Healthy Beginnings provides Nonmoney Payment (NMP) Medical Assistance (MA) to qualified children (including foster children) through age 18 and to pregnant women. 55 Pa. Code § 140.1 55 Pa. Code § 140.21
NOTE: Healthy Beginnings provides outpatient prenatal services to pregnant women who are presumptively eligible. 55 Pa. Code § 140.141
In CIS with MA Eligibility Determination Automation (MEDA), applicant/recipient groups are built according to target type. MEDA may build several applicant/recipient groups for the same Healthy Beginnings household. (See Chapter 310, Applicant/Recipient Groups.)
NOTE: MEDA is an automated process that calculates the information that the CAO worker enters into the electronic system to arrive at the correct category of eligibility for MA benefits.
For Healthy Beginnings program status code PS-16, there are four target types:
P—Pregnant woman.
I—Infant less than 1 year old.
C—Child 1 to 5 years old.
Y—Child 6 to 18 years old.
The CAO must decide who can get Healthy Beginnings using the rules in this chapter and the following chapters: 55 Pa. Code § 140.31
Medical Assistance Eligibility Handbook.
NOTE: The client must report changes in gross monthly earned income of more than $100 and of gross monthly unearned income of more than $50. All other changes, including new sources of income, must continue to be reported. 55 Pa. Code § 181.23
NOTE: A renewal is not required for presumptive eligibility.
Supplemental Handbook.
Exception: The client may not file an appeal when he or she is turned down for presumptive Healthy Beginnings, or when presumptive Healthy Beginnings is stopped. 55 Pa. Code § 140.144
A pregnant woman or a qualified child up to age 1 can get Healthy Beginnings if family income is equal to or less than 185% of the Federal Poverty Income Guidelines (FPIGs) for the family size (see Appendix C). 55 Pa. Code § 140.1(b)
Exception: The pregnant woman, once approved, can get MA coverage through 60 days after giving birth, regardless of her income. The newborn whose mother was getting MA or CHIP at the time of birth can get MA coverage up to age one, regardless of the mother’s income. 55 Pa. Code § 140.122
Children's Health Insurance Program Reauthorization Act (CHRIPRA) of 2009.
NOTE: If the CAO did not know about the pregnancy and it learns that cash or MA benefits were closed during the pregnancy, it must approve MA coverage from the date of the closing through the last day of the month in which the 60-day period ends. If a pregnant woman requests in writing that her case be closed, the case can be closed.
When a provider or other outside source asks for MA benefits for a child under age one, the CAO must review the family’s case record to see if cash or MA or CHIP benefits were open for the mother any time during the pregnancy. If so, the CAO must authorize MA benefits for the child from the date of birth until the first birthday. Children's Health Insurance Program Reauthorization Act (CHRIPRA) of 2009.
A qualified child age 1 to 5 can get Healthy Beginnings if family income is equal to or less than 133% of the FPIG for the family size (see Appendix A).
A qualified child age 6 and under age 19 can get Healthy Beginnings if family income is equal to or less than 100% of the FPIG for the family size (see Appendix B). 55 Pa. Code § 140.31
Reminder: The CAO must consider NMP for the Family (PC 27 or PU 27) and automatic medical coverage extensions before considering one family member’s eligibility. (See Chapter 305, Appendix D, Procedures for Establishing MA Eligibility.)
If the child does not qualify for PC, PU, or PS (Healthy Beginnings), the CAO must decide on his or her eligibility for Medically Needy Only (MNO) benefits.
NOTE: When TANF or MA benefits are ended because an individual or a group earns too much money, the caseworker must consider eligibility for the budget group for other MA benefits. (See Chapter 305, Appendix D, Procedures for Establishing MA Eligibility.) If the budget group is not eligible for any other MA benefits and it includes a pregnant woman or child under age one who was born when the mother was on MA or CHIP, the CAO must approve the pregnant woman or child under age one for Healthy Beginnings benefits, using category PS and program status code 18. 55 Pa. Code § 140.122
Healthy Beginnings provides the following benefits: 55 Pa. Code § 140.1
The benefits provided by MA.
