RULES AND REGULATIONS
Title 55--PUBLIC WELFARE
DEPARTMENT OF PUBLIC WELFARE
[55 PA. CODE CH. 140]
Special MA Eligibility Provisions
[30 Pa.B. 15] Statutory Authority
The Department of Public Welfare (Department), by this order, adopts the amendments in Annex A under the authority of sections 201(2) and 403(b) of the Public Welfare Code (62 P. S. §§ 201(2) and 403(b)) (code). Section 201(2) of the code provides that the Department has the authority to promulgate regulations with approval of the Governor. Section 403(b) of the code provides that the Department establish rules, regulations and standards consistent with law.
Notice of proposed rulemaking is omitted in accordance with section 204(1)(iv) of the act of July 31, 1968 (P. L. 769, No. 240) (45 P. S. § 1204(1)(iv)) (CDL) and 1 Pa. Code § 7.4(1)(iv) because the administrative regulations relate to Commonwealth grants and benefits. Additionally, notice of proposed rulemaking is omitted for good cause as unnecessary and contrary to public interest under section 204(3) of the CDL and 1 Pa. Code § 7.4(3). The amendments are mandated under section 4732(a)(10)(E) of the Balanced Budget Act of 1997 (Pub.L. No. 105-33) (42 U.S.C.A. § 1396a(a)(10)(E)). Failure to conform State regulations with Federal laws will seriously jeopardize Federal Financial Participation (FFP) in the Medicaid Program. The requirements of Federal law are specific, allowing for no alternative means of compliance. The Department is required to strictly adopt the Federal standard set forth in these amendments.
The provision mandates that full or partial Medicaid payment of the Medicare Part B premium is made to or on behalf of those individuals with incomes of at least 120% but less than 175% of the current Federal Poverty Income Guidelines (FPIG) and who meet established resource requirements. This provision is in accordance with section 4732 of the Balanced Budget Act of 1997.
Purpose of the Amendments
The purpose of these amendments is to expand the income limitations to allow individuals to qualify for full Medicaid payment of the Medicare Part B premium if they have income of at least 120% but less than 135% of the current FPIG; and for partial Medicaid payment of the Medicare Part B premium if they have income of at least 135% but less than 175% of the current FPIG.
Background
The Department's existing regulations provide for payment of Medicare Part B premiums for individuals with family income which is more than 100% but less than 120% of the current FPIG. Resources must not exceed twice the Supplemental Security Income (SSI) resource standard for the appropriate family size to qualify for payment of Medicare Part B premiums. These individuals are identified as Specified Low-Income Medicare Beneficiaries.
The Balanced Budget Act of 1997 mandates that there is an expansion in income limits to qualify for payment of the Medicare Part B premium. Individuals with income of at least 120% but not exceeding 135% of the current FPIG can qualify for full Medicaid payment of the Medicare Part B premium. This group will be identified as Qualifying Individuals-1 (QI-1s). Additionally, the Balanced Budget Act of 1997 provides for a partial Medicaid payment of Part B premiums for those individuals whose income is at least 135% but less than 175% of the current FPIG. The amount of partial payment is established by the Federal government in accordance with Federal law. These QIs are eligible for Medicare cost-sharing for a portion of their Part B premium, specifically the increase in the Medicare Part B premium attributable to the shift of Medicare home health coverage from Part A to Part B (as provided in section 4611 of the Balanced Budget Act of 1997). This group will be identified as Qualifying Individuals-2 (QI-2s). The resource limits for these two new groupings must not exceed twice the SSI resource standard for the appropriate family size.
Need for the Amendments
Section 4732 of the Balanced Budget Act of 1997, enacted August 5, 1997, amended section 1902 (a)(10)(E) of the Social Security Act (42 U.S.C.A. § 1396a(a)(10)(E)). The Department is required to implement this mandatory provision of the Balanced Budget Act of 1997. The requirements relating to full and partial Medicaid payment of the Medicare Part B premium were implemented on January 1, 1998, through a notice of rule change published at 28 Pa.B. 3626 (August 1, 1998). The regulatory revisions in Annex A will assure compliance with Federal law. If the Department does not implement these requirements, the Department risks Federal financial sanctions.
Summary
1. Section 140.201--This section has been amended to specify when the Department will participate in Medicare cost-sharing for QIs-1 and QIs-2.
2. Section 140.202--This section, relating to definitions, has been amended to include a definition for QIs and the two subgroups, designated QI-1s and QI-2s.
