The CAO will decide on continuing eligibility for six calendar months in a row beginning with the first day of the month in the retroactive period. If there is no retroactive period, the period begins with the month of application or the following month if increased income in the month of application leads to ineligibility. The six-month period may include up to three retroactive months.
Note: When it receives an application for MA, the CAO will decide whether there is a need for MA coverage in the retroactive period.
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 individual 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 an individual cannot work because they are sick or injured, the individual can meet this rule by proving that he or she will be going back to 100 hours a month of work after getting better.
The applicant/recipient group is eligible for continuing MNO when its total net income for the six-month period is equal to or less than the six-month MNO income limit in Appendix A. If the group is eligible, the CAO will open MNO with a renewal date for the last calendar day of the twelfth month. A SAR is needed every six months to decide whether the group is eligible for continuing MA.
Note: The MNO limit is based on the number of people in the applicant/recipient group, including the unborn child(ren) of a pregnant woman. The pregnancy must be confirmed.
If it looks as though an applicant/recipient group is not eligible for continuing MNO because of higher income in the month of application and that income is not expected to continue, the CAO must decide on eligibility for a six-month period beginning the first day of the calendar month following the month of application.
The six-month period of continuing eligibility for MNO begins with the earliest retroactive month, the date of application, or the date on which eligibility is set.
The date of application is one of the following:
The date on which the CAO receives and date stamps a signed application.
The date on which the application is put into COMPASS.
The earliest date the application is signed by the applicant, if an MA provider submits the application.
The date of the first admission or treatment, if a COMPASS application is submitted by a provider.
Example: An MA provider submits a COMPASS application for a patient on 3/17. The first date of admission was 2/12. MNO eligibility would begin on 2/1.
The date eligibility is set is one of the following:
The date the applicant meets all conditions of eligibility
Examples:
Mr. Duncan signs an application for MA for himself and his daughter on July 1. The CAO receives the application on July 8. At that time, Mr. Duncan is unable to prove his income. On July 14, he turns in all information needed to show that he was eligible on the date of application. The CAO authorizes MA effective July 8.
Mr. and Mrs. Walsh submit an application for MA through the mail. The CAO receives and date stamps the application on November 2. On November 5, Mr. Walsh turns in proof. The Walsh's meet all conditions for MNO except that their resources are $596 over the limit. On November 10, Mr. Walsh proves that the amount over the limit was used to buy a stove on November 9. Eligibility for MA begins November 9, the date the Walsh's resources dropped below the limit.
Note: If the excess resources are used to pay a medical expense, eligibility begins on the first day of the month of application or the first day of the month for which retroactive coverage was needed.
The first day of the month after the month of application, if:
The applicant/recipient group is not eligible in the month of application.
The applicant/recipient group meets all requirements on the first day of that month.
The six-month continuing eligibility period for MNO ends on the last calendar day of the sixth calendar month. The first month of eligibility for MNO is the first month of the six-month period.
When the CAO decides on eligibility for continuing MNO, it must ask the client about any changes in income or other situations that may take place during the six-month period. If a change in income is expected, the CAO will include the change when figuring the six-month income; if not, the CAO must create an alert to review eligibility when the change is expected to take place. Changes in other situations include, but are not limited to, a pregnant member returning to work, a child graduating from high school and planning to join the Army and a child turning 21.
The applicant/recipient group is eligible if its total countable resources are equal to or less than the resource limit. ( Chapter 340, Resources.)
An applicant/recipient group becomes ineligible for MNO on the date its total countable resources go over the limit. The group becomes eligible again on the date its resources drop to within the limit.
Example: The CAO receives and date stamps an application for MA on September 3. The CAO finds that on September 3, the resources are more than the limit. On September 7, the applicant proves that she lowered her resources below the limit on September 5, when she paid some household bills. If all other conditions are met, MA eligibility begins September 5.
When resources are over the limit, the CAO must give the individual the choice of using the excess resources to pay any unpaid medical expenses. If the individual chooses this option, they must prove that: 55 Pa. Code § 178.1(j)
They used resources to pay for medical expenses from the continuing eligibility period or at any time before the date they are asking for MA coverage to begin.
A member of the applicant/recipient group was legally required to pay for the expense.
