare, 477 A.2d 927 (Pa. Cmwlth. 1984).
A general assistance recipient required to vacate his apartment is not entitled to a special grant in the form of a moving allowance when the recipient uses a commercial moving company which is not PUC-licensed and the type of move does not fit within one of the exceptions specified in 25 Pa. Code § 175.23 allowing the use of unlicensed moving companies. Coleman v. Department of Public Welfare, 425 A.2d 1194 (Pa. Cmwlth. 1981).
Since the recipient was financially unable to keep her house adequately heated, and the inability to keep the house heated was detrimental to her health, the DPW erred in denying a one-time grant for her moving costs on the basis that the house could be kept adequately warm if she were willing to spend more money for more heating oil. Felker v. Department of Public Welfare, 411 A.2d 1297 (Pa. Cmwlth. 1980).
It is not an abuse of discretion for the DPW to interpret its regulations narrowly such that one-time cash grants to cover moving expenses will be paid if the home itself is detrimental to the health and welfare of the recipients but will not be paid if it is the location of the home that is detrimental. Hart v. Department of Public Welfare, 409 A.2d 1192 (Pa. Cmwlth. 1980).
A petitioner was not ordered to vacate her home within the meaning of 55 Pa. Code § 175.23(b)(3)(i) (relating to requirements) since the eviction notice in question clearly stated that it could be avoided by the payment of past due rent and was essentially a notice that the rent had not been paid and a warning of the consequences of a continued failure to pay. Hendricks v. Department of Public Welfare, 402 A.2d 288 (Pa. Cmwlth. 1979).
This section cited in 55 Pa. Code § 141.21 (relating to procedures); 55 Pa. Code § 141.42 (relating to definitions); 55 Pa. Code § 141.41 (relating to policy); 55 Pa. Code § 147.24 (relating to procedure); 55 Pa. Code § 153.42 (relating to definitions); 55 Pa. Code § 175.21 (relating to policy); 55 Pa. Code § 175.24 (relating to procedures); 55 Pa. Code § 175.23 (relating to definitions); 55 Pa. Code § 187.22 (relating to definitions); 55 Pa. Code § 227.24 (relating to procedures); 55 Pa. Code § 229.24 (relating to procedures); 55 Pa. Code § 255.4 (relating to procedures); 55 Pa. Code § 275.4 (relating to procedures); 55 Pa. Code § 289.4 (relating to procedures); 55 Pa. Code § 1245.51 (relating to general payment policy); and 55 Pa. Code § 2070.5 (relating to exceptional transportation).
§ 175.24. Procedures.
(a) Preparation and use of Form PA 21-P. An authorization sheet, Form PA 21-P, will be required for each assistance unit. One column on the Form PA 21-P will be used for each grant group. The form will be prepared in ink or indelible pencil as follows:
(1) Record number. The number of the assistance unit record will be entered.
(2) Date. A vertical line will be placed in this space and in the No. of Persons in Assistance Unit space at the right of the last column needed for the grant groups in the assistance unit. The date of authorization will be entered.
(3) Number of persons in assistance unit. The number of persons in the assistance unit will be entered on the No. of Persons in Assistance Unit line within the space marked off by the vertical line at the right of the last column needed for the grant groups. Only persons eligible to receive assistance should be included. Persons receiving SSI benefits may not be included. A fetus is not included.
(4) Grant group. The grant group section will be prepared as follows:
(i) Category. The category symbol will be entered at the head of a separate column for each grant group.
(ii) Control digit. The control digit will be entered as shown on the turnaround Form PA 122. On new openings the control digit will be posted as soon as the turnaround Form PA 122 is received from the Office of Data Processing.
(iii) Persons in grant group. The total number of persons in the grant group will be entered.
(iv) AFDC children specified relatives. These spaces will be used for AFDC cases only. The number of children will be entered in the first space. Children who are receiving SSI benefits and a fetus of a woman who meets the requirements in § 151.43(f) (relating to requirements) may not be entered. The number of specified relatives under § 151.42 (relating to definitions) will be entered in the second space coded Cs in accordance with Appendix A of Chapter 305, or O if a specified relative is not a member of the AFDC grant group.
