A resident of Pennsylvania is someone who is living and intends to reside in Pennsylvania, with or without a fixed or permanent address. The individual continues to be a resident of Pennsylvania during a temporary absence from this state if he or she intends to return when the purpose of the absence has been accomplished, unless another state determined that the person is a resident there for purpose of Medicaid.
Migrant workers who have entered the state for job-related reasons are considered residents and are eligible for MA unless they get MA in the state where they have permanent residence. This also applies to any member of the migrant’s family who comes along with the migrant worker and wants MA.
An individual does not need to have a fixed or permanent address.. See Section 323.3, Homeless Individuals 55 Pa. Code § 148.1(a)
An individual who gets placement maintenance or subsidized adoption assistance under Title IV-E of the Social Security Act is a resident of the state where he or she lives, no matter which state makes the IV-E payments.
NOTE: If a child is placed in a home in Pennsylvania by a Pennsylvania court, the child is considered to be a resident of the county served by the Children and Youth Agency that made the placement. However, if a child is placed in an approved residential youth facility by his or her parents, the child stays covered under the parent's MA budget as long as the parents do not assign custody to the facility ane are still exercising care & control of the child.
For an individual who is receiving a State Supplementary Payment (SSP), the state of residence is the state paying the SSP. 42 CFR § 435.403(f)
The CAO must look at the individual’s age when determining whether the individual meets residency requirements.
42 CFR § 435.403(h) 42 CFR § 435.403(i)
An individual age 21 or older who is not residing in an institution is considered a resident of Pennsylvania if he or she meets any of the following conditions: 42 CFR § 435.403(h)
The individual lives in Pennsylvania,and:
Intends to reside in Pennsylvania or
The individual has moved to Pennsylvania because he or she has a job or plans to look for a job in the state, whether or not currently employed.
NOTE: If he or she meets these criteria, the CAO must consider the individual to be a resident even if he or she is not currently working in the state.
The individual resides in Pennsylvania but is not able to indicate intent to remain a resident. See Section 323.25, Determining an Individual’s Capability to Indicate Intent.
An individual under age 21 who is not residing in an institution and is not a IV-E beneficiary and is not receiving SSP is considered a resident of Pennsylvania if he or she meets any of the following conditions:
The individual is emancipated, or married and capable of indicating intent, resides in Pennsylvania and
Intends to reside in Pennsylvania or:
The individual has moved to Pennsylvania because he or she has a job or plans to look for a job in the state.
The individual is unemancipated,and resides in Pennsylvania.
The individual is unemancipated and resides in Pennsylvania with the parent or person responsible for the individual's care and control.
An individual under age 21, not residing with a parent or legal guardian, is emancipated if the individual is married or is no longer under the control of a parent or legal guardian. See Chapter 321, Age. 55 Pa. Code § 148.2
The state where an institutionalized individual is said to reside depends on the individual’s age. If the individual is incapable of indicating intent, then the age at which he or she became incapable also matters. See Section 323.25, Determining an Individual’s Capability to Indicate Intent. 42 CFR § 435.403(h) 42 CFR § 435.403(i)
An individual is not eligible for MA while he or she is an inmate or resident of certain types of institutions.
NOTE: When determining where someone resides, the term institution means a state-licensed place that provides food, shelter and some treatment services to four or more individuals who are not related to the owner. State-licensed foster care homes that provide food, shelter and supportive services to one or more individuals who are not related to the owner are also considered institutions when determining where someone resides. 55 Pa. Code § 148.2
Institutions licensed by the state include, but are not limited to, the following:
Hospitals.
Skilled or intermediate nursing home care facilities.
Intermediate care facilities for the mentally retarded.
Mental hospitals.
An individual age 21 or older who resides in an institution is a resident of Pennsylvania if any of the following apply:
The individual can make a decision about where to reside and let others know about that decision, and he or she intends to reside in Pennsylvania.
The individual became incapable of indicating intent before age 21 and the application is being made for the individual by a parent or legal guardian, if parental rights have been terminated who is also a resident of Pennsylvania.
NOTE: If the parent or legal guardian is currently not a resident of Pennsylvania but was a resident when the individual was placed, the individual is considered a resident of Pennsylvania.
Any other individual, if the individual living in an institution that is located in Pennsylvania, has been abandoned by his or her parents and has not had a legal guardian appointed.
NOTE: An individual is considered abandoned if his or her parents are both deceased.
The individual became incapable of indicating intent at or after age 21 and is physically living in Pennsylvania, unless another state made or will make the placement.
