The Children with Special Needs category is authorized only after eligibility for all other MA categories has been explored. It is a category of last resort for medical coverage.
The CAO will determine eligibility for Children with Special Needs using the following criteria: 55 Pa. Code §§ 140.601 55 Pa. Code §§ 140.603
The child is under 18 at the time of requested MA coverage.
The child meets the SSA’s disability standards. The disability requires verification from SSA or DHS’s MRT. Supplemental Handbook Chapter 820, Disability Advocacy Program.
NOTE: If the child has been denied SSI or RSDI for a non-medical reason and SSA completed the medical evaluation, an MRT referral is not required.
Review for all categories using parents’ and the child’s income.
If ineligible for other categories of MA review for the Children with Special Needs category using only the child’s countable income.
Determine eligibility for each child individually for households with more than one child with special needs.
Calculate total income for the child only. Apply the Healthy Horizons income deductions.
Retroactive coverage can be authorized when medical documentation (either by SSA or MRT) confirms the disability existed in the retroactive period. There is no presumptive eligibility to qualify for MA in the retroactive period for Children with Special Needs Category.
Medical expenses are not considered for eligibility for the Children with Special Needs category. Therefore, there is no patient pay liability or spend down provision.
Determine the total net countable income of the child for the calendar month and compare the total net countable income to 100% of the Federal Poverty Income Guideline (FPIG).
If the total net countable income of the child is equal to or less than 100% of the FPIG for one person, authorize eligibility in the Children with Special Needs Category “PH,” Program Status Code “95.” Generate a notice of eligibility per Chapter 377, Notices.
If the total net countable income of the child exceeds 100 percent of the FPIG, deny eligibility for the Children with Special Needs Category. Generate a notice of ineligibility per Chapter 377, Notices.
The individual is advised that the denied application, income, resource and household composition information is automatically forwarded to Pennsylvania Insurance Department (PID) through the COMPASS system for a Children’s Health Insurance Program (CHIP) eligibility determination.
55 Pa. Code §§ 140.601 140.603
Updated February 14, 2012, Replacing April 7, 2011