The CAO will determine continuing eligibility for the calendar month in which an individual applies. If the applicant/recipient group is not eligible in the month of application, the CAO will determine eligibility for the following month. 55 Pa. Code § 181.11(a)
NOTE: When the CAO receives an application for MA, the CAO will determine whether there is a need for MA coverage in the retroactive period.
The applicant/recipient group is eligible for NMP when its total countable net income for the calendar month is equal to or less than the NMP limit.
For the TANF/GA-related categories PC, PU and PD, the limit is the family size allowance (FSA) listed in Appendix A.
For the SSI-related categories PA, PM and PJ, the limit is the SSI benefit level listed in Appendix B.
NOTE: The NMP limit is based on the number of people in the applicant/recipient group, including the unborn child(ren) of a pregnant woman who is included. The pregnancy must be confirmed.
If eligibility is for only the month of application or the following month, NMP must be approved as a noncontinuous eligibility (NCE) opening. If eligibility is expected to continue, NMP must be approved as an opening. (See Chapter 380, Issuing the Medical Card)
The period of continuing eligibility for NMP begins with the date of application or the date eligibility is set. 55 Pa. Code § 181.11(a)
The date of application is one of the following:
The date on which the CAO receives and date-stamps an application.
The date on which the application is submitted in COMPASS.
The date of the first admission of treatment, if a COMPASS application is submitted by a MA provider.
The earliest date the application is signed by the applicant, if an MA provider submits the application.
The date eligibility is set is one of the following:
The date the applicant meets all conditions of eligibility.
Example: Mr. and Mrs. Chaney mail in an application for MA. The CAO receives and date stamps the application on July 2. On July 5, the Chaney’s turn in all needed proof. They meet all eligibility conditions except that their resources are $120 over the limit. On July 10, they prove that the amount that was over the limit was used to make a $250 rent payment on July 9.
Eligibility for MA begins July 9, the date the Chaney's met all eligibility conditions.
NOTE: If the excess resource had been used to pay a medical expense, eligibility would have begun on July 2, the date of application. The treatment of resources for MA is different from cash assistance, where having resources that are over the limit makes the applicant ineligible for the entire calendar month.
Example: Mr. and Mrs. Baker mail in an application for themselves and their two children. The CAO receives and date-stamps the application on June 10. On June 15, Mr. Baker turns in proof, and the CAO determines that the family is eligible for NMP. The CAO approves continuing NMP beginning on June 10, the date of application and the date that all eligibility conditions were met.
The first day of the month following the month of application.
The applicant/recipient group is not eligible in the month of application.
The applicant/recipient group meets all requirements on the first day of that month.
Example: Mr. Elliot applies for NMP on May 15. He has been receiving unemployment compensation (UC) benefits. He will receive his last check on May 25. Mr. Elliot is not eligible for NMP for May, because of his UC income. The CAO determines he is eligible for NMP for June and approves benefits starting on June 1.
NOTE: If Mr. Elliot has a medical need between May 1 through May 14, the CAO must look at his eligibility for MNO for May as a retroactive month.
When the CAO determines an individual is eligible for continuing NMP, it must ask the individual about changes in income or situation that may affect eligibility in future months. Changes in situation include, but are not limited to, the following:
A pregnant member returns to work.
An unemployment compensation claim runs out.
An individual expects a raise in pay.
A son graduates from high school and joins the army.
A child turns age 21.
If the CAO expects the applicant/recipient group to be eligible for NMP only for the month of application or the following month (or both), it may use the NCE process to approve non-continuous eligibility.
If the CAO expects the applicant/recipient group to be eligible for NMP for future months, it must approve continuing benefits. For NMP applicant/recipient groups, a renewal must be completed every 12 months. A semiannual reporting (SAR) review is required at six months between annual renewal periods. For NMP spend-down, an annual renewal is required, but a SAR review is not.
Example: An application for MA is date-stamped on July 19. The CAO approves continuing NMP to start July 19 and sets a renewal date of June 30 of the following year.