(b) Family allowances. Family allowances will conform with the following:
(1) In the common items block, the family size allowance for the number of persons in the assistance unit as specified in § 175.23 (relating to requirements) will be entered.
(2) The family size allowances may not exceed the allowances specified in § 175.23 for the number of persons in the assistance unit. Within that figure, the following principles will apply in determining how much of the allowance may be allocated to each grant group:
(i) The allowance for each grant group may not exceed the maximum for the number of persons in each group. Each grant group will be considered as if it were one assistance unit.
(ii) Subject to the limitation set forth in this paragraph, the largest possible share will be distributed to the AFDC grant group, and the smallest share to the GA grant group. If there is more than one AFDC grant group, the allowances may be divided equally or unequally among the AFDC grant groups, as circumstances may indicate or require.
(3) The totals for grant groups may not exceed the allowances specified in § 175.23 for the number of persons in the total assistance unit.
(c) Special items. The items will be specified and the total allowance for the item will be entered in the appropriate grant group column.
(d) Total allowance. The total allowance for each grant group will be entered. The total allowance includes the family size allowance and monthly special need allowance, which may be either a recurring or one-time grant.
(e) Net income. If there is more than one grant group in the assistance unit, the net income will be adjusted to the grant group which contains the person having the income.
(f) Monthly grant. The amount arrived at by subtracting the net income from the total allowance will be entered.
(g) Semimonthly grant. One-half the monthly grant will be entered.
(h) Cash grant. The monthly amount that is to be received by the Public Assistance recipient will be entered. When this amount is not a whole dollar, it will be rounded down to the next lower whole dollar. If the amount is less than $10 for AFDC or GA, the grant group is ineligible unless the amount is due to recoupment under § 225.24(b)(1)(i) (relating to procedures). In the month of application or in other circumstances where proration under § 233.24 (relating to procedures) may occur, proration will be completed before rounding down.
The provisions of this § 175.24 issued under sections 201(2) and 403(b) of the Public Welfare Code (62 P. S. § § 201(2) and 403(b)).
The provisions of this § 175.24 adopted August 4, 1977, effective August 5, 1977, 7 Pa.B. 2180; explained November 6, 1981, 11 Pa.B. 3954; amended November 6, 1981, effective November 7, 1981, 11 Pa.B. 3956; amended November 6, 1981, effective November 7, 1981, 11 Pa.B. 3972; amended July 9, 1982, effective July 10, 1982, 12 Pa.B. 2173; amended October 21, 1983, effective October 22, 1983, 13 Pa.B. 3225; amended March 30, 1984, effective March 31, 1984, 14 Pa.B. 1087; amended April 12, 1991, effective May 1, 1991, 21 Pa.B. 1557; amended August 16, 1991, effective August 17, 1991, 21 Pa.B. 3699. Immediately preceding text appears at serial pages (157054) to (157056).
This section cited in 55 Pa. Code § 175.74 (relating to procedures); and 55 Pa. Code § 225.24 (relating to procedures).
MA ALLOWANCES AND BENEFITS PROVISIONS FOR THE
CATEGORICALLY NEEDY AND SCHOOL CHILDREN WHO ARE
ONLY MEDICALLY NEEDY
§ 175.71. Policy.
(a) The Department of Human Services will pay for those types of medical and allied services given in the home, office, clinic or hospital that are generally recognized as necessary treatment of illnesses.
(b) It will be the intention of the Department of Human Services to pay for adequate medical care, in accordance with accepted standards of good medical practice, to achieve the purposes set forth in this chapter.
(c) There will be no intention to pay for extravagant or superfluous medical care, or care that would be beyond the means of the average family of moderate income. Nor will the Department of Human Services pay for new and expensive medication or treatment that is still in the experimental stage.
(d) The Department of Human Services will expect that the professional participants, in giving services and prescribing supplies within the scope of the program, may not exceed in an individual instance what is essential for adequate medical care for that individual.
