Eligibility for Children with Special Needs ends when:
The child no longer meets disability requirements.
The child moves permanently out of state.
The child attains his or her 18th birthday.
The CAO will review eligibility for other MA programs and generate the appropriate advance or confirming notice informing the parent or representative of the child the reason for ineligibility. Chapter 377, Notices.
When PH 95 eligibility ends because the child turns age 18, the CAO will take the following steps to determine continued MA eligibility:
1. Authorize the 18-year-old in PH 00 (Healthy Horizons) presumptively for 90 days; there is no change in health care coverage.
2. Contact the family to apply for SSI benefits for the individual. Inform the family that MA will continue while the individual is being reviewed for SSI.
NOTE: The Social Security Administration (SSA) will use the adult disability definition and standards to determine SSI eligibility.
3. Inform the family about the Disability Advocacy Program (DAP) and encourage the individual to use the services provided by the DAP advocate. (See the Supplemental Handbook Chapter 820, Disability Advocacy Program)
4. Send the individual a DAP Referral Form (PA731); and an Employability Assessment Form (PA 1663) to be completed by a physician to validate continued disability. The CAO will create an alert to review the case every 30 days for receipt of the disability verification.
NOTE: If verification of disability is not returned within 90 days, the CAO will review eligibility for other MA categories.
5. Upon receipt of the signed PA731, refer the individual to the DAP for assistance with applying for Social Security benefits. As long as the individual is cooperating with the CAO, MA will not be closed.
6. If the individual applies to SSA and is found ineligible for SSI benefits for a reason other than disability, complete an MRT referral for a determination of disability.
Important: If a child was previously certified as disabled by the MRT before their 18th birthday, a new MRT determination must be completed to verify the disability condition meets the SSI disability criteria for an adult.
55 Pa. Code § 140.311(b)(2)(ii)(A)
7. Presumptive eligibility is authorized until the disability decision from SSA or MRT is made. If the individual does not meet disability criteria for Healthy Horizons, review eligibility for all other MA benefits prior to closing PH00.
Updated April 12, 2018, Replacing February 14, 2012