Pennsylvania Code & Bulletin

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The Pennsylvania Code website reflects the Pennsylvania Code changes effective through 54 Pa.B. 1806 (March 30, 2024).

55 Pa. Code § 178.6. Third-party liability for all categories of MA.</B>

§ 178.6. Third-party liability for all categories of MA.

 (a)  An applicant/recipient may have sources other than MA that cover the cost of his medical services and care. The third-party liability sources which are available to pay for medical services and care shall be identified and used to the fullest extent possible before payment is made by MA. The Department is the payer of last resort.

 (b)  Third-party resources include, but are not limited to:

   (1)  Blue Cross and commercial hospital insurance.

   (2)  Health insurance benefits-Medicare.

     (i)   Hospital insurance.

       (A)   Inpatient hospital care.

       (B)   Skilled nursing care after hospitalization.

       (C)   Home health benefits after hospitalization.

     (ii)   Medical insurance.

   (3)  Other hospital insurance paid to the person.

   (4)  Medical insurance included as part of a support agreement.

   (5)  Civilian Health and Medical Program of the Uniformed Services (CHAMPUS).

   (6)  Workers compensation.

   (7)  Negligence action or other tort.

   (8)  Institutional care contracts. This includes a contract between a person and a facility which gives the person the right to receive care at zero or reduced cost at the facility.

   (9)  Payments made toward the cost of medical service by an LRR or other person.

   (10)  LRRs, including spouses and parents of unemancipated minor children.

   (11)  Long term care/nursing home care insurance.

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