Subchapter B. ELIGIBILITY PROVISIONS FOR THE
HEALTHY HORIZONS PROGRAM FOR THE
ELDERLY/DISABLED
GENERAL PROVISIONS Sec.
140.201. Policy on Healthy Horizons.
140.202. Definitions.
ELIGIBILITY REQUIREMENTS
140.221. Conditions of eligibility.
INCOME REQUIREMENTS
140.231. Income eligibility limitations.
140.232. Applicable income.
ITEMS THAT ARE NOT COUNTED AS INCOME
140.241. Items that are not counted as income.
TYPES OF EARNED INCOME COUNTED
140.251. Gross earned income.
140.252. Income from self-employment.
140.253. Payment for services in a sheltered workshop or work activities center.
140.254. Earned Income Tax Credit (EITC).
TYPES OF UNEARNED INCOME COUNTED
140.261. Benefits, dividends and interest.
140.262. Prizes and awards.
140.263. Inheritances.
140.264. Support.
140.265. Profit from rental property income.
140.266. Proceeds as beneficiary of life insurance policy.
INCOME EXCLUSIONS
140.271. Income exempt by Federal statutes.
140.272. Earned income exclusion.
140.273. Unearned income exclusions.
DEDUCTIONS FROM INCOME
140.281. Deductions from unearned income.
140.282. Deductions from earned income.
140.283. Deductions from self-employment.
140.284. Guardian fee deductions.
140.285. Deductions from rental income.
TREATMENT OF LUMP SUM PAYMENTS
140.291. Treatment of lump sum payments.
RESOURCE REQUIREMENTS
140.301. Resource eligibility limitations.
140.305. Resources of children under 21 years of age and families with children under 21 years of age.
VERIFICATION REQUIREMENTS
140.311. Verification requirements.
REDETERMINATION/REAPPLICATION REQUIREMENTS
140.321. Redetermination/reapplication requirements.
BENEFIT COVERAGE
140.331. Benefit coverage.
140.332. Category designation.
140.333. Eligibility begin date.
140.334. Eligibility end date.
140.335. Retroactive eligibility.
140.336. Notification of eligibility/ineligibility.
140.337. Notification of termination.
RIGHT TO APPEAL/FAIR HEARING
140.341. Appeal and fair hearing.
Authority The provisions of this Subchapter B issued under section 403(b) of the Public Welfare Code (62 P. S. § 403(b)), unless otherwise noted.
Source The provisions of this Subchapter B adopted October 26, 1990, effective October 27, 1990, and apply retroactively to January 1, 1989, 20 Pa. B. 5428, unless otherwise noted.
Cross References This subchapter cited in 55 Pa. Code § 140.601 (relating to policy); and 55 Pa. Code § 140.603 (relating to conditions of MA eligibility).
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.
Authority The provisions of this § 140.201 amended under sections 201(2) and 403(b) of the Public Welfare Code (62 P. S. § § 201(2) and 403(b)).
Source The provisions of this § 140.201 amended May 24, 1996, effective May 25, 1996, and apply retroactively to January 1, 1993, for the SLMB Medicare Cost-Sharing Program for persons whose income does not exceed 110% of the FPIGs, and retroactively to January 1, 1995, for persons whose income does not exceed 120% of the FPIGs, 26 Pa.B. 2412; amended December 30, 1999, effective January 1, 2000, 30 Pa.B. 15. Immediately preceding text appears at serial page (216193).
§ 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.
Immediate family—The child, the biological or adoptive parent of a child under 21 years of age, the spouse of the parent, and the brother, sister, step-brother, step-sister, half-brother or half-sister who are under 21 years of age. The immediate family members must be living together.
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). 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.
Authority The provisions of this § 140.202 amended under sections 201(2) and 403(b) of the Public Welfare Code (62 P. S. § § 201(2) and 403(b)).
Source The provisions of this § 140.202 amended May 24, 1996, effective May 25, 1996, and apply retroactively to January 1, 1993, for the SLMB Medicare Cost-Sharing Program for persons whose income does not exceed 110% of the FPIGs, and retroactively to January 1, 1995, for persons whose income does not exceed 120% of the FPIGs, 26 Pa.B. 2412; amended December 30, 1999, effective January 1, 2000, 30 Pa.B. 15; amended June 15, 2001, effective June 16, 2001, 31 Pa.B. 3196. Immediately preceding text appears at serial pages (262298) to (262299).
Cross References This section cited in 55 Pa. Code § 140.305 (relating to resources of children under 21 years of age and families with children under 21 years of age).
ELIGIBILITY REQUIREMENTS
§ 140.221. Conditions of eligibility.
Eligibility for MA under the Healthy Horizons Program is based on the following:
(1) An individual shall meet the following eligibility requirements:
(i) Chapters 125 and 127 (relating to application process; and reserved).
(ii) Chapter 148 (relating to residence).
(iii) Chapter 149 (relating to citizenship and alienage).
(iv) Chapter 155 (relating to enumeration).
(v) Chapter 178 (relating to resource provisions for categorically NMP-MA and MNO-MA).
(vi) Chapter 255 (relating to restitution).
(vii) Chapter 257 (relating to reimbursement).
