A LTC service provider is required to seek payment from any third party resource, including Medicare or any other insurance, prior to billing the Department of Public Welfare (DPW) for payment for LTC services. Third party resources must be used when available; however, neither the CAO nor the LTC service provider may require an individual to buy health insurance or carry specific coverage.
The CAO will enter third party resource information into the Third Party Liability (TPL) system. The individual still qualifies for MA LTC during the period that other insurance, such as Medicare, pays for the cost of LTC services. The LTC service provider will not bill DPW if the individual qualifies for payment from Medicare.
NOTE: Under OBRA ‘90, the individual has the right to refuse transfer to another bed within a LTC facility for the purpose of qualifying for Medicare coverage. If the resident qualifies for MA LTC, the LTC facility may bill DPW.
If other insurance reimburses the LTC service provider based on a flat rate for the month, the LTC service provider will apply the insurance payment to the MA LTC payment rate for the month. If other insurance pays, the LTC service provider may bill the Department at the MA LTC rate for the days of the month not covered by the insurance. The LTC service provider will subtract the individual’s payment towards the cost of care (if there is one) from its bill for the days it is billing DPW for services provided during the calendar month.
Third party resources include payment for medical care, including LTC services, which is required as a result of an accident or injury for which the individual has filed a personal accident or injury claim. As a condition of eligibility, the individual must sign an Agreement and Authorization to Pay Medical Assistance Claim (PW 176KM). The CAO will send the PW 176KM form along with an OIG 173-S to the Division of Third Party Liability within the Bureau of Program Integrity. See the Supplemental Handbook, Chapter 915, Reimbursement, for information about the referral process.
The Client Information System (CIS) will enroll the individual in the Medicare Savings Program also known as Buy-In. See Chapter 488, Buy-In. The enrolling of a person receiving MA LTC in the Buy-In program is a Federal requirement.
The CAO must state on the notice to the LTC service provider that the person is being enrolled in the Buy-In program. The notice tells a LTC facility to subtract the Medicare premium from the individual’s payment towards cost of care. The LTC facility will continue to subtract the Medicare premium until told by the CAO that the Department has started paying the Medicare premium.
IEVS exchange #3 will be posted with a detail screen when the Medicare payer is changed. The CAO must issue a change notice to the LTC service provider to stop the deduction of the Medicare premium when the IEVS screen states Buy-In has started. 55 Pa. Code § 1101.64(b)
Issued March 12, 2012