The CAO will determine eligibility for LTC facility services payments as follows:
1. Review the MA 51 to verify the individual has a medical need for nursing facility services.
2. Choose the appropriate category of MA LTC.
3. Decide whether the individual needs retroactive MA or MA LTC to cover unpaid medical expenses incurred in the retroactive period. (See Section 468.5.)
4. Determine the individual’s eligibility under Step 1. (See Section 468.2.)
5. If the individual is eligible for MA LTC in Step 1, determine how much income the individual has available to pay toward the cost of LTC facility services. Compute the payment toward cost of care by deducting the applicable expenses and allowances in Section 468.3, in the following order:
Personal Needs Allowance.
Court-established guardian fees.
Community Spouse Monthly Maintenance Needs Allowance (CSMMNA).
Maintenance allowance for dependents living with the CS.
Maintenance allowance for a dependent or child who is disabled when there is no CS.
Medical expenses.
NOTE: Medical expense deductions are determined by the LTC facility when the LTC facility submits the claim for payment. If the individual's income after allowing the CSMMNA is not enough to pay medical expenses, the amount of the CSMMNA must be reduced to pay the medical expenses.
HMD.
Only the income the individual actually has available should be used to determine the cost of care in the month the individual was admitted to the LTC facility. If the individual resided in the LTC facility for the entire calendar month then the payment toward cost of care is based on the total amount of income received for the month. If the individual spent the income on medical expenses, such as privately paying for LTC facility services, in the first month for which MA is requested, the amount paid to the LTC facility can be adjusted against the payment toward the cost of care when the facility submits the bill for payment of services provided.
Example: Mr. D entered the LTC facility on April 20 and is requesting payment of LTC facility services effective the same day. Mr. D receives gross RSDI income of $1,000 each month. His bank statements show that he paid his rent of $750 on April 5. Mr. D has $250 available in the month of April, the calendar month in which he entered the LTC facility. The CAO will use $250 as his available income when determining the payment toward cost of care for April.
6. Determine the monthly cost of LTC facility services at the facility by multiplying the MA LTC per diem rate for the facility by the number of days of care. If the person is requesting payment for a full month, multiply the rate by 30 days. 55 Pa. Code § 181.453
7. Compare the individual’s available income (figured in step 5) with the MA LTC payment rate for LTC facility services (figured in step 6).
If the individual’s available income toward the cost of LTC facility services is less than the LTC facility services charge, approve DPW payment for LTC facility services. Send a system-generated PA 162 notice of eligibility including the individual's payment toward cost of care to the individual, the individual’s representative and the LTC facility.
If the individual’s available income is more than the MA LTC rate for a month with 30 days but less than the MA LTC rate for a month with 31 days, approve MA LTC and notify the individual, individual's representative and LTC facility that a payment will be made only for months having 31 days.
If the individual’s available income is equal to or more than the MA LTC payment rate but less than the private pay rate of the LTC facility, approve MA LTC. The LTC facility will deduct any additional medical expenses from the amount set by the CAO as the individual’s payment toward cost of care. The LTC facility will not submit a payment from the MA program to help pay for LTC services if the individual’s income after medical expenses is more than the MA LTC rate for LTC services. The individual remains eligible for all other covered MA services. Send the individual, individual’s representative and the LTC facility a PA 162 notice informing them of the eligibility decision. 55 Pa. Code § 181.453(c)
NOTE: The payment from the individual cannot exceed the MA LTC per diem rate times the number of days in the calendar month while the individual is a MA LTC recipient. The CAO will need to watch the case to make sure that the extra income that is not needed to pay for LTC services is not transferred for less than full market value or, if it is added to additional resources, it is not more than the resource limit.
Example: Mr. M was admitted to the Italian Lakes LTC facility on May 27. An application was signed on June 12. Mr. M is requesting LTC facility services payments beginning May 27 and payment for his hospital bill from May 6 until his admission to Italian Lakes. Mr. M’s monthly income is $1,000 from Social Security, and he receives a state retirement pension of $1750 a month. Mr. M's total gross monthly income is $2750. Mrs. M lives in the community. She receives a pension of $500 a month, $340 in Social Security benefits and $10 from her protected share. Her total monthly income is $850. Mr. M verifies that he spent all his income except $800 in May, the month of his admission to the LTC facility.
Mr. M. pays $104.90 a month for Medicare Part B. The MA LTC per diem rate at Italian Lakes is $120. The private rate is $155 a day.
The CAO must take the following steps:
1. Determine retroactive MA eligibility for the calendar month of May for Mr. M as an applicant residing in the community. See the Medical Assistance Handbook Chapter 368, Determining Eligibility for NMP and Medical Assistance Handbook Chapter 369, Determining Eligibility for MNO.
2. Determine retroactive eligibility for LTC facility services for May 27 through 31 and June 1 through 11.
3. Determine eligibility for continuing LTC facility services beginning June 12.
Step 1
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Step 2
Determining the payment toward cost of care for the calendar month the IS was admitted to the LTC facility using income actually available:
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Determining the payment toward cost of care for the calendar month(s) after the month the IS was admitted to the LTC facility:
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If Mr. M signs the Certification of Payment of Income to Community Spouse or Child form, PA 1847 confirming that he will make $650.10 available to his wife for the month of May and $1,610.00 available to his wife for the month of June and each additional month, the CAO will allow the deduction. The deduction is the actual amount contributed by Mr. M.
Mr. M is eligible for retroactive LTC facility services for May and June. When figuring the income available for May 27 through 31, the CAO counts only the actual available income to Mr. M to figure his payment toward the cost of LTC facility services.
If one spouse enters a LTC facility then both the institutionalized spouse (IS) and community spouse (CS) should be entered in one record. Entering the CS in the record as an non-eligible adult (NA) will allow the system to determine the correct CSMMNA.
If the CS is applying for or receiving benefits in another program and still wishes to receive all or a portion of the CSMMNA, the CS should be assigned a separate record while maintaining an NA status in the IS record.
NOTE: The actual CSMMNA received from the IS must be entered as unearned income in the CS's record and used to determine the eligibility of the CS for other programs.
If the CS elects not to receive a CSMMNA the CS should not be entered in the IS's record.
If both spouses are residing in a LTC facility then each individual should be assigned his or her own record and treated as a single individual when determining eligibility for MA LTC. In these cases a CSMMNA should not be calculated because there is no spouse living in the community. By entering each spouse in their own record a CSMMNA will not be calculated. 55 Pa. Code § 181.452(d)(2)(vii)
If one spouse is applying for or receiving HCBS and the other spouse is applying for or receiving LTC facility services, whether or not the spouse receiving HCBS is requesting and eligible for the CSMMNA will determine whether this individual should be entered in the same record as the spouse residing in the LTC facility.
If the spouse requesting HCBS wishes to receive all or a portion of the CSMMNA then the CS should be entered in the same record as the spouse residing in the LTC facility. By entering the CS as a NA member in the same record as the IS, then the CSMMNA will be determined. The CAO will also need to authorize payment of HCBS for the CS in his or her own record. The CAO must be sure to include the CSMMNA when entering the income of the CS in his or her own HCBS record.
If the spouse requesting HCBS chooses not to receive a CSMMNA, or the CSMMNA when added to the other countable income of the CS would cause income to exceed the NMP Special Income Limit (See Appendix A) then the CS must be entered in his or her own record. The CS should not be entered in the same record as the spouse residing in the LTC facility.
Updated March 12, 2012, Replacing December 2, 2005