(2) Under the Healthy Horizons Categorically Needy Program, an individual shall also meet one of the following criteria:
(i) Be 65 years of age or older.
(ii) Be a disabled person who is receiving Social Security Disability benefits or disability benefits based on SSI disability criteria at § 141.71 (relating to policy).
(iii) Be a disabled person who meets the disability requirements of § 141.71.
(3) Under the Healthy Horizons Medicare Cost-Sharing Program, an individual shall also be a qualified Medicare beneficiary.
Source The provisions of this § 140.221 amended May 24, 1996, effective May 25, 1996, and apply retroactively to January 1, 1993, for the SLMB Medicare Cost-Sharing Program for persons whose income does not exceed 110% of the FPIGs, and retroactively to January 1, 1995, for persons whose income does not exceed 120% of the FPIGs, 26 Pa.B. 2412. Immediately preceding text appears at serial page (211594).
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.
Authority The provisions of this § 140.231 amended under sections 201(2) and 403(b) of the Public Welfare Code (62 P. S. § § 201(2) and 403(b)).
Source The provisions of this § 140.231 amended May 24, 1996, effective May 25, 1996, and apply retroactively to January 1, 1993, for the SLMB Medicare Cost-Sharing Program for persons whose income does not exceed 110% of the FPIGs, and retroactively to January 1, 1995, for persons whose income does not exceed 120% of the FPIGs, 26 Pa.B. 2412; amended December 30, 1999, effective January 1, 2000, 30 Pa.B. 15. Immediately preceding text appears at serial page (216195).
Cross References This section cited in 55 Pa. Code § 140.202 (relating to definitions).
§ 140.232. Applicable income.
Earned or unearned income of the applicant/recipient, except when designated in this subchapter as being income that is not counted or excluded, is considered when determining eligibility.
(1) Countable net income of the applicant/recipient is determined after the allowable deductions listed in § § 140.281—140.285 (relating to deductions from income).
(2) If the applicant/recipient is residing with a spouse, earned or unearned income of the spouse is considered when determining eligibility of the applicant/recipient.
(i) Countable income of the spouse is determined under Chapter 181 Subchapter C (relating to the TANF and GA categories).
(ii) If countable income of the spouse is equal to, or less than, 50% of the Federal Benefit Rate for one person, the spouse is not counted as a family member and the income of the spouse is not considered when determining eligibility, unless the applicant/recipient elects to have the spouse and the income of the spouse counted.
(iii) Earned or unearned income of the spouse is combined with earned or unearned income of the applicant/recipient. The allowable deductions listed in § § 140.281—140.285 are applied to the combined income to determine net countable income.
(3) If the applicant/recipient has children or stepchildren 20 years of age or younger residing in the household, the income of the children or stepchildren is disregarded when determining eligibility unless the applicant/recipient elects to have the child and the income of the child counted.
(i) Countable income of the child is determined in accordance with Chapter 181 Subchapter C.
(ii) Earned or unearned income of the child is combined with earned or unearned income of the applicant/recipient and earned or unearned income, if any, of the spouse. The allowable deductions listed in § § 140.281—140.285 are applied to the combined income to determine net countable income.
(4) A lump sum payment received by the applicant/recipient or the spouse of the applicant/recipient may be considered as income if it is more advantageous to the applicant/recipient than considering the payment as a resource.
ITEMS THAT ARE NOT COUNTED AS INCOME
§ 140.241. Items that are not counted as income.
The following items are not counted as income when determining income eligibility for the Healthy Horizons Program:
(1) Receipts from conversion of a resource. Receipts from the conversion of a resource, such as the sale, exchange or replacement of a resource. This includes cash or an in-kind item that is provided to replace or repair a resource that has been lost, damaged or stolen.
(2) Income tax refunds. An amount refunded on income taxes.
(3) Payments by credit life or credit disability insurance policies. Payments made under a credit life or credit disability insurance policy issued to, or on behalf of, borrowers to cover payments on loans or installment purchases in the event of the death or disability of the applicant/recipient which are made directly to loan companies or mortgage companies and are not available to the applicant/recipient either directly or by sale or conversion for the purposes of meeting basic needs.
(4) Repayment of loan. Money received from another party in repayment of a loan. Interest received on the money lent is counted as income.
(5) Bill paid for applicant/recipient or the spouse. A bill paid by a third party for the applicant/recipient or the spouse.
(6) Replacement income. Income received as a replacement of income lost, destroyed or stolen.
(7) Weatherization assistance.
(8) MA copayment rebates. A refund to the applicant/recipient authorized as a rebate for payment in excess of the amount required as copayment for MA services.
(9) Veterans aid and attendance and housebound allowance. The aid and attendance and household allowance portion of a veterans benefit.
(10) Borrowed money. Money obtained by borrowing.
(11) Medical care and services. Medical care and services if they are:
(i) Given free of charge or paid for directly to the provider by another person.
(ii) Room and board received during a medical confinement.
(iii) Assistance provided in cash or in-kind, including food, clothing or shelter under a Federal, State or local government program, whose purpose is to provide medical care or services including vocational rehabilitation.
(iv) In-kind assistance provided under a nongovernmental program whose purpose is to provide medical care or medical services.
