WILKES-BARRE DO

LUZERNE CAO
205 S. WASHINGTON STREET
WILKES-BARRE, PA 18711-3298

OFFICE OF INCOME MAINTENANCE

Notice ID: 9147628817 | C:22170
Wayne Gribble
108 2nd St
Plains, PA 18702-6953

Mail Date: 05/13/2025 COMPASS: The fast and easy

Record ID: 40/0262585 way to apply for benefits
MCI#: 001631962 www.compass.state.pa.us

The Department of Human Services (DHS) is writing to you about your Medical Assistance (MA) benefits.

Medical Assistance (MA)

Wayne You qualify for Medical Assistance effective 05/12/2025.

You qualify for the state to begin paying your Medicare Part B premium
(Buy-In) effective 05/12/2025.

If you do not agree with this decision, fill out the enclosed Fair Hearing form
and mail or give it to your caseworker. It must be postmarked or received on
or before June 12, 2025.
Wayne:

Wayne:
For the period you qualify, we determined your countable income is $1,277.00 each month after allowable deductions and/
or expenses.

As part of your MA benefits, we will pay your Medicare Part B premium starting with the first month that you qualify. If you
already paid premiums for some of the months that you qualify, you will get a refund from Social Security. Within three
months, you should receive one refund for the entire amount. If you do not get the refund within three months, contact
Social Security.

You may also be eligible for a refund of the Part B premiums that were taken out of your Social Security check for up to
three months before you applied for MA. If DHS has not approved you for Medicare Buy-In for the three months before
you applied, you can appeal.

This is the law we used to make this decision: 55 Pa. Code §§ 140.221, 181.1, 255.4

Your benefits will stay the same until there is a change in your case.

Because you are eligible for Medicaid, you should immediately end your federal premium tax credits or cost-sharing
reductions if you are enrolled in a plan through a health insurance marketplace and you get help paying for coverage. If
(continued on next page)

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Medical Assistance (MA)

you continue to purchase coverage through a marketplace while eligible for Medicaid, you are not eligible to receive
federal financial assistance to help pay for your marketplace coverage.

Qualifying Members Benefit Review Date Access Number

Wayne Adult May 2026 0016319626

Income Details

This is the monthly income based on what you told us and/or information we got from other data sources. Allowable
deductions and expenses may be different for each program.

Member Source 05/2025 06/2025

Wayne Social Security Benefits $1,317.00 $1,317.00

Resource Details

These are the resources based on what you told us and/or information we got from other data sources. The way we count
your resources may be different for each program.

Member Source 05/2025 06/2025

Checking Account-
Wayne $540.42 $540.42
SAMSUNG SOFI

Additional Information
We will review your case on your review date or when there is a change affecting your case.

You are required to report any changes in your circumstances to your caseworker by the tenth of the month
following the month in which the change occurred.

If you are receiving any of the following benefits, you must report your changes within ten days:

• Home and Community Based Services

• SNAP as an Able Bodied Adult Without Dependents
• SNAP in a household comprised only of elderly or disabled members who have no earned income

Failure to do so could result in a loss of benefits. Some examples of changes that you should report are income, address,
and people leaving or moving into your household. You can report a change in your circumstances through a My
COMPASS account or by contacting us using the information below.

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You can use a My COMPASS account (www.compass.state.pa.us) to:

• Apply for and renew benefits • View case information

• Save and submit applications • Receive notices online
• Check application status • Manage case online
• Submit documents electronically • Report a change in your circumstances

If you are denied benefits or your benefits are being closed, you may not need to complete a new application.

If you have an open child support case and your TANF benefits close, we will notify the Domestic Relations Section and
your child support services will continue without application. You may contact your local DRS or visit the Pennsylvania
Child Support Program website at www.childsupport.state.pa.us for additional information about child support.
There may be other services available if you live in a long term care facility or if you receive or need supports and services
to help you live in your home or community, or if you have very high medical bills. If you have any of these special health
care needs and want to know if you qualify, you can contact us.
If you need to contact us, you can contact the Statewide Customer Service Center or your County Assistance Office (CAO)
Monday through Friday between 8 a.m. and 5 p.m.
Statewide Customer Service Center: 1-877-395-8930
County Assistance Office
Phone: 1-570-826-2100
Fax: 1-570-820-4876

If you need free legal help, visit North Penn Legal Services at 33 North Main Street, Suite 200, Pittston, PA 18640
or call 1-(570) 299-4100.
You have a right to appeal and to a Fair Hearing. To learn more about Fair Hearings, read Your Right to Appeal and to
a Fair Hearing document in this packet.

