For households applying for or getting GA-related, SSI-related, or Healthy Horizons Medical Assistance (MA), the CAO will consider each resource an applicant or recipient has or can get and decide whether to count it. The CAO will compare the total countable resources of the applicant/recipient group with the resource limit to decide whether the group is eligible for MA benefits. 55 Pa. Code § 178.1
Exception: The CAO will not count resources of an applicant or recipient:
Who has a natural or adopted child under 21 years old (including unborn children) living in the household.
Has care and control of a child under 21 years old who is living in the household.
Foster parents usually do not meet this condition. In most cases, a foster parent takes care of the child, but a children and youth agency is in charge of the child. If the foster parent can prove that he or she takes care of and is in charge of the child, then this condition is met and the foster parent’s resources are excluded.
NOTE: Resources are not counted for a individual in an applicant/recipient group if:
The individual is a child under age 21 (including unborn children).
The individual is living in the household with a spouse under age 21.
The individual is living with an adopted or natural child under age 21.
The individual is living with a stepchild under age 21.
The individual is living with a child under 21 that he or she is exercising care and control of.
Eligibility for a resource may produce a monthly income that may be counted in deciding on eligibility for MA. Persons applying for or getting MA must pursue all available resources.
Resources include the following:
Personal property.
Life insurance.
Vehicles.
Burial spaces and burial funds.
Real property (including mobile homes).
NOTE: The CAO will not count the value of nonresident property while the individual is making a good faith effort to sell the property. (See Section 340.63, Nonresident Property.)
Ownership, value, and disposition of resources will be considered for all members of the applicant/recipient group, including a spouse in the household. 55 Pa. Code § 178.3(a)
The resources of the following individuals living in the household must not be considered: 55 Pa. Code § 178.3(a)(5)
A stepparent who is not in the applicant/recipient group
A recipient of Temporary Assistance For Needy Families (TANF), General Assistance (GA), Supplemental Security Income (SSI), State Blind Pension (SBP), or Medicaid 55 Pa. Code § 178.1(e)
Exception: The CAO will include the resources of a spouse who gets MA when deciding on eligibility for Healthy Horizons.
The individual is required to apply for any resources he or she might be able to get. Unless he or she has good cause for not doing so, the individual must take reasonable steps to get and make possible resources available. An individual who, without good cause, fails to cooperate in getting possible resources is ineligible for MA. 55 Pa. Code § 178.1(g)
For SSI-related categories, the individual is ineligible until he or she cooperates.
For GA-related categories, the individual is ineligible for 60 days. After 60 days, the individual stays ineligible until he or she cooperates.
The CAO will consider only those countable resources that are actually available. (For treatment of resources deemed from a legally responsible relative, (see Chapter 355, Deeming.) 55 Pa. Code § 178.1(f)
Resources are counted at their equity value unless otherwise specified. 55 Pa. Code § 178.1(d)
Reimbursement does not apply to MA except for repayment of MA payments made on the individual's behalf from a private or public health insurance or any legally responsible third party. 55 Pa. Code § 125.74 55 Pa. Code § 125.84(c)
If resources are not reported, there may be an overpayment of MA if the equity value of the resource would have caused ineligibility. 55 Pa. Code § 178.3(a)(6)
An individual is eligible for MA if his or her resources are not over the resource limit. (See Appendix A for resource limits.) 55 Pa. Code § 178.51(c)
Resource eligibility is determined separately for each applicant/recipient group.
For SSI-related categories, if resources are owned jointly with a spouse or another individual who is not applying for or getting MA, the resource limit is based on the number of individuals who live together and jointly own the resource. 55 Pa. Code § 178.51(c)
At application, if the individual’s resources are over the limit, the CAO will advise the individual that a decision on eligibility can be postponed if he or she plans to spend the excess resources. The CAO will not count resources used to pay for medical expenses or an irrevocable burial. Eligibility is decided on for the retroactive period and for continuing MA as if the resources never existed. If resources are spent for anything other than medical expenses, the eligibility date is the day after the resources are reduced to the limit. 55 Pa. Code § 178.1(j)
For retroactive eligibility, the amount of resources counted should be the amount of resources owned as of the first day of the medical services for which the individual tries to get MA.