(v) Cash provided by a nongovernmental medical care or medical services program or under a health insurance policy if the cash is either repayment for program approved services already paid for by the applicant/recipient or a payment restricted to the future purchase of a program approved service.
(vi) Direct payment of the applicant/recipient’s medical insurance premiums by anyone on behalf of the applicant/recipient.
(12) Social services. Social services if they are one or more of the following:
(i) Assistance provided in cash or in-kind but not received in return for a service performed by the applicant/recipient under a Federal, State or local government program whose purpose is to provide social services including vocational rehabilitation.
(ii) In-kind assistance provided under a nongovernmental program whose purpose is to provide social services.
(iii) Cash provided by a nongovernmental social services program if the cash is either repayment for program approved services already paid by the applicant/recipient or a payment restricted to the future purchase of a program approved service such as cash provided by a private social services agency to an applicant/recipient for homemaker, attendant care and chore services.
(13) Receipt of certain noncash items. Noncash items which are excluded as a resource under Chapter 178, Subchapter A (relating to general provisions for MA resources common to all categories of MA). If the item is retained it is not counted as income.
(14) Assistance for the homeless.
TYPES OF EARNED INCOME COUNTED
§ 140.251. Gross earned income.
Gross earned income, including wages, tips, salaries, commissions, severance pay and bonuses from employment is counted as earned income.
Notes of Decisions Unearned Income
Disability benefits are unearned income even though the stub of the disability check from employer’s insurance carrier designated the income as sick pay. Goldstein v. Department of Public Welfare, 654 A.2d 295 (Pa. Cmwlth. 1995).
§ 140.252. Income from self-employment.
Income from self-employment is counted as earned income. Self-employment includes operating a business, trade or farm, practicing a profession or from renting personal or real property as a trade or business.
§ 140.253. Payment for services in a sheltered workshop or work activities center.
A payment received for services performed in a sheltered workshop or work activities center is counted when received or when the payment is set aside for the applicant/recipient’s use.
§ 140.254. Earned Income Tax Credit (EITC).
(a) The advance monthly EITC payment which an applicant/recipient actually receives is counted as monthly earned income.
(b) An applicant/recipient with earned income who is not receiving a monthly advance EITC does not have EITC counted as monthly earned income. The EITC counts as a lump sum payment when the EITC is refunded.
(c) A reconciliation of the EITC is required for a current recipient of Healthy Horizons following the end of the tax year if the recipient verifies that the total amount of the advance EITC which was counted as earned income received during the tax year by the Department differs from the year-end EITC. The recipient is responsible for providing the information and documentation necessary to complete the reconciliation computation. This information includes the recipient’s income tax return—IRS Form 1040, 1040A or 1040EZ—and the income tax refund check received or a photostatic copy of the income tax refund check.
(1) If the amount of the advance payments counted by the Department is less than the EITC verified on the income tax return—IRS Form 1040, 1040A or 1040EZ—and the income tax refund check or a copy of the income tax refund check, the additional EITC is treated as lump sum payment in the month of receipt. The EITC is attributed to the person who was employed during the tax year. Each person who was employed is considered to have an equal share of the EITC.
(2) If the amount of the advance payments counted by the Department is equal to, or more than, the EITC verified on the income tax return, no further adjustment is necessary.
(3) If the recipient fails to provide the necessary verification, IRS Form 1040, 1040A or 1040EZ and the income tax refund check or a copy of the income tax refund check, the entire amount of the available EITC—the maximum EITC the recipient could receive less the amount of the advance payments counted by the Department—is counted as the EITC refund and as a lump sum payment in the month of receipt.
TYPES OF UNEARNED INCOME COUNTED
§ 140.261. Benefits, dividends and interest.
Annuities, pensions and other periodic payments which include private pensions, social security benefits including Part B Medicare premiums, disability benefits, veterans benefits, worker’s compensation, railroad retirement, unemployment insurance benefits, dividends, interest and royalties are counted as unearned income. In some cases, the amount counted as unearned income is more than the actual amount received by the applicant/recipient. This occurs when the amount received by the applicant/recipient is reduced for a debt resulting from an overpayment of a previously received benefit, or by deduction of an insurance premium. In this situation, the actual amount to count as unearned income is the amount of the unearned income benefit to which the applicant/recipient is entitled before the deduction of an insurance premium or the reduction to recover an overpayment unless § 140.273(14) (relating to unearned income exclusions) applies.
§ 140.262. Prizes and awards.
A prize, which is generally something won in a contest, lottery or game of chance, is counted as unearned income. An award, which is usually something received as the result of a decision by a court, board of arbitration or something similar, is counted as unearned income.
§ 140.263. Inheritances.
An inheritance, which is something received as a result of someone’s death, is counted as unearned income. An inheritance can be cash or in-kind, including a right or interest in real or personal property.
§ 140.264. Support.
Child support, spousal support and alimony are counted as unearned income, regardless of whether the payment or support is voluntary or court-ordered.
§ 140.265. Profit from rental property income.
Profit from rental property income is the payment received by the applicant/recipient for the use of real or personal property including payments for room and board and room rent less the deductions in § 140.285 (relating to deductions from rental income). Profit from rental property income is counted as unearned income.
§ 140.266. Proceeds as beneficiary of life insurance policy.
