The County Assistance Office (CAO) will evaluate each resource an individual has or can get. The CAO will determine whether to count or exclude each resource.
Unless he can show good cause for not doing so, an individual must take reasonable steps to get and make available all resources that he is (or may be) entitled to.
An individual may be ineligible for Medical Assistance (MA) if he fails to take reasonable steps to get and make available all resources. 55 Pa. Code § 178.1(g)
NOTE: Exclude resources for:
Applicant child.
Recipient child under 21 years of age.
Parent eligible for Home and Community-Based Services (HCBS) and living with his or her child under 21 years of age.
The CAO determines ownership, value and disposition of resources. The CAO will count resources at their equity value, unless otherwise specified.
Resources include, but are not limited to:
Personal property.
Life insurance.
Vehicles.
Burial funds.
Real property (including mobile homes).
An individual is “resource eligible” for MA LTC if he is applying for or receiving MA LTC and has total, countable resources equal to or less than the appropriate resource limit. See Appendix A for resource limits. 55 Pa. Code § 178.1(a)
The individual is not eligible for MA or for payment of LTC services if the total countable resources are over the appropriate resource limit. See Section 440.71, Excess Resources at Application and Section 440.72, Excess Resources of a Recipient. 55 Pa. Code § 178.1(c)
Failure to report all countable resources may result in an overpayment of MA services if the resource equity value plus other countable resources would have caused ineligibility. 55 Pa. Code § 178.3(6)
When an individual or their spouse reduces resources in the required look back period, the CAO will determine if the person received fair consideration for the resource. See Section 440.8, Disposition of Assets and Fair Consideration. 55 Pa. Code § 178.104
Income and resources are considered assets for transfer purposes, under the Omnibus Reconciliation Act of 1993 (OBRA 93). When the individual or their spouse transfers income or resources to another person, that transfer may be considered a transfer of assets for less than fair market value (FMV). See Section 440.8, Disposition of Assets and Fair Consideration. 55 Pa. Code § 178.104 55 Pa. Code § 178.104a
The CAO will consider the resources of the spouse of an individual who is:
An institutionalized spouse who is applying for MA LTC as of the date of admission.
Institutionalized for a continuous period (defined as uninterrupted and likely to last at least 30 days).
Assessed functionally eligible for Home and Community Based Services.
This provision, called Spousal Impoverishment, allows the couple to protect all or part of their combined countable resources for the use of the spouse who does not need LTC services. See Section 440.9, Spousal Impoverishment. 55 Pa. Code § 178.121
DPW is the payer of last resort. This means that all third party resources, such as Medicare and Blue Cross, must be used before DPW pays for MA LTC. The individual must report all third party resources. The CAO will verify any payment sources available to meet the cost of medical services.
See Chapter 7 (IMCW Wrap-up) of the Using CIS Handbook for information on identifying third party sources and entering the information into Client Information System/Third Party Liability (CIS/TPL).
The Eligibility Verification System (EVS) displays third party resource information. When an individual has third party carriers, EVS will display a message informing the provider of the resources. The message instructs providers to ask the individual for more information. The CAO will identify any source that is available to meet the cost of medical services.
Third party sources include, but are not limited to:
Blue Cross and commercial hospital insurance.
Medicare Part A, Part B and Part D.
Other hospital insurance paid directly to the person.
Medical insurance included in a support agreement.
TRICARE formerly known as Civilian Health and Medical Program of the Uniformed Services (CHAMPUS).
Workers’ Compensation.
Negligence action or other tort (see Supplemental Handbook Chapter 915, Reimbursement).
Payments made toward the cost of medical services by a Legally Responsible Relative (LRR) or other person
LLRs, including spouses and parents of un-emancipated minor children.
Long Term Care insurance (see Section 450.247, Disability/LTC Insurance, Chapter 450, Income for treatment of LTC insurance policies).