If the CAO expects a change in income or another situation that will affect eligibility before the next scheduled renewal, it must create an alert to determine eligibility again. Eligibility is always looked at for a calendar month. (See Section 368.7, Changes in Income.) If the CAO determines that an applicant/recipient group is not eligible in a calendar month, NMP eligibility ends the day after the advance notice period expires.
Resource eligibility is based on an applicant/recipient group’s situation on the date of application. The applicant/recipient group stays eligible as long as its resources are not above the limit. (See Chapter 340, Resources.) 55 Pa. Code § 178.1
An applicant/recipient group becomes ineligible for NMP on the date its total countable resources go over the limit. The group becomes eligible again on the date its resources drop to within the limit.
Example: The CAO gets and date-stamps an application for MA on September 3. The CAO finds that on September 3, the resources are more than the limit. On September 7, the applicant proves that she lowered her resources below the limit on September 5, when she paid some household bills. If all other conditions are met, MA eligibility begins September 5.
When resources are over the limit, the CAO will give the individual the choice of using the excess resources to pay any unpaid medical expenses. If the client chooses this option, they must prove that: 55 Pa. Code § 178.1(j)
They used resources to pay for medical expenses from the continuing eligibility period or at any time before the date they are asking for MA coverage to begin.
A member of the applicant/recipient group was legally required to pay for the expense.
NOTE: Before letting an individual know that they should lower resources to below the NMP limit, the CAO must consider eligibility for continuing MNO if that program would meet the individual’s needs.
An excess resource used to pay medical expenses has no effect on resource eligibility for continuing or retroactive MA (NMP or MNO). The CAO will treat the excess as if it never existed.
NOTE: The amount used to pay unpaid medical expenses can be used as a paid medical expense for continuing MNO.
Example: Mr. Long was admitted to the hospital on July 10. The hospital obtained his signature on the PA 600 that day. He was treated for a heart attack for six days, at a total cost of $8,950. The hospital confirms that Mr. Long's resources are $3,000 more than the resource limit. Mr. Long uses the $3,000 to pay part of the hospital bill. The CAO finds that his resources are within the resource limit. Mr. Long’s continuing MA eligibility begins on July 10. If he had a medical need in the retroactive months, Mr. Long also meets the resource condition for that period.
The CAO will determine continuing eligibility for the calendar month the application is dated. If the applicant/recipient group is ineligible for NMP for that month, the CAO must look at NMP eligibility for the next calendar month. 55 Pa. Code § 181.11
Important: If possible, the CAO will determine whether the applicant/recipient group needs retroactive medical coverage. For GA-related NMP, if the individual chooses to receive the incentive in a retroactive month, that month counts as one of the four months in a row if continuing NMP is approved. (See Section 360.222, Earned Income Incentive Deduction--GA Related).
The CAO will estimate the applicant/recipient group's future income and allowable deductions by counting the actual income and expenses. Individuals can provide one pay stub that is representative of their income and deductions. This representative pay can be within 60 days before the application date.
NOTE: When estimating future income, the CAO will consider any known future changes in income.
NOTE: For GA-related categories, the CAO will use current Internal Revenue Service (IRS) tax tables to estimate work expenses when pay stubs have not yet been received. However, if the work expense deduction is less than the maximum, the CAO will determine eligibility using the actual work expenses as soon as pay stubs are available.
The CAO will count the actual or expected income the applicant/recipient group will receive during the calendar month. The CAO will determine net income by allowing the following deductions from the countable gross income of each member:
For TANF-related categories:
Unearned income expenses. 55 Pa. Code § 181.315
Work expenses ($120 a month).
The 50% earned income incentive, if the member qualifies for the incentive. 55 Pa. Code § 181.311
The actual earned income dependent care expenses, up to the limit.
NOTE: Applicant/recipient group members who can receive these deductions include the PD parent or stepparent of a TANF, SSI or MA child.
For GA-related categories:
Unearned income expenses. 55 Pa. Code § 181.315
The earned income work, individual and dependent care expense deductions, up to the limit ($25 a month) 55 Pa. Code § 181.313
The earned income incentive deduction, if the member qualifies for the incentive.
