Pennsylvania Code & Bulletin
COMMONWEALTH OF PENNSYLVANIA

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The Pennsylvania Code website reflects the Pennsylvania Code changes effective through 53 Pa.B. 8238 (December 30, 2023).

55 Pa. Code § 1123.60. Limitations on payments.

§ 1123.60. Limitations on payments.

 (a)  Under no circumstances may the provider be paid an amount that exceeds the price the provider currently charges the self-paying public.

 (b)  Payment will be made for either orthopedic shoes or orthotic devices but not both.

 (c)  Payment for orthopedic shoes and orthotic devices is subject to the following limitations:

   (1)  Four pairs of orthopedic shoes, either with or without an attached leg brace per year for those eligible recipients 20 years of age or younger.

   (2)  One pair of orthotic devices every 3 years for those eligible recipients 16 years of age or older. These are not compensable, however, if the recipient has received orthopedic shoes in the 365 days prior to provision of the orthotic device.

   (3)  Four pairs of orthotic devices every 3 years for those eligible recipients under 16 years of age. These are not compensable, however, if the recipient has received orthopedic shoes in the 365 days prior to provision of the orthotic device.

 (d)  Contact lenses are compensable only when prescribed as prostheses, that is, to replace the lens of the eye.

 (e)  Payment for durable medical equipment and surgical supplies is limited to a maximum of $600 unless prior authorized by the Department as specified in §  1101.67 (relating to prior authorization).

 (f)  Unless a shorter period is specified on the MA Program fee schedule, payment for rental of durable medical equipment is limited to 6 months after which time prior authorization is required from the Department as specified in §  1101.67.

 (g)  Payment for prescribed or ordered medical supplies shall be limited to those items in the MA program fee schedule.

 (h)  Only one eyeglass fitting fee will be paid per recipient per year.

 (i)  Prostheses and orthoses shall be prior authorized as specified in §  1101.67.

Authority

   The provisions of this §  1123.60 amended under sections 201(2), 403(b), 443.1, 443.3, 443.6, 448 and 454 of the Public Welfare Code (62 P. S. § §  201(2), 403(b), 443.1, 443.3, 443.6, 448 and 454).

Source

   The provisions of this §  1123.60 adopted May 9, 1980, effective July 1, 1980, 10 Pa.B. 1882; amended September 26, 1980, effective October 1, 1980, 10 Pa.B. 3796; amended December 23, 1983, effective January 1, 1983, 13 Pa.B. 3932; amended November 30, 1984, effective December 1, 1984, 14 Pa.B. 4370, and by approval of the court of a joint motion for modification of a consent agreement dated February 11, 1985 in Turner v. Beal, et al., C.A. No. 74-1680 (E.D.Pa. 1975); amended September 30, 1988, effective October 1, 1988, 18 Pa.B. 4418; amended August 26, 2005, effective August 29, 2005, 35 Pa.B. 4811. Immediately preceding text appears at serial pages (278460) to (278461).

Cross References

   This section cited in 55 Pa. Code §  1123.51 (relating to general payment policy).



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