An individual under age 21 who resides in an institution and is neither married nor emancipated, is a resident of Pennsylvania if any of the following apply: 42 CFR § 435.403(i)
The individual’s parent or legal guardian is a resident of Pennsylvania at the time of placement.
The individual is in an institution in Pennsylvania and the application is filed by one of the following individuals who is also a resident of Pennsylvania:
A parent.
A legal guardian, if parental rights have been terminated.
Another individual, if the individual living in an institution has been abandoned by his or her parents and has not had a legal guardian appointed.
An individual who resides in an institution and is not considered a resident of Pennsylvania is not eligible for MA. 55 Pa. Code § 148.1(a)
Reminder: If two states cannot agree on the residence of an individual who resides in an institution, then the individual is considered a resident of the state where he physically lives. 55 Pa. Code § 148.21
An individual placed by an agency of the state of Pennsylvania in an institution located in another state is considered to be a resident of Pennsylvania. The individual’s ability to indicate intent has nothing to do with his or her state of residence. 55 Pa. Code § 148.81
NOTE: An agency of the state includes any agency that is under contract with the state to place people in institutions under state law.
The following actions are not considered to be a state placement:
Giving basic information to an individual about another state's MA program or about health care services and facilities in another state.
Helping an individual find an institution in another state, if he or she is capable of indicating intent and he or she chooses to move. 55 Pa. Code § 148.81l
An individual placed by another state in an institution located in Pennsylvania is not considered a resident of Pennsylvania.
Exception: An individual who gets placement maintenance or subsidized adoption assistance under Title IV-E of the Social Security Act is a resident of the state where he or she lives, no matter which state makes the IV-E payment.
A competent individual who leaves an institution is considered a resident of the state where he or she is physically located.
When a Pennsylvania resident is placed in an out-of-state institution and is determined eligible for MA, the CAO must take the following steps:
If the individual is a new applicant:
1. Authorize MA to start on the date of application or the date eligibility is established.
2. Set a renewal date for the twelfth month following the open date. e-CIS will calculate the renewal date. Review for correctness; make change, if necessary.
3. Send a notice to the applicant and send a copy to the out-of-state institution. Make sure the notice tells why the out-of-state placement was approved.
4. Contact the Office of Medical Assistance Programs (OMAP), Division of Outpatient Programs (717-772-6140), to ask that a supply of invoices be sent to the out-of-state institution and enrollment in the MA program be completed, if needed.
Department of Public Welfare
Office of Medical Assistance Programs
P.O. Box 8050
Harrisburg, PA 17105-8050
The CAO may also tell the institution to complete the enrollment by going to http://services.dpw.state.pa.us/omap/PartnersProviders/PROMISE.
If the individual is a recipient:
1. Change the individual’s address to that of the out-of-state institution, and issue a replacement medical card if one is needed.
NOTE: Enter the actual date the individual was placed in the institution and the appropriate facility code in e-CIS. Enter information about the reason for the placement in the case record or in e-CIS case comments.
2. Send the individual a confirming notice and send a copy to the out-of-state institution. The notice should include both the effective date and the actual date of the change.
3. Contact the Office of Medical Assistance Programs (OMAP), Division of Outpatient Programs (717-772-6140), to ask that a supply of invoices be sent to the out-of-state institution and enrollment in the MA program be completed, if needed.
If a renewal is due:
4. Contact the institution in the eleventh month to find out the name of the individual there who will help the individual, family member or representative complete the Benefits Review Form (PA 600R).
5. Send the PA 4 and the PA 600R with a letter to the individual who works at the institution and is helping to complete the renewal. Ask for the following actions to be taken in the first week of the twelfth month:
Help the individual or the individual’s representative complete the PA 600R.
Get the signature of the individual or the representative in the shaded area.
List the current balance in the recipient's patient fund account.
Get the individual or representative's signature on the PA 4(s).
Return all forms within five days after getting the individual’s or representative's signature on the PA 600R.
6. When the renewal forms come in from the institution, verify the income and resources, and determine whether the individual is still eligible for MA.
If the recipient is still eligible, establish a new twelve-month renewal date.
If the recipient is no longer eligible, close MA. Send the individual an advance notice, and send a copy of the notice to the institution.
An individual is not considered able to indicate intent if: 55 Pa. Code § 148.71
The individual’s IQ is 49 or lower or the individual’s mental age is 7 or lower, using tests acceptable to the Office of Developmental Programs.
The individual is judged legally incompetent by a court of law.
Medical records from a doctor, psychologist or the individual licensed by the state in the field of mental retardation show that the individual is incapable of indicating intent.
Updated May 21, 2014, Replacing February 14, 2012,