305.2 SSI-Related Categories—NMP and MNO

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

A PH/PG recipient must be age 65 or older or meet Social Security Administration (SSA) disability requirements.

An individual who is eligible for Healthy Horizons Categorically Needy benefits is assigned category PH. 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. (Section 305.25 to determine whether an applicant meets the disability requirements.)    

     

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

 

If an applicant under age 65 appears to meet the Social Security disability requirements, the CAO must approve PH while a determination is being made. ( Section 305.26.)

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

    55 Pa. Code § 140.331

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

 

If an individual qualifies for both Healthy Horizons and PC as a specified relative, the CAO must approve the category of MA that most benefits the individual and the other members of the household applying for or receiving MA.                                                                                                                                                                                                                                                   

  55 Pa. Code § 140.201(f)

Exception: When determining NMP eligibility for a family, all immediate family members must be included in the eligibility decision (including SSI-related/Healthy Horizons individuals). If eligibility is established for the family, 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 NMP, one individual’s eligibility can be established by the removal of the SSI-related/Healthy Horizons individuals from the eligibility determination.

NOTE:  If an elderly or disabled individual is ineligible for Healthy Horizons Categorically Needy, Medically Needy Only, or Medicare Cost-Sharing coverage because he or she has income that is too high, then the caseworker must determine eligibility for Specified Low-Income Medicare Beneficiary (SLMB) or Qualifying Individuals Group 1 (QI-1). (Chapter 319, Healthy Horizons.)

305.22 PA/TA, PAN/TAN, PAW/TAW—Old-Age Category

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 he or she has his or her 65th birthday. The CAO must make sure the individual proves that he or she really is 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)

NOTE:  The CAO must determine eligibility for a Healthy Horizons category before considering PA or TA.

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

A TA individual who is ineligible for Cost-Sharing Healthy Horizons (PG 00) or PA and whose income is more than 100% but less than 120% of FPIGs must be considered for eligibility as SLMB.                  55 Pa. Code § 140.201(d)    

 

A TA individual who is ineligible for coverage as SLMB whose income is at least 120% but less than 135% of FPIGs must be considered for eligibility as a QI-1.

 

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/TAW must be age 65 or older and be receiving Home and Community-Based Services (HCBS).

305.23 PM, TJ, PMN, PMW—Blind Category

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)

 

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).

 

A recipient of State Blind Pension (SBP) may be approved for MNO under the TJ category. The SBP category does not cover inpatient doctor and hospital care. The CAO will determine whether an SBP recipient meets MNO requirements for inpatient doctor and hospital coverage. The caseworker will use CIS to verify SBP eligibility (category B).                                                 

 55 Pa. Code § 178.12(4)  

NOTE:  The CAO will need to close the SBP case if there is a need for NCE coverage in order to pay a medical expense not covered by SBP benefits.

If the SBP recipient qualifies for Healthy Horizons Cost-Sharing, the CAO must assign Program Status Code 80 to the B category.

 

NOTE:  The SBP payment is counted as income when determining eligibility for MNO and Healthy Horizons Cost-Sharing.

305.24 PJ/TJ, PJN/TJN, PJW/TJW—Disabled Category

The PJ/TJ recipient must be under age 65 and be permanently and totally disabled according to Social Security disability requirements (Section 305.25).

 

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, Chapter 319, Healthy Horizons and Chapter 388, Buy-In)

 

When an individual meets the criteria for TJ but is over the income limit, the individuals must be reviewed for QI-1.         

  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 Disability Requirements—PH/PG/PJ/TJ

An individual is permanently and totally disabled if he or she meets one of the following conditions:   

  

    55 Pa. Code § 140.221(2)   55 Pa. Code § 141.81(c)(iv)

NOTE:  An individual who gets VA disability or federal civil service disability may not meet the requirements. Disability criteria for these benefits is different from SSA disability criteria.

 

NOTE:  Effective March 29, 1996, the Contract with America Advancement Act of 1996, P. L. 104-121, which amended the Social Security Act, says that people who are diagnosed only with an alcohol or drug addiction do not get SSI or RSDI benefits. If an individual with an alcohol or drug addiction has another medical or mental problem, the individual may qualify for SSI or RSDI on that basis.

The CAO will make sure the individual truly meets one of the disability requirements and must narrate the information in the case record.