Payments received by the applicant/recipient as a beneficiary of a life insurance policy, except for an amount up to $1,500 that the applicant/recipient verifies that he spent on the insured’s last illness and burial expense, is counted as unearned income. Illness and burial expenses include related hospital and medical expenses, funeral, burial plot and interment expenses and other related costs.
INCOME EXCLUSIONS
§ 140.271. Income exempt by Federal statutes.
The following types of income do not count when determining income eligibility for Healthy Horizons:
(1) Food Stamp Program benefits. The value of food stamps received by an applicant/recipient who is participating in the Food Stamp Program (7 U.S.C.A. § § 2011—2029).
(2) Value of United States Department of Agriculture surplus food donation. The value of United States Department of Agriculture donated foods-surplus commodities distributed under section 32 of the act of August 24, 1935 (7 U.S.C.A. § 612c).
(3) Value of free or reduced price food. The value of free or reduced price food received by women and children under sections 11(b) and 17 of the Child Nutrition Act of 1966 (42 U.S.C.A. § § 1780(b) and 1786); and section 13(h)(3) of the National School Lunch Act (42 U.S.C.A. § 1761(h)(3)).
(4) Assistance to prevent fuel cutoffs. Assistance received under the Energy Crisis Assistance Program or the Emergency Energy Conservation Services Program under section 222(a)(5) of the Economic Opportunity Act of 1964 (42 U.S.C.A. § 2809(a)(5)).
(5) Fuel assistance payments. Fuel assistance payments and allowances under the Low Income Home Energy Assistance Act of 1981 (42 U.S.C.A. § § 8621—8629) as amended by the Human Services Reauthorization Act of 1984 (Pub. L. 99-425) (100 Stat. 966).
(6) Housing subsidies. Housing subsidies paid under the United States Housing Act of 1937 (includes Section 8 Housing) (12 U.S.C.A. § § 1437—1437g), the National Housing Act (12 U.S.C.A. § § 1706(b)—1749bbb-21), section 101 of the Housing and Urban Development Act of 1965 (12 U.S.C.A. § 1701s), Title V of the Housing Act of 1949 (42 U.S.C.A. § § 1471—1490o) or other Federal housing subsidy statutes.
(7) Uniform Relocation Assistance and Real Property Acquisition Policies. Payment received under Title II of the Uniform Relocation Assistance and Real Property Acquisition Policies of 1970 (42 U.S.C.A. § § 4621—4638).
(8) Job Training Partnership Act. Payments received under the Job Training Partnership Act of 1982 (29 U.S.C.A. § § 1501—1781).
(9) Grants or loans to undergraduate students. Grants or loans to undergraduate students for educational purposes made or insured under programs administered by the Secretary of the United States Department of Education under section 507 of the Higher Education Amendments of 1968 (20 U.S.C.A. § 1060, note and § 1091, note).
(10) Wages, allowances or reimbursement for transportation and attendant care costs received by an eligible handicapped individual under Title VI of the Rehabilitation Act. Wages, allowances or reimbursement for transportation and attendant care costs, unless excepted on a case-by-case basis, when received by an eligible handicapped person employed in a project under section 611(b) and (c) of Title VI of the Rehabilitation Act of 1973 (29 U.S.C.A. § 795(b) and (c)).
(11) Alaska Native Claims Settlement Act. Payments under section 21(a) of the Alaska Native Claims Settlement Act (43 U.S.C.A. § 1620(a)).
(12) Payments based on age and residence in Alaska. Payments made under a program established in Alaska before July 1, 1973, and based solely on length of residence in Alaska and attainment of age 65. This includes money received in accordance with the Alaska longevity bonus which is exempt under section 1612(b)(2)(B) of the Social Security Act (42 U.S.C.A. § 1382(b)(2)(B)).
(13) Indian tribe per capita judgment funds. Per capita judgment funds received by the following Indian tribes:
(i) The Blackfeet and Gros Ventre Tribes under section 4 of the act of March 18, 1972 (Pub. L. 94-540) (90 Stat. 2503) (25 U.S.C.A. § 1264).
(ii) The Grand River Band of Ottawa Indians under the act of October 18, 1976 (Pub. L. 94-540) (90 Stat. 2504).
(iii) Tribes or groups under section 7 of the act of October 9, 1973 (Pub. L. 93-134) (87 Stat. 468) (25 U.S.C.A. § 1407).
(iv) The Yakima Indian Nation or the Apache Tribe of the Mescalero Reservation under section 2 of the act of October 10, 1978 (Pub. L. 95-433) (92 Stat. 1047) (25 U.S.C.A. § 609c-1).
(14) Receipts from land to certain Indian tribes. Receipts from land held in trust by the Federal government and distributed to members of certain Indian tribes under section 6 of the act of October 17, 1975 (Pub. L. 94-114) (89 Stat. 579) (25 U.S.C.A. § 459e).
(15) Payment to volunteers. Payment to volunteers in the Foster Grandparent Program and other similar programs under sections 404(g) and 418 of the Domestic Volunteer Service Act of 1973 (42 U.S.C.A. § § 5044(g) and 5058).
(16) Older Americans Act benefits. Benefits received other than wages or salaries under section 210 of the Older Americans Act of 1965 (42 U.S.C.A. § 3020a).
