Eligibility for Children with Special Needs ends when:
The child no longer meets disability requirements.
The child moves permanently out of state.
The child attains their 18th birthday.
The CAO will review eligibility for other MA programs and generate the appropriate advance or confirming notice informing the parent or representative of the child the reason for ineligibility. Chapter 377, Notices.
When PH 95 eligibility ends because the child turns age 18, the CAO will take the following steps to determine continued MA eligibility:
1. Maintain the 18-year-old in PH95 for up to 90 days.
2. Send the individual an Employability Assessment Form (PA 1663) to be completed by a physician to validate continued disability. The CAO will create a case change additional work item to review the case at 30 days for receipt of the disability verification. If the individual requests more time to obtain the disability verification, then the CAO will create a new case change additional work item to review the case again in 30 days.
NOTE: If verification of disability is not returned within 90 days, the CAO will review eligibility for other non-disability MA categories.
3. Authorize the individual in PH00-D (Healthy Horizons) upon receipt of the PA 1663 or other disability documentation indicating the individual may meet SSA disability adult criteria. Refer the individual to DAP via an SSA DAP referral for the disability determination and to track the pursuit of federal benefits. CAO DAP staff can provide assistance to the individual with applying for Social Security benefits, if needed.
NOTE: SSA will use the adult disability definition and standards to determine SSI eligibility.
4. Complete an MRT referral for a determination of disability if the individual applies to SSA and is found ineligible for SSI benefits for a reason other than disability or does not follow through with pursuing SSA benefits and SSA has not rendered a final disability determination of “not disabled”.
Important: If a child was previously certified as disabled by the MRT before their 18th birthday, a new MRT determination must be completed to verify the disability condition meets the SSI disability criteria for an adult.
Exception: A new MRT certification is not needed when a child was certified disabled by MRT using adult criteria and there is no reported change in their medical condition. Adult criteria may be used to determine disability for a child who is within a few months of turning 18.
55 Pa. Code § 140.311(b)(2)(ii)(A)
5. Authorize presumptive eligibility until the disability decision from SSA or MRT is made. If the individual does not meet disability criteria for Healthy Horizons, review eligibility for all other non-disability related MA categories prior to closing PH00.
NOTE: If the individual is under age 19, is within their 12-month certification period, and does not qualify for any other non-disability related MA category, then the individual will transition to MG 18 target type “C” until their next renewal or until they are re-evaluated after their 19th birthday whichever is first.
Updated March 24, 2025, Replacing April 12, 2018