3. Section 140.231--This section has been amended to specify income requirements for QIs-1 and QIs-2.
4. Section 140.301--This section has been amended to specify resource eligibility limitations for QIs-1 and QIs-2.
5. Section 140.331--This section has been amended to specify benefit coverage for QIs-1 and QIs-2.
6. Section 140.332--This section has been amended to specify category designation for QIs-1 and QIS-2.
Affected Persons and Organization
Individuals who are elderly or disabled, or both, who qualify for Medicare coverage and who meet the established income and resource requirements will benefit from these amendments. No individual will be adversely affected by these amendments.
Accomplishments/Benefits
Adoption of these amendments requires the Department to pay all or part of Medicare Part B premiums for the elderly or disabled individuals, or both, who have income of at least 120% but less than 175% of the FPIG. This will permit a vulnerable segment of the population to have more income available for living expenses and assure that these premiums are totally or partially paid.
Fiscal Impact
Commonwealth A capped Federal allocation of funds has been established for this benefit. The capped allocation extends until Federal FY 2002 and increases each year. Currently, there is no State allocation for this change as the Federal funds cover all costs. There will be no costs or savings incurred by State government up to the capped amount.
Public Sector There will be no costs or savings incurred by the public sector.
Private Sector There will be no costs or savings incurred by the private sector.
Paperwork Requirements
Due to the capped funding available through the Balanced Budget Act of 1997, these amendments require the development of two new program status codes for monitoring and reporting of Medicare Part B payments paid for qualifying individuals.
Effective Date
The effective date for the provisions relating to qualifying individuals is retroactive to January 1, 1998.
Sunset Date
Although these amendments have no sunset date, it is important to note that these benefits are financed through a capped and time-limited Federal allocation of funds. This allocation extends until Federal FY 2002.
The Department continuously reviews the Medical Assistance (MA) Program and regulations through the Federally-monitored Quality Control and Corrective Action review process to ensure compliance with Federal law.
Public Comment Period
Although these amendments are being adopted without prior notice, interested persons are invited to submit their written comments, suggestions or objections within 30 days from the date of this application for consideration by the Department as to whether the amendments should be revised. Comments should be sent to the Department of Public Welfare, Edward J. Zogby, Director, Bureau of Policy, Room 43l, Health and Welfare Building, P. O. Box 2675, Harrisburg, PA 17120, (717) 787-4081.
Persons with a disability may use the AT & T Relay Service by calling (800) 654-5984 (TDD Users) or (800) 654-5988 (Voice Users).
Regulatory Review
Under section 5.1(c) of the Regulatory Review Act (71 P. S. § 745.5a(c)), on August 31, 1999, the Department submitted a copy of these amendments with proposed rulemaking omitted to the Independent Regula- tory Review Commission (IRRC) and to the Chairpersons of the House Committee on Health and Human Services and the Senate Committee on Public Health and Welfare. On the same date, these amendments were submitted to the Office of the Attorney General for review and approval under the Commonwealth Attorneys Act (71 P. S. §§ 732-101--732-506).
Under section 5.1(d) of the Regulatory Review Act, these amendments were deemed approved by the Committees on October 30, 1999. Under section 5.1(e) of the Regulatory Review Act, IRRC approved the final-omitted regulations on November 4, 1999.
Findings
The Department finds that:
(l) Public notice of intention to adopt the administrative regulations amended by this order is omitted in accordance with section 204(1)(iv) of the CDL and 1 Pa. Code § 7.4(1)(iv) because the administrative regulations relate to Commonwealth grants and benefits. Additionally, notice of proposed rulemaking is omitted for good cause and contrary to the public interest under section 204(3) of the CDL and the regulations thereunder, 1 Pa. Code § 7.4(3).
(2) The adoption of these amendments in the manner provided in this order is necessary and appropriate for the administration and enforcement of the code.
Order
The Department, acting under the code, orders that:
(a) The regulations of the Department, 55 Pa. Code Chapter 140, are amended by amending §§ 140.201, 140.202, 140.231, 140.301, 140.331 and 140.332 to read as set forth in Annex A.
(b) The Secretary of the Department shall submit this order and Annex A to the Office of Attorney General and the Office of General Counsel for approval as to legality and form as required by law.
(c) The Secretary of the Department shall certify this order and Annex A and deposit them with the Legislative Reference Bureau as required by law.
(d) This order shall take effect upon publication in the Pennsylvania Bulletin as final rulemaking and apply retroactively to January 1, 1998.
(Editor's Note: For the text of the order of the Independent Regulatory Review Commission relating to this document, see 29 Pa.B. 5963 (November 20, 1999).)
FEATHER O. HOUSTOUN,
SecretaryFiscal Note: 14-462. No fiscal impact; (8) recommends adoption. A Federal allocation of funds has been established for this benefit. Currently there is no State allocation for this change.