Any excess resources used to pay medical expenses have no effect on resource eligibility for continuing or retroactive MA (NMP or MNO). The CAO must treat the excess as if it never existed.
Note: The amount used to pay unpaid medical expenses can be used as a paid medical expense for continuing MNO.
The CAO will decide on continuing eligibility for the period of six months in a row beginning the calendar month of application, the first month of the retroactive period, or the next month, if higher income in the month of application leads to ineligibility.
The CAO will count the applicant/recipient group's income and allowable deductions as follows:
If there is no retroactive period:
Count the actual proven income and expenses from the first day of the month of application.
Note: A single pay stub can be used as proof of income if it is representative of their income.
If the income is received once a week or once every two weeks, find the average weekly amount and multiply it by four to receive the monthly amount.
Multiply the monthly amount by six, unless it is not expected to last the entire six-month period.
If there is a retroactive period:
Count the actual proven income and expenses from the first calendar month of the retroactive period.
Note: If the retroactive period starts in the month of application, estimate future income and expenses. A single pay stub can be used as proof of income if it is representative of their income.
If the income is received once a week or once every two weeks, find the average weekly amount and multiply it by four to receive the monthly amount.
Multiply the monthly amount by six, unless it is not expected to last the entire six-month period.
The CAO will count the income separately for each month in which changes are expected.
The CAO will count only the income that is expected in the six-month period. If a source of income is expected to stop during the six-month period, the CAO will not count it in months after it stops.
Example: The CAO will count income from unemployment compensation (UC) benefits for only the weeks that a individual is expected to receive it. The CAO must create an alert to find out whether UC benefits are extended after that time.
If the applicant/recipient group's net income is more than the MNO six-month limit in Appendix A, the CAO may lower the net income more by allowing deductions for certain paid and unpaid medical expenses. (See Section 369.431, Continuing MNO Spend-Down.)
The CAO will count the actual or expected income the applicant/recipient group will receive during each calendar month of the six-month period. The CAO will figure net income by allowing the following deductions from the countable gross income of each member:
For TANF-Related categories, including a TD parent or stepparent of a TANF, SSI or MA child:
Unearned income expenses.
The actual earned income work and individual expenses paid by the client, with a minimum of $120 a month.
The earned income incentive deduction, if the member qualifies for it.
Actual dependent care expenses that are paid while a individual is working.
Example:
Ms. Ross pays $150 a week for child care while she works and goes to college part-time. The babysitter cares for her child nine hours a day, five days a week, while she works. She also cares for the child five hours a week while Ms. Ross goes to college. Child care is provided for a total of 50 hours a week. Child care is provided for 45 hours while Ms. Ross works. The total hourly rate is figured as $3 an hour ($150 divided by 50 hours). The total allowable child care expense is $135 a week (45 hours times $3 an hour).
Note: Use the stated expense without proof if the expense seems reasonable for the situation. If the expense seems unreasonable, ask for proof.
For GA-related categories:
Unearned income expenses.
The actual earned income work and individual expenses paid by the client (no maximum or minimum).
The earned income incentive deduction, if the member qualifies for it.
Actual dependent care expenses that are paid while a individual is working.
Example: Ms. Mathews pays $150 a week for child care while she works and goes to college part-time. The baby-sitter cares for her child nine hours a day, five days a week, while she works. She also cares for the child five hours a week while Ms. Mathews goes to college. Child care is provided for a total of 50 hours a week. Child care is provided for 45 hours while Ms. Mathews works. The total hourly rate is figured as $3 an hour ($150 divided by 50 hours). The total allowable child care expense is $135 a week (45 hours times $3 an hour).
Note: Use the stated expense without proof if the expense seems reasonable for the situation. If the expense seems unreasonable, ask for proof.
Unearned income expenses.
The $20 unearned or earned income deduction, up to $20 for each applicant/recipient group each month.
Note: If there is no unearned income or if there is less than $20 in unearned income, the rest of the deduction is taken off of any earned income.
The earned income incentive ($65 plus 50% of the amount left over), including a deduction for an employed, disabled member to pay impairment-related work expenses.
Note: For SSI-related categories, the employed member does not have to qualify for the incentive. The earned income incentive is always allowed.
