Revised 2024 Federal Poverty Income Guidelines (FPIGs), PMA-21620-319 (Revised February 28, 2024, published January 26, 2024)
2023 Federal Poverty Income Guidelines, PMA-21203-319 (Published January 31, 2023)
2022 Federal Poverty Income Guidelines, PMA-20752-319 (Published January 31, 2022)
2021 Federal Poverty Income Guidelines, PMA-20304-319 (Published January 29, 2021)
2020 Federal Poverty Income Guidelines, PMA-19743-319 (Published January 31,2020)
Healthy Horizons eligibility and applying for potential Social Security income, PMA-18376-319 (Published June 21, 2018)
No MG 91 and MG 90 Eligibility for Individuals Entitled to Medicare, PMA-18053-312 (Published June 7, 2016)
Medical Assistance Program Changes due to the Introduction of Enhanced Federal Medical Assistance Percentage, OPS160305 (Published March 10, 2016)
Healthy Horizons (HH) provides benefits to individuals who are:
Age 65 or older
Disabled according to Social Security Administration
(SSA) disability rules. This includes children under age 21. (See
Section
319.2, Determining Disability.)
Healthy Horizons benefits include the following:
55 Pa. Code § 140.201(a)
55 Pa.
Code § 140.331(a)
HH Categorically needy benefits.
Benefits provide Nonmoney Payment (NMP) Medical Assistance (MA) and Buy-In of Medicare Part A and/or Part B premiums if the individual is eligible for Medicare. (See Chapter 305 for category and program status codes.)
NOTE: PH/80 is used to identify people with Medicare to enroll in Buy-In. PH/00 identifies those who are presumptively eligible or who do not have Medicare coverage.
An elderly or disabled individual meets the income requirements for HH categorically needy benefits if:
The total net countable income of the Healthy Horizons family is 100 percent of the Federal Poverty Income Guidelines (FPIGs) or less.
55 Pa. Code § 140.201(a) 55 Pa. Code § 140.231(a)
The total countable resources of the Healthy Horizons family are the same as the SSI resource limit or less.
Exception: Resources are excluded for a Healthy Horizons applicant or recipient under age 21 and for a Healthy Horizons applicant or recipient with a natural or adoptive child under age 21 who is living in the home. This exclusion also applies to a Healthy Horizons applicant or recipient with a child under age 21 if the individual has care and control of the child.
HH
Cost-sharing benefits.
Benefits provide for Buy-In of Medicare Part A and/or Part B premiums and the payment of Medicare deductibles and coinsurance by the( Department of Human Services (DHS). (See Chapter 305 for category and program status codes.)
55 Pa. Code § 140.201(b) 55 Pa. Code § 140.301(b)
An elderly or disabled individual meets the resource and income requirements for HH cost-sharing benefits if:
The individual is eligible for Medicare Part A and/or Part B.
The total countable resources of the Healthy Horizons couple are twice the SSI resource limit or less (see the preceding exception).
55 Pa. Code § 140.201(b)&(c) 55 Pa. Code § 140.301(b)
The total net countable income of the Healthy Horizons family is 100 percent of the FPIG or less.
Individuals with income and resources above the Healthy Horizons limits must be considered for eligibility in one of the following Medicare Savings Program (MSP) groups:
Specified Low-Income Medicare Beneficiaries (SLMBs)
Benefits provide for the Buy-In of the Medicare Part B premium for an elderly or disabled individual whose income is greater than 100 percent and less than 120 percent of the FPIGs. (See Chapter 305 for the category and program status codes.)
55 Pa. Code § 140.331(c) 55 Pa. Code § 140.201(d)
An elderly or disabled individual meets the resource and income requirements for SLMB benefits if:
He or she is eligible for and receiving Medicare Part A.
Total net countable resources is within resource limits. For SLMB resource limits see 319, Appendix B.
NOTE: The MA resource exclusion for children or spouses under age 21 does not apply to SLMBs.
The individual’s total net countable income is greater than 100 percent and less than 120 percent of the FPIGs.
NOTE: SLMBs may also be eligible for NMP or MNO benefits.
Individuals who are eligible for Medicare and Long-Term Care services under NMP (whether in a Long-Term Care Facility or in the Community) and who have (a) resources that are equal to twice the SSI resource limit or less and (b) income greater than 100 percent and less than 120 percent of the FPIG, are eligible for Buy-In of the Medicare Part B premium as an SLMB.
Individuals who are eligible for MNO receive MNO benefits and Buy-In of the Medicare Part B premium. Eligibility is determined according to the MNO rules in Chapter 369, Determining Eligibility For MNO.
NOTE:
The resource exclusion for children or
spouses under 21 does apply to individuals who are eligible for both MNO
and NMP (for example, PW 66, PAW 66, and TA 66).
Qualifying Individuals Group-1 (QI-1).
55 Pa. Code § 140.201(e) 55 Pa. Code § 140.331(d)
Benefits provide for the Buy-In of the Medicare Part B premium for elderly or disabled individuals whose income is at least 120 percent but less than 135 percent of the FPIG.
An elderly or disabled individual meets the resource and income requirements for QI-1 benefits if:
He or she is eligible for and receiving Medicare Part A.
Total net countable resources is within resource limits. For QI-1 resource limits, see 319, Appendix C.
