An applicant may be eligible for MA to cover the cost of unpaid medical expenses from before the date of application, but not before the beginning of the retroactive period 62 P.S. § 442.1(c)
Note: The CAO will decide on retroactive eligibility even if the individual shows that the expense may be paid by other medical insurance.
When an application for MA is received, the CAO must find out whether there were any medical expenses in the retroactive period. The retroactive period may begin as early as the first day of the third calendar month before the month of application and ends the day before the date of application. 55 Pa. Code § 181.12
Reminder: For individuals age 21 through 58 in a GA-related MNO category (TD) whose eligibility is based on having a job, past, present and continuing work will be looked at to decide whether the individual is meeting the 100 hours a month work rule. The individual must meet this rule in each month of the six-month eligibility period. If a individual cannot work because they are sick or injured, the individual can meet this rule by proving that they will be going back to 100 hours a month of work after getting better.
An individual has a medical need if a medical expense meets all of the following requirements:
The expense is unpaid.
The expense is for a service or item that is covered by the MA program, such as hospital care, doctor bills or dental bills.
A member of the applicant/recipient group had the expense during the retroactive period.
The amount of the expense and the date of the expense have been proven.
The applicant/recipient group is eligible for retroactive MNO when: 62 P.S. § 442.1(c)
Its total net income for the combined retroactive/continuing six-month period is the same or less than the six-month MNO income limit in Appendix A.
When its total net income is more than the limit, the amount over the limit is used as a patient pay liability.
Note: If cash assistance benefits will be received, the income must be included as unearned income in the combined retroactive/continuing period.
The MNO limit is based on the number of people in the applicant/recipient group, including the unborn children of a pregnant woman. The pregnancy must be confirmed. If multiple births are confirmed, the CAO will count each unborn child as a member of the applicant/recipient group. 55 Pa. Code § 181.1(e)
If an applicant needed MA in the retroactive period, the period of eligibility begins on the first day of the month in the retroactive period in which the individual had a medical expense, as long as they are eligible in other ways. 62 P.S. § 442.1(c)
Note: If the individual is not eligible in the six-month period that starts with the month of the first medical expense, they can choose to start the six-month period the following month, as long as there is a need for retroactive coverage.
If an expense was charged in a month before the month when a individual applied, MNO begins on the first calendar day of the month of eligibility and ends on the last calendar day of the sixth calendar month in a row. The month of application may be both a retroactive month and the first month of the six-month eligibility period.
Example: Mr. Nelson applies for MA on December 18. The possible retroactive months are September, October, and November—specifically, the following dates:
September 1–30
October 1–31
November 1–30
December 1–17
If an expense was charged in the month when a individual applied but before the date of application, eligibility is based on the resources and income for the combined retroactive/continuing period of six calendar months in a row. MNO begins on the first calendar day of the first month of eligibility and ends on the last calendar day of the sixth calendar month in a row. The renewal date should be the last calendar day of the twelfth month, with a partial renewal (SAR) every six months to decide whether the individual is eligible for continuing MA.
Example: The Yeager family applies for MA on July 19. Mr. Yeager shows proof of unpaid medical bills for an emergency room visit for his son on April 10 and doctor visits on May 12 and July 3. The CAO decides that Mr. Yeager and his family are eligible for retroactive/continuing MNO eligibility from April 1 through September 30. The CAO approves MNO for that period and sends a notice to applicant.
The applicant/recipient group is eligible if its total countable resources are equal to or less than the applicable resource limit. (See Section 369.42, Continuing Resource Eligibility.)
In deciding on income eligibility for retroactive MNO, the CAO must use the total amount of income available to the applicant/recipient group in the combined retroactive and continuing period (a period of six months in a row). The combined period can be less than six months only if the applicant or recipient has died.
Note: If cash assistance benefits will be received, the income must be included as unearned income in the combined retroactive/continuing period.
If the net income is more than the six-month MNO income limit in Appendix A, the CAO may lower the net income by allowing deductions for certain paid and unpaid medical expenses. (See Section 369.331, Retroactive MNO spend-down.) 55 Pa. Code § 181.12
The CAO will use the actual income available to the applicant/recipient group members in each calendar month. This includes income deemed from a LRR who was not getting cash, State Blind Pension (SBP), SSI or MA benefits and who lived with the applicant/recipient group during all or part of the month.
Exception: Income must not be deemed for any month when a spouse is in an institution.
The CAO must figure net income by allowing the following deductions, in the following order, from the countable gross income of each member:
For TANF-related categories, including a TD parent or stepparent of a TANF, SSI or MA child:
Unearned income expenses. 55 Pa. Code § 181.315
The actual earned income work and individual expenses paid by the client, with a minimum of $120 a month.
The earned income incentive deduction, if the member qualifies for it. 55 Pa. Code § 181.312
Actual dependent care expenses that are paid while an individual is working.
