When deciding on an individual's eligibility for Medical Assistance (MA), the County Assistance Office (CAO) will look at the medical needs of each member of the applicant/recipient group. If the whole applicant/recipient group is ineligible for Nonmoney Payment (NMP) and Medically Needy Only (MNO) benefits, the CAO will consider eligibility for the member or members who have the most need for medical coverage.
Reminder: After closing TANF, the caseworker will complete a review for NMP or Extended Medical Coverage (EMC) or automatic medical coverage extension (because of support) before considering the case for MNO.
The CAO must let the individual know about the choices for including individuals in the applicant/recipient group. The CAO will decide on eligibility for NMP, including NMP spend-down, before applying the rules of this chapter. If an applicant/recipient group that is receiving MNO becomes eligible for NMP, the CAO will close MNO and approve NMP.
The CAO will allow the individual to pick the MA program that best meets their medical needs, even though the individual may be eligible for more benefits under a different program.
Example: An individual who is eligible for GA-related NMP may choose to receive GA-related MNO to cover a retroactive hospital bill or to save the four months of GA-related NMP incentive eligibility for a future period.
The CAO will decide on MNO eligibility by using the countable actual and expected income and resources available to the members of the applicant/recipient group.
The applicant/recipient group may choose to apply for either retroactive months only, continuing months only, or a combination (limited to six calendar months).
The CAO will decide on MNO eligibility for six calendar months in a row. The income for each month in the semiannual period will either be:
The actual income for the month.
If the income is received once a week or once every two weeks, the average income for those weeks multiplied by four.
The CAO will use an averaged weekly amount to estimate the income for the rest of the six-month eligibility period.
The renewal date should be the last calendar day of the twelfth month, with a partial renewal (semiannual reporting, or SAR) every six months to decide whether the group is eligible for continuing MA.
Note: The TD category is enrolled in SAR, which covers the complete renewal that is due every six months.
Reminder: For individuals age 21 through 58 in a GA-related MNO category (TD) whose eligibility is based on having a job, past, present and continuing work will be looked at to decide whether the recipient is meeting the 100 hours a month work rule. The individual must meet this rule in each month of the six-month eligibility period. If a individual cannot work because they are sick or injured, the individual can meet this rule by proving that they will be going back to 100 hours a month of work after getting better.
55 Pa. Code § 141.81(c)(v)(a)(III)
Important: The income eligibility period can be less than six months only if the individual has died. The period of eligibility for someone who has died begins on the first day of the first retroactive month for which coverage is requested and lasts through the date of death. Any income that the individual got during the eligibility period is counted, and any income received by a Legally Responsible Relative (LRR) during the period is deemed.
When an individual reports a change in resources, income, or other situation, the CAO must decide whether the change affects the recipient’s eligibility. The CAO must figure out eligibility again for each calendar month affected by the change. If the change takes place during the six-month continuing eligibility period, the CAO must decide on the recipient's eligibility for that six-month period.
Note: An individual must report changes in earned income of more than $100 and of any changes more than $50 for unearned income. However, if the recipient reports any change in income, the CAO still must take action.
Note: Eligibility is affected for the remaining months of the six-month period. If the change is reported timely, there is no overpayment.
The following types of MNO benefits are available:
Retroactive MNO, including spend-down
Continuing MNO, including spend-down
Retroactive/continuing MNO, including spend-down
Long-Term Care (See the Long-Term Care Handbook for complete eligibility information.)
The CAO will decide on a recipient’s eligibility for the right category of MA. The categories are as follows:
TANF-related and GA-related: TC, TU, and TD
Reminder: For TD (MNO) when both parents of the child live in the household, an unmarried parent who is taking care of the child can receive MNO without using the income of the other parent.
SSI-related: the aged, blind, and disabled categories TA and TJ.
There is a different way of figuring out income for each category.
Exception: The CAO will use TC rules when deciding on eligibility for a TD parent or stepparent who is living with his or her child who receives TANF, SSI, or MA.
Medical expenses for or paid by a member of the applicant/recipient group are allowed as deductions for MNO. The CAO must deduct allowable medical expenses from net income when deciding on eligibility or patient pay liability.
