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COMMONWEALTH OF PENNSYLVANIA

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Pennsylvania Code



Subchapter E. THE CATEGORICALLY NEEDY BREAST AND CERVICAL CANCER PREVENTION AND TREATMENT
PROGRAM FOR QUALIFIED WOMEN


GENERAL PROVISIONS

Sec.


140.701.    Policy on Medical Assistance for women with breast or cervical cancer.
140.702.    Definitions.

ELIGIBILITY


140.721.    Conditions of eligibility.

INCOME, RESOURCES AND VERIFICATION


140.731.    Income eligibility limitations.
140.732.    Resource eligibility limitations.
140.733.    Verification requirements.

REDETERMINATION


140.741.    Complete redetermination.
140.742.    Partial redetermination.

BENEFIT COVERAGE


140.751.    Benefit coverage.
140.761.    Eligibility begin date.
140.771.    Retroactive eligibility.

REPORTING


140.781.    Reporting of changes.

RIGHT TO APPEAL AND FAIR HEARING


140.791.    Appeal and fair hearing.

Authority

   The provisions of this Subchapter E issued under sections 201(2) and 403(b) of the Public Welfare Code (62 P. S. § §  201(2) and 403(b)), unless otherwise noted.

Source

   The provisions of this Subchapter E adopted May 11, 2007, effected upon publication in the Pennsylvania Bulletin, retroactive to January 1, 2002, 37 Pa.B. 2180, unless otherwise noted.

GENERAL PROVISIONS


§ 140.701. Policy on Medical Assistance for women with breast or cervical cancer.

 The Department provides full MA benefits to uninsured women under 65 years of age who have been screened and diagnosed with breast or cervical cancer, or a precancerous condition of the breast or cervix, who are eligible under the Commonwealth’s categorically needy BCCPT Program.

§ 140.702. Definitions.

 The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise:

 BCCPT Program—Breast and Cervical Cancer Prevention and Treatment Program—A Federally-funded option that provides full MA benefits to uninsured women under 65 years of age who have been screened and diagnosed and are in need of treatment for breast or cervical cancer, or a precancerous condition of the breast or cervix. These women have been identified through an entity funded in full or in part by CDC.

 CDC—Centers for Disease Control and Prevention—The lead Federal agency for protecting the health and safety of people at home and abroad by applying disease prevention and control.

 NBCCEDP—National Breast and Cervical Cancer Early Detection Program—A program established by Congress under the Breast and Cervical Cancer Mortality Act of 1990 (Pub. L. No. 101-354, 104 Stat. 409) which authorizes the CDC to promote breast and cervical cancer screening and to pay for screening services for eligible individuals.

 Treatment for breast and cervical cancer—Medical services, which are, or are reasonably expected to provide one of the following:

     (i)   Ameliorate the direct effects of breast or cervical cancer.

     (ii)   Aid in the clinical characterization of breast or cervical cancer, including testing for the effectiveness of curative treatment but excluding screening for recurrence or new primary cancers.

     (iii)   Prevent the recurrence of breast or cervical cancer.

 Uninsured—Having no ‘‘creditable coverage’’ as the term is defined under the Health Insurance Portability and Accountability Act (HIPAA) (Section 2701(c) of the Public Health Service Act (42 U.S.C.A. §  300gg(c)(1)).

ELIGIBILITY


§ 140.721. Conditions of eligibility.

 Eligibility for MA under the BCCPT Program is based on the requirements in the following chapters:

   (1)  A woman shall meet the following eligibility requirements:

     (i)   Chapter 125 (relating to application process).

     (ii)   Chapter 148 (relating to MA residence provisions for categorically needy NMP-MA and MNO-MA).

     (iii)   Chapter 150 (relating to citizenship and alienage provisions for categorically needy NMP-MA and MNO-MA).

     (iv)   Chapter 155 (relating to enumeration).

     (v)   Chapter 255 (relating to restitution).

     (vi)   Chapter 257 (relating to reimbursement).

   (2)  Under the BCCPT Program, a woman shall be:

     (i)   Under 65 years of age.

     (ii)   Screened under the CDC’s NBCCEDP and diagnosed with either breast or cervical cancer, or a precancerous condition of the breast or cervix, and need treatment for either breast or cervical cancer, or a precancerous condition of the breast or cervix.