You have a right to appeal and to have an expedited Fair Hearing for Medical Assistance.
An expedited Fair Hearing may be granted when it’s determined that the normal time for review of an appeal would
jeopardize your life, health or ability to attain, maintain, or regain maximum function.

If you have a disability and need this letter in large print or another format, please call our helpline
at 1-800-692-7462. TDD Services are available at 1-800-451-5886.
To learn more about how we calculated and determined your benefits, see the eligibility handbooks at
https://www.dhs.pa.gov/docs/Publications/Pages/Policy-Handbooks-and-Manuals.aspx.

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Did you know the Department of Human Services developed a mobile app called myCOMPASS PA?

Save time by sending your verification documents right from your smart phone using the myCOMPASS PA mobile app.
Download the app today to:

● Upload documents ● Retrieve username and password

● Check Application and Benefit Status ● Report Changes

With myCOMPASS PA, managing your benefits just got easier.

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The Pennsylvania Department of Human Services (DHS) complies with applicable

federal civil rights laws and does not discriminate on the basis of race, color, national
origin, age, disability, or sex. DHS does not exclude people or treat them differently
because of race, color, national origin, age, disability, creed, religious affiliation,
ancestry, gender, gender identity or expression, or sexual orientation.

DHS PROVIDES:
• Free aids and services to people with disabilities to communicate effectively
with us, such as:
- Qualified sign language interpreters
- Written information in other formats (large print, audio, accessible electronic
formats, other formats)
• Free language services to people whose primary language is not English, such as:
- Qualified interpreters
- Information written in other languages

If you need these services, contact your local county assistance office.
If you believe that DHS has failed to provide these services or discriminated in
another way on the basis of race, color, national origin, age, disability, or sex, you can
file a grievance with: The Bureau of Equal Opportunity, Room 223, Health and Welfare
Building, P.O. Box 2675, Harrisburg, PA 17105-2675, (717) 787-1127, PA Relay Services
711, Fax (717) 772-4366, or Email - RA-PWBEOAO@pa.gov. You can file a grievance
in person or by mail, fax, or email. If you need help filing a grievance, the Bureau of
Equal Opportunity is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and
Human Services, Office for Civil Rights, electronically through the Office for Civil
Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf,
or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

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ATTENTION: If you speak another language, language assistance services, free of charge, are available to you. Call
1-800-692-7462 (TDD: 711).

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-
692-7462 (TDD: 711).

注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-800-692-7462 (TDD: 711)。

ВНИМАНИЕ: Если вы говорите на русском языке, то вы можете воспользоваться бесплатными
услугами перевода. Звоните 1-800-692-7462 (телетайп: 711).

ATTENTION : Si vous parlez français, des services d’aide linguistique vous sont proposés gratuitement.
Appelez le 1-800-692-7462 (ATS : 711).

ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-800-692-
7462 (TDD: 711).

ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-800-
692-7462 (TDD: 711).

KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë.
Telefononi në 1-800-692-7462 (TDD: 711).

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Your Right to Appeal and to a Fair Hearing

You can contact us if you have any questions about this notice...
You can call us:
• You can call the Statewide Customer Service Center at 1-877-395-8930.
In Philadelphia, call 1-215-560-7226.
The call is free. Call Monday through Friday between 8 a.m. and 5 p.m.
• Or call the county assistance office (CAO) using the contact information listed in the CAO section
of this notice.
You can talk to us before the hearing.
You will get a letter from the CAO asking if you want to meet before the fair hearing takes place. This
meeting can be in person or on the telephone. A meeting before the hearing is called a pre-hearing
conference. This meeting will not delay or replace your fair hearing. You can use this meeting to tell
us if you have information that you think might change our decision. You can have someone speak on
your behalf if you want to.
You can get a copy of any information we used to make our decision.
You can ask for a copy of all the documents that will be used at the hearing.
You can bring anyone to the hearing.
You can bring witnesses who might have information. You can speak for yourself or bring someone to
speak for you who knows more about the rules of the program.
You can get help if you speak another language, are deaf, or have another disability.
You can ask for an interpreter to be at the fair hearing, or other assistance, on the attached Fair
Hearing Form. This is a free service. You may bring a friend or relative to help you at the hearing but
the department will provide the official interpreter.