(17) Retroactive SSI and RSDI payments. Retroactive payments received under Title II or Title XVI of the Social Security Act (42 U.S.C.A. § § 401—433 or 1381—1383c) are exempt for 6 months after the month in which the retroactive payment is received. If a portion of the retroactive payment remains after the exclusion period, it is counted as a resource under section 1613 of the Social Security Act (42 U.S.C.A. § 1382b) under Chapter 178 (relating to resource provisions for categorically NMP-MA and MNO-MA).
(18) Japanese-American and Aleutian restitution payments. Restitution payments made by the United States government to eligible Japanese-Americans and Aleuts who were interned or relocated during World War II. If the eligible Japanese-Americans are deceased at the time of payment, payments will be made to certain of their survivors as specified under the Civil Liberties Act of 1988 (50 App. § § 1989b and 1989b-1—1989b-9). This payment is also excluded. This paragraph does not apply to eligible Aleuts who are covered under the Aleutian and Pribilof Islands Restitution Act (50 App. § § 1989c and 1989c-1—1989c-8). Interest received on retained restitution payments is also not excluded but is subject to the usual regulations governing interest as specified in this chapter.
(19) Agent orange settlement payments. Payments made from the Agent Orange Settlement Fund or another fund established pursuant to the settlement in the agent orange product liability litigation.
(20) Interest from certain burial space arrangements. Interest earned on agreements representing the purchase of burial spaces which are excluded under Chapter 178 (relating to resource provisions for categorically NMP-MA and MNO-MA) if the interest is left to accumulate. Interest that is not left to accumulate is counted as interest income.
Source The provisions of this § 140.271 adopted October 26, 1990, effective October 27, 1990, and apply retroactively to January 1, 1989, 20 Pa.B. 5428; amended March 22, 1991, effective upon publication in the Pennsylvania Bulletin, and applies retroactively to August 10, 1988, 21 Pa.B. 1182; amended August 27, 1993, effective August 28, 1993, with the exception of the Agent Orange Settlement Payments requirement which is retroactive to January 1, 1989, 23 Pa.B. 4071. Immediately preceding text appears at serial pages (153022) to (153024) and (157009).
§ 140.272. Earned income exclusion.
Earned income that does not exceed $10 in a month is excluded if it is irregular or infrequent and received from a single source.
§ 140.273. Unearned income exclusions.
The following do not count when determining income eligibility for Healthy Horizons and shall be excluded in the order listed:
(1) Refund or return of taxes paid on real property. A refund or return from a public agency of taxes paid on real property.
(2) Educational expenses. The amount of a grant, scholarship or fellowship used for paying tuition, fees or other necessary educational expenses.
(3) Home produce. The value of food produced by an applicant/recipient which is used by the applicant/recipient and his household for their own personal consumption and not for sale.
(4) Disaster relief assistance.
(i) Support and maintenance provided as disaster relief assistance, including income-in-kind, received as the result of a catastrophe declared by the President as a major disaster under the Disaster Relief Act of 1974 (42 U.S.C.A. § § 5121—5202) or another Federal statute, if the following conditions are met:
(A) At the time of the catastrophe, the applicant/recipient was living in and maintaining his own home but discontinued living in his home because of the catastrophe.
(B) The applicant/recipient began to receive disaster assistance within 30 days after the last day of the catastrophe.
(C) The applicant/recipient received the disaster assistance while living in a residential facility, including a private household maintained by another person.
(D) The exclusion applies for a period beginning on the date the assistance is received and ending on the last day of the 18th full month following the month the cash was received.
(ii) Other assistance is not counted as income if received under the Disaster Relief Act of 1974 or under Federal law because of a catastrophe which the President declares to be a major disaster.
(5) Interest on disaster relief assistance. Interest earned on disaster relief assistance for a period beginning on the date the assistance is received and ending on the last day of the 9th full month following the month the cash was received. Interest earned for a period beginning on the date the assistance is received and ending on the last day of the 18th full month following the month the cash was received, if the applicant/recipient has good cause for not repairing or replacing the property or contracting for the repairing or replacing the property for which the disaster relief assistance was given.
(6) German reparations payments. Payments made under the Republic of Germany’s Federal Law for Compensation of Nationalist Socialist Persecution—German Restitution Act—to certain survivors of the holocaust. The payments may be made periodically or as a lump sum.
(7) Unearned income not exceeding $20 in a month. Unearned income that does not exceed $20 in a month, if it is received irregularly or infrequently. If the total amount of infrequent or irregular unearned income is received in a month exceeds $20 or the unearned income is received more than once in a quarter, this exclusion is not given.
(8) Periodic payments by a state based solely on residence. Periodic payments made by a state under a program established before July 1, 1973, and based solely on the length of residence and attainment of age 65.
(9) Payments for providing foster care. Payments for providing foster care to a child who is not included as a family member when determining the eligibility of the applicant/recipient and who was placed in the home of the applicant/recipient by a public or private nonprofit child placement or child care agency.
(10) Interest earned on burial funds. Interest earned on burial funds if the burial fund is excluded as a resource under Chapter 178 Subchapter A (relating to general provisions for MA resources common to all categories of MA) and the interest is left to accumulate and become part of the burial fund.