For GA-related categories:
Unearned income expenses. 55 Pa. Code § 181.315
The actual earned income work and individual expenses paid by the client.
The earned income incentive deduction, if the member qualifies for it. 55 Pa. Code § 181.314
Actual dependent care expenses that are paid while a individual is working.
For SSI-related categories:
Unearned income expenses. 55 Pa. Code § 181.131
The $20 unearned or earned income deduction, up to $20 for each applicant/recipient group each month. 55 Pa. Code § 181.131
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 work 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 their income
Note: See Section 361.5, Medical Expense Deductions, for information about deducting medical expenses.
If the applicant/recipient group's net income is over the six-month MNO income limit in Appendix A, the CAO may lower the net income by deducting medical expenses. (See Chapter 361, MNO Deductions, for information on what medical expenses may be deducted.) The CAO must deduct the following:
62 P.S. § 442.1(c) 55 Pa. Code § 181.12(c)
Expenses that were paid in the month of application or any of the retroactive months
Unpaid expenses from any of the retroactive months
Note: The deduction of medical expenses to decide on retroactive eligibility is used only for the MNO program. There is no spend-down for retroactive NMP.
If a TANF-related or GA-related applicant/recipient group includes a member who is employed and who qualifies for the earned income incentive, the CAO must deduct medical expenses before applying the incentive.
Note: The CAO must always apply the earned income incentive to the earnings of a individual getting SSI-related MNO.
The CAO must deduct only the part of allowable medical expenses needed to lower the net income to the monthly MNO limit. Once an expense is used to approve MNO, the expense may not be used again.
Note: The part of an unpaid expense that is not used may be used in a future decision of MA eligibility, if it is in the allowable retroactive period.
The applicant/recipient group is eligible for retroactive MNO if its net income, after spend-down of medical expenses, is equal to or less than the six-month MNO income limit in Appendix A.
The CAO will decide on retroactive MNO eligibility for a six-month period beginning with the first day of the month in the retroactive period in which the first medical expense came about. 62 P.S. § 442.1(c) 55 Pa. Code § 181.12
Important: If it can, the CAO will decide on eligibility beginning with the earliest retroactive month when there is a medical need. Once eligibility is set for a retroactive month, the member is considered to be a recipient in that month for purposes of deciding on eligibility for the incentive in future months. Eligibility for MNO is figured by using an income period of six months in a row, which could include the retroactive months. 62 P.S. § 442.1(c) 55 Pa. Code § 181.12
The CAO will decide on income eligibility for the retroactive period as follows:
1. Decide on the category of MNO for each applicant. (See Chapter 305, Category.)
2. Figure out who was in the applicant/recipient group in the month of medical need. (See Chapter 310, Applicant/Recipient Groups.)
Reminder: Include any unborn child(ren) if pregnancy is confirmed.
3. Figure out the amount of countable gross earned and unearned income that was available to the applicant/recipient group for each calendar month of the six-month period. (See Chapter 350, Income.) 55 Pa. Code § 181.1(b)
Note: If cash assistance benefits will be received, the income must be included as unearned income in the combined retroactive/continuing period.
4. Figure out the total net income for the calendar month by allowing the deductions in Chapter 361, MNO Deductions. Apply the earned income incentive to the income of a qualified employed TANF-related or GA-related client.
Note: SSI-related clients with earned income always get the incentive.
5. Add the net income for the six-month period. Compare the total net income with the six-month MNO income limit in Appendix A.
If the total net income is equal to or less than the limit, approve MNO to cover the month of eligibility.
If the total net income is more than the limit, find out whether the applicant/recipient group has any allowable paid or unpaid medical expenses. (See Section 361.5, Medical Expense Deductions), for information about deducting medical expenses.)
6. Deduct allowable medical expenses from the net income. Deduct unpaid expenses and expenses that the applicant/recipient group expects have during the six-month period. Deduct expenses paid in the month of application or renewal or any of the three calendar months before the month of application.
Note: Deduct expenses paid after the month of the renewal due date if a renewal has not been completed on a timely basis.
7. Compare the countable net income, after medical expense deductions, with the MNO six-month income limit in Appendix A.
If the net income is equal to or less than the limit, approve MNO to cover the period of eligibility. Go to step 9.
If the net income is over the limit, decide whether the applicant/recipient group is eligible with a patient pay liability. Go to step 8.
8. Use the patient pay liability rules in Section 369.13 to decide whether the applicant/recipient group has enough medical expenses to qualify for MNO with a patient pay liability.
If the expenses are equal to or more than the excess income, approve MNO with a patient pay liability to cover the period of eligibility.
If the expenses are less than the excess income, do not approve MNO.
9. Send a notice to applicant letting the applicant/recipient group know of eligibility or ineligibility and the amount of any patient pay liability. Send a copy of the notice to applicant to each provider to whom the individual must make a patient pay.
Updated February 14, 2012, Replacing December 24, 2008