Your rights...
You have a right to appeal.
This means that you have the right to ask us to review our decision if you think we made a
mistake. You can ask a judge to review the CAO's decision at a fair hearing.
You have a right to a fair hearing.
A fair hearing is a formal meeting where you, the CAO, and a judge can talk about your
appeal. The judge will follow the law and the department's policies in making a decision. You
should be prepared for the meeting. If you want to present any evidence that supports your
claim that the decision was not correct, bring that evidence with you.
You have a right to appeal and to have an expedited Fair Hearing for Medical Assistance.
An expedited Fair Hearing may be granted when it’s determined that the normal time for
review of an appeal would jeopardize your life, health, or ability to attain, maintain, or regain
maximum function.

You have a right to free legal help.

If you need free legal help, visit North Penn Legal Services 33 North Main Street , Suite 200,
Pittston, PA 18640 or call 1-(570) 299-4100.

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Your choices...
You can ask for a fair hearing by:
• Calling the Statewide Customer Service Center or the CAO to ask for a fair hearing, or
• Mailing or hand delivering the completed, attached Fair Hearing Form to the CAO.
You can choose the kind of fair hearing you want:
• A telephone hearing at a place you choose. Tell us which phone number to use, such as your
own, or a friend or relative’s phone number. If you choose this kind of hearing, make sure we can
reach you at this phone number.
The judge will call you, your witnesses, anyone helping you, and the CAO.
• A telephone hearing at the CAO. You will go to the CAO for your hearing.
The judge will call you there in the office, and call your witnesses and anyone helping you.
• A face-to-face hearing with you and the people you bring in the hearing room with a judge and
CAO staff on the phone.
Your witnesses and anyone helping you will be in the hearing room with a judge. The CAO
staff will be on the phone.
You must travel to the assigned Bureau of Hearings and Appeals office for a face-to-face
hearing. The location will be assigned to you based on where you live.
• A face-to-face hearing with you and the people you bring in the hearing room with a judge and
the CAO staff in the hearing room.
The judge, you, CAO staff, witnesses, and anyone helping you will be in the room.
You must travel to the assigned Bureau of Hearings and Appeals office for a face-to-face
hearing. The location will be assigned to you based on where you live.
You may continue to receive your benefits while you wait for your fair hearing if:
1. This letter tells you that your benefits will stop or be reduced and:
This letter provides you a date to request an appeal and continue your benefits while you wait
for the Fair Hearing Decision, and
Your request for appeal is received or postmarked by that date and you do not waive
continuation of benefits; OR
2. This letter tells you that your benefits will stop or be reduced, and:
The reason for this change is because of information you provided on a semiannual reporting
form, and
Your request for appeal is received or postmarked within 10 days of the mailing date on this
letter and you do not waive continuation of benefits.
The judge will send you the decision within 90 days (within 60 days for SNAP) of the day you asked
for the hearing. If the judge decides that the CAO made the right decision, your benefits will change
or stop. You may have to pay back some or all of the benefits you got while waiting for your hearing.

During the hearing...

You will have time to tell the judge your side of the case at the hearing.
Someone can speak for you (if you want), and your witnesses can speak. You may show documents to
the judge.
You can appeal again if you do not agree with the judge’s decision.
The judge’s decision letter will tell you how to appeal.

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Fair Hearing Form

1. Name: Wayne Gribble Record ID: 40/0262585

Phone number: 272-249-1176 Address: 108 2nd St
Plains, PA 18702-6953
2. Tell us which program you want to appeal:
Medical Assistance (MA) - You must mail or give the form to the CAO before 06/12/2025 .
MA (Expedited Appeal): Check one of the following reasons for requesting an expedited Fair Hearing
and provide details in the line next to the box you check below. An expedited Fair Hearing may be
granted when it's determined that the normal time for review of an appeal would jeopardize your:
Life: ,
Health: , or
Ability to attain, maintain, or regain maximum function: .
If you have medical documentation of your urgent health needs, please submit them with this fair
hearing request.
3. Tell us why you disagree with this decision (use back of page if necessary):