The total net countable income is at least 120 percent but less than 135 percent of the FPIG.
55 Pa. Code § 140.231(c) 55 Pa. Code § 140.201(e)
NOTE: QI-1s cannot be eligible for other MA benefits.
NOTE: QI-1s are not considered MA applicants or recipients, because the only benefit they receive is the payment of their Medicare Part B premiums. The MA resource exclusion for children or spouses under 21 does not apply to QI-1s.
The CAO will determine eligibility for Healthy Horizons, SLMB, and QI-1 benefits using the requirements listed in this chapter and the following chapters:
NOTE: The CAO may accept the Social Security
Administration’s MSP Model Application as an application for the Medicare
Savings Program (MSP) also known as Buy-In. The date the CAO
receives the Model Application is considered the date of application. The
CAO may need to contact the individual for additional information that
has not been provided on the Model Application.
NOTE: The individual must report
changes in earned income of more than $100 and of any amount for unearned
income. However, if the individual reports a change in earned income of
$100 or less, the CAO will not take any action.
An elderly or disabled individual who is eligible for Healthy Horizons categorically needy benefits receives the following:
A Pennsylvania ACCESS card to show to medical providers when obtaining medical services.
Payment
of the Medicare Part A premium, if the individual is enrolled in and
paying Part A.
NOTE:
Most people receive Part A coverage without having to pay
a monthly premium. This is because they or a spouse
paid Medicare taxes while working.
Payment
of the Medicare Part B premium.
NOTE: A individual is eligible for Medicare if he or she:
Is age 65 or older.
Is under age 65 and receiving Social Security disability benefits, and 24 months have gone by since he or she was determined to be disabled by the Social Security Administration.
Is eligible for Medicare Part A because of End-Stage Renal Disease. (End-Stage Renal Disease is permanent kidney failure requiring dialysis or a kidney transplant.)
Payment of Medicare A and B deductibles and coinsurance.
An elderly or disabled individual who is eligible for Healthy Horizons cost-sharing benefits receives the following:
Payment of the Medicare Part A premium, if the individual is enrolled in and paying Part A.
Payment of the Medicare Part B premium.
Payment of Medicare A and B deductibles and coinsurance charges.
A
Pennsylvania ACCESS card to show to medical providers to pay for deductibles
and coinsurance charges only.
NOTE: The Healthy Horizons Cost-Sharing Health Care Benefit package includes only the benefits listed above. It does not include other MA benefits.
NOTE:
CAOs should tell Healthy
Horizons cost-sharing applicants and recipients that they may be able
to get prescription coverage through the Pharmaceutical
Assistance Contract for the Elderly (PACE) program.
The DHS will pay the Medicare premiums beginning with the month in which the individual is determined eligible for Healthy Horizons or Healthy Horizons cost-sharing. If the applicant or recipient becomes eligible for Medicare after Healthy Horizons or HH cost-sharing eligibility begins, the DHS will pay the premium beginning in the month the individual becomes eligible for Medicare.
An elderly or disabled individual who is eligible for Specified Low-Income Medicare Beneficiaries (SLMB) benefits receives the following:
Payment of the Medicare Part B premium, if the individual is enrolled in or eligible for Medicare Part A.
An elderly or disabled individual who is eligible for SLMB benefits and is eligible for MA benefits under MNO or NMP receives the following:
Payment of the Medicare Part B premium.
MNO or NMP MA benefits.
Pennsylvania ACCESS card to present to medical providers when obtaining medical services for MNO or NMP benefits.
An elderly or disabled individual who is eligible for QI benefits receives the following: 55 Pa. Code § 140.331(d)
Payment
of the Medicare Part B Premium, if the individual is enrolled in or
eligible for Medicare Part A.
NOTE:
The CAO must tell the Pure SLMB or QI applicant or recipient
that he or she may be able to get prescription coverage through the Pharmaceutical
Assistance Contract for the Elderly (PACE) Program.
NOTE:
CIS/e-CIS
will not automatically issue an ACCESS card to an SLMB or QI applicant
during the initial CIS authorization process. The CAO cannot issue a replacement
ACCESS card to an SLMB. The individual may have an ACCESS card from an
earlier period of MA eligibility. If an SLMB or QI recipient presents
an ACCESS card to a provider
to verify eligibility, the provider will receive an ineligible response
message from EVS.
The DHS will pay the Medicare Part B premium beginning
with the month the eligibility determination is made. SLMB
and QI coverage may be retroactive for up to three months. The
CAO must ask the individual if he or she wants retroactive payment of
the Medicare Part B premium.
NOTE: For more information, see Chapter 388, Buy-In and “Using IEVS – Chapter 10, Exchange 7 – Buy-In.”
The CAO will verify the following:
The age of an individual who is 65 or older
Medical verification of disability and a pending application for a disability that must be reviewed by the SSA or DHS’s Medical Review Team (MRT) for an individual under age 65 who is not currently receiving Social Security Disability Benefits.
55 Pa. Code § 140.311(b)(1) 55 Pa. Code § 140.311(a)(2)
The
individual’s participation in Medicare for Healthy Horizons cost-sharing,
SLMB, or QI benefits (The individual’s Medicare card or other proof
from the SSA can be used.)
The CAO must not deny eligibility of an individual who cooperates in providing information.
Updated August 30, 2018, Replacing July 6, 2018