In some situations, the CAO must extend MA coverage without a review of eligibility. The recipient must get MA for a certain time as an NMP or MNO recipient.
The following individuals and budget groups can get extended MA benefits:
A newborn whose mother has MA at the time of birth
A newborn is eligible for Children’s Health Insurance Program (CHIP) if the mother has CHIP at the time of birth.
A pregnant woman following the termination of pregnancy 55 Pa. Code § 140.401
A TANF budget group whose benefits were stopped because of support income IMB 100-88-1
A TANF budget group whose benefits were stopped because of:
A new job.
More income from a job.
More hours at a job.
NOTE: This extension is known as extended medical coverage. (See Chapter 339, Extended Medical Coverage.)
If the recipient is not eligible for extended medical coverage, then the CAO must review eligibility for other MA programs. If all conditions are met, the CAO must approve NMP or MNO before stopping the current benefits.
The CAO approves NMP, MNO, or Healthy Beginnings for up to one year for a newborn child if all of the following conditions are met:
55 Pa. Code § 141.71(c)(3) 55 Pa. Code § 141.81(c)(3)(ii)(A)
The child is born to a woman with MA or CHIP at the time of birth.
NOTE: This may include an MA recipient with foster care or adoption assistance. 55 Pa. Code § 141.71(c)
The mother is eligible or would still be eligible if she were still pregnant.
NOTE: Changes in the mother's income do not affect the newborn's eligibility, because if she were still pregnant, the mother would still be eligible even if her income changed.
The CAO was notified by the mother, another responsible individual, the provider, a baby alert from Headquarters or got a Newborn Eligibility Form (MA 112), an application for MA benefits signed by the mother confirming the birth.
NOTE: These rules also apply to a child born to an illegal alien mother whose labor and delivery were covered by MA even though the mother was eligible for emergency services only.
NOTE: When an invoice from an MA provider cannot be processed because the newborn has not been added to CIS, the CAO must get no more than three case alerts before the newborn is approved for MA. If a third alert is issued, CIS will send a report to the Executive Deputy Secretary, the Deputy Secretary for Income Maintenance, and the Area Manager. The CAO will consider the first case alert it gets to be notice of the birth of the child.
A renewal is not required for a newborn until the newborn reaches the first birthday. A renewal will be completed before the end of the child’s one year of eligibility.
When the CAO is told of the birth they will do the following:
1. Enter the information in Application Processing.
2. Approve MA for the newborn’s date of birth if the mother had MA on that date. The date of birth is the eligibility date on CIS.
NOTE: This applies to a child of a woman who is retroactively eligible, and to a child born to an illegal alien mother whose labor and delivery were covered by MA even though the mother was eligible for emergency services only.
NOTE: A newborn does not need to have a Social Security number for MA benefits. If the newborn does not have a Social Security number at renewal, enumeration conditions must be met at that time.
Approve Healthy Beginnings (PS-16) if the mother has MA in any program. The eligibility date is the newborn’s date of birth.
NOTE: The family can choose the program that meets their needs. When a newborn is eligible for PS-16 and the family chooses another program for the newborn, that decision must be narrated.
NOTE: If the mother has TANF, TANF-U, or GA, approve cash assistance benefits. (See Cash Assistance Handbook, Chapter 168, Section 168.812, Additions of Newborn Children to the Budget Group.)
Exception: If the child is born during the 45-day Healthy Beginnings presumptive eligibility period, do not use the MA 112. The newborn is not automatically eligible for one year but is eligible if the mother is eligible. (See Chapter 318, Healthy Beginnings.)
Approve PS-18 for the newborn if the mother is not eligible for MA benefits because of income.
NOTE: There is a separate budget group for the newborn, such as PS2. Twins, triplets, and so on must be approved in the same budget group.
3. Set a renewal due date 12 months from the date of birth. A renewal is not needed until the newborn reaches the first birthday. It must be completed before the end of the child’s one year of eligibility.
4. Contact the hospital to give them the CIS billing information for the newborn.
5. Send the mother a notice to applicant to let her know that the newborn is eligible for MA.
The medical facility fills out the MA 112 when it knows the mother is an MA recipient. The medical facility must contact the CAO as soon as possible after the birth of the child. MA for the newborn should be approved at the first contact.
NOTE: If the hospital does not provide an MA 112 in a timely way, the CAO will approve MA back to the date of birth when it finds out about the child’s birth or when it gets a signed and dated application.
When the CAO gets the MA 112, it does the following within three working days:
1. Complete the MA 112 following the instructions in Appendix B.
NOTE: If the newborn was approved and added to the applicant or recipient group before the MA 112 came in, the CAO fills out the form and returns it to the provider.
NOTE: If the newborn has not been approved by the time the MA 112 comes in, follow instructions in 338.41.
2. Return the hospital copy within three working days.
A woman who has MA at the end of her pregnancy is eligible for continued MA through the last day of the month in which the postpartum period ends. MA is continued for any woman who loses eligibility for cash assistance, NMP, or MNO because of a change in family income.
Exception: The CAO does not continue eligibility if the woman moves permanently to another state.
