To be included in an applicant/recipient group, an individual must be related to at least one other member of the group.
NOTE: The relationship may be by blood or by marriage, such as mother, brother, aunt, stepgrandmother, or cousin.
A related individual or relative who takes care of and is in charge of a child under age 21 may be included in the same applicant/recipient group as the child or be included in the MA eligibility determination for the child. The reverse is true as well; that is, the child under age 21 may be included in the same applicant/recipient group as the relative who takes care of and is in charge of him or her or be included in the MA eligibility determination for that relative. The CAO will consider all choices when setting up different applicant/recipient groups and choose the one that helps household members the most.
An individual who takes care of and is in charge of a child under age 21 must:
Take part in planning for the support, education and maintenance of the child, be able to carry out those plans, and request MA eligibility for the child.
Live with the child or be in the process of setting up a home where he or she and the child will live within 30 days of approval for MA.
Only individuals who want MA are included in the applicant/recipient group. Unlike the cash assistance program, no one is required to be included in the applicant/recipient group and apply for benefits. 55 Pa. Code § 181.2 55 Pa. Code § 178.2
Exception: When determining eligibility for NMP for the family (PC/PU 27), all family members who meet the requirements to be included must be included. (See Cash Assistance Handbook, Chapter 110, Budget Groups, Section 110.4, Mandatory TANF Budget Group Members.) They only need to be included in the eligibility determination for NMP for the Family. If they do not wish to receive benefits, they will not be authorized MA benefits. If a family member is eligible for SSI-related MA or Healthy Horizons and meets the requirements, he or she will be included in the eligibility decision for NMP for the Family (PC/PU 27). However, the individual’s case will be opened in the right SSI-related or Healthy Horizons (See MAH 319) category.
If a legally responsible relative (LRR) is not included in the applicant/recipient group, his or her income may be deemed available to the other members. (See Chapter 355, Deeming Income and Resources.)
Relatives who are not members of the immediate family may be included or may be placed in a separate applicant/recipient group. The CAO will tell the applicant how the choice affects eligibility.
Stepbrothers and stepsisters may be treated as separate applicant/recipient groups if the parents are not applying and only if there is no common child in the household.
A stepchild of a stepparent and a stepparent may be treated as two separate applicant/recipient groups.
Unrelated individuals who apply for and receive MA are separate applicant/recipient groups.
NOTE: Boyfriends and putative fathers are not considered related to other family members.
An individual who receives State Blind Pension (SBP) is a separate applicant/recipient group.
An individual or couple (a) receiving Healthy Horizons benefits or (b) eligible but not yet receiving Healthy Horizons benefits is a separate applicant/recipient group.
A pregnant woman and qualified children who (a) receive Healthy Beginnings benefits or (b) are eligible but do not yet receive Healthy Beginnings benefits are a separate applicant/recipient group.
NOTE: Pregnant women and children who are eligible for NMP for the Family (PC/PU 27) will be opened in NMP for the Family (NMPF) rather than Healthy Beginnings.
A spouse, couple, or child (a) eligible for an SSI-related category of NMP or (b) is eligible but does not yet receive NMP is a separate applicant/recipient group.
A spouse, couple, or child (a) eligible for an SSI-related category of MNO-MA or (b) is eligible but does not yet receive MNO-MA is a separate applicant/recipient group.
NOTE: In SFU MNO eligibility determination, TANF-related, GA-related, and SSI-related household members and their income are counted together.
Individuals (including children) who are no longer eligible for SSI must be reviewed for other MA programs. The individual may be added to an existing applicant/recipient group, or may be opened in a different group. The CAO will consider all choices when setting up different applicant/recipient groups and choose the one that helps household members the most.
SSI-related spouses applying for Healthy Horizons (HH) are included in the same applicant/recipient group. Other immediate family members, relatives, or nonrelatives are a separate applicant/recipient group.
Example: Mr. and Mrs. J., both age 70, apply for MA for themselves and their 32 year old son with special needs. Each has Social Security beneifts. Mr. and Mrs. J. are included in the same HH applicant/recipient group. The son is a separate HH applicant/recipient group.
If a spouse is in a waiver program and is eligible for MA using the special income limit of 300 percent of the Federal Benefit Rate, the spouse’s income is counted.
If a parent is in a waiver program and is eligible for MA using the special income limit of 300 percent of the Federal Benefit Rate, the parent’s income is not counted.
For the Healthy Horizons family, the CAO may include the following household members living with the applicant or recipient and the members’ income, if it benefits the applicant or recipient:
The natural or adoptive child or stepchild under 21 years of age.
