Pennsylvania Code
Title 55 - HUMAN SERVICES
Part II - Public Assistance Manual
Subpart A - Assistance Policies and Procedures
Chapter 100 - STATEMENTS OF POLICY
Section 100.2 - Health insurance provisions for Single Point of Contact (SPOC)

Universal Citation: 55 PA Code ยง 100.2

Current through Register Vol. 54, No. 44, November 2, 2024

The Department will provide health insurance coverage through a new type of Medically Needy Only-MNO-coverage.

(1) Eligibility for coverage. An individual, or the individual's spouse, children under 21, or other dependents in the household, may elect health insurance coverage if that individual meets the following requirements:

(i) Participated in a SPOC program.

(ii) Enters employment during or within 90 days of completion of SPOC activities.

(iii) No longer qualifies for Medicaid benefits.

(iv) Elects the insurance coverage by signing a written statement consenting to pay premiums for the coverage.

(v) Is not covered-or could not have elected coverage-under a group health plan of the individual or spouse, if a contribution toward the plan's cost is being made by an employer, former employer, union or entity other than the individual or the spouse. If employers or other entities pay any part of a health plan's costs, the clients are not eligible for this SPOC health insurance coverage. If the employer makes a contribution toward the cost of the employe's coverage but not the employe's dependents' coverage, the dependents may be covered by SPOC health insurance, if otherwise eligible.

(2) Type of coverage. A participant receives Medicaid coverage in a new category-TR-for health insurance clients only. This TR category is similar to MNO benefits, except that no nursing home care coverage is included. A client will receive a green medical assistance identification-MAID-card semi-monthly that the client may use for covered services from providers participating in the Medical Assistance Program.

(3) Cost to enrollee.

(i) Following receipt of the appropriate extended Medicaid benefits, health insurance enrollees shall pay:

Period of TR Insurance CoveragePercnetage Paid by ClientAmount of Monthly Premium Cost Per Person Allegheny/Philadlephia/All Other Counties
Months 1 and 20 0 0 0
Months 3 through 825%$ 8.25$10.25$ 7.50
Months 9 through 1450%$16.50$20.50$15
Months 15 through 2075%$24.75$30.75$22.50
Thereafter100%$33 $41 $30

(ii) Premium costs in subparagraph (i) were based on the actual average per capita costs to the Department for the medical services provided.

(4) Length of coverage.

(i) The client is enrolled for health insurance upon receipt of an application, including the signed consent to pay the premium amount for the health insurance coverage. Coverage ends when one of the following occurs:
(A) Appropriate premiums have not been paid.

(B) Employment ends.

(C) The SPOC participant becomes eligible for Medicaid or other health insurance as specified under paragraph (1).

(ii) If a client enrolled in the health insurance program changes jobs but still meets the criteria under paragraph (1), the client may continue to receive the health insurance coverage.

Disclaimer: These regulations may not be the most recent version. Pennsylvania may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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