Reminder: The CAO will not assume that an individual who is under age 65 and getting Social Security is disabled. The benefit may be for early retirement, a widow's benefit, or a surviving child's benefit. The CAO will find out what type of Social Security the individual is getting.

Proof that someone is disabled includes, but is not limited to, the following:

305.26 Presumptive Eligibility—PH/PJ/TJ

If an individual does not meet one of the disability requirements in Section 305.25 but appears to be disabled, the CAO will refer him or her to the Disability Advocacy Program (DAP). (Supplemental Handbook, Chapter 820.) A individual may be considered permanently and totally disabled if one of the following conditions is met:

NOTE:  For an adult, “substantial gainful activity” is any significant mental or physical work that he or she is 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.

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

The DAP advocate will refer the individual to SSA or the 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 Medical Review Team (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.  

 See  Supplemental Handbook, Chapter 820 for referral information and procedures.

305.27 NMP Special Circumstances—PA/PJ/PM

MA coverage is extended for a 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 a review:

The PICKLE Amendment as expanded by the Lynch v. Rank court decision, provides for the disregard of Title II RSDI Cost-of-Living increases when an individual who is receiving both SSI and RSDI is determined to be ineligible for SSI due to the increase in the RSDI income. The CAO will determine eligibility for NMP as for any other SSI-related applicant or recipient, but will disregard any RSDI COLAs received since the SSI closure. Eligibility for NMP is determined using the RSDI benefit received in the last month of SSI eligibility.  (Chapter 387, Section 387.61 Loss of SSI—Disregard of COLAs.)

NOTE:  The CAO must count any increases in RSDI that were given for reasons other than a COLA.

A disabled adult child who has lost SSI benefits because he or she got an increase in Title II Social Security benefits may continue to be eligible for NMP. (Section 387.62, Title II Disabled Adult Child.)

Special SSI recipient status is given to a individual with a disability or who is blind whose earnings from employment make him or her ineligible for an SSI cash payment. SSA makes the determination for special SSI recipient status. (Section 387.63, Disabled Employment.)

 

Certain disabled widows and widowers who lost SSI because of entitlement to or increase in Title II RSDI benefits continue to be eligible for MA. For MA eligibility purposes, the CAO must consider these people to be recipients of SSI benefits. (Section 387.64, Disabled Widows and Widowers.)

NOTE:  The SDX MA eligibility codes on IEVS Exchange #6, SDX, usually show the recipient’s MA eligibility. The CAO must look at codes for continued MA coverage. (“Using IEVS.”) The CAO may need to contact SSA for more information if the IEVS information is unclear or incomplete.

The Balanced Budget Act (BBA) of 1997 says that children getting SSI on August 22, 1996, who lost SSI because the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996 changed the SSI definition of disability for children, remain eligible for MA.

As a result of the PRWORA change to the disability definition, children receiving SSI benefits on August 22, 1996, were reviewed by SSA for continuing SSI eligibility using the revised disability definition. SSI was terminated on or after July 1, 1997, for these children who did not meet the new disability definition.

(Section 387.65, MA-Eligible Disabled Children under the Balanced Budget Act (BBA) of 1997.)

305.28 PW/PI Medical Assistance for Workers with Disabilities

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

     Public Law 106-170   Act 2001-77 (P. L. 755)

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.)

 

305.29 Special-Needs Categories

305.291 PH—Breast and Cervical Cancer Prevention and Treatment

PH 20 identifies women who are eligible for coverage under the Breast and Cervical Cancer Prevention and Treatment (BCCPT) Program.

Public Law 106-354

 

BCCPT provides full MA health care coverage for women who need treatment for breast or cervical cancer or a precancerous condition of the breast or cervix. (Chapter 317.)

 

305.292 PH—Children with Special Needs

The PH 95 category is for children with special needs. The child must be considered for all other MA categories before PH 95 is approved.

NOTE:  PH 95 is a category of last resort for children with special needs.

For a child to be eligible for the PH 95 category, the following conditions must be met:

305.293 PSF—SelectPlan for Women

SelectPlan for Women program will increase access to family planning services for women in Pennsylvania.

Services Provided.

NOTE:  Per Federal law, abortion is NOT a family planning service and is NOT a covered service.

Eligibility Requirements.

 

NOTE:  A college student who is under 21, attends college in Pennsylvania and whose parents reside in another state may not claim Pennsylvania residency.

 

Updated March 16, 2018,  Replacing February 14, 2012