NOTE: The incentive is $20 plus 50% of the next $60. Unlike retroactive eligibility, the incentive is applied even if the applicant/recipient group is eligible without it. The individual is not given the choice whether to receive the incentive.
Unearned income expenses. 55 Pa. Code § 181.131(a)
The $20 unearned or earned income deduction, up to $20 for each applicant/recipient group each month 55 Pa. Code § 181.132(b)
NOTE: If there is no unearned income or if there is less than $20 in unearned income, the rest of the deduction is taken off of any earned income.
The earned income incentive ($65 plus 50% of the amount left over), including a deduction for an employed, disabled member to pay impairment related work expenses. 55 Pa. Code § 181.132
NOTE: For SSI-related categories, the employed member does not have to qualify for the incentive. The earned income incentive is always allowed.
The actual expenses of an employed blind individual in the group that are related to earning his or her income.
NOTE: For more information, see Chapter 360, NMP Deductions.
The CAO will first determine continuing NMP eligibility without considering medical expenses. If the applicant/recipient group is ineligible, the CAO must follow the NMP spend-down procedures in Section 368.4. 55 Pa. Code § 181.11(d)
The CAO will determine continuing eligibility as follows:
1. Determine the category of NMP for each individual. (See Chapter 305, Category.)
2. Determine who is in the applicant/recipient group for the calendar month. (See Chapter 310, Applicant/Recipient Groups.)
3. Determine the countable gross earned and unearned income that was available to the group in the calendar month. (See Chapter 350, Income.)
4. Estimate the countable gross earned and unearned income that will be available to the group for the rest of the calendar month.
5. Add the actual and expected income. If the income is received weekly or biweekly, find the average weekly amount and multiply it by four to obtain the monthly amount.
6. Determine the total actual or expected net income for the calendar month by allowing the deductions in Chapter 360, NMP Deductions.
Reminder: Apply the earned income incentive deduction to the income of an employed TANF/GA-related applicant if the individual is qualified to receive the incentive. SSI-related individuals with earned income always receive the earned income incentive.
7. Compare the countable net income with the NMP limit.
For TANF/GA-related limits, see Appendix A, Family Size Allowance.
For SSI-related limits, see Appendix B, SSI Benefit Levels.
NOTE: Use the limit for the number of people in the applicant/recipient group. Include any unborn child(ren) if pregnancy is proven.
If the total net income is equal to or less than the limit, approve NMP.
If the total net income is over the limit, determine eligibility for NMP spend down or MNO, if it would help the applicant.
The CAO must create an alert to review NMP eligibility for any month in which a change in the applicant/recipient group’s income or situation may make them ineligible.
The CAO must send a notice to applicant letting them know of the decision.
Example: On October 7, Mr. and Mrs. Thompson apply for NMP for themselves and her two children (ages 7 and 10) from a previous marriage. The older child is diabetic and needs medications on a regular basis. Mr. Thompson is employed full-time and makes $195 a week. Mrs. Thompson provides child care in her home for one child. She proves earnings of $50 a week and a cost of $15 a week for the child’s lunch. The CAO determines that Mr. Thompson is category PD and Mrs. Thompson and her children are PC. The Thompson's have not received any type of assistance in the past. They have no unpaid medical expenses in the three months before October 7.
Earned income incentive eligibility for October.
Mr. Thompson’s gross earnings $780
Work expense deduction -120
Child care expense -0
Total income without incentive $660
Mrs. Thompson’s gross earnings (profit) $140
Work expense deduction -120
Child care expense -0
Total income without incentive $20
Applicant group’s total income $680
Standard of Need $662
Neither Mr. nor Mrs. Thompson qualifies for the earned income incentive deduction.
Net income eligibility for October.
Mr. Thompson’s gross income $660
Mrs. Thompson’s gross income +20
Total income $680
Family size allowance (FSA) $497
The four-person Thompson family is ineligible for NMP. The children are eligible and approved for Healthy Beginnings. Mr. and Mrs. Thompson will be reviewed for MNO.
Updated February 14, 2012, Replacing October 25, 2008