(e) The fees paid by the Department of Human Services will be in full payment of services given. A practitioner who seeks or accepts additional remuneration of any kind from the patient, or another person, shall be considered as violating the regulations of the medical care program and will be subject to disciplinary action.
(f) The program of medical care will include physicians, clinic, and dental services, medications, medical goods and supplies, ambulance service, inpatient hospital care, hospital-home care, nursing care in the home, public nursing home care, private nursing home care, care in a mental institution and medical-social services, in accordance with the regulations and fees established by the Department.
(g) The program of medical care will be supplemental to other existing resources for medical services or supplies, and presupposes full use of other tax-supported or voluntary agencies or facilities for meeting medical needs.
(h) It will be the responsibility of a County Assistance Office to be aware of the resources in the area and to see that these are fully used in meeting the medical needs of assistance recipients and others who apply for medical assistance.
(i) The Department should be charged only for services that are not available through another existing tax-supported or voluntary facility. It is recognized that the services of many facilities are limited in scope and availability. However, some are available throughout the Commonwealth. The Department will not pay for or duplicate services that are available from these statewide facilities and agencies. They include treatment for rabies, which is available through County Authorities, vaccinations, which is available through local school districts or facilities of the State Department of Health or local boards of health, physicians services to assistance recipients in hospitals, medical care for recipients certified for medical services under the Workmens Compensation Act (77 P. S. § § 11031) or the Occupational Disease Act (77 P. S. § § 12011603), services for handicapped children, which are provided by the State Department of Health, treatment for tuberculosis or venereal diseases, which is the responsibility of State Health Clinics. Since the diagnosis of tuberculosis and venereal disease may not be known to the patient when he first seeks medical care, the Department will pay for the initial visit to a private physician or a hospital clinic when necessary to establish a diagnosis. This will not be paid for a school child who is only medically needy, since diagnostic service is provided in the course of the school health examination.
(j) The program of medical care as defined in regulations is designed to provide treatment for the usual medical needs arising from illness, disability or infirmity, and for certain needs associated with restoration to self-support. Specific situations may arise in which adequate medical care requires unusual or exceptional types of treatment, medication or supplies that are not specified in the public assistance regulations and are not available from any other source. In these cases, at the request of the practitioner, transmitted through the County Assistance Office, the State Office of Public Assistance will review the circumstances and approve and preauthorize the service when it is deemed necessary to meet adequately the needs of the eligible patient.
The provisions of this § 175.71 adopted August 4, 1977, effective August 5, 1977, 7 Pa.B. 2180.
Notes of Decisions
Since a hospital patient was eligible for both MA benefits and no-fault motor vehicle insurance benefits, the allegations of the patient that the hospital exercised unreasonable care in seeking no-fault insurance benefits for his expenses instead of MA benefits set forth a valid claim. Harleysville Mutual Insurance Co. v. Yocolano, 9 Pa. D. & C.3d 226 (1978).
§ 175.73. Requirements.
(a) Services paid for. The following services will be paid for in accordance with the following requirements:
(1) Physicians services. Physicians services will be paid for in accordance with the following:
(i) In accordance with the specific regulations governing physicians services, the Department will pay for office and home calls for chronic or acute illness. Home calls will be paid for only when it is situationally impossible or medically inadvisable for the patient to go to the physicians office.
(ii) In cases of acute illness the Department will pay for the minimum number of calls deemed necessary by the physician for adequate medical care in each individual instance.
(iii) In chronic illness, payment will be limited to a maximum of three calls per month. It will not be expected, however, that this maximum will be charged in instances where one or two calls would have been sufficient.
(iv) Obstetrical care and minor surgery, performed in the home or office, will be paid for.
(v) X-ray study in the physicians office, if necessary for diagnosis, may be paid only for persons receiving public assistance money payments. The Department will not pay for diagnostic laboratory tests and x-rays provided in the course of the school health examination.
(vi) The services of a physician for a complete physical examination may be paid if needed to determine the condition of a recipient or the eligibility of an applicant for assistance, for the annual general medical examination of public assistance recipients in private nursing homes and for other needed special medical examinations. Prior authorization will be required.
