315.5 Determining Eligibility and Authorizing Benefits

The Children with Special Needs category is authorized only after eligibility for all other MA categories has been explored, see MAEH 315.1 General Policy for additional information. It is the category of last resort for medical coverage.

Children must meet the following criteria to be eligible for the Children with Special Needs Category:    

  55 Pa. Code § 140.601

55 Pa. Code § 140.603

• The child is under 18 at the time of requested MA coverage.

• The child meets the SSA’s disability standards. The disability requires verification from SSA or DHS’s MRT, but if the CAO receives documentation of disability from a physician, or licensed psychologist, and the child has not been determined disabled by SSA or MRT, the child should be authorized presumptively.  See Section 305.26, Presumptive Eligibility – PH/PJ/TJ and  Supplemental Handbook Chapter 820, Disability Advocacy Program.

NOTE: If the child has been denied SSI or RSDI for a non-medical reason and SSA completed the medical evaluation, an MRT referral is not required.

In addition, if the child was previously certified as meeting disability criteria for the same condition by the MRT, another MRT referral is not needed.

• The child is not eligible for a premium-free MA category using parental income.

Reminder:  The Children with Special Needs category is a MA category of last resort. Review for other non-spend-down MA categories first using the parents’ and the child’s income.

When it is determined the child meets Children with Special Needs criteria, the CAO will take the following steps:

• Review for the Children with Special Needs category using only the child’s countable income if ineligible for other MA categories.

• Determine eligibility for each child individually for households with more than one child with special needs.

• Calculate total income for the child only. Apply the Healthy Horizons income deductions.

• Authorize retroactive coverage when medical documentation (either by SSA or MRT) confirms the disability existed in the retroactive period. There is no presumptive eligibility to qualify for MA in the retroactive period for Children with Special Needs category.

• Medical expenses are not considered for eligibility for the Children with Special Needs category. Therefore, there is no patient pay liability or spend down provision.

• • Medical expenses should not be entered into eCIS. Entry of medical expenses in eCIS may cause the child to be incorrectly authorized in a MNO spend-down category instead of the Children with Special Needs category.

• Determine the total net countable income of the child for the calendar month and compare it to 100% of the Federal Poverty Income Guideline (FPIG).

• Authorize eligibility in the Children with Special Needs category “PH,” with program status code “95", if the total net countable income of the child is equal to or less than 100% of the FPIG for one person. Generate a notice of eligibility per Chapter 377, Notices.

• • Authorize eligibility effective the date of application. See Section 304.14, Date of Application and Date When MA Begins.
  • Data enter any third-party liability coverage (ex. private health insurance, including supplemental plans) and explain that MA is the payer of last resort.
  • Refer the child to DAP for an MRT review if the child is being authorized in the Children with Special Needs category presumptively.

Reminder: The child should not be referred to SSA to apply for SSI benefits (unless the family wants to apply for SSI benefits) in the PH 95 category since it is assumed by the child’s eligibility in that category that the child does not qualify for SSI.

If the child qualifies for any other MA category (based on income eligibility), an SSA DAP referral should be initiated to encourage the pursuit of Federal benefits and the disability determination since it is beneficial to the child.

The CAO should not use SSA’s parental deeming or Federal Benefit Rate charts to determine which type of DAP referral to make.  

NOTE: The issuance of the PA Access card is authorized upon the completed transaction of the MA authorization. The CAO will ensure that   the authorization and data entry process is completed timely to meet the medical needs of the eligible child. See Chapter 380, Issuing the ACCESS Card.

• Deny eligibility for the Children with Special Needs Category if the total net countable income of the child exceeds 100 percent of the FPIG. Generate a notice of ineligibility per Chapter 377, Notices.

If the CAO determines the child is not eligible for any MA category, including the Children with Special Needs category due to financial reasons or because the child is determined not to be disabled, then the child will be reviewed for the Children’s Health Insurance Program (CHIP).

