§ 181.13. Eligibility under NMP-MA spend-down.
(a) Eligibility under NMP-MA spend-down is available to an applicant/recipient except for an applicant/recipient receiving skilled nursing care or intermediate care.
(b) The applicant/recipient shall meet the NMP-MA eligibility criteria, including the income criteria, to qualify for NMP-MA spend-down.
(c) The period of NMP-MA spend-down eligibility begins the day of the calendar month in which eligibility for NMP-MA spend-down is established and continues through the last day of that calendar month.
(d) Income eligibility for NMP-MA spend-down exists when the applicant’s/recipient’s:
(1) Countable net income less $10 is equal to, or less than, the appropriate NMP-MA income limits in Appendix A for the aged, blind and disabled categories not receiving skilled nursing care or intermediate care.
(2) Countable net income less $10 and medical expenses in subsection (e) is equal to, or less than, the appropriate NMP-MA income limits in Appendix A for the aged, blind and disabled categories not receiving skilled nursing care or intermediate care.
(3) Countable net income less $10 is equal to, or less than, the appropriate NMP-MA income limits in Appendix C for the AFDC categories and the GA categories not receiving skilled nursing care or intermediate care.
(4) Countable net income less $10 and medical expenses in subsection (f) is equal to, or less than, the appropriate NMP-MA income limits in Appendix C for the AFDC categories and the GA categories not receiving skilled nursing care or intermediate care.
(e) 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 NMP-MA Program once NMP-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 requirements in this paragraph. The paid medical expenses:
(i) Are paid in the calendar month for which spend-down is requested.
(ii) Have not previously been used as a deduction in the determination of eligibility for a prior authorization of MA.
(f) Medical expenses meeting the requirements in subsection (e) are deducted in the calendar month for which spend-down is requested 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 required by the Department. 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.
(3) Expenses incurred—paid and unpaid—by the applicant/recipient for necessary medical and remedial services recognized under State statutes or regulations but not included in the NMP-MA Program.
(4) Expenses incurred—paid and unpaid—by the applicant/recipient for necessary medical and remedial services that are included in the NMP-MA Program.
(g) A monthly review of eligibility for NMP-MA spend-down is required except when the countable net income less $10 is equal to, or less than, the appropriate income limit. A monthly review does not require a reapplication unless:
(1) The monthly review falls in the month that a complete reapplication of eligibility for NMP-MA is due.
(2) Three consecutive months have elapsed since the applicant/recipient requested a determination of eligibility for NMP-MA spend-down.
Authority The provisions of this § 181.13 issued under section 403(b) of the Public Welfare Code (62 P. S. § 403(b)).
Source The provisions of this § 181.13 adopted August 26, 1988, effective November 1, 1988, 18 Pa.B. 3949.
Cross References This section cited in 55 Pa. Code § 181.11 (relating to continuing eligibility).
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