     (iii)   Uninsured.

     (iv)   Otherwise ineligible for categorically needy Medicaid as defined in §  1101.21 (relating to definitions).

Cross References

   This section cited in 55 Pa. Code §  140.781 (relating to reporting of changes).

INCOME, RESOURCES AND VERIFICATION


§ 140.731. Income eligibility limitations.

 There are no income limits when determining eligibility under the BCCPT Program. An individual who meets the income limits to be eligible for screening by the CDC’s NBCCEDP is income-eligible for the BCCPT Program.

§ 140.732. Resource eligibility limitations.

 There are no resource limits when determining eligibility under the BCCPT Program.

§ 140.733. Verification requirements.

 (a)  Under the BCCPT Program, the following verification is required:

   (1)  Verification that the woman was screened for breast or cervical cancer, or a precancerous condition of the breast or cervix, by a provider or facility funded in full or in part by the CDC under its NBCCEDP, and diagnosed and found to need treatment for either breast or cervical cancer, or a precancerous condition of the breast or cervix. Verification of the continued need for treatment must be provided at each partial and complete redetermination.

   (2)  Verification that the woman is a United States citizen or qualified alien as the term is defined in 8 U.S.C.A. §  1641(b) (relating to definitions).

   (3)  Verification that the woman is under 65 years of age.

   (4)  Verification that the woman is a resident of this Commonwealth.

   (5)  Verification that the woman is uninsured.

 (b)  The verification specified in subsection (a) must be provided on a form established by the Department.

REDETERMINATION


§ 140.741. Complete redetermination.

 (a)  A complete redetermination is required at least every 12 months for women who continue to require treatment for either breast or cervical cancer, or a precancerous condition of the breast or cervix.

 (b)  For the BCCPT Program, the eligibility factors in §  133.84(c) (relating to MA redetermining eligibility procedures) apply.

§ 140.742. Partial redetermination.

 (a)  A partial redetermination is required at the end of the initial period of treatment for a woman whose initial period of treatment is expected to last less than 12 months. The initial period of treatment is based on the diagnosing or treating physician’s attestation regarding the woman’s diagnosis.

 (b)  For the BCCPT Program, the partial redetermination eligibility factors in §  133.84(d) (relating to MA redetermining eligibility procedures) apply.

BENEFIT COVERAGE


§ 140.751. Benefit coverage.

 The Department will provide full MA coverage for a woman determined eligible under the BCCPT Program.

§ 140.761. Eligibility begin date.

 The eligibility begin date is the date the woman is diagnosed with breast or cervical cancer, or a precancerous condition of the breast or cervix, but not prior to January 1, 2002. Retroactive BCCPT Program benefits are available under §  140.771 (relating to retroactive eligibility).

§ 140.771. Retroactive eligibility.

 The earliest possible date for retroactive BCCPT Program benefits to begin is the first day of the third month preceding the month of application, but not prior to January 1, 2002. The period of eligibility for retroactive BCCPT Program 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.

Cross References

   This section cited in 55 Pa. Code §  140.761 (relating to eligibility begin date).

REPORTING


§ 140.781. Reporting of changes.

 The recipient shall report changes that would affect eligibility for the BCCPT Program under §  140.721 (relating to conditions of eligibility) to the Department within 10 days from the date of the change.

RIGHT TO APPEAL AND FAIR HEARING


§ 140.791. Appeal and fair hearing.

 The applicant or recipient is entitled to the appeal and fair hearing rights under Chapter 275 (relating to appeal and fair hearing and administrative disqualification hearings).

APPENDIX A



EXTENDED MEDICAL COVERAGE (EMC)
MONTHLY INCOME LIMITS
185% OF THE 2013 FEDERAL POVERTY INCOME
GUIDELINES

Family Size185% of the Federal
Poverty Income Guidelines
1 $1,772
2 $2,392
3 $3,011
4 $3,631
5 $4,251
6 $4,871
7 $5,490
8 $6,110
Each Additional Person $620