Annex A
TITLE 55. PUBLIC WELFARE
PART II. PUBLIC ASSISTANCE MANUAL
Subpart C. ELIGIBILITY REQUIREMENTS
CHAPTER 140. SPECIAL MA ELIGIBILITY PROVISIONS
Subchapter B. ELIGIBILITY PROVISIONS FOR THE HEALTHY HORIZONS PROGRAM FOR THE ELDERLY/DISABLED
GENERAL PROVISIONS § 140.201. Policy on Healthy Horizons.
(a) The Department provides MA under the Healthy Horizons Categorically Needy Program to elderly/disabled persons who are otherwise eligible with family income up to 100% of the current Federal Income Poverty Guidelines and resources not exceeding the SSI resource standard for the appropriate family size.
(b) The Department participates in QMB Medicare cost-sharing only under the Healthy Horizons Medicare Cost-Sharing Program for qualified Medicare beneficiaries with family income up to 100% of the current Federal Poverty Income Guidelines and resources not exceeding twice the SSI resource standard for the appropriate family size.
(c) The Department also participates in the Medicare Cost-Sharing for qualified Medicare beneficiaries found eligible for benefits under the Healthy Horizons Categorically Needy Program.
(d) The Department participates in SLMB Medicare Cost-Sharing only under the Healthy Horizons Medicare Cost-Sharing Program for SLMBs with family income which on or after January 1, 1995, is more than 100% but does not exceed 120% of the current Federal Poverty Income Guidelines and resources not exceeding twice the SSI resource standard for the appropriate family size. Prior to January 1, 1995, for calendar years 1993 and 1994, family income shall be more than 100%, but may not exceed 110% of the applicable Federal Poverty Income Guidelines and resources may not exceed twice the SSI resource standard for the appropriate family size.
(e) The Department participates in Medicare cost-sharing under the Healthy Horizons Program for qualifying individuals whose family income is at least 120% and less than 135% or at least 135% and less than 175% of the current Federal Poverty Income Guidelines and whose resources do not exceed twice the SSI resource standard for the appropriate family size. These individuals are designated as QI-1s and QIs-2s, respectively.
(f) MA is provided under the program which is mot advantageous for the client based on individual circumstances. Eligibility for MA benefits under both the NMP-MA and MNO-MA Programs is also explored.
§ 140.202. Definitions.
The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise:
Applicant/recipient--A person who is applying for, or receiving, benefits under the Healthy Horizons Program.
Calendar quarter--A period of 3-full calendar months beginning with January, April, July or October.
Countable net income--Income counted in determining income eligibility for Healthy Horizons, less appropriate exemptions, deductions and disregards.
Earned income--Money or other compensation received in return for services rendered.
Infrequent income--Income that is received not more than once in a calendar quarter.
Irregular income--Income that is not subject to scheduling or is unpredictable.
Legal guardian--A person who is court appointed as the legal guardian.
Personal property--Privately owned possessions which are not real property. The term includes cash, bank accounts, stocks, bonds, mortgages, cash value of life insurance policies, household furnishings, personal effects, motor vehicles, boats and Federal, State and local tax refunds.
QI--Qualifying individual--An individual who is enrolled in Medicare hospital insurance under Part A and meets the income requirements in § 140.231(c) or (d) (relating to income eligibility limitations) and resource requirements in § 140.301 (relating to resource eligibility limitations).
QI-1s--Qualifying Individual-1s--A qualifying individual who meets the income requirements in § 140.231(c). Eligibility for Medicaid benefits is limited to full payment of Medicare Part B premiums.
QI-2s--Qualifying Individual--2s--A qualifying individual who meets the income requirements in § 140.231(d) (relating to income eligibility limitations). Eligibility for Medicaid benefits is limited to partial payment of Medicare Part B premiums.
QMB--Qualified Medicare beneficiary--An individual who is entitled to, or voluntarily enrolled in, Medicare hospital insurance under Part A.
Real property--Land, buildings, mobile homes and improvements thereto.
SLMB--Specified low-income Medicare beneficiary--An individual who meets the eligibility requirements for QMB status except for income in excess of the QMB income limit, but not exceeding the limits specified in § 140.231.
SSI--Supplemental Security Income--The benefit amount paid to an eligible person or to an eligible person and the eligible spouse under Title XVI of the Social Security Act (42 U.S.C.A. §§ 1381--1383c).
Spouse--A person who is married to another by legal ceremony or by common-law.
INCOME REQUIREMENTS § 140.231. Income eligibility limitations.
(a) For the Healthy Horizons Categorically Needy and Healthy Horizons QMB Cost-Sharing Programs, net family income after applicable deductions and disregards cannot exceed 100% of the current Department of Health and Human Services Annual Update of Federal Poverty Income Guidelines for the appropriate family size.
