Reviewing for SSI-Related Medical Assistance (MA) when MG 91 and MG 90D Recipients Turn 65 Years Old , PMN19658305 (Revised October 9, 2019)
Medical Review Team (MRT) Disability Determinations , PMN19579-305 (Published August 16, 2019)
Individuals Receiving Home and Community-Based Services (HCBS) in Modified Adjusted Gross Income (MAGI) Budget Categories, PMN19521489 (Revised August 13, 2019)
MG 18 C Closure Prior to Renewal, PMG19337305 (Published April 4, 2019)
Reviewing for Medical Assistance (MA) when General Assistance (GA) Cash Closes, PMG19272305 (Published February 19, 2019)
Reviewing Medical Assistance (MA) when General Assistance (GA) Cash Budgets Close, PMA19190305 (Published November 26, 2018)
Medical Assistance Program Changes due to the Introduction of Enhanced Federal Medical Assistance Percentage, OPS160305 (Published March 10, 2016)
Reinstatement of Medically-Needy Only (MNO) for Non-pregnant Adults Aged 21 through 64, OPS160301 (Published March 7, 2016)
The County Assistance Office (CAO) must determine which category and program each Medical Assistance (MA) applicant or recipient belongs in. The program is based on the individual’s income and resources. The category for which the applicant or recipient is qualified affects how income and resources are treated.
55 Pa.
Code § 178.11
55
Pa. Code 178.12
NOTE: The following categories are non-medical assistance (MA) categories:
ACX is managed by the Office of Long Term Living (OLTL).
EIX is managed buy the Office of Child Development and Early Learning (OCDEL).
MHX is managed by the Office Mental health and Substance Abuse Services.(OMHSAS).
MRX is managed by the Office of Developmental Programs (ODP)
These categories are entered into e-CIS by the appropriate program office for billing purposes only. Individuals enrolled in these categories do not have medical assistance benefits. CAO staff is not able to update these cases.
Individuals may apply for and receive Cash, SNAP or MA benefits if the individual is non-financially and financially eligible. If an individual is found eligible for Cash, SNAP or MA , the benefits must be authorized in a new e-CIS case record number.
Supplemental Security Income (SSI)-related.
PH (Healthy Horizons Categorically Needy—(65 and older/Disabled).
PG (Healthy Horizons Medicare Cost-Sharing—(Elderly/Disabled).
PA/TA (Old-Age Assistance).
PAN/TAN (Old-Age Assistance Long-Term Care Facility).
PAW/TAW (Old-Age Assistance (Home and Community Based Services).
PJ/TJ (Aid to the Disabled).
PJN/TJN (Aid to the Disabled Long-Term Care Facility).
PJW/TJW (Aid to the Disabled Home and Community Based Services).
PM (Aid to the Blind).
PMN (Aid to the Blind Long-Term Care Facility).
PMW (Aid to the Blind Home and Community Based Services).
PW/PI (MA for Workers with Disabilities).
Public Law 106-170 Act 2001-77 (P. L. 755)
TANF/GA-related.
PC/PU – NMP for the Family.
PC/TC (Temporary Assistance for Needy Families).
PU/TU (Unemployment).
PS (Healthy Beginnings)—Pregnant Woman or Qualified Child).
PD/TD (General Assistance).
PCW (Refugee Home and Community Based Services).
PCN (Long-Term Care Facility).
Special eligibles.
PMC17977317 Evaluating Eligibility for BCCPT (PH 20), April 21, 2016
PH 95 (Children with Special Needs).
PSF (SelectPlan for Women).
The category of MA is based on the following criteria, which are not related to money or income (non-financial):
Age.
Temporary/Permanent and Total Disability.
Blindness.
Resident in a long-term care facility.
Individual receives home and community-based services.
Specified relatives.
Deprivation of support or care.
Pregnancy.
Employability.
Diagnosis and the need for treatment (BCCPT).
Family Planning Services for Women (SPFW).
The category of MA identifies a budget group. Each member of the budget group is eligible for the same category. An applicant/recipient group may include one or several budget groups. Separate budget groups may be set up for members of the applicant/recipient group, even if they qualify for the same category.
