Subchapter D. ELIGIBILITY PROVISIONS UNDER THE MEDICAID
FOR CHILDREN WITH SPECIAL NEEDS CATEGORY
GENERAL ELIGIBILITY PROVISIONS Sec.
140.601. Policy.
140.602. Definitions.
140.603. Conditions of MA eligibility.
140.604. Premiums.
Authority The provisions of this Subchapter D issued under sections 201(2), 403(b), 447(c) and 454 of the Public Welfare Code (62 P. S. § § 201(2), 403(b), 447(c) and 454), unless otherwise noted.
Source The provisions of this Subchapter D adopted upon receipt of written notification that the United States Department of Health and Human Services has granted the waiver requested by the Department under section 1115 of the Social Security Act, the Department will publish notice thereof in the Pennsylvania Bulletin. The regulations adopted by this order become effective 30 days after receipt of the Federal waiver, 35 Pa.B. 7013, unless otherwise noted.
GENERAL ELIGIBILITY REQUIREMENTS
§ 140.601. Policy.
(a) A child who meets the disability criteria as defined by section 1614 of the Social Security Act (42 U.S.C.A. § 1382c) and who is not receiving benefits under Title XVI of the Social Security Act (42 U.S.C.A. § § 1381—1383f), may qualify for MA benefits under this subchapter. MA will be provided in the Medicaid for Children with Special Needs Category only if the child does not qualify in any other category of MA.
(b) Unless there is a provision to the contrary in this subchapter, Subchapter B (relating to eligibility provisions for the healthy horizons program for the elderly/disabled) applies.
§ 140.602. Definitions.
The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise:
Applicant or recipient—A child who meets the eligibility conditions of this subchapter.
Child—An individual under 18 years of age.
Custodial parent—The natural or adoptive mother or father living with an applicant or recipient.
Family size—Includes custodial parent, step-parent, applicant or recipient, siblings of the applicant or recipient and other dependents of the custodial parents listed on the custodial parent’s Federal Income Tax Return of the previous calendar year.§ 140.603. Conditions of MA eligibility.
(a) An applicant or recipient shall meet the eligibility provisions of Subchapter B (relating to eligibility provisions for the healthy horizons program for the elderly/disabled) except the following types of income are not counted:
(1) Court-ordered child support.
(2) Retirement, Survivor’s, Disability Insurance (RSDI) benefits received from the Social Security Administration by the applicant or recipient.
(b) The applicant or recipient shall meet the following eligibility provisions:
(1) Chapter 125 (relating to application process).
(2) Chapter 148 (relating to MA residence provisions for categorically needy NMP-MA and MNO-MA).
(3) Chapter 150 (relating to citizenship and alienage provisions for categorically needy NMP-MA and MNO-MA).
(4) Chapter 155 (relating to enumeration).
(5) Chapter 255 (relating to restitution).
(c) The custodial parent shall report and verify earned and unearned income and allowable medical and dental expense deductions specified in § 140.604(b) (relating to premiums).
(1) 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.
(2) 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.
(3) 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:
(i) Pay stubs.
(ii) Pay envelopes.
(iii) Statement by the employer.
(iv) Other documentary proof of the income of the custodial parent.
(d) An applicant or recipient is ineligible for MA if the custodial parent does not report or verify earned or unearned income.
Cross References This section cited in 55 Pa. Code § 140.604 (relating to premiums).
§ 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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