4. Do you want your SNAP benefits to continue at the same amount pending the hearing
decision?
Yes No
5. Choose the way you want your hearing:
By telephone, at the phone number you write on this form. Make sure we can reach you at
this phone number. The judge will call you, your witnesses, anyone helping you, and the CAO.
By telephone, at the CAO. You will go to the CAO for your hearing. The judge will call you
there in the office, and call anyone helping you.
Face-to-face, with you and the people you bring in the hearing room with a judge and CAO
staff on the phone. You must travel to the assigned Bureau of Hearings and Appeals office for
a face-to-face hearing. The location will be assigned to you based on where you live.
Face-to-face, with you and the people you bring in the hearing room with a judge and CAO
staff in the hearing room. You must travel to the assigned Bureau of Hearings and Appeals
office for a face-to-face hearing. The location will be assigned to you based on where you live.
You can ask for an interpreter to be at the fair hearing, or other assistance because of an impairment
or other disability. This is a free service.
6a. Do you need a free interpreter? You may bring a friend or relative to help you at the hearing, but
the department will provide the official interpreter.
Yes No If yes, what language:
6b. If you will need help at the appeal because of a hearing impairment or other disability, please
tell us how we can help you:
7. Signature: 8. Date:
9. Phone number (where you wish to be contacted):

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If someone will be helping you with your appeal, please fill out the information for the representative below.
9a. Representative Name:

9b. Representative Telephone Number:

9c. Representative Address:

WILKES-BARRE DO, LUZERNE CAO, 205 S. WASHINGTON STREET WILKES-BARRE,

10. Mail or give the form to: PA 18711-3298

The Bureau of Hearings and Appeals will send you a letter to tell you when and where your hearing will be.

Additional Information:

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Do you need help with

your phone bill?
If you get any of these:

Supplemental Nutrition Assistance Program (SNAP);

Veterans and Survivors Pension Benefit;

Medical Assistance (MA);

Federal Public Housing Assistance; or,

Supplemental Security Income (SSI),

You may also be able to get

Lifeline 100 or Lifeline 135.
Most phone companies in Pennsylvania provide Lifeline
service. These programs lower your phone costs for one
phone line. Verizon Pa customers can get Lifeline 100 or
Lifeline 135. All other customers get Lifeline 135.

Start saving today!

See the other side of this flier for more information.

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 Notice ID: 9147628817
Pennsylvania Telephone Companies Offering Lifeline Services
Find your local phone company or wireless provider listed below and contact them today.
For faster service, call your local phone company or wireless provider directly to enroll.
To find the local phone company for your county, please visit the Public Utility Commission’s website at www.puc.pa.gov.

Armstrong Tel. Company NORTH . . . . . . . . . . . . 814-966-3207 Northeastern PA Telephone Co. . . . . . . . . . . . . . . . 570-785-3131

693 Main St., P.O. Box 342 • Duke Center, PA 16729 720 Main Street, P.O. Box D • Forest City, PA 18421-0150

Armstrong Telephone . . . . . . . . . . . . . . . . . . . 724-899-2211 Palmerton Telephone Company. . . . . . . . . . . . . . . 610-826-2115

1755 State Route 30 • Clinton, PA 15026-0418 P.O. Box 215 • Palmerton, PA 18071

CentryLINK Data Services . . . . . . . . . . . . . . . . 1-800-829-8009 Pennsylvania Telephone Company . . . . . . . . . . . . . 570-745-7101