(b) For the Healthy Horizons SLMB Cost-Sharing Program, on or after January 1, 1995, net income after applicable deductions and disregards shall be more than 100% of the current Department of Health and Human Services annual update of Federal Poverty Income Guidelines for the appropriate family size but may not exceed 120%. Prior to January 1, 1995, for calendar years 1993 and 1994, net income after applicable deductions and disregards shall be more than 100% of the applicable Department of Health and Human Services Annual Update of Federal Poverty Income Guidelines for the appropriate family size, but cannot exceed 110%.
(c) For the Healthy Horizons Medicare Cost-Sharing Program for QI-1s, net income after applicable deductions and disregards shall be at least 120% and less than 135% of the current Department of Health and Human Services annual update of Federal Poverty Income Guidelines for the appropriate family size.
(d) For the Healthy Horizons Medicare Cost-Sharing Program for QI-2s, net income after applicable deductions and disregards shall be at least 135% and less than 175% of the current Department of Health and Human Services annual update of Federal Poverty Income Guidelines for the appropriate family size.
RESOURCE REQUIREMENTS § 140.301. Resource eligibility limitations.
(a) An applicant/recipient is resource eligible for the Health Horizons Categorically Needy Program if his total resources considered in accordance with Chapter 178, Subchapters A and B (relating to general provisions for MA resources common to all categories of MA; and aged, blind and disabled categories of MA), do not exceed the SSI resource standard for the appropriate family size.
(b) An applicant/recipient is resource eligible for the SLMB, QMB, QI-1, and QI-2 Healthy Horizons Medicare Cost-Sharing Programs if total resources considered under Chapter 178, Subchapters A and B do not exceed twice the SSI resource standard for the appropriate family size in Chapter 178, Appendix A, Part (a) (relating to NMP-MA resource limits).
BENEFIT COVERAGE § 140.331. Benefit coverage.
(a) The Department will provide the following under the Healthy Horizons Categorically Needy Program:
(1) Full categorically needy benefits.
(2) Qualified Medicare beneficiaries are also eligible for the following:
(i) Buy-in of the Medicare Part A premium if the individual is enrolled in Medicare Part A and paying the Part A premium.
(ii) Buy-in of the Medicare Part B premium.
(iii) Payment of the Medicare Part A and Part B deductibles and coinsurances. The combined Medicare and Medicaid payment will not exceed the Department's Medicaid fee for the service provided.
(b) The Department will provide the following under the QMB Healthy Horizons Medicare Cost-Sharing Program:
(1) Buy-in of the Medicare Part A premium if the individual is enrolled in Medicare Part A and paying the Part A premium.
(2) Buy-in of the Medicare Part B premium.
(3) Payment of the Medicare Part A and Part B deductibles and coinsurances. The combined Medicare and Medicaid payment will not exceed the Department's Medicaid fee for the services provided.
(c) Under the Healthy Horizons SLMB Medicare Cost-Sharing Program, the Department will provide buy-in of only the Medicare Part B premium if the individual is enrolled in or eligible for Medicare Part A.
(d) For QI-1s, to the extent that Federal funding is provided, the Department will provide full Medicaid payment of the Medicare Part B Premium if the individual is enrolled in or eliglble for Medicare Part A.
(e) For QI-2s, to the extent that Federal funding is provided, the Department will provide partial Medicaid payment of the Medicare Part B Premium if the individual is enrolled in or eligible for Medicare Part A. This is a reimbursement to the recipient, not a premium payment to Medicare.
(f) For QI-2s, partial payments of Medicare Part B premium payment will be made for the calendar year. For all other recipients of payments, the Department will pay the Medicare Part A premium, if appropriate, and the Medicare Part B premium beginning with the month following the month in which the applicant is determined eligible.
§ 140.332. Category designation.
(a) Elderly/disabled persons who are eligible to receive Healthy Horizons Categorically Needy benefits are designated as ''PS'' category and are identified by the appropriate program status code.
(b) Elderly persons who are eligible for Medicare Cost-Sharing only are designated as ''PG'' category.
(c) Disabled persons who are eligible for Medicare Cost-Sharing only are designated as ''PL'' category.
(d) Elderly disabled persons who are eligible for SLMB Medicare Cost-Sharing are designated as TA/TJ category and the appropriate program status code.
(e) Elderly/disabled persons who are eligible under the Healthy Horizons Medicare Cost-Sharing Program for QI-1s and QI-2s are designated as TA/TJ category and are identified by the appropriate program status code.
[Pa.B. Doc. No. 00-9. Filed for public inspection December 30, 2000, 9:00 a.m.]
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