Temporary Assistance for Needy Families

Medical Assistance in Pennsylvania:

Staff Training Part I

The Health, Education and Legal Assistance Project:A Medical-Legal Partnership betweenWidener University School and Law and Crozer-Keystone Healthy Start

(HELP: MLP-CKHS)

Medical Assistance (MA)

• Medical Assistance (also known as Medicaid or MA) is medical coverage provided through the Pennsylvania Department of Public Welfare (DPW) to certain people with low incomes and limited resources.

• In order to be eligible for MA, it is not enough to have a low income and low resources. The individual or family must also fit within one of a variety of categories.– The services for which MA pays also varies depending on what

category of MA the person fits.– The amount of income and resources an individual or family can

have and still be eligible for MA varies, depending upon what category of MA the person or family fits.

• There are also special rules for non-citizens.


• People who get MA either receive services in the traditional fee- for-service (FFS) model, or, as is becoming more and more common, are enrolled in a Medicaid Health Maintenance Organization (HMO).

• There is also a system called Access Plus. This system combines access of the managed care system with parts of the traditional fee-for- service program. Every Medicaid recipient receives a yellow plastic medical card known as an ACCESS card; Recipients who are in an HMO also get a card, such as Health Partners or Keystone-Mercy.


• There are also limits on the amount and types of services that individuals on MA can receive.– These limits include restrictions on the number of doctor

visits, hospitalizations, and prescriptions.• MA recipients are also subject to co-pay requirements,

including for prescriptions.• The precise contours of these limits and restrictions vary

depending upon the individual's MA category and whether the individual receives services through fee for service (FFS), a managed care organization (MCO) or Access Plus.

• It is therefore very important not only to help a Healthy Start participant/HELP: MLP client in obtaining MA, but also to determine the MA category with the most extensive services and benefits.


• When someone applies for MA benefits, DPW caseworkers are supposed to consider eligibility under every category before they deny an application.

• Similarly, when somebody is already on MA, and their ongoing eligibility in their current category is in question, before terminating MA because the individual loses eligibility in that one category, DPW must check to determine if the individual is eligible in a different category– Note, however, that caseworkers often do not do this.– Do not assume that a caseworker is right if he or she tells you that an

MA applicant is not eligible for benefits. Get more information, and find out whether or not the applicant has been screened for every MA category.

• When dealing with an individual who is already a benefit recipient now facing a termination, the individual should be advised to file an appeal immediately within 10 days of receipt of a termination notice so that her benefits can continue while the appeal is pending.


• Application process – 3 options:– Apply in person at the local welfare office

• Bring all the paperwork documenting identity (such as birth certificate, Social Security card, driver’s license, etc.) and residence (such as a lease, rent receipts, bills in her name, etc.)

– Proof of income– DPW can help pay for out-of-state birth certificates and other required

documentation if necessary– Proof of citizenship/immigrant status

» Note: immigrants do not necessarily need to supply birth certificates• Do not delay application on account of missing documents; bring as

much as you have and supply the remaining documents later– Fill out application at home and mail

• Adults = PA 600 form• Children = PA 600CH

– Apply online through DPW’s COMPASS website

Medical Assistance (MA):Categories of Eligibility

• In addition to meeting the income, resource and citizenship requirements, MA applicants must fit into one of the following categories:

– Pregnant women– Children– Households with TANF-eligible children– Eligible custodial parent– Eligible parents in a two-parent household with child(ren)– Caretaker of ill or disabled household member or non-parental caretaker of

child– Families with Extended Medical Coverage (EMC)– SSI, TANF and GA recipients– Victims of domestic violence receiving protective services– Participants in drug & alcohol treatment– Seniors 65 and older– Adults 59-64– Persons with disabilities– Individuals with breast or cervical cancer– Persons requiring health-sustaining medications– Adults working 100 hours per month


• People who get or are eligible for Cash Assistance (TANF or GA) or SSI (Supplemental Security Income)

– Temporary Assistance for Needy Families (TANF)• A cash assistance program for pregnant women and families, is

a federally-funded program.– General Assistance (GA)

• Provides cash to certain categories of people, including adults with disabilities, children living with non-relatives, certain people in drug and alcohol treatment programs, some survivors of domestic violence, and others.

– Supplemental Security Income (SSI)• A means-tested public benefit for people who are poor and

disabled



– Families who receive TANF automatically receive MA.• This includes the qualifying parent(s) and all children in the physical

custody of (living with) the parent who is the head of the family budget group.

