§ 140.604. Premiums.
(a) Eligibility. An applicant or recipient who meets the eligibility conditions specified in § 140.603 (relating to conditions of MA eligibility) shall be eligible for MA upon receipt of payment of a premium, if any, established by the Department under subsection (b).
(b) Calculation of premium.
(1) The custodial parent shall report and verify earned and unearned income and allowable medical and dental expenses.
(2) If the custodial parent’s total gross adjusted earned and unearned income is greater than 200% of the Federal Poverty Income Guidelines, the custodial parent’s income is considered in calculation of the premium.
(3) The medical and dental expenses reported on the custodial parent’s Federal Income Tax Return of the previous calendar year are allowable deductions from the income of the custodial parent as specified in paragraph (2).
(i) The verification of income is limited to the custodial parent’s Federal Income Tax Return listing the reported adjusted gross income of the previous calendar year.
(ii) If the Federal Income Tax Return of the previous calendar year is not available or there is a decrease in income from the previous calendar year, any of the following items may be used to verify current income:
(A) Pay stubs.
(B) Pay envelopes.
(C) Statement by employer.
(D) Other documentary proof of the income of the custodial parent.
(iii) The verification of allowable medical and dental expenses is limited to those medical and dental expenses that were not reimbursed and that the custodial parent deducted on the Federal Income Tax Return of the previous calendar year.
(4) The amount of the premium is based on income that is considered as specified in paragraph (2) less allowable medical and dental expenses specified in paragraph (3) and the family size.
(5) The premium is determined under Appendix B (relating to Medicaid for Children with Special Needs Monthly Premium Chart).
(6) Revisions to the premium amounts will be published as a notice in the Pennsylvania Bulletin for codification in Appendix B.
(7) The premium is established for a 12-month period.
(8) There is one premium per family.
(9) The premium can be lowered during the 12-month period if the custodial parent reports and verifies a decrease in income or an increase in family size.
(c) Notice. The Department will provide a written notice of a requirement for a premium or a change in a premium. The Department will provide an advance written notice at least 10 days before the date of a premium increase or requirement of a premium.
(d) Premium payment or hardship waiver.
(1) The premium payment is due on or before the last day of the calendar month. The premium is considered overdue when payment of the premium is not received by the last day of the calendar month.
(2) An advance written notice to discontinue MA for the recipient will be issued if the overdue premium payment is not received within 45 days of the day the payment was due.
(3) The premium payment may be waived if the requirement to pay a premium will result in an undue hardship for the custodial parent.
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