The child under 21 years of age if the Healthy Horizons applicant or recipient has care and control of the child.
The relative who has care and control of a Healthy Horizons child.
The stepparent of a Healthy Horizons child.
NOTE: Their eligibility status code will be “CA” or “CC” (counted individuals).
Spouses who are both applying for NMP Spend-down in SSI-related categories are included in the same applicant/recipient group.
55 Pa. Code § 181.2 55 Pa. Code § 178.2
Example: Mr. and Mrs. A. are applying for NMP Spend-down. Mr. A. is age 67 (PA category). Mrs. A. is age 59 and is disabled (PJ category). They are a two-member applicant/recipient group.
An SSI-related NMP applicant/recipient group must not include TANF/GA-related individuals, regardless of their relationships.
Example: Mr. and Mrs. L. are applying for NMP spend-down. Mr. L., age 47, is disabled (PJ category). Mrs. L. is also age 47 (PD category). Mr. and Mrs. L. are two separate applicant/recipient groups.
If a spouse is in a waiver program and is eligible for MA using the special income limit of 300 percent of the Federal Benefit Rate, the spouse and the spouse’s income is not counted.
If a parent is in a waiver program and is eligible for MA using the special income limit of 300 percent of the Federal Benefit Rate, the parent and the parent’s income is not counted.
An SSI-related NMP applicant/recipient child’s group must not include TANF-related, GA-related, or SSI-related parents or other individuals, regardless of their relationships. 55 Pa. Code § 181.110(a)
Example: Mr. and Mrs. P. and their son, age 19, who has a proven disability, are applying for NMP spend-down. Mr. P., age 42, is disabled (PJ category). Mrs. P., age 37, is PC category. Their son is PJ category. There are three one-member applicant/recipient groups.
For MNO, SSI-related, TANF-related, and GA-related categories, immediate family members who are applying for or receiving MNO are included as eligible members in one applicant/recipient group. 55 Pa. Code § 181.2
If a spouse is in a waiver program and is eligible for MA using the special income limit of 300 percent of the Federal Benefit Rate, the spouse and the spouse’s income is not counted. 55 Pa. Code § 181.110(a) 55 Pa. Code § 178.2
If a parent is in a waiver program and is eligible for MA using the special income limit of 300 percent of the federal benefit rate, the parent and the parent’s income is not counted.
If GA-related spouses qualify for separate programs, they may be in separate application/recipient groups. If either spouse does not meet the non-financial eligibility criteria or chooses not to be included in the same group,the CAO will consider the income and resources of the spouse.
Families with children must first be evaluated for NMP for the Family (PC/PU 27). If the family is not eligible for NMP for the Family (NMPF) as a single budget group, the CAO will decide whether each individual is eligible for other MA categories.
When determining eligibility for NMP for the Family (PC/PU 27), all family members who meet the requirements must be included in the eligibility decision. (See the Cash Assistance Handbook, Chapter 110, Budget Groups, Section 110.4, Mandatory TANF Budget Group Members.) If they do not wish to receive benefits, they will not be authorized MA benefits.
Example: A mother is applying for MA for her child only. Her income is below the two-person NMPF income limit. The child is approved PC27. The mother is a counted specified relative (CS) in the PC27 budget.
NOTE: The mother would not be eligible for EMC, because she was not an eligible member of the original PC27 budget.
Example: Mrs. C. applies for MA for herself and two of her three children on August 1st. She does not wish to apply for her son Paul, because he receives $400 a month in support and his father has medical insurance for him. The CAO allows PC 27 for Mrs. C. and the two children. On November 15, Mrs. C. requests MA for Paul. His father is unemployed, the support order has been reduced, and his father no longer has medical insurance. Paul is added to the existing PC 27 applicant/recipient group of Mrs. C and her other two children.
NOTE: A spouse or parent who lives away from home only because of work is considered to be living in the household and is included in the applicant/recipient group. Also, a spouse who is absent from the home only because of military service is still considered to be living in the home. The absent spouse may be included in the applicant/recipient group. If an LRR is not applying for or receiving MA, income and resources are considered to be available regardless of whether they are actually made available. (See Chapter 355, Deeming Income and Resources.)
If a family member is eligible for SSI-related MA or Healthy Horizons and falls within these criteria, he or she must be included in the eligibility decision for NMPF (PC/PU 27). However, his or her case must be opened in the right SSI-related or Healthy Horizons category.
Each immediate family member who is eligible for Healthy Beginnings is included in each applicant/recipient group as either an eligible member or a counted member.
