MEDICAL ASSISTANCE

AS OF: 07/21/2008 04:03

0300                 MEDICAL ASSISTANCE PROGRAM OVERVIEW.. 27

0300.05             MEDICAL ASSISTANCE PROGRAM PURPOSE. 27

0300.10             PROGRAM ADMINISTRATION.. 27

0300.15             CATEGORIES OF MEDICAL ASSISTANCE. 28

0300.15.05          Categorically Needy. 28

0300.15.10          Medically Needy. 28

0300.20             SCOPE OF SERVICES. 28

0300.20.05          Medical Services Provided. 28

0300.20.05.05       Emergency Room Co-Payment Required. 30

0300.20.05.10       EPSDT. 31

0300.20.05.15       Abortions, Rape, or Incest 32

0300.20.05.20       Abortions, To Save the Life of the Mother 33

0300.20.05.25       Organ Transplant Operations. 33

0300.20.05.30       Transportation Services. 35

0300.20.05.35       Pharmacy Services. 37

0300.20.05.35.05    Pharmacy Services Cost Sharing Requirements. 37

0300.20.20          Waiver Programs. 38

0300.20.25          MA Payment Policy. 38

0300.20.30          Provider Deficiencies/Plan of Correction. 39

0300.20.35          Medicare Buy-in. 39

0300.20.40          Pharmacy Lock-In Program.. 40

0300.20.40.05       Enrollment in Pharmacy Lock-In Program.. 40

0300.20.40.10       REVS Identification of Lock-In Recipients. 41

0300.20.40.15       Primary Pharmacy of Choice. 41

0300.20.40.20       Primary Care Physician. 41

0300.20.40.25       Change in Primary Pharmacy/Physician. 41

0300.20.40.30       Change in Recipient Status. 41

0300.25             OVERVIEW OF MA ELIGIBILITY REQUIREMENTS. 41

0300.25.05          Technical Eligibility Requirements. 42

0300.25.10          Characteristic Eligibility Requirements. 42

0300.25.15          Cooperation Requirements. 42

0300.25.20          Financial Eligibility Requirements. 43

0300.25.20.05       Income Flex-Test and Spenddown. 43

0300.30             METHODOLOGY FOR DETERMINING COVERAGE GROUP. 43

0300.35             ORGANIZATION OF THE MANUAL. 44

0300.40             Procedure for Imposing Admin Sanctions. 44

0300.40.05          Statutory Authority. 44

0300.40.10          Definitions. 45

0300.40.15          Sanctionable Violations. 46

0300.40.20          Provider Sanctions. 47

0300.40.25          Notice of Violations and Sanctions. 48

0300.40.30          Informal Hearing. 49

0300.40.35          Administrative Hearing. 49

0300.40.40          Appeal for Judicial Review.. 49

0300.40.45          Administrative Actions. 49

0300.40.50          Stay of Order 49

0300.40.55          Reinstatement 50

0302                 THE APPLICATION PROCESS. 50

0302.05             THE REQUEST FOR MEDICAL ASSISTANCE. 50

0302.05.05          Request for a Medicare Part D Application. 51

0302.10             CONTENTS OF THE APPLICATION PACKET. 51

0302.10.05          Assistance in Completing the Application. 52

0302.10.10          Who Must Sign the Application. 53

0302.15             DECISION ON ELIGIBILITY.. 53

0302.20             PERIOD OF ELIGIBILITY.. 54

0302.25             CERTIFICATION OF ELIGIBILITY.. 55

0302.30             PAYMENT PROCESS. 55

0302.30.05          MA as Payor of Last Resort 56

0302.30.10          Direct Reimbursement to Recipients. 56

0304                 TECHNICAL ELIGIBILITY REQUIREMENTS. 59

0304.05             REQUIREMENTS OF CITIZENSHIP/ALIENAGE. 59

0304.05.05          The SAVE Program.. 60

0304.05.10          Eligibility as a United States Citizen. 61

0304.05.10.05       Verification of Citizen Status. 62

0304.05.15          Elig as a Qualified Non-Citizen. 66

0304.05.15.05       Five Year Ban. 68