Two types of MA benefits are available:
Nonmoney Payment (NMP). This includes Healthy Horizons and Healthy Beginnings. The letter "P" before the category means it’s NMP. An NMP recipient receives a Pennsylvania ACCESS card to present to medical providers when receiving medical services.
Exception: PG identifies a Healthy Horizons Medicare Cost-Sharing recipient.
Medically Needy Only
(MNO). The letter "T" designates MNO. An MNO recipient
receives a Pennsylvania ACCESS card to present to medical providers
when receiving medical services.
Exception: MNO categories TA and TJ with program status codes 65 or 67 are used to identify the Medicare Savings Programs. The only benefit of these categories is the payment of monthly Medicare premiums. These individuals do not receive MNO MA benefits or a Pennsylvania ACCESS Card.
NOTE: To identify individuals who receive NMP/MNO and live in a Long Term Care (LTC) facility, the letter “N” is added after the category.
NOTE: To identify individuals who receive NMP/MNO and receive home and community-based services, the letter “W” is added after the category.
The CAO must determine whether someone is eligible for NMP before determining eligibility for MNO. The CAO must provide the coverage that best meets the medical needs of the individual. The CAO must explain the benefits of each type of coverage and let the individual choose the type that will best meet his or her needs.
Within MA, a category is assigned. Individuals who are applying together, even if the CAO determines they are in the same applicant/recipient group, may not always qualify for the same category. The CAO must determine each individual’s category separately.
The CAO must first determine eligibility for SSI-related
categories and then for TANF-related categories. The CAO must assign the
GA-related category only if the individual does not meet the requirements
for an SSI-related or TANF-related category.
Exception: When determining eligibility for NMP for the Family (NMPF), all immediate family members (including SSI-related/Healthy Horizons individuals) must be included in the eligibility determination. If the family is found to be eligible, any SSI-related/Healthy Horizons–eligible family members must be opened in the appropriate SSI-related/Healthy Horizons category. If the family is not eligible for NMPF, one individual’s eligibility can be established by the removal of SSI-related/Healthy Horizons individuals from the eligibility determination.
The automated process for determining MA eligibility will
review eligibility in the following order for MA applicants, MA recipients,
and TANF recipients who are to stop receiving benefits:
1. Presumptive eligibility for pregnant woman.
2. Foster care/adoption subsidy.
3.Long-term care (LTC) facility and home and community-based services (HCBS).
4. Extended NMP special circumstances (MEH 387.6).
5. Refugee unaccompanied minor.
6. Healthy Horizons.
7. SSI-related NMP.
8. NMP for the Family (NMPF).
9. Extended MA Coverage (EMC).
10. Refugee MA (RMA)—Non-SSI/non-pregnant.
11. TANF and GA-related NMP.
12. Breast and Cervical Cancer Prevention and Treatment (BCCPT).
13. Income-ineligible pregnant woman.
14. MA for workers with disabilities (MAWD).
Public
Law 106-170 Act 2001-77 (P. L. 755)
NOTE:
Be sure to enter the appropriate code in the MAWD request
field on CADISB in order for the cascade to review for MAWD eligibility.
15. Home and community-based services for individuals with AIDS or symptomatic HIV.
16. SSI-related, TANF-related, and GA-related MNO.
17. Income-ineligible newborn.
18. RMA—family with children.
19. SSI-ineligible children (PJ 98).
20. Children with Special Needs (PH 95).
21. Healthy Horizons cost-sharing.
22. Medicare Buy-In (payment of monthly Medicare premiums).
23. Prison inmate—children.
24. SelectPlan for Women.
NOTE:
See
Appendix
E for
the entire MA cascade
.
If an individual meets the eligibility requirements for both SSI-related and TANF-related categories of MA, the CAO must approve the category of MA that:
Gives the most coverage for families and reimbursement of federal dollars possible.
Is most helpful to the individual and to other household members who are applying for or receiving MA.
Updated August 19, 2019, Replacing August 30, 2018