NOTE: If the child is within their 12-month certification period, the child will be transitioned to  MG 18 target type “C” until their next renewal.

If the child is not eligible for the Children with Special Needs category because their family did not provide the pending medical documentation for the MRT review process (including if it was needed to provide presumptive eligibility), the CAO will update the Disability screen as follows in order to capture the reported disability:

• If the child is eligible for non-disability related MA or CHIP, the CAO will:
  • Update the Medical Assistance Disability Status field to “50- Temporary Disability”.
  • Select “P-Pending Verification” on the Medical Assistance Disability Verification field.
  • Enter a future date in the “End Date” and “Review Date” fields.

NOTE: The “Review Date” entered must be twenty-three months from the process date and the “End Date” must be two years from the process date. The CAO may need to update the dates in the “End Date” and Review Date” fields at renewal if the medical documentation is still not provided and the child continues to qualify for non-disability related MA or CHIP.

• If the child is not eligible for non-disability related MA or CHIP and would be eligible for disability-related MA if they provided the medical documentation for the MRT review (including if it was needed to provide presumptive eligibility), then the CAO will:
  • Update the Medical Assistance Disability Status field to “51- Permanent Disability”.
  • Select “P-Pending Verification” on the Medical Assistance Disability Verification field.
  • Issue an 042 rejection/closure notice to the individual after the PH-00(D) fails non-financially.

NOTE: Updating the Disability screen to fail the PH-00(D) budget in order to reject or terminate the child’s MA should only be done at application or renewal.

55 Pa. Code § 140.601

 55 Pa. Code § 140.603

315.51  Referrals from CHIP for Children Potentially Eligible for PH95

Some children currently covered by CHIP may meet SSA disability criteria, making them eligible for MA coverage under the PH95 (or another MA) category. It is a federal requirement that if a child is eligible for MA, the child is ineligible for CHIP. 

To ensure that children who are potentially eligible for MA are enrolled in MA, a process was implemented to send referrals from CHIP to MA for children with special health care needs. During this process, CHIP insurance coverage continues until MA eligibility is established.  

CHIP Contractor Responsibilities 

Prior to sending a referral, the CHIP contractor will do the following:

• Confirm the child is under age 18.

• Confirm citizenship and identity.

•  Make three telephone attempts to notify families the child is being referred to MA for an eligibility determination; and follow up with a letter to the family.

• Contact the medical provider and send the provider a Physician Certification for Child with Special Needs form (PA 1960), to be returned to the CHIP contractor. The CHIP contractor will follow-up with the medical provider until the PA 1960 is returned.

• Forward the referral packet to the Central Unit at RA-PWCHIPTOPH95@pa.gov, upon the receipt of the completed PA 1960 which shows the child is "Permanently Disabled" or "Temporarily Disabled, 12 months Or More." A completed packet includes:

• • PH95 Referral Cover Sheet (HS 2113)

  • Physician Certification for Child with Special Needs Form (PA 1960)

NOTE: See Appendix A, CHIP to PH-95 Referral for a copy of these forms.

For referrals that are being returned to the referring CHIP MCO because the family previously did not follow through with providing the medical documentation needed for the MRT review process, the CHIP MCO will provide an update to the family that the child will not be referred to MA because comprehensive and current medical documentation needed for the original MRT referral was not provided to the CAO. The CHIP MCO will inform the family that they (the family) can provide the missing documentation to the CAO for the MRT review process to be reinitiated.

Central Unit (CU) Repsonsibilities

The CU will receive and process all referrals from CHIP through the presumptive MA eligibility determination, including for cases that have other open benefits (cash, MA or SNAP) for anyone in the family.

Exception:  The CU is not responsible to process referrals if the family previously did not provide the pending documentation needed for the MRT review process.

Upon the receipt of the PH95 referral packet, the CU will do the following:

• Review the referral packet received from the CHIP contractor for completeness.