(vii) On written prescription by the physician, payment will be made for drugs included in the Drug Formulary. Payment for drugs on one prescription will be limited to a 45-day supply. If the charge for the medication is more than $10 or if the physician plans to prescribe the same medication in an amount likely to exceed $35 per month, prior authorization through the County Assistance Office will be required.
(viii) Medication dispensed by a physician during a home or office call may be paid for if the medication costs the physician $2 or more. Prior authorization will be required if the charge is more than $10.
(ix) In addition to the physicians services in subparagraphs (i)(vii), the Department also will pay for eye examinations and refractions, eye glasses, and surgeons fees for certain specified operations for an eligible child.
(x) For a patient who is receiving a public assistance payment for nursing home care, the Department will not pay for medical services given by a physician who owns that institution in whole or in part, has a financial interest in it, operates it or is acting in another capacity that indicates he is not an independent contractor.
(2) Pharmaceutical services. Pharmaceutical services will be paid for in accordance with the following:
(i) The Drug Formulary of the Department will list the medications and medical supplies included in the program, and the charge the Department will pay for the item.
(ii) If the charge for an item is more than $10 for one prescription, the Department will pay the pharmacist only if he has written authorization from the County Assistance Office before filling the prescription.
(iii) Payment for a prescription will be limited to a 45-day supply.
(iv) For a person in a nursing home for whom the Department is making a nursing home care payment, payment will not be made for any services, medications and supplies included in the public assistance definition of nursing home care.
(3) Clinic services. Clinical services will be paid in accordance with the following:
(i) Payment may be made for prenatal care and treatment for chronic and acute illness, with limits on the number of chargeable visits, as outlined above under physicians services, and x-ray studies for diagnosis or definition, with the exception outlined in this section under physicians services. For the eligible school child, payment may be made for eye examinations and refractions.
(ii) Clinic pharmacies will be expected to fill prescriptions written by clinic physicians. Payment will not be made for drugs and supplies that are ordinarily dispensed without charge to nonassistance patients who are unable to pay.
(4) Dental services. Dental services will be paid for in accordance with the following:
(i) In line with the intent of the Department to provide adequate, but not extravagant or superfluous care, priorities for dental treatment have been established as a basis for restrictions on services.
(ii) To receive payment from the Department for full and partial dentures, and major denture repairs, the dentist or dental clinic must have written authorization from the County Assistance Office before providing these services.
(iii) Payment may be made for dental x-rays and medications prescribed by dentists, in addition to other dental care.
(5) Ambulance services and other types of transportation. Payment may be made for necessary ambulance services if they are not available without charge to other needy persons in the community.
(6) Nursing care in the home. Nursing care in the home will be paid for in accordance with the following:
(i) Payment may be made for the initial visit of the nurse on the request of the patient or any interested person. Subsequent visits will be paid for only if made on the written order of the attending physician.
(ii) The Department will pay for nursing service for chronic or acute illness, maternity service or instruction of the patient in accordance with the public assistance regulations and the fee schedule.
(7) Inpatient hospital care. Payment may be made for inpatient hospital care.
(8) Hospital-home care. Payment may be made for hospital-type care in the home provided by the hospital as an uninterrupted continuation of inpatient hospital care.
(9) Skilled nursing or intermediate care in public or private facilities. Skilled nursing or intermediate care in public or private facilities will be paid in accordance with the following:
(i) Payment may be made for nursing home care in a public nursing home for persons found to be categorically needy, including children up to 21, and specified relatives 21 years and over, but excluding persons who meet the definitive conditions of GA.
(ii) Payment may continue for as long as the need and eligibility continue.
(10) Care in a mental institution. Payment may be made for service in an institution for mental diseases for a person under 21 or over 65.
(11) Medical-social services. Medical-social services will be provided in accordance with the following:
(i) A broad range of social services, including specific services related to illness, will be provided as needed to persons applying for or receiving public assistance money payments. The objective will be to enable them to attain or retain independence or self-care or both.
