305.2 Supplemental Security Income (SSI)-Related Categories

An SSI-related category is approved for an individual who meets the aged, blind, or disabled Social Security requirements.

305.21 PH/PG—Healthy Horizons (Categorically Needy, Cost-Sharing, and Buy-In)

A PH/PG recipient must be age 65 or older or meet Social Security Administration (SSA) disability requirements. See Section 319.2, Determining Disability for information on disability determinations.

• An individual who is eligible for Healthy Horizons Categorically Needy benefits is assigned category PH.

If an applicant under age 65 appears to meet the Social Security disability requirements, the CAO must approve PH while a disability determination is being made

An individual who meets requirements for the PH category is eligible for:

• MA and Buy-In of their Medicare premiums (if they is eligible for Medicare).

• Payment of Medicare deductibles and coinsurances.                                                                      

• An individual who is eligible for Healthy Horizons Cost-Sharing benefits is assigned category PG. The PG recipient must be age 65 or older or disabled according to SSA requirements and qualify for Medicare.

   55 Pa. Code § 140.221(2)   55 Pa. Code § 140.332

An individual who meets requirements for the PG category is eligible only for Buy-In of their Medicare premiums and payment of Medicare deductibles and coinsurances.

  55 Pa. Code § 140.201(f)

• An individual who is eligible as a Specified Low-Income Medicare Beneficiary (SLMB) is assigned category TA (Aged) or TJ (Disabled) with Program Status Code (PSC) 65. The TA/TJ 65 recipient must be age 65 or older or disabled according to SSA requirements and qualify for Medicare.

• An individual who is eligible as a Qualifying Individual (QI-1) is assigned category TA (Aged) or TJ (Disabled) with PSC 67. The TA/TJ 67 recipient must be age 65 or older or disabled according to SSA requirements and qualify for Medicare.                                                                                                                                                                                           

305.22 PA/TA, PAN/TAN, PAW/TAW - Age 65 and Older

A PA/TA recipient must be age 65 or older. The category is based only on age and identified by “A”. An individual meets the age requirement on the first day of the month in which they have their 65th birthday. The CAO must make sure the individual proves that they really are age 65 or older, and then the age must be recorded. Once that takes place, age does not have to be proven again unless it appears that the individual may not have been truthful about age.

   55 Pa. Code § 178.11(1)      

 55 Pa. Code § 178.12(1)

People who are eligible for PA/TA must also be considered for Buy-In of Medicare premiums. (IEVS Handbook, Chapter 10(VPN required if teleworking); Chapter 319, Healthy Horizons; and Chapter 388, Buy-In.)

• A PAN/TAN recipient must be age 65 or older and be living in a Long-Term Care (LTC) facility or ICF/MR.

• A recipient of PAW must be age 65 or older and be receiving Home and Community-Based Services (HCBS).

305.23 PM, PMN, PMW, SBP—Blindness

• A PM recipient must be age 21 or older and meet the following vision requirements of the Social Security Administration (SSA) for SSI blind individuals:

55 Pa. Code § 178.11(3)

• Have 20/200 or poorer vision in the better eye with the best correcting lens.

• Have such limited vision that the widest diameter of the visual field subtends an angle no greater than 20 degrees.
  

• A PMN recipient must be age 21 or older and living in a nursing facility or ICF-MR. The individual must also meet the same vision criteria as the PM recipient (see above).

• A PMW recipient must be age 21 or older and be found eligible to get home and community-based services. The individual also must meet the same vision criteria as the PM recipient (see above).

• Any individual receiving State Blind Pension (SBP) benefits (B category) are assigned an MA category of SBP.

305.24 PJ/TJ, PJN/TJN, PJW/TJW—Disability

The PJ/TJ recipient must be under age 65 and be permanently and totally disabled according to Social Security disability requirements (Section 305.25). See Section 319.2, Determining Disability for information on disability determinations.

55 Pa. Code §§ 178.11(a)(2)     

 55 Pa. Code § 178.12(a)(2)

The PJ/TJ category includes children of any age who are permanently and totally disabled.

People who are eligible for PJ/TJ must also be reviewed for Buy-In of Medicare premiums. (IEVS Handbook, Chapter 10 (VPN required if teleworking), Chapter 319, Healthy Horizons and Chapter 388, Buy-In)

  55 Pa. Code § 140.201(e)

• A PJN/TJN recipient must be under age 65, disabled, and living in a LTC facility or ICF-MR.

