Section 141.81. Eligibility policy for Medically Needy Only

(a) Conditions of eligibility.

(1) To be eligible for MNO-MA, the person shall comply with the following:

(i) Meet financial and nonfinancial eligibility standards established by the Department and approved by the Governor and the appropriate conditions of eligibility set forth in the following chapters or sections:

(A) Chapter 147 (relating to residence).

(B) Chapter 149 (relating to citizenship and alienage).

(C) Chapter 161 (relating to persons in institutions).

(D) Chapters 177—179 and 181.

(E) Chapter 183 (relating to income).

(F) Section 175.84 (relating to procedures).

(G) Section 175.73(b) (relating to requirements).

(2) To be eligible for MA, the person shall supply evidence, as required, of the following factors:

(i) Chapter 145 (relating to age).

(ii) Dependent children (subsection (c)(3)(ii)).

(iii) Blind (subsection (c)(3)(iii)).

(iv) Permanent and total disability (subsection (c)(3)(iv)).

(3) To be eligible for MA, the person shall provide other information as is requested by the Department (subsection (b)).

(4) To be eligible for MA, the person shall sign forms.

(5) Chapter 183 (relating to income).

(6) Section 175.84 (relating to procedures).

(7) Section 175.73(b) (relating to requirements).

(8) Supply evidence, as required, of the factors peculiar to the following categories:

(i) Chapter 145 (relating to age).

(ii) Dependent children (subsection (c)(2)(ii)).

(iii) Blind (subsection (c)(2)(iii)).

(iv) Permanent and total disability (subsection (c)).

(9) Provide other information as is requested by the Department (subsection (b)).

(10) Sign forms.

(b) Social Security number. Applicants for or recipients of Medical Assistance will not be required to obtain a Social Security number. However, each client, other than those eligible for TD, will be requested to sign a consent form permitting the County Office to obtain a Social Security number for the individual.

(c) Other eligibility conditions and categories. Other eligibility conditions and categories are as follows:

(1) Federal participation in MA for the medically needy is limited to persons who meet certain definitive conditions. Therefore, as a condition of eligibility for MA, the client or person acting in his behalf must provide sufficient information about factors such as age, condition of the parent, visual acuity and disability, to permit a determination of the category of MA to which MA payments for his care can be assigned.

(2) Federal participation in MA for the medically needy is also limited, within the range of covered services, to payment for those services for which another resource for payment does not exist. Therefore, as a condition of eligibility for MA, the client or person acting in his behalf must provide sufficient information about potential medical resources such as health insurances, accident and indemnity coverages, and eligible status in other government programs, having medical benefits available to the client. This will permit payment responsibility for medical services rendered to recipients to be assigned to liable third party medical resources.

(3) The categories of MA and the eligibility conditions for them are set forth as follows. A decision that the client does not meet the definitive conditions for old age, dependent children, blind or permanent and total disability must be supported in the case record.

(i) Old Age Category (TA). This includes persons 65 years or older. A person shall meet the age requirement for the category on the first day of the month in which he has his 65th birthday.

(ii) Dependent Child Category (TC). A parent will be considered incapacitated during the period institutional medical care, hospital-home care or nursing services in the home are received. The suffix “E” will be added to the category symbols, such as TCE, to identify migrant worker applicant groups with children who are eligible for emergency MA services. This category applies to the following:

(A) Persons under 21 regardless of school attendance, marital status, or emancipation. A person shall meet the age requirement through the end of the month in which the 21st birthday occurs provided that the birthday falls on or after the third day of the month.

(B) Specified relatives as defined in § 151.42 (relating to definitions) age 21 or over who are living with a dependent child receiving MA. This includes the specified relatives of a child who is receiving SSI. For MA purposes, a dependent child is a child under 21 years of age, regardless of school attendance, with whom the relative is living, and who is deprived of parental support by reason of the death, continued absence, or physical or mental incapacity of a parent, or by the unemployment of the principal wage earner. Reference should be made to § 153.44(d) (relating to procedures) for procedures relating to the unemployed principal wage earner, for determining whether a parent is considered to be in that category. Determinate conditions apply except that the unemployed principal wage earner is not required, as a condition of eligibility for MA, to register for work related training or employment.

(iii) Blind Category (TB). This category applies to a person 21 years or older but under 65 who meets any of the following criteria:

(A) A recipient of SBP.

(B) Has both eyes missing.

(C) Pregnant women.

(iv) Permanent and total disability category (TJ). This category applies to a person 18 years of age or older but under 65 who is permanently and totally disabled, a person with a disability who is receiving Social Security disability benefits who has been referred to the SSA for a determination of eligibility for SSI disability benefits or a person under review for a disability by the Department based upon Social Security disablity criteria. For MA purposes, a person will be considered permanently and totally disabled under the following circumstances:

(A) A person currently eligible for Social Security disability benefits as a disabled person. No further evaluation will be needed nor must the Review Team rule on the matter. However, substantiation that the person is currently eligible for Social Security benefits as a disabled person will be required.