(ii) Specific social services related to illness will be provided as needed in relation to a school child for whom an application is being made for medical assistance, or who is receiving medical assistance. This will include social services in medical emergencies.
(b) Benefit period. The benefit period will include the following:
(1) Inpatient hospital care. Reference should be made to Chapter 1163 (relating to inpatient hospital services).
(2) Hospital-home care. Reference should be made to Chapter 1249 (relating to home health agency services).
(c) Eligibility of school children. Eligibility of school children for medical care will be determined as follows:
(1) A school child shall be eligible for medical care if any of the following occurs:
(i) He is categorically needy.
(ii) He has been certified as medically needy.
(iii) The referral to public assistance has been made by the School Nurse.
(2) A school child will include attending, or scheduled to enter within the current year, a public or private Commonwealth elementary, grade or high school, or kindergarten that is an integral part of a local school district.
(3) A summary of the services and eligibility conditions for medical assistance for school children is given in Leaflet No. 5 available from the County Board of Assistance, or from the Department of Human Services, Harrisburg.
(d) Professional participation. Professional participation in the Public Assistance Medical Care Program shall be as follows:
(1) The Public Assistance Medical Care Program, operating on a voluntary participation basis, will be open to a practitioner of medicine, osteopathy or dentistry; a clinic, pharmacist, nursing home, hospital, clinic or vendor of medical supplies in the Commonwealth or in another state who meets the requirements described under the regulations for each of the participating professions. The practitioner or vendor who participates in the program, giving services, thereby signifies his agreement to comply with the regulations and intent of the program.
(2) Subject only to the willingness of the practitioner, vendor or institution to participate in the program and abide by the regulations, the patient will have the right of free choice of practitioner, vendor or institution.
The provisions of this § 175.73 adopted August 4, 1977, effective August 5, 1977, 7 Pa.B. 2180.
This section cited in 55 Pa. Code § 141.81 (relating to eligibility policy for Medically Needy Only); and 55 Pa. Code § 175.84 (relating to procedures).
§ 175.74. Procedures.
(a) Method of payment. The method of payment to practitioners and vendors will be as follows:
(1) In accordance with public assistance regulations and fee schedules, the Department will make direct payments to practitioners and vendors for services, medications and medical supplies provided. This system is necessary because medical needs are extremely varied and unpredictable, requiring an individualized and flexible way of meeting these needs.
(2) Payment for the health items as the usual household medicine chest supplies and items of personal care will not be included in the system of practitioner and vendor payments because these items constitute a common, predictable, continuing need. Therefore, an amount of money to meet this need will be included in the money payment to the recipient, in the determination of eligibility of the need amount of the nonmoney payment recipient, and in the evaluation of resources of a medically needy school child.
(b) Responsibility of practitioner or vendor. Since medical care is paid only for eligible persons, it will be the responsibility of the practitioner or vendor, in order to be assured of payment, to verify with the County Board of Assistance that the person is eligible.
(c) Form PA 21-P (Authorization Sheets). Form PA 21-P will be used in accordance with the following:
(1) The Form PA 21-P is used for determining need for PA, PC, PD and PJ.
(2) The method for determining need will be the same as the method used to compute the grant as outlined in § 175.24 (relating to procedures), except that when the NMP client is a person who would be included as a member of an existing assistance unit if he were a money payment recipient, the following modifications will apply:
(i) NMP. The Family Size Allowance of the NMP will be determined as if the NMP person were included in the assistance unit.
(ii) Category. Enter the appropriate category symbol as determined in § 141.71 (relating to policy). For groups containing more than one category, a separate column will be used for each category. After the unadjusted monthly grant on the Form PA 21-P has been computed and is in the amount of $.01 or more, medical assistance to the categorically needy will be authorized by filling in the column opposite the spaces below Cash Grant as follows:
(A) Effective date. For openings, changes or discontinuances enter the date the decision is made or the date the Form PA 124 is completed, whichever is later.
(B) Statistical code. Enter one of the action code letters listed as follows and the appropriate reason code:
(III) Deletion of person or personsD.
(IV) Addition of person or personsE.
(V) Addition or deletion of persons without change in total number of persons; change of addressF.
