Pennsylvania Code & Bulletin
COMMONWEALTH OF PENNSYLVANIA

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The Pennsylvania Code website reflects the Pennsylvania Code changes effective through 53 Pa.B. 6142 (September 30, 2023).

55 Pa. Code § 1221.57. Payment conditions for necessary abortions.

§ 1221.57. Payment conditions for necessary abortions.

 (a)  Coverage for abortions funded under the MA Program will be available only under the following circumstances:

   (1)  Where a physician has certified in writing and documented in the patient’s record that the life of the woman would be endangered if the pregnancy were allowed to progress to term. The decision as to whether the woman’s life is endangered is a medical judgment to be made by the woman’s physician. Payment will be made only if a ‘‘Physician Certification for an Abortion’’ form, signed by a licensed physician, is submitted with the Medical Services Invoice. A sample of the required ‘‘Physician Certification for an Abortion’’ form appears in the provider handbook with instructions for its completion.

   (2)  Where the recipient was the victim of rape or incest and the incident was reported to a law enforcement agency or to a public health service within 72 hours of its occurrence in the case of rape and within 72 hours of the time the physician notified the patient that she was pregnant in the case of incest. A law enforcement agency means an agency or part of an agency that is responsible for the enforcement of the criminal laws, such as a local police department or sheriff’s office. A public health service means an agency of the Federal, State or local government or a facility certified by the Federal government as a Rural Health Clinic that provides health or medical services except for those agencies whose principal function is the performance of abortions.

     (i)   Payment will be made if a ‘‘Physician Certification for an Abortion’’ form is submitted with the Medical Services Invoice along with documentation signed by an official of the law enforcement agency or public health service to which the rape or incest was reported. The documentation must include the following:

       (A)   Information specified in subparagraph (ii).

       (B)   A statement that the report was signed by the person making the report.

     (ii)   The report of the rape or incest need not be made by the victim herself but can be reported by another person. The report need not be made in person but may be made by mail. The report itself shall be signed by the person who reports the rape or incest and shall include the following information:

       (A)   The name and address of the victim.

       (B)   The name and address of the person who made the report if different from the victim.

       (C)   The date of the incident if it was rape.

       (D)   The date the report was made.

 (b)  Insofar as required by the Department of Health regulations, during the first 12 weeks of pregnancy payment will only be made under the MA Program for an abortion performed in a licensed physician’s office, a clinic or a hospital facility that has been licensed/approved by the Department of Health for that purpose.

 (c)  Insofar as required by the Department of Health regulations, after the first 12 weeks of pregnancy, payment will only be made under the MA Program for abortions performed in a hospital which has been licensed/approved by the Department of Health.

Authority

   The provisions of this §  1221.57 issued under the Public Welfare Code (62 P. S. §  453).

Source

   The provisions of this §  1221.57 adopted December 5, 1980, effective December 1, 1980, 10 Pa.B. 4599; amended February 13, 1981, effective February 15, 1981, 11 Pa.B. 657; amended August 7, 1981, effective August 8, 1981, 11 Pa.B. 2770. Immediately preceding text appears at serial pages (60745) and (60746).

Cross References

   This section cited in 55 Pa. Code §  1221.51 (relating to general payment policy).



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