Important:  If the CHIP MCO attempts to refer a child to MA whose family previously did not follow through providing medical documentation needed for the MRT review process, the CU will take the following actions:

• Review the closed DAP Functions Module for an MRT decision of “Client Did Not Cooperate”, review narratives at the time the MRT referral was closed noting the family did not follow through with providing needed medical documentation or respond to requests for medical documentation and review the Disability screen to see if “P-Verification Pending” is on the Medical Assistance Disability Verification field.

• Return the new referral to the referring CHIP MCO if the CU determines, after reviewing all three areas in the case record, that the child’s family did not follow through with providing medical documentation needed for the MRT review process. CU will note that no action will be taken to transition the child back to MA because current and comprehensive medical documentation to support the diagnosis/medical condition indicated on the PA 1960 form (or other documentation used for the presumptive disability related MA opening) was not received.  CU will provide the CHIP MCO a copy of the MRT Letter (CM 584) so that the CHIP MCO is aware of what is needed to be able to transition the child back to MA.

NOTE:  The CHIP MCO will provide an update to the family that the child will not be referred to MA because comprehensive and current medical documentation needed for the original MRT referral was not provided to the CAO.

• Return incomplete referrals to the referring CHIP contractor.

NOTE: The child will continue in CHIP until a complete referral packet is received.

• Determine presumptive MA eligibility within 30 days of receipt of the referral packet.

• Request any clarifying case information from the referring CHIP contractor, such as diagnosis, credentials of the medical professional completing the form, child’s full name, etc. if needed.

• Authorize presumptive MA eligibility in the electronic Client Information System (eCIS).

•  The effective date is the date the case is processed in eCIS. 

•  Enter “Yes” in the Referred to Disability Advocacy (DAP) dropdown, select “MRT Only” in the Type of Referral drop down, and select “Pending” in the MRT Decision drop down on the Disability screen. The CU will also ensure the MRT Decision Date on the Disability screen is blank to initiate an MRT referral, which is required for the child to receive a disability determination.

NOTE: If the child is eligible for an MA category other than PH95, the CU will refer the family to the SSA instead of the MRT. If an SSA referral is selected on the Disability screen, a File for SSA Benefits Letter (CM587) will automatically be generated and sent from the system if there is no current SSA application or appeal on Exchange 6. The DAP worker assigned to the child’s county of residence will follow current SSA referral procedures.

•  The system will set a DAP alert for the worker in the CAO of the child’s county of residence.

•  Narrate and scan all information pertaining to the case, including the PA 1960 and any other information received regarding the disability (such as an IEP form)

• Issue a PA ACCESS card, even if the child previously received one.

• If found eligible, the child will be disenrolled from CHIP through the usual CHIP disenrollment process, including sending advance notice to the family.

NOTE: The CU is responsible for appeals on any referral they authorize or reject.

CAO Responsibilities

The CAO in the child’s county of residence will retain the case from this point and process the MRT referral established for all PH95 cases.

NOTE: Once PH95 (or another MA category) is authorized, a new application is not required if a category change is needed.  

The CAO will:

• Review medical documentation scanned into Imaging.  If more medical documentation is needed prior to sending the referral to the MRT, the CAO will send the MRT Letter (CM 584) to the family from the Forms Generations module, which is accessible from Case Management Action.

• Complete an MRT referral using the Medical Review Team Transmittal form (PA 749), which can be accessed from the Forms Generation module once the CAO has sufficient medical documentation for the child. The CAO will indicate the reason for referral as “Medical Card Only – Child” and submit the form along with the PA 1960 and all disability documentation received from the family and/or CHIP contractor.  

NOTE:  The PA 1960 alone is not enough to send to the MRT for a disability determination and can only be used to authorize presumptive MA.  If the PA 1960 is sent without supporting disability documentation, the MRT referral will be returned to the worker with “Additional Information” indicated on the PA 749.  See the MRT Referral Checklist – MA Card Only or MAWD for more information.

