When determining an individual’s eligibility for Medical Assistance (MA), the County Assistance Office (CAO) will consider a family with children for NMP for the Family (NMP-F) first. If the whole applicant/recipient group is ineligible for Nonmoney Payment (NMP) and Medically Needy Only (MNO) benefits, the CAO will consider eligibility for the member or members who have the most need for medical coverage. The CAO will let the individual know about the choices for including individuals in the applicant/recipient group. The CAO will determine eligibility first for NMP and then for NMP spend-down. If the CAO determines that the applicant/recipient group does not meet the income and resource rules for NMP, it must look at eligibility for MNO.
NOTE: Spend-down does not apply to NMP-F. If a family does not qualify for NMP-F, Extended Medical Coverage (EMC), or ongoing NMP, then NMP spenddown, MNO spend-down or GA-related NMP may be considered.
The CAO will allow the individual to pick the MA program that best meets their medical needs, even though they may be eligible for more benefits under a different program. 55 Pa. Code § 181.1(a)
The CAO will determine NMP eligibility by using the countable income and resources and expected income and resources available to the members of the applicant/recipient group. Eligibility is determined for each calendar month. NMP may be approved for retroactive months, a limited period of one or two months, or for a continuing period.
When an individual reports a change in income, resources or another situation, the CAO will determine whether the change affects the individual’s eligibility. The CAO will figure out an individual’s eligibility again for each calendar month when there is a change. 55 Pa. Code § 181.23
The following types of NMP are available:
Continuing NMP.
A family with children must always be reviewed for NMP-F first. If the family is not eligible for NMP as a single budget group or for any other MA extensions (for example, EMC), then the family must be reviewed for MA for each family member under Healthy Beginnings, Healthy Horizons, NMP (PC/PU 00, PC/PU 22) orMNO (TC/TU 00, TC/TU 22). See Chapter 305, Category
Extended NMP—Special circumstances. See Chapter 387, Supplemental Security Income (SSI)
Healthy Beginnings. See Chapter 318, Healthy Beginnings.
Healthy Horizons. See Chapter 319, Healthy Horizons
NMP spend-down. See Chapter 368, Determining Eligibility for NMP
Retroactive NMP. See Chapter 368.2, Determining Eligibility for NMP
Long Term Care. See the Long-Term Care Handbook.
Supplemental Security Income (SSI) See Chapter 387, Supplemental Security Income (SSI).
If the applicant/recipient group does not qualify for one of the NMP categories, the CAO will consider eligibility for MNO.
The CAO will determine eligibility of the applicant/recipient group in the following categories: 55 Pa. Code § 181.41
TANF-related and GA-related: PC, PU and PD.
NOTE: The requirement that there must be two parents for PD NMP applies to both parents in a two-parent household, whether or not they are married, as long as paternity has been established for the child. Therefore, the income of both parents must be considered in the eligibility determination
SSI-related: PA (aged), PM (blind) and PJ (disabled).
There is a different way of figuring out who is eligible or what the eligibility limit is for each category. The correct way must be used for each one.
Exception: The CAO must use PC/PU rules when determining eligibility for a PD parent or stepparent who is living with their child who receives TANF, MA or SSI.
Medical expenses for or paid by a member of the applicant/recipient group are allowed as a deduction for NMP. 55 Pa. Code § 181.13(e)
NOTE: The CAO must not allow a deduction for medical expenses paid by a legally responsible relative (LRR) whose income is deemed available. An unpaid medical expense for an LRR may be allowed if a member of the applicant/recipient group is legally responsible for payment of the expense.
The CAO must use proven medical expenses to determine continuing NMP spend-down eligibility for both TANF/GA-related and SSI-related categories.
NOTE: Spend-down does not apply to retroactive NMP. NMP spend-down must not be used to determine the eligibility of individuals who are receiving Medical Assistance and payment of Long Term Care Services (MA LTC).. 55 Pa. Code § 181.13(a)
Paid or unpaid medical expenses may be deducted. The CAO will use a paid expense only if it is paid in the month for which eligibility is being considered. The CAO will not use an expense that was paid in a past month. The CAO may only use unpaid medical expenses charged in the three-month retroactive period.
NOTE: See Chapter 360, NMP Deductions for complete information about medical expenses.
Updated February 14, 2012, Replacing October 25, 2008