An applicant may be eligible for MA to cover the cost of unpaid medical expenses from before the individual applied for MA. 55 Pa. Code § 181.12
NOTE: The CAO will determine retroactive eligibility even if the applicant says that the expense may be paid by other medical insurance.
When the CAO receives an application for Cash Assistance or MA, the CAO will find out whether there were any medical expenses from the retroactive period. The retroactive period may begin as early as the first day of the third calendar month before the month when an individual applies and end the day before the date the individual applies. If an applicant has a medical bill during the retroactive period, the CAO will determine eligibility for NMP for the earliest calendar month of the medical bill.
NOTE: Spend-down does not apply to retroactive NMP. Medical expenses must be reviewed only to find out whether the applicant had a medical bill in the retroactive period.
The medical expense must meet 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.
The expense was charged to a member of the applicant/recipient group in the retroactive period.
The amount and the date of the expense are confirmed.
The applicant/recipient group is eligible for retroactive NMP when its total net income for the calendar month is equal to or less than the NMP income limit.
For the TANF/GA-related categories PC, PU and PD, the limit is the family size allowance (FSA) listed in Appendix A.
For the SSI-related categories PA, PM and PJ, the limit is the SSI benefit level listed in Appendix B.
The NMP limit is based on the number of people in the applicant/recipient group, including the unborn child(ren) of a pregnant woman. If multiple births are confirmed, the CAO will count each unborn child as a member of the applicant/recipient group.
If an applicant needed MA in the retroactive period, the CAO will determine the individual’s eligibility for each calendar month in which there was a medical expense. If an expense was charged in a month before the month when an individual applied, NMP begins on the first calendar day of the month of eligibility and ends on the last calendar day of the month of eligibility. If the applicant/recipient group is eligible for two or more months in a row, MA begins on the first calendar day of the first month of eligibility and ends on the last calendar day of the final month of eligibility. The CAO must determine eligibility for each calendar month.
If the individual is eligible for GA-related MA, eligibility must begin on the date they became eligible. For example, if an individual became disabled on the 11th of the month, that is the date that GA-related MA can begin.
If an expense was charged in the month when an individual applied but before the date of application, eligibility is based on the resources and income for that calendar month. If the applicant/recipient group is eligible for two or more months in a row, including the month of application, NMP begins on the first calendar day of the first month of eligibility. The NMP limit is based on the number of people in the applicant/recipient group, including the unborn child(ren) of a pregnant woman. If multiple births are confirmed, the CAO will count each unborn child as a member of the applicant/recipient group.
NOTE: The month of application may be both a retroactive month and the first month of the continuing eligibility period.
Example: Mr. Evans applies for MA on May 22. He shows proof of unpaid medical bills for inpatient hospital care in February and visits to his dentist on March 13 and May 2. The CAO determines that Mr Evans can receive retroactive NMP for February, March, and May as well as continuing NMP. The CAO approves retroactive NMP for February 1 through March 31 and continuing benefits beginning May 1. The CAO sends Mr. Evans a notice to applicant.
The CAO will complete a separate count of resources for each calendar month in which an individual has a medical need. Resource eligibility is based on the individual’s situation in each retroactive month. 55 Pa. Code § 178.1
An applicant/recipient group cannot receive retroactive NMP if its total countable resources in the retroactive month are more than the resource limit. ( Chapter 340,Resources).
NOTE: The CAO must deem resources from a LRR who lived with the applicant/recipient group during the retroactive period. (Chapter 355, Deeming Income and Resources)
When resources are more than the limit, the CAO must give the individual the choice of spending the resources that put them over the limit by paying any unpaid medical expenses. If the individual chooses to do that, he or she must prove: 55 Pa. Code § 178.1(j)
They used the resources to pay for medical expenses from the retroactive month for which they are requesting MA coverage or from any month before that month.
The applicant/recipient group was required by law to pay the expense.
NOTE: Before letting the individual know that they can lower resources to the NMP limit, the CAO must consider eligibility for retroactive MNO if that program would better meet the applicant/recipient group’s needs.
A resource that is over the limit and is used to pay medical expenses has no effect on resource eligibility for retroactive or continuing NMP or MNO. The CAO will treat the excess resource as if it never existed.
When an excess resource is used to pay medical expenses, the amount paid can be used as a paid medical expense when determining eligibility for NMP spend-down for the month in which the bill is paid or for future periods of MNO spend-down.
Example: Mr. Martin applies for MA on August 8. He was injured in an accident on July 18. His resources are more than the resource limit by $2,000. The CAO tells Mr. Martin that he has resources that are over the limit and holds the application while waiting for Mr. Martin to decide whether to use the resources to pay medical expenses. On August 30, Mr. Martin confirms that he used his excess resources to pay $2,000 toward his hospital bill. Mr. Martin's resources are now within the limit. The CAO approves retroactive MA for July. The CAO also uses part of the $2,000 paid medical expense to approve NMP spend-down for August and continuing MNO starting on September 1.
The CAO will determine the applicant/recipient group's net income for each calendar month for which retroactive NMP is requested. 55 Pa. Code § 181.12(a)
Important: If possible, the CAO will determine the group’s eligibility beginning with the earliest retroactive month in which 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 determining eligibility for the incentive in future months.