The actual expenses of an employed blind individual in the group that are related to earning his or her income
Note: For more information, see Chapter 361, MNO Deductions.
If the applicant/recipient group's expected six-month income is more than the MNO limit in Appendix A, the CAO may lower the net income by deducting medical expenses. See Section 361.5, Medical Expense Deductions, for information on what medical expenses may be deducted. The CAO must deduct only the following:
Expenses that were paid in the first calendar month of application or renewal.
Unpaid expenses that were already charged or that are expected to be charged in the six-month period.
If the TANF-related or GA-related applicant/recipient group includes a member who is employed and who qualifies for the earned income incentive, the CAO must deduct medical expenses after applying the incentive.
Note: The CAO will always apply the earned income incentive to the earnings of an individual receiving SSI-related MNO.
The CAO will deduct only the part of allowable medical expenses needed to lower the net income to the monthly MNO limit. Once an expense is used to approve MNO, the expense may not be used again.
Note: The part of an unpaid expense that is not used may be used in a future decision of MA eligibility if it is in the allowable retroactive period.
The applicant/recipient group is eligible for continuing MNO if its net income, after spend-down of medical expenses, is equal to or less than the six-month MNO income limit Appendix A.
The CAO will decide on continuing MNO eligibility for a six-month period. The renewal date should be the last calendar day of the twelfth month, with a partial renewal (SAR) every six months to decide on continuing eligibility.
Exception: Category TD is a six-month renewal (SAR).
Important: If possible, the CAO must decide whether the applicant/recipient group needs retroactive medical coverage. If MA is approved for a retroactive month, the member is considered a recipient in that month when deciding on eligibility for the incentive. Eligibility for MNO is decided on by using a period of six months in a row, which may include the retroactive months.
The CAO will decide on income eligibility as follows:
1. Decide on the category of MNO for each client. (See Chapter 305, Category.)
2. Decide who is in the applicant/recipient group. (See Chapter 310, Applicant/Recipient Groups.)
Reminder: Include any unborn children if pregnancy is confirmed.
3. Figure out the amount of countable gross earned and unearned income available to the group in each calendar month of the six-month period. (See Chapter 350, Income.)
Note: If cash assistance benefits will be received, the income must be included as unearned income in the combined retroactive/continuing period.
4. Deduct allowable unearned and earned income deductions to figure the net income for each calendar month of the six-month period. (See Chapter 361, MNO Deductions.)
Note: SSI-related clients with earned income always receive the incentive.
5. Add the net income for the six-month period.
6. Compare the total net income with the six-month MNO income limit in Appendix A.
If the net income is equal to or less than the limit, approve MNO to cover the six-month period.
If the net income is over the limit, decide whether the applicant/recipient group has any medical expenses that can be used to spend down the net income. (See Section 361.5, Medical Expense Deductions, for information about deducting medical expenses.)
7. Deduct allowable medical expenses. Deduct unpaid expenses, including expenses that the applicant/recipient group expects in the six-month period. Deduct expenses paid in the month of application or renewal or any of the three calendar months before that.
Note: Deduct expenses paid after the month of the renewal due date if a renewal has not been completed on a timely basis.
8. Compare the total countable net income, after medical expense deductions, to the six-month MNO income limit in Appendix A.
If the net income is equal to or less than the limit, approve MNO to cover the six-month period. Go to step 10.
If the net income is over the limit, decide whether the applicant/recipient group is eligible with a patient pay liability. Go to step 9.
9. Use the patient pay liability rules in Section 369.13 to decide whether the applicant/recipient group has enough medical expenses to qualify for MNO with a patient pay liability.
If the expenses are less than the excess income, do not approve MNO.
If the expenses are equal to or more than the excess income, approve MNO with a patient pay liability to cover the period of eligibility.
10. Send a notice to applicant letting the applicant/recipient group know of eligibility or ineligibility and the amount of any patient pay liability. Send a copy of the notice to applicant to each provider to whom the individual must make a patient pay.
Examples:
On August 6, Mr. and Mrs. King apply for MA for themselves and their twin sons, age 16. Mr. King was employed as a truck driver, but he has been unable to work since February 10 because of a back injury. The injury was not work related. His doctor has recommended that he have surgery within the next several months. His insurance will not cover the entire cost of the surgery.
