319.8 Determining Eligibility

319.81 Retroactive Eligibility

The CAO must use the following steps to determine retroactive eligibility for Healthy Horizons categorically needy, SLMB, or QI benefits:   

  55 Pa. Code § 140.335  

1. Determine whether the individual has an unpaid, covered medical expense from the retroactive period. (See Chapter 338, Section 338.3, Retroactive Medical Assistance Eligibility.)

Reminder: There is no retroactive eligibility for Healthy Horizons cost-sharing benefits.

2. Determine who was in the Healthy Horizons family in the month when medical care was needed.

3. Determine resource eligibility for each retroactive month for which the individual had a medical need. (See Section 319.5.)

4. Determine the total net unearned income of the family members for the calendar month by allowing the unearned income deductions in Section 319.71.

            NOTE:  Do not count cost-of-living adjustment (COLA) income for individuals until the second month following the month that the FPIGs are published. Normally, the FPIGs are published in January of each year, which means the COLA income would not be counted until March.

5. Add up the total countable gross earned income for the family members for the calendar month. Allow the earned income deductions in Section 319.72.

6. Add up the total net earned and unearned income, and compare the total to the  appropriate monthly income limit in Appendix A, B, or C for the number of people in the Healthy Horizons family.    

       55 Pa. Code § 140.231

            NOTE:  If the spouse’s countable income is equal to or less than 50 percent of the federal benefit rate for one individual, do not include the spouse as a family member or count the spouse’s income, unless the applicant or recipient chooses to include the spouse.  

55 Pa. Code § 140.232(ii)

            NOTE:  In most cases, it is to the individual’s advantage to include the spouse.

7. Approve or deny benefits as follows:

• If the income is equal to or less than the limit for Healthy Horizons categorically needy or cost-sharing benefits, authorize benefits.

• If the income is less than the limit for SLMB or QI-1, authorize benefits.

• If the income is more than the limit, deny benefits and determine eligibility for retroactive MA or retroactive Buy-In of Medicare Part B for SLMB or QI.

Example: On March15, Mr. Jones, age 65, and his wife, age 62, apply for MA. Mr. Jones was hospitalized in January and has unpaid doctor bills from February.  Mr. Jones receives Social Security benefits of $950 before the deduction for Medicare Part B. Mrs. Jones began receiving Social Security retirement benefits in February.  Her monthly benefit is $320. They had total countable resources of $2,655 in January and $2,720 in February. The Jones' resources are within the two-person limit.

Mr. Jones is eligible for retroactive Healthy Horizons benefits for January but not for February.  The CAO looks at retroactive eligibility for MNO for February.

            NOTE:  The CAO cannot allow deductions for medical expenses when determining Healthy Horizons eligibility, but they can consider those expenses, such as Mr. Jones's Medicare premium, when determining NMP and MNO eligibility.

319.82 Continuing Eligibility

The CAO must use the following steps to determine continuing eligibility for Healthy Horizons categorically needy, cost-sharing, SLMB, or QI benefits:

1. Determine who is included in the family.

2. Determine resource eligibility. (See Section 319.5.)

3. Determine the total net unearned income of the family members by allowing the deductions in Section 319.71.    

         55 Pa. Code § 140.232

4. Determine the total countable gross earned income for the family members. Allow the earned income deductions in Section 319.72. If the income is received weekly or biweekly, determine the average weekly amount and multiply it by four or two to arrive at the monthly amount.

            NOTE:  Multiply the average weekly income by four (or biweekly by two) even if the individual gets paid three or five times in the calendar month.

5. Add the total net earned and total unearned income, and compare the total with the  appropriate income limit in Appendix A, B, or C for the number of people in the family.   

        55 Pa. Code § 140.231

6. Approve or deny benefits as follows:

• If the income is equal to or less than the limit for Healthy Horizons categorically needy or cost-sharing benefits, authorize benefits.

• If the income is less than the limit for SLMB or QI-1, authorize benefits.

• If the income is more than the monthly limits and is not due to a temporary increase in income, deny benefits and determine the individual’s eligibility first for NMP spend-down and then for MNO spend-down.

            NOTE:  If the individual’s regular monthly income is more than the monthly income limit by less than one dollar, determine the annual income and compare it with the annual income limit or FPIG. The individual is eligible if the income is less than the annual limit.

• If the income is more than the monthly income limit because of a temporary increase in income or income that is not expected to continue, determine eligibility using the income for the calendar year when the individual is applying.

7. Determine the countable gross earned and unearned income available to the Healthy Horizons family for January 1 through December 31. Use the best available information for actual income received in past months, such as year-to-date amounts on the most recent pay stub, IEVS match, or a statement from an employer. Combine it with the income anticipated for the rest of the calendar year.

            NOTE:  If income is from self-employment, use the most recent tax return.

8. Determine the net calendar year income by subtracting the unearned income deductions in Section 319.71 and the earned income deductions in Section 319.72.

            NOTE:  Apply the earned income deductions, by determining the average monthly earned income.  Determine average income by dividing total earnings during the year by the number of months in which the earnings were received.

9. Compare the total net calendar year income for all family members with the  appropriate annual limit in Appendix A or B.

10. Approve or deny benefits as follows:

• If the calendar year income is equal to or less than the annual limit for Healthy Horizons categorically needy or cost-sharing benefits, authorize benefits.

• If the calendar year income is less than the annual limit for SLMB or QI-1, authorize benefits.

• If the calendar year income is more than the annual limit, deny benefits and  determine the individual’s eligibility first for NMP spend-down and then for MNO spend-down.

11. If changes in income are reported before the scheduled renewal,determine the eligibility again, using steps 5 through 10.

NOTE:  The individual is required to report and verify earned income within ten days after he or she receives the income.   

       55 Pa. Code § 125.24(d)(1)

       NOTE:  If an annual amount is needed,determine the income for the calendar year in which the change occurs.

Examples:

Mr. Harris, age 65, and his family apply for MA. He works part-time at a grocery store and earns $50 a week. He also receives Social Security benefits of $450 a month. Mrs. Harris, age 52, also works part-time, earning $75 a week. They have two children, ages 14 and 15. Each child receives $150 a month in Social Security benefits. Mr. Harris chooses to include his children and their income.

            NOTE:  If Mrs. Harris were elderly or met the disability requirements, the CAO would allow a separate earned income incentive deduction from her earned income.

Mr. Harris is eligible for Healthy Horizons benefits. The CAO must determine MA eligibility for the remaining family members. Since Mr. Harris qualifies for Healthy Horizons, his income and resources are not counted when determining MA eligibility for his wife and children.

• Mr. Ortega, age 65, receives a $950 Social Security check after the Medicare Part B premium is deducted. Mrs. Ortega, age 50, works part-time and earns $7.25 an hour. Their daughter, Cyndy, age 16, does not go to school. She works part-time and earns $7.25 an hour.

NOTE:  The daughter, Cyndy, was not included as a family member. Because Cyndy was not included, her income was not included. If Cyndy had been included as a family member, her income would have been added to her mother's income. (Cyndy does not meet any of the earnings exclusions according to the TANF-related or GA-related rules in Chapter 350, Income.) One $65 deduction would have been deducted from the combined earned income, and a three-individual SLMB income limit would have been used.

Updated March 19, 2013, Replacing   February 14, 2012