NOTE: Do not enter information about LTC insurance policies into CIS/TPL. Send a copy of the policy to:
Bureau of Program Integrity
Division of Third Party Liability
Attn: LTC Insurance Policies
P.O. Box 8486
Harrisburg, Pa 17105-8486
Institutional contracts, including contracts between an individual and a facility giving the individual the right to receive care at zero or reduced cost at the facility. 55 Pa. Code § 178.6
A community may raise money to help an individual with a serious illness. The money must be:
Held in an account on the individual’s behalf, or
Given directly to the individual to use as needed, or
Placed in a revocable or irrevocable trust.
The CAO will determine how and to whom to distribute the money. If money is given directly to the individual to use, the CAO will determine whether to treat the money as a lump sum, resource or income.
NOTE: If the CAO is not sure how to handle such funds, it will forward all available information to the Area Manager for guidance.
If DPW pays for medical care, including LTC services, while awaiting money or payment of medical expenses from a personal damage claim or accident settlement, the CAO must get the person’s agreement to repay DPW from the settlement proceeds. See Supplemental Handbook Chapter 915, Reimbursement, to learn how to complete the Agreement and Authorization to Pay Medical Assistance Claim form (PW 176KM).
Do not consider automobile insurance as a third party liability resource. In cases involving accidents and/or litigation, the CAO must complete these forms:
Agreement and Authorization to Pay Claim (FIRM 0176K)
Agreement and Authorization to Pay Medical Assistance Claim (PW 176KM)
Reimbursement Referral (OIG 173)
See Supplemental Handbook, Chapter 915, Reimbursement.
55 Pa. Code § 257.24 55 Pa. Code § 178.6
The CAO will verify resources at application and at each renewal. The CAO may ask MA LTC recipients for more resource verification as needed.
An individual, family member, guardian, trustee or any other person acting on an individual’s behalf must:
Report all resources
Take reasonable steps to get resources an individual is entitled to, unless there is good cause for not doing so
Provide proof of ownership and value of all resources, and
Report all changes within ten days
The CAO will use the Income Eligibility Verification System (IEVS) to identify resources that may be available to the individual. IEVS information includes interest income reported to the Internal Revenue Service (IRS).
The CAO will review interest income information to determine if the individual has bank accounts, certificates of deposit, stocks, bonds, etc. The individual or his representative must verify resource information. See Using IEVS for information and instructions.
If resource information conflicts with information in the case record, the CAO will resolve the discrepancy and record the information and decision in the case record.
Verify previously reported resources if closed, transferred or given away.
At application, the CAO may use any financial proof including (but not limited to) income tax forms to identify resources that the applicant and/or spouse owns or owned and transferred within the required look back period before the application date. See Section 440.8, Disposition of Resources and Fair Consideration. 55 Pa. Code § 178.3 55 Pa. Code § 201.3
A $6,000 resource disregard applies to LTC services applicants and recipients who are under Categorically Needy Non-money Payment (NMP) MA and whose eligibility is determined using the special NMP income limit. The income limit is 300% of the monthly Federal Benefit Rate (FBR). For current limits, see Chapter 468 Appendix A, Determining MA LTC Eligibility and Payment Towards Cost of LTC Facility Services.
Apply the $6,000 disregard to the total of all countable resources. Disregard (subtract) $6,000 from the total resources sum. Compare the resulting amount to the $2,000 NMP MA resource limit.
An individual with income at or below the special NMP income limit can have $8,000 in resources and qualify for MA LTC.
NOTE: The $6,000 disregard does not apply to determining eligibility for buy-in. A person must have resources below $6,940 to possibly qualify for Medicare B premium payment.
Example: Mr. R has income of $800 per month. He has these resources:
| Savings account | $5,400 |
| Stocks worth | $1,000 |
|
Life insurance (cash value of $2,000) |
$1,000 |
|
Checking account |
$600 |
|
Total resources |
$8,000 |
|
Less $6,000 disregard |
$6,000 |
|
Total countable resources |
$2,000 |
|
|
|
|
LTC NMP resource limit |
$2,000 |
Mr. R would be eligible for NMP MA LTC. He would not be eligible for payment of his Medicare B premium because his total resources are $8,000. This is over the resource limit for the Medicare Savings Program, also known as Buy-In. 55 Pa. Code § 140.301(b)
Issued March 12, 2012