Source

   The provisions of this Appendix A adopted October 16, 1992, effective upon publication and apply retroactively to April 1, 1990, 22 Pa.B. 5164; amended July 2, 1993, effective February 12, 1993, 23 Pa.B. 3168; amended April 15, 1994, effective upon publication and apply retroactively to February 10, 1994, 24 Pa.B. 1972; amended August 25, 1995, effective August 26, 1995, and apply retroactively to February 9, 1995, 25 Pa.B. 3490; amended May 10, 1996, effective upon publication and apply retroactively to March 4, 1996, 26 Pa.B. 2213; amended July 3, 1997, effective March 10, 1997, 27 Pa.B. 3235; amended November 6, 1998, effective November 7, 1998, and apply retroactively to February 24, 1998, 28 Pa.B. 5628; amended April 26, 2002, effective and apply retroactively to February 14, 2002, 32 Pa.B. 2165; amended May 2, 2003, effective retroactively to February 7, 2003, 33 Pa.B. 2227; amended May 14, 2004, effective retroactively to February 13, 2004, 34 Pa.B. 2645; amended April 28, 2006, effective January 24, 2006, 36 Pa.B. 2072; amended May 4, 2007, effective May 5, 2007, 37 Pa.B. 2158; amended April 4, 2008, effective retroactively to January 23, 2008, 38 Pa.B. 1644; amended May 22, 2009, effective retroactively to January 23, 2009, 39 Pa.B. 2648; amended April 15, 2011, effective retroactively to January 20, 2011, 41 Pa.B. 2095; amended May 24, 2013, effective retroactively to January 24, 2013, 43 Pa.B. 2967. Immediately preceding text appears at serial page (356551).

Cross References

   This appendix cited in 55 Pa. Code §  140.431 (relating to income eligibility limits).

APPENDIX B



MEDICAID FOR CHILDREN WITH SPECIAL NEEDS MONTHLY PREMIUM CHART



Family Size

Parents
Annual Income

At least—Less Than
2 3 4 5 6 7 8 Each Additional member
$0-$39,999.99 NO PREMIUM IF INCOME BELOW 200% FPIG
$40-$49,999.99 $30 $29 $27 $26 $24 $0 $0 $0
$50-$59,999.99 $40 $38 $36 $34 $33 $31 $0 $0
$60-$69,999.99 $50 $48 $45 $43 $41 $39 $37 $0
$70-$79,999.99 $60 $57 $54 $51 $49 $46 $43 $0
$80-$89,999.99 $75 $71 $68 $64 $61 $58 $55 (-$3)
$90-$99,999.99 $100 $95 $90 $86 $81 $77 $73 (-$4)
$100-$109,999.99 $150 $143 $135 $129 $122 $116 $111 (-$5)
$110-$119,999.99 $200 $190 $181 $171 $163 $155 $148 (-$7)
$120-$129,999.99 $250 $238 $226 $214 $204 $193 $185 (-$8)
$130-$139,999.99 $300 $285 $271 $257 $244 $232 $222 (-$10)
$140-$149,999.99 $350 $333 $316 $300 $285 $271 $259 (-$12)
$150-$159,999.99 $400 $380 $361 $343 $326 $310 $297 (-$13)
$160-$169,999.99 $475 $451 $429 $407 $387 $368 $352 (-$16)
$170-$179,999.99 $600 $570 $542 $514 $489 $464 $442 (-$22)
$180-$189,999.99 $675 $641 $609 $579 $550 $522 $497 (-$25)
$190-$199,999.99 $800 $760 $722 $686 $652 $619 $588 (-$31)
$200-$249,999.99 $925 $879 $835 $793 $753 $716 $679 (-$37)
$250-$299,999.99 $1,000 $950 $903 $857 $815 $774 $739 (-$35)
$300-$349,999.99 $1,000 $950 $903 $857 $815 $774 $739 (-$35)
$350-$399,999.99 $1,000 $950 $903 $857 $815 $774 $739 (-$35)
$400-$449.999.00 $1,000 $950 $903 $857 $815 $774 $739 (-$35)
$450-$499,999.99 $1,000 $950 $903 $857 $815 $774 $739 (-$35)
$500,000 + $1,000 $950 $903 $857 $815 $774 $739 (-$35)



Source

   The provisions of this Appendix B adopted December 30, 2005, effective 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.

Cross References

   This appendix is cited in 55 Pa. Code §  140.604 (relating to premiums).



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