Continued eligibility starts on the date the pregnancy ends and finishes on the last day of the month in which the 60th day after the end of the pregnancy falls. Postpartum includes live birth, stillbirth, miscarriage, or abortion. Coverage is also extended if the child is placed for adoption or in foster care.
Example: Brenda George is pregnant and getting Healthy Beginnings (PS-16). On June 15, she has a miscarriage. On June 22, she starts a new job. The CAO finds that she is no longer eligible for NMP, but it continues PS-16 through August. On September 1, Brenda’s eligibility ends, and she must meet all eligibility conditions to keep getting NMP.
The CAO will review eligibility for MA, including SelectPlan when postpartum period is ending.
MA coverage must continue for pregnant women and eligible children under age one even if family income is more than the limit for cash assistance or MA.
If cash benefits are stopped because of too much income and the budget group includes a TANF pregnant woman or eligible child under age one, the CAO must continue MA coverage as follows:
1. Determine eligibility for TANF-related NMP for the Family (NMPF) . (See Chapter 368, Determining Eligibility for NMP.)
2. If the budget group is not eligible for TANF-related NMPF and the reason for closure was earned income, determine eligibility for extended medical coverage (EMC). (See Chapter 339, Extended Medical Coverage.)
3. If the EMC budget group is ineligible or becomes ineligible at a later date or the EMC period expires before the end of the pregnancy, approve MA for the pregnant woman or eligible child until the child’s first birthday, using category PS with program status code 18.
If cash or MA benefits are stopped because of too much income, the CAO continues MA coverage as follows:
1. Determine whether the budget group or MA recipient group is eligible for any other MA program.
NOTE: The budget group or MA recipient group may qualify for more than one MA program. Explain the possible choices and allow the recipient to choose the best one.
2. If the budget group or MA recipient group is not eligible for any other MA program, continue MA for the pregnant woman or eligible child until the child’s first birthday, using category PS with program status code 18.
When the CAO finds out about the birth of a child to a woman who is getting Healthy Beginnings in category PS with program status code 18, it must approve the newborn in PS-18 with a renewal due date 12 months from the date of birth.
To prevent any break in MA coverage, the CAO will:
1. Approve PS-18 coverage starting the day after the cash assistance or MA benefits were stopped.
2. Enter the end date for the pregnant woman with reason code 074. The date should be the last day of the month in which the postpartum period ends.
NOTE: MA coverage cannot go later than that date.
3. Upon finding out about the end of the pregnancy, determine MA eligibility for the woman. If she is not eligible, continue MA for the woman through the last day of the month in which the postpartum period ends.
4. Approve PS-18 for the newborn starting on the date of birth, and enter a 12-month renewal date. A renewal must be completed before the end of the child’s one-year eligibility.
When the CAO finds out about the end of a pregnancy, it must continue MA coverage as follows:
1. Find out the woman’s MA category.
2. Continue category PC, PU, PS, PJ, TC, TU, or TJ through the last day of the month in which the postpartum period ends, unless the woman moves permanently from Pennsylvania.
3. Approve a future close date as of the last day of the calendar month in which the postpartum period ends.
4. Review the woman’s eligibility for other MA programs before stopping the current benefit.
5. Send the woman an advance notice at least 13 days before the future close date to let her know that benefits will be stopping or her category will be changing.
The CAO will continue NMP for four months when a TANF (C or U) or TANF-related NMP for the Family (NMPF) budget is closed because of income from support if the following conditions are met: 55 Pa. Code § 140.551
A individual is ineligible in part or totally because of collection or increased collection of support; and
The budget group got TANF (C or U) or TANF-related NMPF in at least three of the six months right before the month of the closure.
NOTE: See the Cash Assistance Handbook, Chapter 131, Support, for information on support collections.
The CAO will extend NMP benefits as follows:
1. Approve an opening in the NMP category (PC or PU) for the day after the cash or NMPF closing date. Use program status code 23.
NOTE: If cash or NMPF should have been stopped earlier, the four-month period begins with the date that the benefits should have been stopped.
2. Send an Advance Notice to let the family know when cash or NMPF benefits will stop.
3. Continue to watch the case to make sure that all eligibility conditions other than income are met.
Important: MA eligibility must be determined for a recipient whose four months of extended NMP (program status 23) has expired.
4. Narrate all decisions and actions in the case record.
See Chapter 339, Extended Medical Coverage (EMC).
When a TANF case closes for reasons that do not affect MA eligibility, all members of the TANF budget will still be for the 12-month eligibility period from the last completed application or renewal.
See Cash Assistance Handbook, Chapter 185, Medical Benefits for Cash Recipients, for examples of when MA is extended after a cash closure.
The CAO will not close MA benefits for people in a cash assistance or MA budget when cash eligibility ends unless the CAO finds that each group member is not eligible under any other cash assistance or MA category. If a group member is still eligible for MA, the CAO will open the MA budget as of the day after the cash budget closes.
NOTE: The extension of MA when a TANF case closes part of the Auto MA and Auto AP/CI processes.
See Chapter 387, Supplemental Security Income (SSI).
Updated February 14, 2012, Replacing April 12, 2007