– Most people who receive GA get it because they are temporarily or permanently disabled.

• This includes individuals who are receiving GA while waiting for their SSI or SSDI claims to be decided.

• Individuals who receive General Assistance (GA) may be eligible for a better package of MA benefits if they are permanently disabled or temporarily disabled for more than twelve months.

– Where applicable, have a doctor check the appropriate box on the Employability Assessment Form (EAF) (PA 1663), indicating that the individual is permanently disabled or temporarily disabled for more than twelve months

Medical Assistance (MA): Categories of Eligibility


– A person who receives any amount of SSI automatically gets MA.

• This includes people who get some SSI and some Social Security Disability, or who are working but do not earn enough to lose their SSI.

– Individuals who lose their SSI because they are working despite their disability and make too much to get an SSI check can often keep their MA despite their income.

• This group of individuals often gets missed by DPW. The Social Security office can help these clients to keep their coverage.

• The toll free number for the Social Security Administration is 1-800-772-1213.


• People who get or are eligible for Cash Assistance (TANF or GA) or SSI (Supplemental Security Income) (cont.)

– People who would be eligible for a Cash Assistance but have chosen not to receive it are also eligible for MA. This category is called Non Money Payment (NMP).

– These individuals can be eligible based on the criteria for GA, TANF or SSI.


• Children and pregnant women:

Healthy Beginnings– There are three separate income categories under

Healthy Beginnings.– For each of these categories DPW will count the

parent's income when deciding if the minor child is eligible:

(1)Pregnant women and children under age one(2)Children age one through five(3)Children from six up to age 19.



Healthy Beginnings

– Pregnant women can qualify if their income is less than 185% of the federal poverty guidelines

• In 2011, this is $2,268 a month or less for a family of two.– A pregnant woman counts as two people for purposes of MA

eligibility.

– This coverage ends the last day of the month in which the 60 day postpartum period ends.

• Example: mom gives birth on February 16. Healthy Beginnings eligibility ends for mom on April 30.



Healthy Beginnings– A child up to age one can qualify if the child

and parents’ income is less than 185% of the federal poverty guidelines

• In 2011, this is $2,268 for a family of two.

– Note that if the mother qualifies for MA as a pregnant woman, the child born to her is automatically eligible for MA for one year, regardless of any change in family income.



Healthy Beginnings– A child age one through five can qualify if the child

and parent’s income is less than 133% of the federal poverty guidelines


– A child aged six through 18 can qualify, if the child and parent’s income is less than 100% of the federal poverty guidelines




Healthy Beginnings– NOTE: For children age 18 and under 21 who do

not qualify for Healthy Beginnings because of their parents’ income, consider eligibility under the Medically Needy Only (MNO) category

• Under MNO, the parents’ income is not automatically included in determining eligibility for 18 to 21-year-olds.

– An individual qualifies for MNO if:• Income is $425 per month or less• Resources for one person cannot exceed $2400



Healthy Beginnings– IMPORTANT REMINDER: For families who have

received TANF or TANF-related NMP MA in one of the four previous calendar months, 50% of the earned income is disregarded in determining the child’s eligibility for MA under the Healthy Beginnings program.

– This 50% disregard is important to retain eligibility for children in families who lose TANF or TANF-related MA eligibility due to increased earnings.

• Also, remember that there is no resource test in the Healthy Beginnings program.


• Children– In addition to Healthy Beginnings MA, Pennsylvania has another

program that provides free or low-cost health insurance to children whose income is too high to qualify for MA.

– The program is called CHIP (Children’s Health Insurance Program). It is administered by the Department of Insurance.

– The income limit for free CHIP is 200% of poverty.• In 2011, $2,452 per month for a family of two

– Families with incomes more than 200% of poverty, but less than 300% may qualify for low cost CHIP.

• In 2011, $4290 per month for a family of two

– For more information call 800-464-KIDS or consult with the HELP: MLP attorney.


• Children

– Children in families from 200% to 300% of the poverty guidelines will qualify for CHIP with a monthly premium ranging from $38 to $60 per month.

– Children in families with an income greater than 300% of poverty will be eligible for CHIP with a monthly premium of $150 if they do not have other affordable and available coverage.

• They will also have various co-pay requirements.