(11) Certain support and maintenance assistance. In-kind support or maintenance assistance benefits furnished in-kind by a certified private, nonprofit organization or furnished as cash or in-kind assistance by a certified supplier of home heating oil or gas, by a certified entity providing home energy whose revenues are primarily derived on a rate-of-return basis and regulated by the Pennsylvania Public Utility Commission or by a certified municipal utility providing home energy. Support and maintenance assistance includes home energy assistance (HEA) and may include payments for heating or cooling, storm doors, weatherization services and blankets. HEA benefits do not include food or clothing.
(12) Interest income. Interest income if it is received only once during a calendar quarter and the total of the interest income plus infrequent or irregular unearned income received in a month in which the interest income is received does not exceed $20.
(13) Property tax and rent rebate payments. Property tax and rent rebate payments and inflation dividend payments received under the Senior Citizens Rebate and Assistance Act (72 P. S. § § 4751-1—4751-12).
(14) Reduction in unearned income to recover a previous overpayment. If unearned income of the applicant/recipient is reduced to cover a previous overpayment, the amount of the reduction is exempt from consideration as current income if the amount of the overpayment was considered in determining financial eligibility for Healthy Horizons at the time the overpayment was received.
(15) Advance payments against expenses of obtaining income. A lump sum advance to cover expenses to obtain income. The advance is considered reimbursement for expenses of obtaining the income.
Cross References This section cited in 55 Pa. Code § 140.261 (relating to benefits, dividends and interest).
DEDUCTIONS FROM INCOME
§ 140.281. Deductions from unearned income.
(a) Unearned income expenses. For each applicant/recipient, the expenses which the applicant/recipient pays to be eligible for, or to receive, unearned income are deducted. These unearned income expenses include attorney fees, court costs and transportation costs. Personal income taxes are not expenses the applicant/recipient had to pay to get this income and are not allowable deductions.
(b) First $20 of income in a month other than income based on need. The first $20 of income received in a calendar month by an applicant/recipient group is deducted after allowable expense deductions in subsection (a) are deducted. The application of the deduction is as follows:
(1) The deduction does not apply to unearned income based on need and funded in whole or in part by the Federal government or by a nongovernment agency.
(2) This exception applies to income based on need and funded wholly by the State.
(3) This deduction applies to veterans benefits received by an applicant/recipient who is a veteran or is a dependent of a veteran on the basis of one of the following:
(i) A special act of Congress.
(ii) Service in the Indian Wars (January 8, 1817—December 31, 1881).
(iii) Service in the Civil War (1861—1865).
(iv) Service in the Spanish-American War (April 12, 1898—July 4, 1902).
(4) The deduction is first applied to the unearned income received by the applicant/recipient.
(5) If the applicant/recipient does not have unearned income or has less than $20 of unearned income in a calendar month, the remaining portion of the $20 deduction is applied to the earned income received in the calendar month under § 140.282(1) (relating to deductions from earned income).
Notes of Decisions Deductions; Conflict with Handbook
Under regulation, unavoidable bank fees, paid to access Social Security Disabilities benefits that are directly deposited into recipient’s account, are deductable expenses from unearned income. Although the Department’s Medical Assistance Eligibility Handbook indicates that they are not deductible, the regulation controls over the handbook, which is purely advisory. Franks v. Department of Public Welfare, 804 A.2d 144 (Pa. Cmwlth. 2002).
Cross References This section cited in 55 Pa. Code § 140.232 (relating to applicable income); 55 Pa. Code § 140.282 (relating to deductions from earned income); and 55 Pa. Code § 140.291 (relating to treatment of lump sum payments).
§ 140.282. Deductions from earned income.
The following amounts are deducted from earned income in the order listed in determining income eligibility:
(1) Portion of $20 monthly deduction not deducted from unearned income. The portion of the $20 monthly deduction in § 140.281(b) (relating to deductions from unearned income) which has not been deducted from unearned income is deducted from earned income in the same month for each applicant/recipient group.
(2) Sixty-five dollars of earned income in a month. An employed applicant/recipient is entitled to an earned income deduction of $65 of his gross earned income per month.
(3) Earned income of a disabled applicant/recipient used to pay impairment-related work expenses. Earned income used by an applicant/recipient who is disabled and 64 years of age or younger to pay impairment-related work expenses is excluded. Impairment-related work expenses include:
(i) Payments for attendant care services if assistance is needed by the applicant/recipient in traveling to and from work, while at work, and at home because of impairment.
(ii) Payments for a medical device if the applicant/recipient’s impairment requires use of the device to work.
(iii) Payments for a prosthetic device if the applicant/recipient’s impairment requires the use of the prosthetic device to work.
(iv) Payments for impairment related nonmedical appliances and equipment and residential modifications needed by the applicant/recipient for employment.
(v) Payments for drugs, medical services and prescribed medical supplies if necessary to the applicant/recipient to control the impairment.
(vi) Payments for installing, maintaining and repairing the items listed in subparagraphs (i)—(v) that are necessary for the applicant/recipient’s employment.
(vii) Payments for similar items and services not listed in subparagraphs (i)—(vi) which are directly related to the applicant/recipient’s impairment and needed by the applicant/recipient to work.
