The CAO is responsible for reviewing the application and verification received from the AAA/applicant. If the CAO determines that additional information/forms are needed, the CAO will contact the applicant to obtain the necessary information.
The CAO may authorize payment for LTC services without an interview if it has sufficient information to establish MA LTC eligibility and the amount of the person’s payment towards the cost of LTC facility services. 55 Pa. Code § 125.84(c)
NOTE: A face-to-face interview is not required. If all necessary information or questions can not be resolved by other means, contact the applicant or the applicant’s representative and schedule a telephone or face-to-face interview. The applicant or the applicant’s representative must sign the application.
When a recipient of MA requests payment for LTC services, the CAO will review the case record to determine if additional information is needed to determine functional, nonfinancial, and financial eligibility. The additional information may be obtained without requiring a face-to-face interview.
During the application process the CAO will: 55 Pa. Code § 125.84(d)
1. Review the information on the application.
NOTE: If necessary, the CAO will complete or assist in the completion of the MA LTC application
2. Explore and resolve any unclear or incomplete information. Inform the applicant if additional information is needed to establish eligibility.
3. Complete or update the information on the application based on the facts presented. Review any information already in the case record and resolve any discrepancies.
4. Determine if there are any unpaid medical expenses incurred in the retroactive period, including expenses which may be paid by a third party.
5. If applicable, the CAO will notify the applicant of the need to complete an Agreement and Authorization to Pay a Medical Assistance Claim (PW 176 KM). Provide the applicant a copy of the signed forms. 55 Pa. Code § 178.6
Example: Reimbursement for LTC facility services payments, HCBS, and other medical services provided under the MA program is required if there is a settlement of a lawsuit from an automobile accident, personal damage award, or other personal injury claim.
6. Explain basic program requirements and procedures. 55 Pa. Code § 125.84(d)
7. Advise the applicant in writing of his or her responsibility to report any changes in circumstances within ten days.
8. Provide the applicant with the Rights and Responsibilities page from the application form.
9. Advise the applicant in writing of his or her right to appeal the CAO's determination if he or she is not satisfied with the decision.
10. Explain the use of the PA 4 or PA 4 LTC and obtain the signature of the applicant if needed. 55 Pa. Code § 201.4(2)(ii)
11. Advise the applicant that he or she must cooperate with quality control (QC) reviews. 55 Pa. Code § 111.4(b)(5)
12. Verify identity of the applicant and note on the application the source of the verification such as, but not limited to, a driver's license, selective service card, or voter registration card, if needed. 55 Pa. Code § 125.1(b)
13. Advise the applicant who is receiving SSI that the CAO will advise the Social Security Administration that the applicant has entered an LTC facility, if necessary.
NOTE: An individual who receives SSI only and is residing in an LTC facility is limited to $30 per month. The individual will also receive a supplement for personal needs (SPN) payment of $15. SSI benefits are discontinued for those individuals with other income that exceeds $30 per month. See Section 450.243, SSI Benefits.
14. Determine if the individual applying for payment of LTC facility services plans to maintain and return to a home in the community. 55 Pa. Code § 181.452(d)(6)
NOTE: If the individual indicates that he or she intends to return home, regardless of his or her physical condition, obtain a written statement (unless the individual has indicated on the application) from the individual or the individual’s representative that he or she intends to return home. This statement allows the individual to exclude his or her resident property as a resource. See Section 440_42, Resident Property. A home maintenance allowance cannot be deducted when determining payment towards cost of care unless a physician certifies that he or she is expected to return home within six months from the date of admission to the LTC facility.
NOTE: If the physician certifies on the MA 51 that the individual is expected to return home in six months (short-term stay) and the individual indicates that he or she intends to return home, the individual is entitled to receive a home maintenance allowance deduction when determining payment towards cost of care. See Section 468.38, Home Maintenance Deduction.
15. Gather information needed to complete the assessment if the applicant is married and an RA was not completed. 55 Pa. Code § 178.121
16. Determine if the individual has an LTC insurance policy, institutional care contract, or maintenance agreement, and obtain a copy of the policy, contract, or agreement.
17. Make sure the applicant has signed the affidavit on page 10 of the application. 55 Pa. Code § 125.84(d)(6)
18. Provide the brochure “Medical Assistance Estate Recovery Program” (PUB 332). See future Chapter 495, MA Estate Recovery, for additional information, when posted. 55 Pa. Code § 258.1
19. Obtain income/resource information from IEVS and resolve any discrepancies between the information obtained and the information included in the application.
The applicant is the primary source of information when establishing eligibility for benefits. If the applicant is unable to participate in the LTC services eligibility process, his or her representative must fulfill the following responsibilities: 55 Pa Code § 201.1
1. Cooperate in obtaining the verification required to establish eligibility.
2. Give true and complete information on anything that may have an effect on eligibility.
3. Complete a personal interview if it is required. 55 Pa. Code § 125.84(c)
4. Furnish information for third-party liability coverage to determine medical coverage carried by another person or organization. 55 Pa. Code § 178.6
5. Sign a PA 4, consenting to the disclosure of information from third parties if needed. 55 Pa. Code § 201.4(2)(ii)
6. Cooperate in establishing eligibility for potential resources or sources of income. 55 Pa. Code § 178.1(g) 55 Pa. Code § 181.1(d)
NOTE: Failure to cooperate without good cause will result in ineligibility for MA LTC until compliance.
7. Give DPW the right to seek payment from any liable third party for the amount of medical expenses paid.
8. Agree to authorize payments under Medicare to be made directly to providers.
9. Give DPW the right to inspect, review, and copy any and all medical records for services received through the MA LTC program.
The CAO will advise the applicant that every recipient must cooperate with state and federal quality control (QC) reviews. A recipient who fails to cooperate is ineligible for the program being reviewed. If the CAO discontinues MA LTC for noncooperation with QC, MA LTC may not be authorized again until QC has been contacted and has approved the authorization. See Supplemental Handbook Chapter 900, Quality Control. 55 Pa. Code § 111.4(b)(5)
Issued March 12, 2012