(B) A person determined to be permanently and totally disabled on the basis of medical and social findings as specified in subsection (e)(4)(i).

(C) A disabled person who is a former applicant or recipient whose Disability Certification is still valid as specified in § 133.84(b) (relating to MA redetermining eligibility procedures).

(D) A person in a State school and hospital for the mentally retarded determined to need skilled nursing care or intermediate care as specified in subsection (e). The review team rules on permanent and total disability and makes the final decision on eligibility for skilled nursing or intermediate care.

(v) General Category (TD). Category TD will be treated as follows:

(A) This category is financed by Commonwealth funds only. It applies to persons who do not meet the conditions for the Federally-aided categories of MA (TA, TC, TB, TD (migrants or refugees), TU or TJ) and meet one of the following conditions:

(I) A custodial parent of a dependent child under 21 years of age.

(II) A person 59 years of age or older.

(III) A person who verifies employment of at least 100 hours per month earning at least the minimum wage. For persons whose eligibility is based upon the work requirement, past, present and continuing employment will be evaluated to determine compliance with the 100 hours per month requirement. If an episode of illness or injury is the reason for the interruption of work and it is verified that 100 hours per month employment will resume subsequent to recovery from that illness or injury, the applicant will be considered to have met the work requirement.

(B) The suffix ‘‘E’’ will be added to the category symbols, that is, TDE, to identify migrant workers eligible for emergency MA services.

(d) Eligibility conditions for disabled persons. Eligiblity conditions for disabled persons will conform with the following:

(1) General. A disabled person eligible in all other respects will receive Medical Assistance (Category Symbol TJ) if he meets the conditions set forth in this subsection.

(2) Permanent and total disability. A person is ‘‘permanently and totally disabled’’ if he has a disability which meets the conditions as specified in this section.

(i) Permanent disability. The elements of permanent disability are as follows:

(A) ‘‘Permanent disability’’ means a physical or mental impairment that is substantiated by a medical diagnosis and which is not likely to improve or which will continue the lifetime of the individual.

(B) ‘‘Blindness’’ exists if central visual acuity with best correcting lens is 20/200 or poorer in the better eye.

(C) Alcoholism and drug addiction, like other anatomical, physiological or psychological abnormalities which meet the criteria set forth in this paragraph are permanent disabilities.

(ii) Total disability. The elements of total disability are as follows:

(A) ‘‘Total disability’’ means inability to engage in substantial gainful activity that exists in the community.

(B) ‘‘Substantial gainful activity’’ is work of a nature generally performed for remuneration or profit, involving the performance of significant physical or mental duties, or a combination of both.

(e) Determination of permanent and total disability. The determination of permanent and total disability will be in accordance with the following:

(1) No further finding of disability will be necessary for a person in a State school and hospital for the mentally retarded for whom the need for skilled nursing care or intermediate care has been determined.

(2) The review team will rule on total and permanent disability and will make the final decision regarding eligibility for skilled nursing or intermediate care.

(3) A determination by the Social Security Administration that an SSI recipient’s degree of disability has changed so that he is no longer eligible for SSI disability is sufficient evidence that the person does not meet the definitive conditions described in subsection (c)(1)(i). A determination by the county review team will not be needed.

(4) For other persons age 18 or 65 who appear to be permanently and totally disabled, and whose income precludes referral to SSI, a determination will be made on the basis of medical and social findings as specified in subsection (d)(2)(i) and (ii).

(i) Medical and social findings. Both medical and social findings are needed for a decision on permanent and total disability. The necessary information is obtained as follows:

(A) Medical findings. Medical findings must include a substantiated diagnosis of an existing permanent impairment. Medical findings may be used in reaching a decision on permanent and total disability as long as it includes a substantiated diagnosis showing that a permanent impairment exists. The medical findings may consist of existing medical records including documented evidence such as institutional or school reports and psychologist’s reports. To obtain medical information on individuals who have applied for benefits under the Occupations Disease Act from the Bureau of Workmen’s Compensation, a request including the client’s name, address and Social Security Number and if available, the name and address of the employer in whose employment the disease occurred, should be sent to the Central Location and Resources Unit of the Bureau of Claim Settlement, DHS, Harrisburg, Pennsylvania 17120. Medical information for a person who has applied for benefits under the Occupational Disease Act from the Bureau of Vocational Rehabilitation. If the existing medical findings do not seem to be adequate for disability purposes a medical examination will be required. A Report of Medical Examination, PA 41, will be obtained.