• People leaving welfare for work:

Extended Medical Coverage (EMC)– Families who lose their eligibility for Cash Assistance under TANF

because of earnings are usually still eligible for MA for one year under the EMC program.

• This applies as well to TANF-related Non Money Payment (NMP) MA.– For the first six months after TANF stops, the family is eligible for

EMC regardless of their income.– For the second six months, the family is eligible as long as their

monthly income is below 185% of the poverty level.• As of 2011, 185% is $2,268 a month for two people. For three people,

the 2011 limit is $2,857 a month.– DPW caseworkers frequently miss this category, especially for

families who were not receiving cash but were only receiving TANF-related Non Money Payment MA.


• People who are elderly or disabled, but who do not receive SSI:

Healthy Horizons– Many people who are severely disabled or 65 years of age

or older do not get SSI, usually because their incomes are too high.

• i.e., people who are getting Social Security Disability or Retirement, Workers’ Compensation, Veterans benefits or a pension, in an amount too high to qualify for SSI.

– Under the Healthy Horizons MA program, people who are severely disabled (i.e. their disability meets the SSI standard for disability) or who are 65 years of age or over may be eligible for full MA coverage, if they meet these criteria:

• Their countable income does not exceed 100% of the federal poverty guidelines for their family size (Family of two, 2011 = $1226/month).

• The resource limit is $2,000 for an individual and $3,000 for a couple.



Healthy Horizons– In order to apply for HH, applicant must submit an

Employability Assessment Form (EAF) certifying that she is either permanently disabled or temporarily disabled for more than 12 months.

• Note: this applies to clients who are not already receiving Social Security Disability (SSD) benefits. Clients who are receiving SSD benefits will not need to submit an EAF.

• Sample EAF.



Healthy Horizons

– For the year 2011, the income limit for one person for Healthy Horizons is $908 a month plus a $20 per-person deduction, making the income limit for a single person $888.

• The limit for a two-person family is $1,226 a month plus the $20 deduction.

– DPW will also allow you to deduct certain expenses you pay in order to get the income, such as transportation costs, reasonable bank fees or attorney’s fees.

• Reasonable bank fees include low balance fees, account fees and ATM charges.

– In addition, if the Healthy Horizons applicant or spouse has earned income, less than half of that income counts. Specifically, the first $65 of earned income is disregarded, plus 50% of the remaining earned income!



Healthy Horizons– Example: Ms. A is disabled and receives $400 per month in

Social Security benefits. She also works and earns $700 per month. Ms. A’s countable income for Healthy Horizons is $400 (minus the $20 general disregard) plus $700 - $65 ($635), less 50% ($317.50), which is $380 plus $317.50 for a monthly total of $697.50. That is less than the limit for a one person family and Ms. A is eligible for MA under the Healthy Horizons program.

– Note: DPW often incorrectly counts income in evaluating eligibility for Healthy Horizons, especially if the applicant or spouse is working.


• Disabled Children who do not receive SSI because of parental income

– Children who are disabled enough to meet the SSI disability test but who can not get SSI because their parents’ income is too high are eligible for MA regardless of the parents’ income.

• In determining eligibility under this category, the disabled child’s own income is counted, except for child support and Social Security survivors’ or dependents’ benefits

• This is a big help for families who have children with special medical needs!


• ADULTS: People who need certain medications in order to be able to work:

Health Sustaining Medications– This special category is for people who are not disabled, but who

need health sustaining medications to be able to work.– In order to qualify under this category, the participant’s doctor must

complete a form indicating that she is able to work but only with the help of health sustaining medications.

• Example: the person with diabetes who needs insulin but is able to work if she gets it.

– The income limits for this program are very low – the same as GA.• For a one person family, the monthly income limit ranges from $174 to

$215.• For a two-person family, the limit ranges from $279 to $330.• It is possible to become eligible for this program through a “spend-

down” (to be discussed later).


• Low-income households with “TANF-eligible dependent children”

– Eligible for MA, if:• You are responsible for a “TANF-eligible

dependent child”• You are a “specified relative,” and• You meet the income eligibility requirements

– NO resource test in this category – only income counts!