P.O. Box 7086 • London, KY 40742 191 Middle Road • Jersey Shore, PA 17740
(Only serves 570 area code/745 prefix.)
Citizens Telephone Co. of Kecksburg . . . . . . . . . . . 724-423-4444
P.O. Box 156 • Mammoth, PA 15664 Pymatuning Independent Tel. Co. . . . . . . . . . . . . . . 724-646-5400
5 Edgewood Drive • Greenville, PA 16125
Consolidated Communications . . . . . . . . . . . . . . . 724-443-9521
4008 Gibsonia Road • Gibsonia, PA 15044-0395 RCN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-800-746-4726
100 Baltimore Avenue • Wilkes Barre, PA 18702
Fairpoint Communications . . . . . . . . . . . . . . . . 877-524-8293
(Bentleyville Telephone Co.) (Marianna & Scenery Hill Telephone Co.)
Service Electric Telephone . . . . . . . . . . . . . . . . . .610-841-4100
Offline Services Group • 30 East Main Street • Westerfield, NY 14787
4242 Mauch Chunk Road • Coplay, PA 18037
Frontier Communications . . . . . . . . . . . . . . . . 1-800-921-8101
P.O. Box 5156 • Tampa, FL 33675 1-800-225-5282 South Canaan Telephone Co. . . . . . . . . . . . . . . . . 570-937-4114
P.O. Box 160 • South Canaan, PA 18459
Full Service Network, LP . . . . . . . . . . . . . . . . . 1-888-347-6000
ATTN: Lifeline Dept. • 600 Grant St., Ste. 3075 • Pittsburgh, PA 15219 TDS Telecom-Lifeline . . . . . . . . . . . . . . . . . . . .1-888-225-5837
P.O. Box 608 • Lancaster, WI 53813 877-271-2861 (fax)
Hancock Telephone Co. . . . . . . . . . . . . . . . . . . .607-637-9911
P.O. Box 608, 34 Read St. • Hancock, NY 13783 Venus Telephone Corporation . . . . . . . . . . . . . . . . 814-354-2192
Hickory Telephone Co. . . . . . . . . . . . . . . . . . . . 724-356-2211 1698 County Line Rd., Box 75 • Venus, PA 16364
75 Main Street • Hickory, PA 15340-1118
Verizon Lifeline Service - PA . . . . . . . . . . . . . . . 1-800-837-4966
Ironton Telephone Company . . . . . . . . . . . . . . . . 610-799-3131 P.O. Box 33075 • St. Petersburg, FL 33733-8075
4242 Mauch Chunk Road • Coplay, PA 18037
West Side Telecommunications . . . . . . . . . . . . . . 1-800-296-9113
Lackawaxen Telephone Company . . . . . . . . . . . . . 570-685-7111 1449 Fairmont Road • Morgantown, WV 26501
P.O. Box 8, 104 Hotel Rd. • Rowland, PA 18457
Windstream Communications . . . . . . . . . . . . . . . 1-800-347-1991
Laurel Highland Telephone Co. . . . . . . . . . . . . . . 724-455-2411 ATTN: Support Services - Lifeline • 1720 Gallieria Blvd. • Charlotte NC 28270
P.O. Box 168 • Stahlstown, PA 15687
North Penn Telephone Co. . . . . . . . . . . . . . . . . . 570-549-3705 Yukon Waltz Telephone Co. . . . . . . . . . . . . . . . . . 724-722-3131
4145 State Route 549 • Mansfield, PA 16933 P.O. Box 398 • Yukon, PA 15698-0398

WIRELESS COMPANIES
AirVoice Wireless d/b/a FeelSafe Wireless . . . . . . . .1-877-247-7799 Limitless Mobile . . . . . . . . . . . . . . . . . . . . . . 1-888-249-8030
2425 Franklin Road • Bloomfield Hills, MI 48302 2574 Interstate Drive • Harrisburg, PA 17110
American Broadband d/b/a AB&T Wireless . . . . . . . 1-866-966-2628 Q Link Wireless, LLC . . . . . . . . . . . . . . . . . . . .1-855-754-6543
PO Box 577 • Toledo, OH 43604 499 E. Sheridan St., Ste 300 • Dania, FL 33004
Amerimex d/b/a Safety Net Wireless . . . . . . . . . . . 1-888-224-3213 T-Mobile d/b/a InReach . . . . . . . . . . . . . . . . . . .1-800-937-8997
1007 Mansell Rd, Suite A • Roswell, GA 30076 Customer Relations • P.O. Box 37380 1-800-866-2453
Alburquerque, NM 87176-7380
Blue Jay Wireless . . . . . . . . . . . . . . . . . . . . . 1-855-425-8529
4240 International Pkwy • Suite 140 • Carrollton, TX 75007 Tag Mobile . . . . . . . . . . . . . . . . . . . . . . . . . .1-866-959-4918
Customer Service • 1330 Capital Parkway • Carrollton, TX 75006
Boomerang Wireless d/b/a enTouch Wireless . . . . . .1-866-488-8719
955 Kacena Rd., Ste. A • Hiawatha, IA 52233 Telrite Corporation d/b/a Life Wireless . . . . . . . . . . 1-888-543-3620
Customer Service Department • PO Box 2840 • Covington, GA 30015
Buffalo-Lake Erie d/b/a Blue Wireless . . . . . . . . . . . 716-605-9500
email: info@bluelimited.com • www.blueunlimited.com (Erie, Scranton & TerraCom Wireless (YourTel) . . . . . . . . . . . . . . . 1-888-716-8880
Wilkes Barre only) www.terracomwireless.com