• Access the DAP Functions module and update the “MRT Referral Date” field with the date information was sent to the MRT. This will set a “DAP 252 – MRT Certification Decision Not Received” alert for the case to be reviewed within 90 days. 

• Take action, based on the applicable scenario below, after MRT has reviewed  the referral and corresponding medical documentation and has returned the PA 749 with an accompanying letter and/or certification form.

• • If the MRT returns a disability certification, then access the DAP record through the DAP Functions module and data enter the MRT Decision and Final MRT Decision Date.  The DAP record will close and the “DAP 252 - MRT Certification Decision Not Received” alert will clear.  The certification and certification date that were data-entered in the DAP Functions module will be automatically updated on the Disability screen in Case Processing (CP).  If the ongoing PH95 budget can be automated, it will be.  If the case fails automation for any reason, a “DAP 250 - Review and Run Eligibility” alert will be generated and assigned to the caseworker maintaining the case.

• • If the MRT returns the referral requesting additional information, then reach out to the family to request the additional information by sending a new CM 584 along with a copy of the MRT’s letter.  The “DAP 252 - MRT Certification Decision Not Received” alert will remain active on the MRT worker’s Workload Dashboard (WLD) during this time.  The MRT worker will not need to update the open DAP record with the date a case is re-sent to the MRT.  

• • If the family does not provide the medical documentation needed for the MRT review process, then close out the MRT referral as “Client Did Not Cooperate”.
    • The child will be transitioned to category MG 18 with target type “C” if the child qualifies for no other non-disability related MA category until the child’s next renewal.

Important: The CAO will update the Disability screen as follows in order to capture the reported disability and cascade to non-disability related MA, and CHIP:

• • • • • Update the Medical Assistance Disability Status field to “50-Temporary Disability”.
        • Select “P-Verification Pending” on the Medical Assistance Disability Verification field.
        • Enter a future date in the “End Date” and “Review Date fields.

NOTE:  The “Review Date” entered must be twenty-three months from the process date and the “End Date” must be two years from the process date. The CAO may need to update the dates in the “End Date” and Review Date” fields at renewal if the medical documentation is still not provided and the child continues to qualify for non-disability related MA or CHIP.

• • • • • Review the case record at renewal, to see if the family provided the requested medical documentation for MRT.
        • If the requested medical documentation is in the case record, then transition the child to the appropriate MA category and complete an MRT referral.
        • If the requested medical documentation is not in the case record, then maintain the Disability screen as described above and evaluate the child for CHIP at the child’s next renewal unless the child is eligible for MA in a non-disability related category, such as MAGI.

Important: If the child is not eligible for non-disability related MA or CHIP and would be eligible for disability related MA if the family provided medical documentation needed for the MRT review process, then the CAO will update the Disability screen as follows at the child’s next renewal:

• • • • • •  Update the Medical Assistance Disability Status to “51-Permanent Disability”
          • Select “P- Verification Pending” on the Medical Assistance Disability Verification field.
          • The PH-00(D) will fail non-financially and the CAO must issue an 042-closure notice to the individual for the child.

• • • • If the MRT returns a completed form which indicates the child is not certified disabled, then access the DAP record through the DAP Functions module and data enter the MRT Decision and Final MRT Decision Date. The DAP record will close and the “DAP 252 - MRT Certification Decision Not Received” alert will clear. The “Not Certified”decision and Decision Date that were data-entered in the DAP Functions module will be automatically updated on the Disability screen in CP. A “DAP 250 - Review and Run Eligibility” alert will be generated    and assigned to the caseworker maintaining the case. The disability should be end-dated, and the child should be evaluated for other MA. If the child is not eligible for other non-disability related MA, they will be transitioned to MG 18 with target type “C” until the child’s next renewal.

Updated March 24, 2025, Replacing April 12, 2018