Mr. King receives $300 a week from his employer's insurance. Mrs. King is employed at Weis Market. Based on her paychecks for the last 30 days, she earns an average of $180 a week. The twins have no income. The King's have unpaid medical bills. They also have several medical bills from the retroactive period. They prove the following paid medical expenses:
|
5/18 |
Oral surgery (Mrs. King) |
$5,100 |
|
6/10 |
Dental expenses |
1,000 |
|
7/20 |
Eye exam and glasses for son |
110 |
|
7/25 |
Eyeglasses for son |
+130 |
|
|
Total expenses |
$6,340 |
The CAO decides that the King's do not qualify for Healthy Beginnings or NMP. Mr. and Mrs. King and their sons qualify for category TU. The CAO decides on eligibility for MNO as follows:
Net income eligibility without medical expenses or the incentive, August–January
|
Mr. King’s gross unearned income, averaged (300 × 4) |
$1,200 |
|
|
|
Unearned income deductions |
-0 |
|
|
|
Mr. King’s net income |
$1,200 |
|
|
|
6 months |
×6 |
|
|
|
Mr King’s. total net income |
$7,200 |
|
$7,200 |
|
Mrs. King’s gross earned income |
$720 |
$720 |
|
|
Earned income deductions: |
|
|
|
|
Payroll deductions ($55/week × 4) |
$220 |
|
|
|
Transportation ($12/week × 4) |
48 |
|
|
|
Car payment ($85/month) |
+30 |
|
|
|
Averaged work and individual expenses |
$298 |
-$298 |
|
|
Mrs. King’s net income |
|
$422 |
|
|
Six months |
|
×6 |
|
|
Mrs. King’s total net income |
|
$2,532 |
+$2,532 |
|
Total net income for six months |
|
|
$9,732 |
|
Six-month MNO income limit (4 individuals) |
|
|
$3,400 |
The King'.s are unable to qualify for MNO without medical deductions.
Net income eligibility without the incentive
|
Total net income |
$9,732 |
|
Total allowable medical expenses |
-6,340 |
|
Net income |
$3,392 |
|
Six-month MNO income limit (4 individuals) |
$3,400 |
The King's are eligible for MNO without the earned income incentive. Only $6,332 of paid medical expenses will be used to lower the income to the MNO limit of $3,400.
Mr. Burns, age 68, and his wife, age 65, apply for MA when both are admitted to the hospital. Mrs. Burns signs the application on February 15, the date of admission. Both receive Social Security benefits. Mr. Burns receives $620 a month, and Mrs. Burns receives $550 a month before the Medicare deduction. They prove the following paid and unpaid medical expenses:
|
Unpaid medical bill from 11/12 |
|
$2,704 |
|
Unpaid medical bill from 1/15 |
|
+2,485 |
|
Total unpaid medical bills |
|
$5,189 |
|
Paid doctor bills: |
|
|
|
2/1 |
$20 |
|
|
2/8 |
35 |
|
|
2/10 |
20 |
|
|
2/10 |
30 |
|
|
2/14 |
+110 |
|
|
|
$215 |
|
|
Paid prescriptions |
+$260 |
|
|
Total paid medical bills |
$475 |
+$475 |
|
Total medical expenses |
|
$5,664 |
Mr. and Mrs. Burns do not qualify for Healthy Horizons or NMP spend-down.
Net income eligibility, February–July
|
Gross earned income |
$1,370 |
|
Unearned income exclusion |
-20 |
|
Net unearned income |
$1,350 |
|
Six months |
×6 |
|
Net six-month income |
$8,100 |
|
Six-month income limit |
-2,650 |
|
Excess income |
$5,450 |
Mr. and Mrs. Burns do not qualify for MNO without considering medical expenses. The CAO decides that the Burns are eligible for TA, effective February 1. The CAO uses only the part of medical expenses needed to make them eligible for MNO. The CAO uses $475 of paid expenses and $4,975 of unpaid expenses. Unpaid expenses of $214 can be used for future eligibility decisions if the expenses meet all of the conditions for an unpaid medical expense.
Updated February 14, 2012, Replacing December 24, 2008