(B) Social findings. Form MA 62 provides a comprehensive written report of the social findings necessary for a determination of total disability. This form will be required for every determination.

(ii) Decision on permanent and total disability and certification. Decisions on permanent and total disability and certification will be made in accordance with the following:

(A) The decision on permanent and total disability will be made by a Review Team composed of the County Medical Consultant and a designated and qualified member of the Income Maintenance staff. The Income Maintenance staff member must be experienced and skilled in evaluating the limiting effects of physical, emotional, or mental impairments.

(B) The Review Team will certify as to the client’s disability on the Form MA 62 and will include recommendations for treatment, training, or other rehabilitative services and any requests for information needed at a later date.

(f) Submission of information to regional office. Submission of information to Regional Office will be in accordance with the following:

(1) In County Offices without a Medical Consultant, the Regional Office will arrange for another County Office to make the decision until a Medical Consultant is obtained.

(2) When the medical findings are obtained, the County Office will stamp the date of receipt on the reverse of the document and send the following forms to the Regional Office, accomplishing the following:

(i) Attach a transmittal memo to the material. The memo indicates whether initial determination or redetermination lists all applicable attachments, and may include remarks that are pertinent.

(ii) Material clearly indicates the category. If there is more than one case of the same category in the assistance unit, the appropriate suffix will be included, such as TJ2.

(iii) Reports and forms will be separated in the groupings shown in paragraph (2)(iii) and assembled in the order indicated. Material in each group should be in chronological order with the earliest report or form on top.

(A) Medical Information, which includes the Form PA 41 if one is obtained; and, if applicable, a Form PA 60-P, and physician’s or specialist’s and hospital reports which may be in narrative form.

(B) Form MA 62.

(3) If the Reviewing County Office needs additional medical or social information to make a decision, the Form MA 215 will be used to notify the Regional Office of the information needed, the date required, and the like. The Regional Office will send the new medical or social findings, or both, to the Reviewing County Office along with Reports of Medical Findings and Social Information previously submitted. If the requested information cannot be obtained, the Regional Office will inform the Reviewing County Office by memorandum of this fact and the reasons. The Reviewing Office will then notify the Regional Office whether other information may be substituted. If the required information is not obtainable, the Reviewing Office will advise that no decision regarding permanent and total disability can be made because of insufficient information.

(g) Period when eligibility begins. The eligibility period will begin in accordance with the following:

(1) Initial application. Eligibility for MA services will begin with the service provided during the 90-day period preceding the date of application for Medical Assistance, if the applicant was eligible for the service during that period.

(2) After initial application. Eligibility for MA services will begin with the date the service starts, if the person meets the appropriate eligibility conditions. Eligibility will end on the date the individual or family no longer meets the eligibility conditions.

(h) Conditionally eligible applicants.

(1) If the applicant is unconditionally eligible (no available excess assets) or conditionally eligible (the applicant has excess assets that, in the judgment of the County Assistance Office, would be insufficient to meet all of the expected costs of the service), a Form PA 162 will be sent to the vendor.

(2) If the applicant has been found conditionally eligible, a contact must be made with the hospital to obtain the amount of the cost of care. If the cost of care is in excess of the individual’s assets, the Form PA 5-C card is issued. If the individual’s assets exceed the cost of the service, a determination of ineligibility is made and a Form PA 162 must be sent to the individual and vendor. In this instance a new application is required at the next request for service.

The provisions of this § 141.81 adopted August 4, 1977, effective August 5, 1977, 7 Pa.B. 2180; amended July 7, 1978, effective August 7, 1978, 8 Pa.B. 1954; amended February 22, 1980, effective March 1, 1980, 10 Pa.B. 850; amended November 13, 1981, effective November 14, 1981, 11 Pa.B. 4045; amended December 25, 1981, effective December 26, 1981, 11 Pa.B. 4444; amended July 28, 2000, the provisions under Act 49 effective retroactive to September 1, 1994, provisions under Act 35 effective retroactive to June 17, 1996, 30 Pa.B. 3779. Immediately preceding text appears at serial pages (209168) to (209170), (220867) to (220868) and (266103) to (266104).

Notation

Notes of Decisions

55 Pa. Code § 141.81(g)(1) (relating to policy) is reasonable and is clear and unambiguous, and an exception to its application is not warranted even though a private insurance carrier alters its stated coverage after tentatively agreeing to cover the expenses, since the insurance carrier gave notice of its revised coverage before the end of the 90 day period. Berry v. Department of Public Welfare, 401 A.2d 602 (Pa. Cmwlth. 1979).

Cross References

This section cited in 55 Pa. Code § 141.71 (relating to policy); 55 Pa. Code § 145.83 (relating to requirements); and 55 Pa. Code § 289.4 (relating to procedures).