55 Pa. Code § 133.84 - MA redetermining eligibility procedures
(a)
Redetermining permanent and total
disability. The degree of a person's disability may change so that he
will no longer be totally disabled or so that he will have become totally
disabled. Whenever any kind of change takes place in the condition or
circumstances of an individual or when new information becomes available that
may affect his eligibility for MA, the case should be reevaluated. In these
cases information in the record that was submitted earlier will be resubmitted
to the review team with the new medical findings and current social
information.
(b)
Reapplication. If a disabled person who was previously found
eligible reapplies for MA, an evaluation will be made of the physical,
emotional and social situation of the client to determine whether the
permanence or totality of the disability has changed. If this study indicates
there has been no change in these conditions, the original disability
certification will still be valid. However, if there is reason to believe there
may have been a change in the permanence or totality of the disability, a
review and finding of permanent and total disability will be required. If a
reexamination or social information had been required by a specific date and
the person reapplies after the date, this information will be obtained as
promptly as possible and sent to the review team.
(c)
Complete
redetermination. A complete redetermination is a review of eligibility
factors. A personal interview will be required, except for patients in State
institutions and children in court determined placement provided by a county
children and youth social service agency. A Form PA 743-R and Form PA 743-S are
completed and signed at each complete redetermination. Also, a Form PA 743-TPR
or Form PA 743-TPR-T is completed at each complete redetermination only if
medical indicator 2, 3 or 7 has been entered in item 35 on the Form PA 743.
This information will be used to ensure that medical assistance payments are
not made when another person or organization is responsible for the medical
bills of the recipient. The decision on when to redetermine eligibility is
based on the eligibility requirements for the individual, the possibility of
change in the circumstances of the individual, and the frequency requirements
for redetermination for the specific category. Appropriate controls must be
established. Eligibility will be redetermined as frequently as warranted by the
circumstances of the individual case, but no less frequently than the
following:
(1) At least every 12 months for
aged, blind and disabled categories. Note, however, that Income and Assets
Evaluation must be made every 6 months as required by subsection
(d)(1).
(2) At least every 6 months
for other categories.
(3) Within 30
days following the receipt of the case record of a person who has made a
permanent move into the county.
(4)
When a person is added to an existing family unit.
(d)
Partial redetermination.
A partial redetermination is a review that focuses on specific eligibility
factors. A partial redetermination will be required as frequently as indicated
by the individual case circumstances, including a determination of income and
assets every 6 months for MA persons in the aged, blind and disabled
categories. A personal interview will not be required for a partial
redetermination and a Form PA 743-R will not be required. The review may be
made by telephone or correspondence, pending subsequent verification if, in the
worker's judgment, the client's credibility and reliability are such that his
statements about his circumstances can be accepted without a face-to-face
contact. When the partial redetermination involves a change in income,
verification of the change is required and the income change is recorded on the
Form PA 742. If verification is not available immediately, MA may continue only
if the facts presented by the client are consistent and reasonable and a
definite plan is made to obtain the needed verification. The maximum lapse of
time to obtain the verification will be no more than 30 days following the date
of the partial redetermination. A partial redetermination will be required as
follows:
(1) Every 6 months for aged, blind
and disabled cases.
(2) Within 5
days of anticipated changes in circumstances about which there is advance
information on hand.
Example: Mass Social Security, VA, Railroad Retirement increases and the like.
(3) Within 10 days following the receipt of
information indicating a possible change in eligibility.
(e)
Redetermination forms.
The provisions of §
133.4 (relating to procedures)
will apply.
Notes
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