• Low-income households with TANF-eligible dependent children– “TANF-eligible dependent child” defined:

• A child must meet the following criteria for the adult in the household to be eligible for MA:

– Child is under age 18 or 18 and a full-time student in high school, vocational or technical school, AND

– Meets one of the TANF “deprivation of support” conditions:» One or both biological parents are continuously absent» A parent is incapacitated or impaired, OR» The parent is “unemployed,” meaning:

has no work has work in which the net income is lower than the NMP limit has work in which the net income is lower than the MNO limit has “on the job training” in an approved project or program


• Low-income households with TANF-eligible dependent children

– A “specified relative” is an adult who:(1) Is related to the child

(2) Exercises responsibility for the care and control of the child, AND

(3) Lives with the child or is in the process of setting up a home where the child will live within 30 days


• ADULTS: MA for parents in a two-parent household

– If the child in the household does not qualify for TANF (i.e., does not meet the deprivation of support criteria), parents in a two-parent household with a child under 13 years old OR 13 or older and disabled may be eligible for MA, if

• The child is under 13 or is a verified disabled child (i.e., receives Social Security Disability [SSD] or Supplemental Security Income [SSI])

• Both parents must reside in the same household; they need not be married, but paternity must be established

– The income limits are LOW for this category; approx. $205 for a single person.

• BUT, can become eligible through “spend-down” option (we will cover this category later).


• ADULTS: MA for custodial parent exercising care and control of a dependent child

– Custodial parents exercising care and control of a dependent child (natural or adoptive) under 21 years of age may be eligible for MA

• In those cases where both parents of a child reside in the household, an unmarried parent may receive MA without having the other parent’s income deemed to her/him

• Eligibility will be in the MNO category, which does not cover prescription drugs or most durable medical equipment


• ADULTS: MA for caretakers of ill or disabled or for non-relative children under 13

– May be eligible for MA if caring for someone in the home who is:• Ill or disabled (child or adult), or• Under 13 years old and not a relative

– In order to qualify as a caretaker for an ill/disabled person, one must:

• Get a note from a physician indicating that the person being cared for is “ill or disabled” (can also be proven with SSI/SSD receipts)

• Get a doctor to describe in the note the kind of care that the individual needs (i.e., feeding, bathing or safety), AND

• Show that there is no one else in the household who is able to perform the caretaking task (i.e., pay stubs from others who are working)


• Adults without children and who are not disabled: Medically Needy Only (MNO) Category

– Low-income adults who are not taking care of children and are not disabled have a really difficult time qualifying for MA.

– Single adults who do not qualify for cash under any of the General Assistance categories are only eligible for MA if they are in one of several narrowly-defined groups and meet strict income limits.

– Except for children, people who get MA under the MNO program do not have coverage for prescriptions, medical supplies and equipment or dental services.

• Therefore, MNO is the program of last resort.


• Adults without children and who are not disabled – Medically Needy Only (MNO)

– The income limits for MNO are determined by looking at the person’s income over a six-month period.

– As of 2011, the income limit for one person for six months is $2,550 (or $425 a month); for two people the limit is $2,650 (or about $442 a month).


• Adults without children and who are not disabled: Medically Needy Only (MNO)

– In addition to meeting the income test, the applicant must show that s/he is in one of the relevant categories, including:

• Age 59 or over, but under age 65– remember that those 65 or older fit in the Healthy Horizons

• 21-58 years old and working 100 hours per month (each month of the six month eligibility period) and earning at least minimum wage

• Refugees in their first eight months in the United States– but only consider MNO if they do not qualify for any other type of

MA

• Children under age 21– pay particular attention to children age 18-21 whose parents’

income is too high for them to get Healthy Beginnings

• Parents with children– but only consider MNO if they do not qualify for any other type of

MA


• Victims of domestic violence who are receiving protective services

– Eligible for MA in the Non Money Payment (NMP) Category if:

• Receiving domestic violence protective services, AND• Meet the citizenship, resource and income requirements.

– 9 month lifetime limit for eligibility under this category.

– Explore possibility of eligibility in another MA category first!


• Participants in drug and alcohol treatment programs

– Eligible for MA in the Non Money Payment (NMP) category if:

• Undergoing active treatment for drugs or alcohol, and

• Participation in the treatment program precludes employment, and

• The program is licensed and approved by the Department of Health or is administered by an agency of the federal government, AND

• Meet the citizenship, resource and income requirements.

– 9 month lifetime limit for eligibility under this category.– Explore possibility of eligibility in another MA category first!


• Breast and Cervical Cancer Prevention and Treatment Program (BCCPTP)– Full MA coverage is available to uninsured women under 65

with cancer or pre-cancerous conditions of the breast or cervix.