NOTE: To become eligible for retroactive MA, a individual can borrow money to pay a portion of any unpaid medical expenses for which he or she is responsible.
Example: Mr. Smith’s hospital bill for December is $5,647. At that time, he had excess resources of $450, which he spent on new furniture after he was released from the hospital. Mr. Smith borrows $450 and pays a portion of the hospital bill with the money. Mr. Smith is resource eligible, because he used the borrowed money to pay unpaid medical expenses, thereby lowering his excess resources to zero.
The CAO will make an eligibility decision within 30 days. The decision may be made within 45 days if the CAO tells the individual about the delay in writing. If the individual lowers resources after eligibility is denied, he or she must fill out a new application.
If the resources of a recipient are over the limit, the CAO will send the individual an advance notice telling the individual that he or she is ineligible. If the individual proves that resources are reduced within ten days of the notice, eligibility will be continued. There is no overpayment.
Any time the individual has or receives resources that, when added to other countable resources, puts the individual over the resource limit for the MA category, he or she is ineligible for MA unless the resources are reduced.
The Department of Public Welfare (DPW) is the payer of last resort. This means that any third party resources that are available must be used before payment is made by the DPW.
The CAO will let the individual know that he or she should show insurance cards and the Pennsylvania ACCESS card to all providers. The CAO will also let the individual who gets MA benefits from a managed care plan (such as a health maintenance organization or health insuring organization) know that he or she should show those cards to providers. 55 Pa. Code § 178.6
Third-party resource information is shown on the Eligibility Verification System (EVS). When an individual has third party resources, EVS displays a message letting providers know of the other resources. Providers are instructed to ask the individual or the institution (for example, the individual’s Long Term Care) for more information. The CAO will find any resource that is available to meet the cost of medical services. Third party resources include, but are not limited to, the following:
Blue Cross or other hospital insurance. 55 Pa. Code § 178.6
Medicare Part A and Part B.
Hospital insurance paid directly to the individual.
Medical insurance included as part of a support agreement.
Tricare, formerly known as Civilian Health and Medical Program of the Uniformed Services (CHAMPUS).
Workers Compensation.
Negligence action or other tort (see Supplemental Handbook, Chapter 915, Reimbursement)
Payments made toward the cost of medical service by a legally responsible relative (LRR) or another individual.
LRRs, including spouses and parents of unemancipated minor children.
Long Term Care/nursing home care insurance.
NOTE: The CAO must send a copy of policy to:
Bureau of Program Integrity
Division of Third Party Liability
ATTN: LTC Insurance Policies
PO Box 8486
Hbg, Pa 17105
Fax to : (717) 772-6598
Institutional contracts, including contracts between an individual and a facility that gives the individual the right to get care at the facility for free or at reduced cost.
A community may raise funds to help a family when there is a serious illness or death of a family member or a disaster such as a fire. The CAO will determine how the funds are given out. If the funds are given directly to the family for their use, the funds are an available resource. If the funds are managed by a trust and given to a medical provider for specific treatment of an illness or a related expense, the funds are considered a third party resource and must be entered in the Third Party Liability (TPL) file. 55 Pa. Code § 178.1(d)
NOTE: If the CAO is unsure how to handle such funds, it will send all available information to the area manager, who can tell the CAO how to handle them.
NOTE: Car insurance is not considered a third party liability or resource. Caseworkers will complete a Firm 176K, PW176KM and OIG 173 in cases involving accidents or lawsuits. (See Supplemental Handbook, Chapter 915, Reimbursement.)
The CAO will find out whether or not any resource is available at application and at each renewal. 55 Pa. Code § 178.3
A individual, guardian, trustee, or any other individual acting for a individual must: 55 Pa. Code § 178.3
Report all resources.
Try to obtain all resources that an applicant or recipient may entitled to, unless there is good cause for not doing so.
Provide documentation showing ownership and the value of all resources.
Report any change in resources by the tenth day of the month following any change happening. 55 Pa. Code § 125.24(d)(1)
If several sources show different values for a resource, such as a car or nonresident property, the CAO must use the lowest value.
If resource information is different from information in the case record, the CAO must figure out why.
Updated February 14, 2012, Replacing March 8, 2008