Example: Mr. and Mrs. A and their sons, ages six and four, apply for MA. The CAO determines HB eligibility for the children. Each child is an eligible member in their own applicant/recipient group based on the income limit for the child’s age. The sibling is included when counting the family members to determine the correct income limit.
|
Eligible Child |
4 yr. old |
Counted Child |
4 yr. old |
|
Counted Child |
6 yr. old |
Eligible Child |
6 yr. old |
|
Counted Specified Relative |
Counted Specified Relative |
||
|
4 person Group = |
133% FPIG |
4 person Group = |
100% FPIG |
NOTE: If a spouse or parent is in a waiver program and is eligible for MA using the special income limit of 300 percent of the federal benefit rate, the spouse or parent’s income is counted. 55 Pa. Code § 140.32
Immediate family members who are applying for or receiving NMP are included in each applicant/recipient group as either an eligible member or a counted member. 55 Pa. Code § 181.2 55 Pa. Code § 178.2
If a spouse is in a waiver program and is eligible for MA using the special income limit of 300 percent of the federal benefit rate, the spouse and the spouse’s income is not counted.
If a parent is in a waiver program and is eligible for MA using the special income limit of 300 percent of the federal benefit rate, the parent and the parent’s income is not counted. 55 Pa. Code § 181.285(a)(1)
A parent of the TANF-related or GA-related applicant/recipient who is applying for but is not yet found eligible for an MA coverage group is treated as a possible eligible member of the applicant/recipient group, and his or her income is counted but not deemed. 55 Pa. Code § 181.2 55 Pa. Code § 178.2
A parent of the TANF-related or GA-related NMP applicant/recipient who is not applying for or receiving MA is included in the eligibility decision for NMP. The income of the parent is deemed under the rules in Chapter 355, Deeming Income and Resources.
The child of a TANF-related NMP applicant/recipient who is applying for but is not yet found eligible for any other coverage group is included as a possibly eligible child in the eligibility determination for the NMP group.
The child of a TANF-related applicant/recipient who is not applying for or receiving MA has an eligibility status code of noneligible child (NC). Neither the child nor the child’s income is included in the eligibility determination for the parent.
The spouse of the TANF-related NMP applicant/recipient who is applying for but is not yet found eligible for an MA coverage group is treated as a possibly eligible member of the AR group, and his or her income is counted.
The spouse of the TANF-related NMP applicant/recipient who is not applying for or receiving MA is included in the eligibility decision for NMP. The income of the spouse is deemed under the rules in Chapter 355, Deeming Income and Resources.
The spouse of the GA-related NMP applicant/recipient who is applying for but is not yet found eligible for any other coverage group is included as a possibly eligible adult, and his or her income is counted.
NOTE: If the spouse is eligible for SSI-Related NMP, the spouse and the spouse’s income must not be counted.
The spouse of the GA-related NMP applicant who is not applying for or receiving MA or who does not meet categorical eligibility for GA-related NMP is a legally responsible relative (LRR) whose income is deemed under the rules in Chapter 355, Deeming Income and Resources.
NOTE: The income of an LRR who is eligible for or is receiving HB must be counted when determining NMP eligibility for other family members.
SSI-related, TANF-related, and GA-related immediate family members who are applying for MNO are included in one applicant/recipient group as eligible members. 55 Pa. Code § 181.2 55 Pa. Code § 178.2
If a parent or spouse is not applying for or receiving MA, that individual’s income is deemed but not counted. (See Chapter 355, Deeming Income and Resources.) If a child is not applying for or receiving MA, neither the child nor the child’s income is counted in the eligibility determination.
If a spouse is in a waiver program and is eligible for MA using the special income limit of 300 percent of the federal benefit rate, the spouse and the spouse’s income is not counted. 55 Pa. Code § 181.285(a)(1)
If a parent is in a waiver program and is eligible for MA using the special income limit of 300 percent of the federal benefit rate, the parent and the parent’s income is not counted.
The MNO applicant/recipient group includes all related individuals who choose to apply and who are not applying for or receiving NMP, including HB and HH. However, the income of an LRR who is eligible for or who is receiving HB will be counted when determining MNO eligibility for other family members.
55 Pa. Code § 181.2 55 Pa. Code § 178.2
Example: The household consists of a husband, wife, and two common children under age 18. The father is disabled. The household income exceeds the limits for NMPF, Healthy Horizons, Healthy Beginnings, and NMP (including spend-down). CIS/e-CIS will determine MNO eligibility. All family members are included in the same AR group as possibly eligible members. The father is category TJ, and the mother and children are in category TC.
Updated February 14, 2012, Replacing November 2, 2007