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STATEMENTS OF POLICY

Title 55--PUBLIC WELFARE

DEPARTMENT OF PUBLIC WELFARE

[55 PA. CODE CH. 1101]

Clarification Regarding the Definition of ''Medically Necessary''

[37 Pa.B. 1880]
[Saturday, April 21, 2007]

Scope

   This statement of policy applies to providers enrolled in the Medical Assistance (MA) Program.

Purpose

   The purpose of this statement of policy is to clarify the definition of ''medically necessary'' in § 1101.21 (relating to definitions).

Background

   On February 1, 1997, the Commonwealth implemented the HealthChoices Program, the mandatory managed care program for both physical and behavioral health care services for MA recipients. More than 70% of MA recipients currently receive their physical and behavioral health care through HealthChoices. The remaining MA population is served in the voluntary managed care or the fee-for-service delivery system.

Discussion

   The Department of Public Welfare (Department) only pays for medically necessary services, items, procedures and levels of care. The definition of ''medically necessary'' is in § 1101.21. The HealthChoices contract contains a definition of ''medical necessity'' that uses language that is similar, but not identical, to the language in the regulatory definition of ''medically necessary.'' Although the language is not identical, the intended meaning is the same. The HealthChoices definition merely clarifies the intent of the regulatory definition.

   To assure consistent application of the terms ''medical necessity'' and ''medically necessary'' in both the mandatory and voluntary managed care and the fee-for-service delivery systems, the Department is clarifying when a service, item, procedure or level of care is ''[n]ecessary to the proper treatment or management of an illness, injury or disability'' as required by subparagraph (ii) of the regulatory definition of ''medically necessary.''

Effective Date

   This statement of policy is effective immediately upon publication in the Pennsylvania Bulletin.

Contact Person

   Comments and questions regarding this statement of policy should be directed to the Department of Public Welfare, Office of Medical Assistance Programs, c/o Regulations Coordinator, Room 515, Health and Welfare Building, Harrisburg, PA 17120, (717) 772-6341. The Office of Medical Assistance Programs website is www.dpw.state. pa.us/omap.

   (Editor's Note: Title 55 of the Pennsylvania Code is amended by adding a statement of policy in § 1101.21a to read as set forth in Annex A.)

ESTELLE B. RICHMAN,   
Secretary

   Fiscal Note: 14-BUL-072. No fiscal impact; (8) recommends adoption.

Annex A

TITLE 55. PUBLIC WELFARE

PART III. MEDICAL ASSISTANCE MANUAL

CHAPTER 1101. GENERAL PROVISIONS

DEFINITIONS

§ 1101.21a. Clarification regarding the definition of ''medically necessary''--statement of policy.

   A service, item, procedure or level of care that is necessary for the proper treatment or management of an illness, injury or disability is one that:

   (1)  Will, or is reasonably expected to, prevent the onset of an illness, condition, injury or disability.

   (2)  Will, or is reasonably expected to, reduce or ameliorate the physical, mental or developmental effects of an illness, condition, injury or disability.

   (3)  Will assist the recipient to achieve or maintain maximum functional capacity in performing daily activities, taking into account both the functional capacity of the recipient and those functional capacities that are appropriate of recipients of the same age.

[Pa.B. Doc. No. 07-687. Filed for public inspection April 20, 2007, 9:00 a.m.]

   



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