(4) One-half of remaining earned income in a month. An employed applicant/recipient is entitled to a deduction of one-half of the remaining earned income after the deduction in paragraph (2) and when applicable, the deductions in paragraphs (1) and (3).
Cross References This section cited in 55 Pa. Code § 140.232 (relating to applicable income); and 55 Pa. Code § 140.291 (relating to treatment of lump sum payments).
§ 140.283. Deductions from self-employment.
For each self-employed person, the verified costs to produce or continue the income are deducted. The deductible costs include expenses reported on the Federal income tax return except depreciation, personal business, entertainment expenses and depletion.
Cross References This section cited in 55 Pa. Code § 140.232 (relating to applicable income).
§ 140.284. Guardian fee deductions.
Guardian fees are deducted from earned or unearned income if having a guardian is a requirement for receiving the income.
Cross References This section cited in 55 Pa. Code § 140.232 (relating to applicable income).
§ 140.285. Deductions from rental income.
(a) Expense deductions from rental income include:
(1) Necessary expenses paid for the production or collection of the rental income.
(2) Real estate insurance costs related to the rental property, whether or not the mortgage holder requires the insurance.
(3) The interest portion of a mortgage payment.
(4) A repair which is an incidental correction to an existing structure, or to a piece of equipment.
(b) Items such as depreciation or depletion, personal expenses which are not related to the rental income and capital expenditures are not allowable deduc tions. A capital expenditure represents an expenditure for an addition or increase in the value of fixed assets, and is subject to depreciation for income tax purposes.
(c) Allowable expenses are prorated if only a portion of the total property is designated for rent, regardless of whether it is actually rented.
Cross References This section cited in 55 Pa. Code § 140.232 (relating to applicable income); and 55 Pa. Code § 140.265 (relating to profit from rental property income).
TREATMENT OF LUMP SUM PAYMENTS
§ 140.291. Treatment of lump sum payment.
(a) A lump sum payment is a nonrecurring payment. Types of lump sum payments include delayed wages, bonuses, earned income tax credit (EITC), cash prizes, cash lottery winnings, life insurance benefits, cash inheritances, personal injury and other damage awards and settlements and retroactive benefits, such as retirement, survivors and disability insurance, delayed unemployment compensation and workers compensation.
(b) A lump sum payment is counted as a resource under Chapter 178, Subchapter A (relating to general provisions for MA resources common to all categories of MA) unless it would be more helpful to the applicant/recipient group to have the lump sum treated as income.
(c) If the lump sum is treated as income, it is counted as income in the calendar month received.
(1) An earned lump sum such as delayed wages, bonuses and EITC is treated as earned income and is added to other earned income received in the calendar month. The deductions listed under § 140.282 (relating to deductions from earned income) are applied to determine countable net earned income.
(2) An unearned lump sum such as cash prizes, cash lottery winnings, life insurance benefits, cash inheritances and personal injury is treated as unearned income and is added to other unearned income received in the calendar month. The deductions listed under § 140.281 (relating to deductions from unearned income) are applied to determine countable net unearned income.
(d) The balance of the lump sum remaining subsequent to the calendar month the lump sum was received and counted as income as described in subsection (c) is considered a resource to the applicant/recipient or the spouse of the applicant/recipient.
Authority The provisions of this § 140.291 amended under section 201(2) of the Public Welfare Code (55 P. S. § 201(2)).
Source The provisions of this § 140.291 amended September 10, 1999, effective September 11, 1999, 29 Pa.B. 4784. Immediately preceding text appears at serial page (216199).
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).
Authority The provisions of this § 140.301 amended under sections 201(2) and 403(b) of the Public Welfare Code (62 P. S. § § 201(2) and 403(b)).
Source The provisions of this § 140.301 amended May 24, 1996, effective May 25, 1996, and apply retroactively to January 1, 1993, for the SLMB Medicare Cost-Sharing Program for persons whose income does not exceed 110% of the FPIGs, and retroactively to January 1, 1995, for persons whose income does not exceed 120% of the FPIGs, 26 Pa.B. 2412; amended December 30, 1999, effective January 1, 2000, 30 Pa.B. 15. Immediately preceding text appears at serial page (259598).
Cross References This section cited in 55 Pa. Code § 140.202 (relating to definitions).
§ 140.305. Resources of children under 21 years of age and families with children under 21 years of age.
The resources of the Healthy Horizons child under 21 years of age and the Healthy Horizons applicant/recipient immediate families with children under 21 years of age are excluded. If the child who is under 21 years of age is living with a care-taker who is not immediate family as defined in § 140.202 (relating to definitions) and who exercises care and control of the child, the resources of the caretaker are excluded.
Authority The provisions of this § 140.305 issued under sections 201(2) and 403(b) of the Public Welfare Code (62 P. S. § § 201(2) and 403(b)).
Source The provisions of this § 140.305 adopted June 15, 2001, effective June 16, 2001, 31 Pa.B. 3196.
VERIFICATION REQUIREMENTS
§ 140.311. Verification requirements.