– The income guidelines for this program are significantly higher than that for most other MA programs – 250% of the federal poverty level

• In 2011, this is $2,269 per month for a household of one.

– There is no resource limit!– Applications are handled through the Healthy Woman

Program rather than DPW.– Coverage lasts so long as the individual is receiving

treatment and can be extended beyond the initial period.


• Medical Assistance for Workers With Disabilities (MAWD)– A health insurance program for individuals who are disabled AND

who are working.– Persons accepted into the MAWD program get full MA benefits,

including full prescription coverage, by paying a monthly premium of 5% of their countable income.

– MAWD can be your only insurance (if you have no coverage) or it can be a secondary insurance (if you have some coverage that doesn’t cover all of your healthcare needs).

– To qualify:• Must be between the ages of 16-64• Have an illness or condition that meets Social Security’s definition of

“disability”• Must be working and earning a wage (traditionally has not mattered

how many hours or how little money you make; recently, DPW cracking down in some counties, wanting more formality than before; be aware)

• Must have a countable income less than 250% of the federal poverty guidelines (in 2011, that’s $2260/month for one person or $3065/month for a family of two), and

• Have countable assets valued at less than $10,000.


• Medical Assistance for Workers With Disabilities (MAWD)– MAWD covers two groups:

1) Individuals who receive SSD or who do not receive SSD but who are disabled under the Social Security standard and who work even a few hours per month may be eligible.

• This work can be informal for a friend or relative as long as it performed and payment is made.

• Note recent DPW crackdowns, however.

2) Individuals who previously received SSD (or who did not receive SS benefits but were previously disabled using the same disability standard), but whose conditions have improved and now work at least 40 hours per month may also be eligible.


• Medical Assistance for Workers With Disabilities (MAWD)– The cost of the coverage is 5% of the individual's

“countable” income.• Reminder – less than one half of the individual's earned

income counts in determining “countable” income.– The MAWD program uses the same income counting rules

as the Healthy Horizons program, but with a much higher allowable income.

– If eligible, the individual receives full MA coverage including prescriptions and dental!


• Spending down to eligibility (“Spend-down”)– Spend-down is a category that allows individuals who would

otherwise be ineligible for MA due to excess income, to become eligible for MA.

– To use spend-down, you must satisfy all other requirements for a a particular MA category (i.e., pregnant, disabled, etc.), except for that category’s income limit.

– How it works: medical expenses (ongoing and sometimes retroactive) can be deducted from your income for MA eligibility purposes.

• Once the medical expense deductions bring your income under the limit for the MA category for which you are applying, MA will pay your remaining medical bills either for one month or for a six month period, depending upon the type of spend-down for which you qualify.

• Please note that under spend-down, MA will not pay for the bills that were used to meet the spend-down.


• Spending down to eligibility (“Spend-down”) - There are two kinds of spend-down:

– Type 1: NMP (Non Money Payment)• Submit your application for MA and the worker at the County

Assistance Office will tell you your monthly spend-down amount.• Each month you will need to send in receipts, bills, etc. showing that

you have been billed for or paid the amount in medical expenses for which you are responsible.

– These expenses include insurance premiums, prescriptions costs, etc.

• For the remainder of the month, MA will pay your medical expenses.– Please note: MA will not pay for the expenses that were used to meet

the spenddown.

• Also note: NMP MA does cover prescription drugs and most durable medical equipment.


• Spending down to eligibility (“Spend-down”) - There are two kinds of spend-down:

– Type 2: MNO (Medically Needy Only)• At the time you submit your application, your eligibility is

determined for a six month period.• This period can be retroactive for up to three months, so this

option may be beneficial if you owe back bills (e.g., a hospitalization).

• The income limits are higher under MNO than NMP; however, please note: MNO does not cover prescriptions nor most durable medical equipment!


• For ongoing questions, consultations or participant referrals:

– Contact Laura Handel, HELP: MLP/HS Staff Attorney• Phone: 610-497-7355• E-mail: [email protected]• Referrals can be placed in my bin in the Healthy Start office, or• Just come knock on my door; I’d love to see you!

• Stay tuned for Medical Assistance Staff Training Part II, where we will cover issues such as:

– What services MA will (and may not) cover– Appealing denials of MA insurance or individual MA services– Appealing terminations– Immigrant access to public healthcare

mailto:[email protected]

Temporary Assistance for Needy Families

Health & Medicine

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