NOTE: Healthy Beginnings recipients with program status code 16 or 18 can enroll in a Health Maintenance Organization (HMO).
NOTE: People who are presumptively eligible (program status code 17) cannot enroll in an HMO, PCCM, or HIPP.
60-day eligibility following birth.
A woman who is getting MA, including Healthy Beginnings, at the end of her pregnancy is automatically eligible for extended MA. The CAO must continue MA through the last day of the month in which the 60-day period ends. A child born to a mother who is getting MA or CHIP at the time of birth is automatically eligible for MA for one year. See Chapter 338.421 Medical Assistance Benefits, for information about both extensions. 55 Pa. Code § 140.122
NOTE: If the CAO did not know about the pregnancy and it learns that cash or MA benefits were closed during the pregnancy, it must approve MA coverage from the date of the closing through the last day of the month in which the 60-day period ends. If a pregnant woman requests in writing that her case be closed, the case can be closed.
NOTE: When a provider or other outside source asks for MA benefits for a child under age one the CAO must look over the family’s case record to see if cash or MA or CHIP benefits were open for the mother any time during the pregnancy. If so, the CAO must approve MA benefits for the child from the date of birth until the child’s first birthday.
One year eligibility for newborns. 55 Pa. Code § 140.125
A child born to a woman getting MA or CHIP on the date of the child's birth is automatically eligible for MA for one year.
Children's Health Insurance Program Reauthorization Act (CHRIPRA) of 2009.
NOTE: This rule also applies in the following situations:
The child is born to an undocumented non-citizen mother whose labor and delivery were covered by MA, even though the mother is eligible for emergency services only.
The child is born to a lawfully-admitted non-citizen mother temporarily admitted to the U.S. whose labor and delivery were covered by MA.
NOTE: A newborn is automatically eligible up to age one if the mother is eligible for MA in Pennsylvania when the child is born. If the newborn’s case is closed because the family moved to another state and the family later returns to Pennsylvania during the one-year eligibility period, the newborn’s case must be reopened for the rest of the one-year period.
Reminder: Changes in the mother's family income never affect the child's eligibility for this one-year period. When the child reaches age one, the CAO will process a renewal to determine if the child remains eligible for MA no later than the first workday of the week after the child’s birthday.
The newborn must remain open for MA for the automatic one year eligibility period under the following conditions:
The newborn does not come home from the hospital to live with the mother.
If the whereabouts of the newborn are known, the CAO should open the newborn in its own case record and list the guardian or caretaker as the payment name.
Adopted newborns who were born to a birth mother on MA at the time of the newborn’s birth can also receive the one year of eligibility if information is known and adoptive parents opt for the MA coverage.
The newborn does not remain a member of the mother’s household.
Example: A pregnant woman is getting MA. She gives birth and takes the newborn home. Once at home she feels she is not ready to care for the newborn. The mother allows the baby to be cared for by and reside with a family friend. The newborn is no longer residing with the biological mother, but is to remain on MA until age one.
The mother of the newborn is no longer eligible for MA.
The newborn of a low-income woman getting free or low cost CHIP must be screened for MA eligibility.
NOTE: A Pennsylvania Insurance Department (PID) CHIP contractor screens CHIP newborns. If the newborn is eligible for MA a referral will be made to DPW through Healthcare Handshake (HCHS).
NOTE: The CAO gets the referral and must open MA for the newborn within five working days of receiving the referral. MA begins the date the referral was received in the CAO. CHIP covers the newborn from the date of birth until the day before the referral is made to DPW.
NOTE: All family members are to be added to the record with only the newborn applying for MA.
If the mother of the newborn is unemancipated and still under the care and control of her parent, then the grandparent of the newborn is to be used as the payment name on the record.
Reminder: Newborns that are eligible for MA or CHIP because their mother was getting MA or CHIP at the time of birth are considered to have satisfactory documentation of citizenship and identity by the sole fact of being born in the United States. Citizenship and identity documentation for the newborn are not required at birth or at any renewal or application for MA or CHIP in the future.
