Section 181.12. Retroactive eligibility

(a) The earliest possible date for retroactive MA benefits to begin is the first day of the third month preceding the month of application.

(1) The period of eligibility for retroactive MA benefits under NMP-MA begins with the first day of the month in the retroactive period in which the first medical service was incurred, if the applicant was otherwise eligible during that month.

(2) The period of eligibility for retroactive MA benefits under MNO-MA begins with the first day of the month in the retroactive period in which the first medical service was incurred, if the applicant was otherwise eligible during that month.

(b) For NMP-MA categories with the exception of the persons covered in § 181.71 (relating to special NMP-MA income limit for institutionalized aged, blind and disabled persons), income eligibility for retroactive MA benefits exists when the applicant’s/recipient’s countable monthly net income for the retroactive period is equal to, or less than:

(1) The appropriate NMP-MA income limits in Appendix A for persons in the aged, blind and disabled categories not receiving skilled nursing care or intermediate care.

(2) The appropriate NMP-MA income limits in Appendix C for persons in the AFDC categories and the GA category.

(c) For MNO-MA categories, income eligibility for retroactive MA benefits exists if one of the following applies:

(1) The applicant’s/recipient’s countable net income in the combined retroactive/prospective period, less medical expenses is equal to, or less than, the appropriate MNO-MA 6-month period income limits in Appendix F.

(2) The applicant’s/recipient’s countable net income in the combined retroactive/prospective period, less medical expenses is equal to, or less than, the appropriate MNO-MA 6-month period income limits in Appendix F. Unpaid medical expenses that are not subject to payment by a third-party, which remain the legal obligation of the applicant/recipient, and are not to be paid for under the MA Program once MA is authorized and paid medical expenses, are deducted from the countable net income in the combined retroactive/prospective period as provided under § 181.14(e)(1)—(6) (relating to eligibility under MNO-MA spend-down). This includes medical expenses incurred before the retroactive period.

The provisions of this § 181.12 adopted August 26, 1988, effective November 1, 1988, 18 Pa.B. 3949; amended February 15, 1991, effective March 1, 1991, 21 Pa.B. 624; amended August 16, 1991, effective August 17, 1991, 21 Pa.B. 3704; amended July 28, 2000, the provisions under Act 35 effective retroactive to June 17, 1996, the expansion of allowable medical expense income deductions effective retroactive to February 1, 1999, 30 Pa.B. 3779. Immediately preceding text appears at serial pages (267115) to (267116).

Notation

Authority

The provisions of this § 181.12 issued under section 403(b) of the Public Welfare Code (62 P. S. § 403(b)); amended under sections 201, 403 and 443.1 of the Public Welfare Code (62 P. S. § § 201, 403 and 443.1).

Notes of Decisions

Because they relate to different things, the 60-day time period for submitting an exception under this section does not conflict with the three-month time period established at 55 Pa. Code § 181.12(a) which pertains to determinations of retroactive eligibility. Ashton Hall, Inc. v. Department of Public Welfare, 743 A.2d 529 (Pa. Cmwlth. 1999).