• A PJW/TJW recipient must be under age 65, disabled, and eligible for Home and Community-Based Services (HCBS) program.
  

NOTE: If an individual under age 65 appears to meet the Social Security disability requirements, the CAO must approve PJ/TJ while a determination is made. (Section 305.26)

305.25 Presumptive Eligibility—PH/PJ/TJ

Individuals who report a disability, but the disability is not verified by the Social Security Administration (SSA) or the Medical Review Team (MRT) must first be reviewed for Modified Adjusted Gross Income (MAGI)-related MA. See Appendix A, Determining Category Using Information Provided on the PA 1663, PA 1664, and PA 1671 for more information.

If an individual does not meet one of the disability requirements in Section 319.2, Determining Disability, but appears to be disabled and is not eligible for MAGI-related MA, the CAO will refer them to the Disability Advocacy Program (DAP) (Supplemental Handbook, Chapter 820) and review eligibility for SSI-related MA.

A individual may be considered permanently and totally disabled if one of the following conditions is met:

• The individual has a physical or mental impairment that may last at least 12 months in a row or may lead to death.

• The individual cannot engage in substantial gainful activity (SGA).

NOTE:  For an adult, SGA is any significant mental or physical work that they  are paid for. Although SGA is still one way that SSA can determine eligibility for disability benefits, the SGA limit must no longer be used in determining eligibility for Healthy Horizons.

• The individual cannot perform  their former job and cannot work in any other job in the national economy.

NOTE:  For MA purposes there is no conflict between disability determination and receipt of UC. The receipt of UC does not prevent an individual from meeting the definition of disabled.

• The individuals’ vision is 20/200 or worse in the better eye even with glasses or other correcting lenses.

• The individual is a disabled child who has a physical or mental condition or conditions that can be medically proven and that cause severe limitations on how they function. The condition must be expected to last at least 12 months or cause the individual to die.

The DAP advocate will refer the individual to SSA or the Medical Review Team (MRT) to determine whether the individual meets a permanent and total disability requirement. The CAO will approve PH, PJ, or TJ until the determination is made.           

55 Pa. Code § 141.81 (e) (ii)

NOTE:  This approval is based on Presumptive Eligibility. It applies mostly for the period when the MRT determination is still being made. However, it can be approved for an earlier period if (a) the medical assessment form is returned showing a permanent disability and (b) the doctor or psychologist notes a begin date before or on the date for when coverage for past dates is requested.

The request for retroactive coverage can be pended until the MRT review is made, but the CAO must request the MRT review of the individual’s condition during the retroactive period (inclusive date) on the DAP Referral Form.  

305.26 SSI Special Circumstances—PA/PJ/PM

MA coverage is extended for an individual who becomes ineligible for SSI cash payment because of special circumstances. (Section 387.53, End of SSI Benefits and Section 387.6, Extended NMP—Special Situations.) Benefits for the individual who qualifies under these special circumstances are opened in either the PA, PJ, or PM category.

The following are some of the special circumstances that would require review:

• Lynch v. Rank, “PICKLE”.

• Disabled Adult Child (DAC) benefits.

• Employment benefits/1619(b) Eligibles.

• Widows and widowers benefits.

305.27 PW/PI Medical Assistance for Workers with Disabilities

Medical Assistance for Workers with Disabilities (MAWD) has two groups.

• PW (Workers With a Disability) identifies recipients who:                                                                                                                                       

     Public Law 106-170  

 Act 2001-77 (P. L. 755)

• Are at least 16 years old but younger than 65.

• Are employed and receiving income.

• Are disabled according to the SSA or the MRT.

• PI (Workers With a Medically Improved Disability) identifies recipients who:

• Meet the age, income, and resource requirements of the PW category.

• Are employed at least 40 hours a month and are earning at least minimum wage.

• Have a disability that has improved over time so that it no longer meets SSA’s disability criteria.

• Have previously gotten on-going MA coverage in the PW category and have been discontinued because their medical condition has improved.

NOTE:  The CAO will continue PW coverage until the determination for PI coverage is made. PW must be closed and PI opened with no break in coverage.

Recipients who meet the income and resource requirements are eligible for Buy-In of Medicare premiums. (See Chapter 316, MAWD.)

Updated August 21, 2024, Replacing March 8, 2021