55 Pa. Code § 181.12(c) 55 Pa. Code § 181.14(c)
Note: The CAO must not allow a deduction for medical expenses paid by an LRR whose income is deemed available. An unpaid medical expense for an LRR may be allowed if a member of the applicant/recipient group is legally responsible for payment of the expense.
Reminder: Under federal policy, medical and remedial care expenses that are paid by a public program (other than MA) of a state are to be deducted for spend-down.
The CAO will use proven medical expenses to decide on MNO eligibility when:
Deciding whether a TANF-related/GA-related category needs the earned income incentive deduction to qualify for MNO.
Deciding on retroactive or continuing MNO spend-down eligibility for TANF-related, GA-related, and SSI-related categories;
55 Pa. Code § 181.12(c)(2) 55 Pa. Code § 181.11(d)
Paid or unpaid medical expenses may be deducted. The CAO may use a paid expense if it is paid in the month for which eligibility is being considered or in any of the retroactive months. The retroactive months cannot begin before the first day of the third month before the month of application and ends the day before the date of application.
See Section 361.5, Medical Expense Deductions, for information about deducting medical expenses.
If the applicant/recipient group's net income, after all allowable deductions, is more than the MNO limit, the CAO will consider the amount that goes over the limit as available to pay for medical expenses. If the applicant/recipient group has unpaid medical expenses that can be paid for by the MA program, the extra amount may be treated as a patient pay liability.
The CAO will approve MNO with a patient pay liability for a medical expense if all of the following are true:
The expense is covered by the MNO program.
The expense is unpaid.
Note: If an individual applies for MNO in advance of a hospitalization or other medical service and his or her net income is more than the eligibility limit, the CAO will not approve MNO. It must let the individual know that he or she can reapply after the hospital bill or other expense is charged.
The amount of the expense is proven.
The total expense is more than the amount of income over the limit.
A patient pay liability may be set for the income eligibility period of six calendar months in a row. The CAO will commit the recipient to pay the amount above the limit by entering the amount on the notice to recipient and into the third-party liability (TPL) system. The CAO will approve MNO to pay for medical expenses that go over the amount of the liability.
The CAO will send a copy of the notice to recipient to the provider.
Note: If the CAO finds out that the income did not continue or was higher than expected, it does not need to figure out a new patient pay amount.
The patient pay liability may be used as an unpaid medical expense for future MA eligibility if it is used within the allowable retroactive period. The CAO must use the beginning date of eligibility as the date of the unpaid medical expense.
Example: On May 2, the hospital sends in an application dated April 26 for admission of Ms. Lewis on April 24. She was sent home on April 28. The CAO decides that Ms. Lewis is eligible for the combined retroactive/continuing period of April 1 thru September 30, with a patient pay liability of $100. The CAO completes the notice to recipient and enters the amount into the TPL system. The CAO can use the $100 as a deductible unpaid medical expense, if it remains unpaid, to decide on continuing eligibility if and when the individuals' situation changes.
Any amount of the patient pay liability that is paid in the month of application or the retroactive months is an allowable medical expense deduction.
Example: Mrs. Garcia applies for MA on June 1 for a hospital stay from April 27 through May 9. The CAO decides that Mrs. Garcia is eligible for the combined retroactive/continuing months of April 1 through August 31, with a patient pay liability of $700. The notice to recipient and the TPL data entry are completed to show that the $700 is owed to General Hospital. On June 17, Mrs. Garcia’s medical condition worsens, and she applies for MA again. Mrs Garcia pays the $700 patient pay liability and is eligible for MA on June 17, with the use of the paid $700 medical expense as a deduction.
At renewal, allowable paid expenses are those paid in the month of renewal only.
Example: The CAO authorizes MNO for Mrs.. Hoffman on June 1, with a patient pay liability of $500. In November, at renewal, Mrs. Hoffman shows a receipt to prove that she paid $500 to Harrisburg Hospital on November 2. The $500 paid in the month of renewal is used as a medical expense deduction.
Paid expenses that were already used for eligibility are not allowed.
Example: The CAO approves continuing MNO for Mrs. Campbell effective February 1, with a patient pay liability of $900. At renewal in July, Mrs. Campbell proves that she paid $300 on July 2. The CAO allows the paid amount, because it was not used as a paid expense for eligibility before.
Updated August 30, 2018, Replacing February 14, 2012