(C) Reference No. The letter of that section of the Form PA 21 which is affected will be entered.
(D) Authorized By. Enter the name or initials of the person authorizing NMP will be entered. After the form is completed up to this point it will be checked and the NMP Authorization Card, PA 124, or the NMP Closing Card, PA 124-C, will be typed.
(E) Typed. The Authorization Typist will enter initials and the date the Form PA 124 is typed. The initials of the typist will indicate that all items indicated in the Reference No. block have been taken care of.
(d) Identification cards. A paper ID card, PA 5-A for categorically needy recipients, will be issued to certify the eligibility of a person for Medical Assistance. In addition, an embossed plastic card may be issued as a convenience for pharmacists in preparing invoices. The paper ID card will be the only card entitling a person to an MA service. Embossed plastic cards will have no value without the appropriate Medical Assistance Identification Card.
(e) Quarterly reports. Quarterly reports will be prepared in accordance with the following:
(1) The CAO will prepare quarterly calendar reports by memorandum of the total number of PA 5-A and PA 5-C ID cards by category issued in the quarter. If no cards were issued in certain categories or if no cards were issued at all, this should be indicated.
(2) The information should be sent to the Office of Income Maintenance, Room 415, Health and Welfare Building, the 20th of the month following the end of the calendar quarter using an envelope with the CAO return address.
The provisions of this § 175.74 adopted August 4, 1977, effective August 5, 1977, 7 Pa.B. 2180; amended July 28, 1978, effective August 28, 1978, 8 Pa.B. 2104. Immediately preceding text appears at serial pages (29231) to (29232).
This section cited in 55 Pa. Code § 175.23 (relating to requirements).
MA ALLOWANCES AND BENEFITS PROVISIONS FOR THE
§ 175.84. Procedures.
(a) Services paid for. The Department will pay for the following medical services for eligible persons who are taking care of their everyday living expenses themselves, but have insufficient income, according to law and regulations, to pay for these major medical expenses:
(1) Inpatient hospital care. The same as for categorically needy medical assistance recipient as set forth in § 175.73 (relating to requirements).
(2) Hospital-home care. The same as for categorically needy medical assistance recipient as set forth in § 175.73.
(3) Nursing care in the home. The same as for categorically needy medical assistance recipient as set forth in § 175.73.
(4) Skilled nursing and intermediate care in public and private facilities. Payments may continue for as long as the need and eligibility continue and may be made for persons who meet any of the following criteria:
(i) 65 years of age or over.
(ii) 21 years of age or over and who are blind.
(iii) Under the age of 21.
(iv) Parents of a dependent child.
(v) 21 years or over and who are permanently and totally disabled.
(vi) 16 years of age or under needing skilled nursing home care in state schools and hospitals.
(5) Care in a mental institution. The same as for categorically needy individual assistance recipient as set forth in § 175.73.
(6) Medical-social services. Specific social services related to illness will be provided as needed to persons applying for or receiving medical assistance. This will include social services in medical emergencies.
(7) Transportation. Ambulance services and related transportation needs.
(b) Identification cards. A paper Medical Assistance Identification Card, PA 5-C for medically needy recipients, will be issued to certify the eligibility of a person for medical assistance. In addition, an embossed plastic card may be issued as a convenience for pharmacists in preparing invoices. The paper ID card will be the only card entitling an individual to medical assistance. A plastic card has no value without the appropriate Medical Assistance Identification Card.
(c) Quarterly reports. Quarterly reports will be prepared in accordance with the following:
(1) The CAO will prepare quarterly calendar reports by memorandum of the total number of PA-5C ID cards by category issued in the quarter. A negative report will be submitted if no cards were issued in particular categories or at all.
(2) The information should be sent to the Office of Income Maintenance, Room 415, Health and Welfare Building, by the 20th of the month following the end of the calendar quarter.
The provisions of this § 175.84 adopted August 4, 1977, effective August 5, 1977, 7 Pa.B. 2180.
This section cited in 55 Pa. Code § 141.81 (relating to eligibility policy for Medically Needy Only).
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