The CAO will use the actual income available to the applicant/recipient group members in each calendar month. This includes income deemed from an LRR who was not receiving cash, State Blind Pension (SBP), SSI or MA benefits and who lived with the applicant/recipient group for all or part of the month.
Exception: Income must not be deemed for any month when a spouse is in an institution.
NOTE: If an applicant has a medical need in the month when they apply but before the date when they applied, the CAO must use both actual and expected income for that month.
The CAO must determine net income by allowing deductions, in the following order, from the countable gross income of each member:
For TANF-related categories, including a PD parent or stepparent of a TANF cash, SSI or MA child:
Unearned income expenses. 55 Pa. Code § 181.315
Work expenses ($120/month).
The 50% earned income incentive deduction, if the member qualifies for it. 55 Pa. Code § 181.311
The actual earned income dependent care expenses, up to the limit.
For GA-related categories:
Unearned income expenses. 55 Pa. Code § 181.315
The actual earned income work, individual and dependent care expense deduction, up to the limit ($25 a month). 55 Pa. Code § 181.313
The earned income incentive deduction, if the member qualifies for, needs and chooses to use the incentive. The incentive is $20 plus 50% of the next $60.
NOTE: The use of the incentive in the retroactive period must count toward the four-month limit. For this reason, the CAO will explain the pros and cons of using the incentive and must use the incentive only if it is needed and the individual chooses to receive it. For continuing NMP, the incentive is used unless there is a break or it is used up.
For SSI-related categories:
Unearned income expenses. 55 Pa. Code § 181.131(b)
The $20 unearned or earned income deduction, up to $20 for each applicant/recipient group each month. 55 Pa. Code § 181.132(l)
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
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
Reminder: Paid or unpaid medical expenses must not be counted when determining retroactive eligibility for NMP. There is no retroactive NMP spend-down.
The CAO must determine income eligibility for the retroactive period as follows: 55 Pa. Code § 181.12
1. Determine the category of NMP for each applicant. (See Chapter 305, Category.)
NOTE: Individuals who are in need of health-sustaining medications can be considered for retroactive PD if the doctor fills out a Health-Sustaining Medication Assessment Form (PA 1671) and includes the date when the individual began needing the medication.
2. Determine who was in the applicant/recipient group in the month of medical need. (See Chapter 310, Applicant/Recipient Groups.)
3. Determine the amount of countable gross earned and unearned income that was available to the applicant/recipient group for the calendar month. (See Chapter 350, Income.)
NOTE: Use the actual income. If the income is received once a week or once every two weeks, determine the average weekly amount and multiply it by four to determine the average monthly amount.
4. Determine the total net income for the calendar month by allowing the deductions in Chapter 360, NMP Deductions.
Reminder: Let the individual know how the use of the earned income incentive deduction can meet his or her medical needs. Apply the incentive to the income of an employed GA-related applicant only if the individual is qualified to receive the incentive, the incentive is needed to make the applicant/recipient group eligible and the individual chooses to receive the incentive. Apply the incentive to the income of an employed TANF-related applicant only if the individual is qualified to receive the incentive. SSI-related individuals with earned income always receive the incentive.
5. Compare the countable net income with the NMP limit.
For the TANF/GA-related limit, see Appendix A, Family Size Allowance.
For the SSI-related limit, see Appendix B, SSI Benefit Levels.
NOTE: Use the limit for the number of people in the applicant/recipient group for the retroactive month. Include the unborn(s) if pregnancy is proven.
If the total net income is equal to or less than the limit, approve NMP to cover the month of eligibility.
If the total net income is over the limit, do not approve NMP, and determine the individual’s eligibility for MNO for the calendar month.
The CAO must send a notice to applicant letting them know the decision. (See Chapter 377, Notices.)
Example: On June 7, Mrs. Sims applies for MA for herself and her two children, ages 9 and 10. She asks for help from the CAO to pay the following unpaid medical bills:
January 26, doctor visit for Mrs. Sims.
March 12, emergency room and X-ray charges for the 9-year old.
May 22, dental work for Mrs. Sims.
The CAO finds that the retroactive period must include only March and May. The family unit is made up of Mrs. Sims and the two children in both of the retroactive months. The category of MA is PC, because the children’s father is absent. Mrs. Sims proves gross income of $160 a week from her work. She received four paychecks in March and four in May. She pays $20 a week to a neighbor who sees that the children get on the school bus each day.
Earned income incentive eligibility for March.
Mrs. Sims did not receive a TANF-related category of cash assistance or MA in the four months before March.
Gross income $640
Work expense deduction -120
Child care expense -80
Net income $440
Standard of need $587
Mrs. Sims qualifies for the incentive. The CAO first determines her eligibility for the incentive for March. If MA is approved for March, Mrs. Sims is considered a recipient and qualifies for the incentive for May and for continuing eligibility, if it is approved.
MA eligibility for March and May.
Gross income $640
Work expense deduction -120
$520
Work incentive deduction -260
Child care expense -80
Net NMP income $180
Family size allowance (FSA) $403
Mrs. Sims and her children are eligible for retroactive NMP for March and May.
Updated February 14, 2012, Replacing October 25, 2008