§ 133.84. MA redetermining eligibility procedures.
(a) Redetermining permanent and total disability. The degree of a persons 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 workers judgment, the clients 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.
The provisions of this § 133.84 adopted August 4, 1977, effective August 5, 1977, 7 Pa.B. 2180; amended July 21, 1978, effective July 22, 1978, 8 Pa.B. 2060; amended February 22, 1980, effective March 1, 1980, 10 Pa.B. 850; amended December 24, 1981, effective December 26, 1981, 11 Pa.B. 4444. Immediately preceding text appears at serial pages (49734) and (49735).
This section cited in 55 Pa. Code § 141.81 (relating to eligibility policy for Medically Needy Only); 55 Pa. Code § 140.741 (relating to complete redetermination); and 55 Pa. Code § 140.742 (relating to partial redetermination).
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