Section 181.14. Eligibility under MNO-MA spend-down

(a) Eligibility under MNO-MA spend-down is available to applicants/recipients.

(b) The applicant/recipient shall meet the MNO-MA eligibility criteria, including the income criteria, to qualify for MNO-MA spend-down.

(c) Income eligibility for MNO-MA spend-down exists when the applicant’s/recipient’s countable net income less medical expenses is equal to, or less than, the appropriate MNO-MA income limits in Appendix F (relating to six-month period medically needy income limits (MNIL)) for a 6-month period. Medical expenses deducted include those identified in subsection (d) and deducted in the order provided in subsection (e).

(d) Deductible medical expenses include:

(1) Unpaid medical expenses, including those reasonably expected to be incurred, which meet the requirements in this paragraph. The unpaid medical expenses:

(i) Are not subject to payment by a third-party.

(ii) Are not to be paid for under the MNO-MA Program once MNO-MA is authorized.

(iii) Are the legal obligation of the applicant/recipient.

(iv) Have not previously been used as a deduction in the determination of eligibility for a prior authorization of MA.

(2) Paid medical expenses which meet the conditions listed in this paragraph. The expenses:

(i) Have been paid in the month of application, or any month in the retroactive period or a combination of both, for which the individual is applying.

(ii) Have not been previously used as a deduction in the determination of eligibility for a prior authorization of MA.

(ii) Are the legal obligation of the applicant/recipient and are not subject to payment by a third party.

(3) Medical and remedial expenses paid by a public program if the following apply:

(i) The public program is not financed in whole or in part by Federal funds.

(ii) The expenses are wholly financed by the State or a subdivision of the State, for example, county or municipality.

(iii) The expenses have been paid in the month of application, or any month in the retroactive period, or a combination of both, for which the individual is applying.

(iv) The expenses have not been previously used as a deduction in the determination of eligibility for a prior authorization of MA.

(e) Medical expenses meeting the requirements in subsection (d) are deducted from the countable net income in the following order:

(1) Medicare and other health insurance premiums, including enrollment fees, deductibles or coinsurance charges incurred by the applicant/recipient regardless of whether they are paid or unpaid.

(2) Copayments or deductibles under the following programs:

(i) An applicant/recipient participating in the Copayment Program required by the Department is permitted a medical expense deduction for copayment expenses, subject to the copayment limit established by the Department.

(ii) The allowable medical expense for an applicant/recipient determined eligible for the Pharmaceutical Assistance Contract for the Elderly (PACE) Program is limited to the current PACE payment for each prescription.

(3) For persons not eligible for, or not receiving, the PACE benefits, the allowable medical expense is the full prescription payment if:

(i) The applicant/recipient had been denied PACE benefits and the reasons for denial have not changed.

(ii) The applicant/recipient has not been determined eligible for PACE.

(iii) The applicant/recipient had good cause for not applying for, or participating in, the PACE program. Factors that constitute good cause include the following:

(A) The client’s health or age precludes participation or makes it impractical.

(B) The client had been unaware of the responsibility to apply for PACE participation.

(C) The client had previously been denied PACE benefits and the circumstances that caused denial have not changed.

(4) Paid and unpaid expenses incurred by the applicant/recipient for necessary medical and remedial services recognized under State statutes or regulations but not included in the MNO-MA Program.

(5) Paid and unpaid expenses incurred by the applicant/recipient for necessary medical and remedial services that are included in the MNO-MA Program.

(6) Medical and remedial expenses paid by a public program meeting the requirements in subsection (d)(3).

(7) For an applicant/recipient receiving skilled nursing care or intermediate care, the projected cost of his care, for a period not to exceed 6 months, at the private rate for the appropriate level of care anticipated to be received by the applicant/recipient in the skilled nursing or intermediate care facility.

The provisions of this § 181.14 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 January 17, 1992, effective January 18, 1992, 22 Pa.B. 275; amended July 28, 2000, 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 (211630) to (211632).

Notation

Authority

The provisions of this § 181.14 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).

Cross References

This section cited in 55 Pa. Code § 181.11 (relating to continuing eligibility); 55 Pa. Code § 181.12 (relating to retroactive eligibility); 55 Pa. Code § 181.312 (relating to deductions from earned income for the AFDC categories of MNO-MA); and 55 Pa. Code § 181.314 (relating to deductions from earned income for the GA categories of MNO-MA).