Global Connection d/b/a StandUp Wireless . . . . . . . 1-800-544-4441 Tracfone d/b/a Safelink Wireless . . . . . . . . . . . . . 1-800-723-3546
5555 Oakbrook • Norcross, GA 30093 Attn: Executive Resolution Department • 9700 N.W. 112th Ave.
Miami, FL 33178
iWireless, LLC d/b/a Access Wireless . . . . . . . . . . 1-888-900-5899 Virgin Mobile d/b/a Assurance Wireless . . . . . . . . . 1-888-321-5880
1 Levee Way Ste 3104 • Newport, KY 41071 P.O. Box 686 • Parsippany, NJ 07054-9726

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This benefit package meets the requirements of minimum essential coverage as detailed under the Affordable Care Act.

Your Medical Assistance benefit package is called Adult

and is for people who are 21 and older.
Welcome to Medical Assistance
Here are some helpful tips on using Medical Assistance:
● Be sure to carry your ACCESS card with you at all times. When you go to get health care services, please show all of your insurance cards,
including your ACCESS card.
● If you need a new ACCESS card, call: 1-877-395-8930. If you live in Philadelphia, call: 1-215-560-7226.

You may get these services:

● Certified Registered Nurse Practitioner Services ● Nutritional Supplements
● ●
Chiropractic Services Optometrist Services
● ● Outpatient Drug & Alcohol Services
Clinic Services
● ● Outpatient Hospital Services
Crisis Services
● ● Partial Psychiatric Hospitalization
Contact Lenses (Limited to individuals with aphakia)
●
● Dental Care Services Peer Support Services
● ●
Durable Medical Equipment Physician Services
● ●
Emergency Room/Ambulance Services Podiatrist Services
●
● Eyeglass Frames (Limited to individuals with aphakia) Prescription Drugs
●
● Eyeglass Lenses (Limited to individuals with aphakia) Primary Care Provider Services
● ● Prosthetics and Orthotics (Orthopedic shoes
Family Planning Services and Supplies
● Federally Qualified Health Center Services/Rural Health Clinic and hearing aids are not covered)
Services ● Psychiatric Clinic Services
● Home Health Services ● Radiology Services (Examples: x-rays, MRIs,
● Hospice Services CTs)
● Renal Dialysis Services
● ICF/IID and ICF/ORC (Requires an institutional level of care)
● Targeted Case Management Services -
● Inpatient Drug & Alcohol Services
●
Behavioral Health Only (Limited to individuals
Inpatient Hospital Services
with SMI only)
● Inpatient Mental Health Services
● Targeted Case Management Services - Other
● Laboratory Services than Behavioral Health (Limited to individuals
● Maternity - Physician, Certified Nurse, Midwives, Birth Centers identified in the target group)
● Medical Supplies ● Therapy (Physical, Occupational, Speech)
●
Methadone Maintenance - Habilitative and Rehabilitative (Only when
● Mobile Mental Health Treatment provided by a hospital, outpatient clinic or
●
home health provider)
Non-Emergency Transportation
● Tobacco Cessation
(Only to and from covered services)
● Nursing Facility Services

If you are enrolled in a HealthChoices or Community HealthChoices Managed Care Organization (MCO) or the LIFE program,
please check with your MCO or LIFE provider. The MCO or LIFE provider may provide more services than those required by the
Medical Assistance program.

RC/O: 980/B
914762881730000707
Record ID: 40/0262585 Mail Date: 05/13/2025 Page 13 of 14 PA162
PA 1911 (SG) 11/17
 Notice ID: 9147628817

RC/O: 980/B
914762881730000707
Record ID: 40/0262585 Mail Date: 05/13/2025 Page 14 of 14 PA162
PA 1911 (SG) 11/17