Continuation of coverage to the pregnant woman.
If a change in family income makes a pregnant woman ineligible for TANF and MA, MA coverage must continue for the pregnant woman throughout her pregnancy and for 60 days following the birth. The 60-day period begins on the day of birth and ends on the last day of the month in which the 60th day falls. MA coverage may not go beyond the last day of the 60-day period. The CAO must change the category to PS-18. 55 Pa. Code § 140.122
Continuation of coverage to the qualified child.
A qualified child who is receiving inpatient hospital care at the time he or she becomes too old to be considered qualified will continue to be eligible for Healthy Beginnings until the end of the hospital stay, as long as the family is income eligible. 55 Pa. Code § 140.123
NOTE: The CAO will process a renewal to determine if the child can remain eligible for MA no later than the first workday of the week after the child’s birthday.
Retroactive coverage.
Healthy Beginnings benefits may be allowed retroactively if the client has a need for medical coverage for an unpaid medical expense during the three months before the month of application. The CAO must allow retroactive Healthy Beginnings for a mother who applies after the birth of her child but within the month of birth. If she is eligible in the month she applies or in any of the preceding three months, the mother is eligible through the 60-day period following birth. The child is also eligible for Healthy Beginnings back to the date of birth. 55 Pa. Code § 140.124 55 Pa. Code § 181.12
Reminder: The CAO must look at retroactive eligibility for PC/PU or MNO if the application is submitted after the month of birth.
NOTE: Persons who are presumptively eligible for Healthy Beginnings are not eligible for retroactive coverage.
Healthy Beginnings Plus.
A pregnant woman who gets MA in any category may be eligible to get extra maternity care. (See Chapter 338, Medical Assistance Benefits.)
NOTE: There is no spend-down for Healthy Beginnings. If spend-down is needed, the CAO must decide on PC/PU or MNO eligibility.
Healthy Beginnings provides outpatient services before birth for up to 45 days to pregnant women who are considered presumptively eligible by a qualified provider. The presumptively eligible pregnant woman is not eligible for enrollment in an HMO. 55 Pa. Code § 140.142(b)(2)
A list of qualified providers is available on PROMISe. To get information on providers, log in to the PROMISe Web page, and click on “provider search” on the left side of the main page. You can select up to five fields or just the county and type of provider.
NOTE: A woman can get one period of presumptive eligibility for each pregnancy. A client who is presumptively eligible for Healthy Beginnings is not eligible for retroactive coverage.
Only a qualified provider can decide that a woman is presumptive eligible. The following conditions must be met: 55 Pa. Code § 140.141
The provider has found that the woman is pregnant.
The family income is within the income limits in Appendix C.
NOTE: For presumptive eligibility, the provider does not need to get proof of income or family size. The size of the family must always include the unborn child or children. 55 Pa. Code § 140.31(b)
NOTE: No work incentive deductions are allowed when deciding on a woman’s presumptive eligibility.
The woman meets the requirements of Chapter 322, Citizen/Noncitizen and Chapter 323, Residence.
The woman has signed the Presumptive Eligibility Form (MA 332) and completed the Application for Benefits (PA 600) (See Section 318.8, Authorizing Presumptive Eligibility, for information on processing the (MA 332.) 55 Pa. Code § 140.141(1) (iii)(C)
The CAO must make sure the following is true and accurate:
Pregnancy and expected date of delivery.
This must be verified by a licensed medical doctor, clinic or other medical source. 55 Pa. Code § 140.101
Income. 55 Pa. Code § 140.103
Exception: Proof of income is not required for presumptive eligibility.
Birthdate of a qualified child. 55 Pa. Code § 140.102
Benefits may be allowed before proof is received if the stated birthdate appears to be reasonable.
NOTE: The CAO must not verify the birthdate of the child more than once unless there appear to be different dates.
Updated February 14, 2012, Replacing October 13, 2009