Cooperating with Medical Review Team (MRT) Requirements, and Eligibility for the Children’s Health Insurance Program (CHIP), PMA-21600-315 (Published January 8, 2024)
Counting Medical Expenses for the Children with Special Needs (PH95) Medical Assistance (MA) Category , PMA20635315 (Published August 2, 2021)
DAP/MRT Referral for Disabled Child, PMA18939315 (Published July 26, 2018)
PMB18517315 -Removal of minimum age requirement for participation in the Office of Developmental Program’s (ODP) Person/Family Directed Support (68) and Consolidated (77) Waivers- May 31, 2017
The Children with Special Needs Category provides full Medical Assistance (MA) benefits to children up to age 18 who meet disability requirements and do not receive Supplemental Security Income (SSI) benefits under Title XVI of the Social Security Act.
The Children with Special Needs category is authorized only after eligibility for all other MA categories has been explored.
The County
Assistance Office (CAO) will determine eligibility for Children
with Special Needs based on the requirements in this Chapter and the following
chapters: 55
Pa Code § 140.21
General Information - Chapter 303
Application - Chapter 304
Students - Chapter 314
Identity – Chapter 320
Citizen/Alien – Chapter 322
Residence – Chapter 323
Income – Chapter 350
Self-Employment – Chapter 352
Reporting Changes – Chapter 370
Renewal – Chapter 376
Notices – Chapter 377
Verification – Chapter 378
Disability Advocacy Program – Supplemental Handbook Chapter 820
Appeal and Fair Hearing – Supplemental Handbook Chapter 870
Overpayment Recovery – Supplemental Handbook Chapter 910
Reimbursement – Supplemental Handbook Chapter 915 Reimbursement
Enumeration- Supplemental Handbook Chapter 950
The Children with Special Needs category provides the following
benefits:
Children's HealthCare Benefits Package (Chapter 338, Appendix A, Health Care Benefits Packages.)
Retroactive Coverage – Children with Special Needs benefits may be authorized for the retroactive period when medical documentation [either by the Social Security Administration (SSA) or the Medical Review Team (MRT) determination] confirms the disability existed in the retroactive period.
A child should be authorized presumptively when:
The CAO receives documentation of a disability from a physician or psychologist. The documentation must detail the child’s medical condition.
The
child with special needs has not been determined disabled
by SSA or MRT. A Disability
Advocacy Program (DAP) referral
should be completed for MRT review.
Acceptable disability verification for presumptive eligibility includes, but is not limited to:
An Individualized Education Plan (IEP).
An Individualized Family Service Plan (IFSP).
An Early Intervention evaluation.
A
Mental Health facility discharge report.
There is no presumptive eligibility for retroactive MA for the Children with Special Needs category.
The CAO will verify the following:
Income: Parents (natural and adoptive) and child must report and verify all earned and unearned income.
Birth date.
Disability
or a pending application for a disability determination by SSA or
by DHS’s MRT.
Explain the use of the Authorization for Information (PA 4) when collateral contacts are necessary. Complete the form only if the collateral contact requires written consent from the individual for the verification to be released. (Section 378.4, Collateral Contacts)
Updated July 26, 2018, Replacing April 12, 2018