Effective January 1, 2014, the (Affordable Care Act (ACA) changed Medical Assistance (MA) rules in Pennsylvania. The changes affect the way eligibility is determined for certain individuals, while having only a minor impact on others. (Modified Adjusted Gross Income (MAGI) is the new income methodology used for determining eligibility for children through age 18, parents (biological, adoptive or step), caretakers, and pregnant women.
MA rules have not changed for individuals whose eligibility is determined on the basis other than MAGI:
Individuals for whom income determinations are not required, such as individuals receiving Supplemental Security Income (SSI), federal foster care or adoption assistance recipients or recipients of Breast and Cervical Cancer Prevention and Treatment (BCCPT) services.
Individuals whose eligibility is based on being 65 or older, disabled or blind.
Individuals evaluated for Medically Needy Only (MNO).
Individuals evaluated for Long Term Care (LTC) facility services or Home and Community Based Services (HCBS).
Individuals eligible for Medicare cost sharing.
Individuals evaluated for General Assistance (GA) related MA.
The MA category MG is used to identify the majority of MAGI-related budget groups, (See Detailed MA Cascade). Individuals receiving category MG will be assigned a program status code based on the coverage group.
MAGI categories and program status codes:
MG00 - pregnant women and children (under age 1) with income at or below 215 percent of the Federal Poverty Income Percentage (FPIG), children (ages 1-5) with income at or below 157 percent of the FPIG and children (ages 6-18) with income at or below 133 percent of the FPIG.
MG18 - pregnant women and children under 1 who are eligible for extended medical coverage despite an increase in income over 215 percent of the FPIG.
MG19 - children age 6-18 with income between 100 percent and 133 percent of the FPIG who were previously eligible under CHIP but are now eligible for MA OR who are determined newly eligible for MA.
MG27 - individuals with income at or below 33 percent of the FPIG. Individuals could be parents/caretakers and children ages 0-17, or children age 18, if they are a full-time secondary or vocational student.
MG71 - Individuals eligible for Transitional Medical Assistance (TMA)
NOTE: Women enrolled in SelectPlan will have their eligibility determined using MAGI rules and are designated with the category and program status, PSF10.
See Chapter 305, Category for information about program status codes and a target type indicator based on demographics of the targeted individual.
MAGI-related households are built using the following target types:
The CAO must decide who can get MA using the rules in this chapter and the following chapters:
Medical Assistance Eligibility Handbooks
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.
Supplemental Handbook
A pregnant woman or a qualified child up to age 1 can get MAGI-related MA if household income is equal to or less than 215 percent of the (Federal Poverty Income Level (FPIG) for the household size (See Appendix D.)
The pregnant woman, once approved, continues to be eligible for MA coverage through the end of the month in which the 60 day post- partum period ends, 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 parents’ income, per the Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA).
NOTE: If the CAO did not know about the pregnancy and 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 post-partum period ends.
NOTE: If a pregnant woman or the parent/caretaker of a child under 1 requests in writing that the MA 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 at 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.
A qualified child under age 6 can receive MAGI-related MA if household income is equal to or less than 157 percent of the FPIG for the household size (See Appendix C.)
A qualified child age 6 - 18 can receive MAGI-related MA if household income is equal to or less than 133 percent of the FPIG for the household size (See Appendix B.)
For a child age 18, student status will impact the program status code that is assigned. An 18 year old can be eligible as MG27 if they meet all eligibility criteria and he or she has the following student status:
Full-time secondary student, or
Full-time vocational student
If the 18 year old does not have the above student status, MG00 or MG19 can be assigned if all other eligibility criteria are met.
A parent (biological, adoptive or step) or caretaker can receive MAGI-related MA. The following criteria must be met:
Have care and control of a child age 0-17 or age 18 and a full-time secondary or vocational technical school (vo-tech) student.
Have household income equal to or less than 33 percent of the FPIG (See Appendix A.)
NOTE: Individuals other than parents with care and control of a child in the MAGI-related household can be caretakers, if the parent is not living in the household. For MAGI MA, an individual does not need to be related to the child to be a specified relative in the parent/caretaker category. Caretakers are individuals age 19 or older.
NOTE: If no parents are taking care and control of the child in a household, only one non-parent caretaker is a valid target. If multiple non-parent caretakers are present in the household, only one caretaker will be selected in order of age, oldest to youngest.
See Chapter 338, Medical Assistance Benefits for information about MA benefits.
Issued September 19, 2014