(a) Verification requirements under Healthy Horizons are as follows:
(1) Verification of income. Verification of income is required prior to the authorization of Healthy Horizons benefits. However, an applicant/recipient may not be denied MA under the Healthy Horizons Program for lack of verification if the applicant/recipient has cooperated in the verification attempt under Chapter 125 (relating to the application process) and § 133.73 (relating to requirements).
(2) Verification of resources. Verification of ownership, the value of resources and the disposition of resources is required of an applicant/recipient or the person acting on behalf of the applicant/recipient including guardians and trustees under § 178.3 (relating to resource reporting and verification for all categories of MA).
(3) Verification of qualified Medicare beneficiary status. The Medicare Part A Card is considered verification of qualified Medicare beneficiary status.
(b) Under the Healthy Horizons Categorically Needy Program, the following verification is also required:
(1) Verification of age.
(i) Documentation verifying the date of birth for persons 65 years of age or older is required. Benefits may be authorized if the stated date of birth appears to be reasonable. The applicant/recipient is required to provide verification of age within 30 days from the date of authorization.
(ii) Documentation of date of birth is not required if previously verified and properly notated in the case record unless a discrepancy exists.
(2) Verification of disability.
(i) Recipient of Social Security Disability Benefits or disability benefits based on SSI disability criteria is considered verification of disability.
(ii) If the applicant is not receiving disability benefits, the following shall be submitted:
(A) Medical verification of a disability which meets the SSI disability criteria.
(B) Proof that the person has applied for disability benefits and is awaiting a decision.
REDETERMINATION/REAPPLICATION
REQUIREMENTS
§ 140.321. Redetermination/reapplication requirements.
The redetermination/reapplication requirements in Chapter 133 (relating to redetermining eligibility) apply.
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.
Authority The provisions of this § 140.331 amended under sections 201(2) and 403(b) of the Public Welfare Code (62 P. S. § § 201(2) and 403(b)).
Source The provisions of this § 140.331 amended May 24, 1996, effective May 25, 1996, and apply retroactively to January 1, 1993, for the SLMB Medicare Cost-Sharing Program for persons whose income does not exceed 110% of the FPIGs, and retroactively to January 1, 1995, for persons whose income does not exceed 120% of the FPIGs, 26 Pa.B. 2412; amended December 30, 1999, effective January 1, 2000, 30 Pa.B. 15. Immediately preceding text appears at serial pages (216201) to (216202).
§ 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.
Authority The provisions of this § 140.332 amended under sections 201(2) and 403(b) of the Public Welfare Code (62 P. S. § § 201(2) and 403(b)).
Source The provisions of this § 140.332 amended May 24, 1996, effective May 25, 1996, and apply retroactively to January 1, 1993, for the SLMB Medicare Cost-Sharing Program for persons whose income does not exceed 110% of the FPIGs, and retroactively to January 1, 1995, for persons whose income does not exceed 120% of the FPIGs, 26 Pa.B. 2412; amended December 30, 1999, effective January 1, 2000, 30 Pa.B. 15. Immediately preceding text appears at serial page (216202).
§ 140.333. Eligibility begin date.
The eligibility begin date may be the date the application is signed or the date the signed application is date stamped by the CAO.
§ 140.334. Eligibility end date.
(a) Eligibility ends, following proper notification, on the date that eligibility conditions are no longer met.
(b) When benefits are terminated due to increased income or resources, or because the applicant/recipient is no longer considered disabled, eligibility for continuing MA coverage under the MNO-MA Program is explored. If the individual is determined eligible, MA benefits are continued under the MNO Program with no interruption in MA coverage.
§ 140.335. Retroactive eligibility.
(a) The earliest possible date for retroactive Healthy Horizons Categorically Needy benefits to begin is the first day of the third month preceding the month of application. The period of eligibility for retroactive Healthy Horizons Categorically Needy benefits begins the first day of the month in which the first medical service was incurred if the applicant was otherwise eligible during that month.
(b) There is no retroactive coverage under the Healthy Horizons QMB Medicare Cost-Sharing Program, but eligibility for the SLMB Medicare Cost-Sharing Program may be retroactive for up to 3 months.
Source The provisions of this § 140.335 amended May 24, 1996, effective May 25, 1996, and apply retroactively to January 1, 1993, for the SLMB Medicare Cost-Sharing Program for persons whose income does not exceed 110% of the FPIGs, and retroactively to January 1, 1995, for persons whose income does not exceed 120% of the FPIGs, 26 Pa.B. 2412. Immediately preceding text appears at serial page (211610).
§ 140.336. Notification of eligibility/ineligibility.
The applicant is notified in writing regarding eligibility/ineligibility for benefits under the Healthy Horizons Categorically Needy Program.
§ 140.337. Notification of termination.
The recipient is given advance notice in writing issued at least 10 days prior to the termination date.
Notes of Decisions Increased Resources
The Department properly terminated recipient’s Medical Assistance after she received disability insurance proceeds that caused her resources to exceed the applicable eligibility limit. Filoon v. Department of Public Welfare, 819 A.2d 188 (Pa. Cmwlth. 2003).
RIGHT TO APPEAL/FAIR HEARING
§ 140.341. Appeal and fair hearing.
The applicant/recipient is entitled to the appeal and fair hearing rights under Chapter 275 (relating to appeal and fair hearing and administrative disqualification hearings).
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