A complete renewal is a full review of all eligibility factors to decide if a recipient still qualifies for MA LTC. The CAO will review the individual's eligibility for MA LTC (STEP 1) and the amount of the payment toward the cost of care (STEP 2) if necessary.
The CAO may time the review to match with the yearly cost-of-living (COLA) increases for those individuals who receive income from Social Security, Veterans' benefits, or other benefits affected by the COLA.
NOTE: A renewal is timely if it is completed within the calendar month in which it is due. The renewal will appear as overdue on a supervisory alert if the renewal due date is not updated in CIS on or before the last day of the month.
The CAO will obtain a completed PA 600L and verify the case information (items subject to change) as part of the complete renewal. If the individual or representative who made the initial application is not able to complete the form and provide information, the CAO will accept a form which is submitted and signed by a representative of the LTC facility who is acting on behalf of the individual. The CAO will contact the representative or other family members as needed to verify income and resources. Information can be obtained by telephone, mail, or face-to-face interviews if necessary. 55 Pa. Code § 201.1
The CAO will review the following factors:
Resources of the individual. 55 Pa. Code § 178.3
Gross earned and unearned income of the individual. 55 Pa. Code § 181.452(a)
NOTE: The CAO will recompute interest income based on the previous 12 months. See Chapter 450.24 Income.
Gross earned and unearned income of the community spouse and dependents if a community spouse/dependent deduction is needed or requested.
55 Pa. Code § 181.452(d)(3)(iv)
Income expense deductions. 55 Pa. Code § 133.83(a)(2)
Shelter expenses of the community spouse, if a community spouse maintenance deduction is given. 55 Pa. Code § 181.452(d)(2)(iii)
Third party medical resources, to update the Third Party Liability File. 55 Pa. Code § 133.84
Medical insurance expenses, such as Medicare and Blue Cross/Blue Shield premiums. 55 Pa. Code § 181.452(d)(5)
If the CAO decides that an eligibility factor requires verification, the individual or representative must provide the requested proof. See the Medical Assistance Eligibility Handbook, Chapter 378, Verification.
Before processing a renewal, the CAO will:
1. Review the alerts to determine which individuals are due for renewal.
2. Send the individual or representative the correct LTC or HCBS renewal packet and let the individual or representative know what documents are needed to for continued eligibility.
3. Complete an Income Eligibility Verification System (IEVS) Status Inquiry and review the information which is already available in the " Wage Match Details" and "Wage History" screens. If new information may be available, complete an " Verification Request" inquiry. See "Using IEVS," for complete IEVS procedures.
NOTE: Use the BENDEX Master Benefit Record (MBR) File (IEVS Exchange 3) to verify the amount of the individual’s Social Security or SSI benefit and whether or not the individual is paying the Medicare Part B premium. Use the IRS - Unearned Income File (IEVS Exchange 5) to verify the amount of interest and dividend income reported to IRS. Also use Exchange 5 information to identify resources which the individual may have, such as bank accounts, stocks, etc.
4. Conduct a telephone or face to face interview if requested by the individual or POA.
Reminder: An interview is not required to determine eligibility for MA.
As part of the renewal, the CAO will:
1. Assist the individual or representative in completing the new PA 600-L, if necessary, and review the information with the individual.
2. If the individual wants benefits to continue, review the eligibility factors that are subject to change. See Section 476.2 Complete Renewal, for a list of factors which must be reviewed.
3. Review IEVS information with the individual or representative. If verification is needed, provide a Client Verification Request Form (PA 162-VR) and give the individual or representative 10 calendar days to provide the information.
4. Verify the eligibility factors and income and resource items which were reviewed. Tell the individual or representative that he is required to provide any needed verification by the end of the month in which the renewal is due. 55 Pa. Code § 133.1(b)
Help the individual or representative obtain verification, if necessary, or establish a reasonable plan for the individual to obtain verification on his own. Attempt to notify the individual or representative before making any collateral contacts, except in cases of suspected fraud.
Reminder: It is not necessary to verify eligibility factors which have already been verified and are not likely to change, such as birth date, unless there is an indication of a change or a difference with current information.
5. When a delay is due to a third party and the individual or representative is cooperating, the CAO will continue benefits and review progress in securing documentation and cooperation every 30 days.
6. Discuss potential resources and income, including third party resources, and obtain the agreement of the individual or representative to get those resources.
7. Make sure the individual receives a copy of the Rights & Responsibilities.
8. Advise the individual or representative of his responsibility to report changes within 10 days. Create alerts for any potential changes, such as resources approaching the limit.
9. Decide if the individual still qualifies for MA LTC.
10. Determine the amount of the individual’s contribution toward the cost of care if necessary.
11. Update the eligibility information, the renewal due date, and any other case record information.
12. Send a notice if the MA LTC benefits have increased or decreased.
13. Enter a case comment in the system.
The Automated Renewals (AR) system lets caseworkers identify and review monthly 001 alerts for renewal. The AR system creates and sends out renewal packets and lets caseworkers schedule interviews as needed.
The AR system creates each packet on the basis of the categories that are due for renewal. Each packet has certain forms that are required. The caseworker can select other forms that the individual may need to fill out. (For more information, see MA Handbook Chapter 376 Appendix B, Automated Renewal Forms.)
The AR system provides two types of processes:
Quick Process
The Quick Process lets the CAO schedule renewals for several cases at the same time. The CAO enters the appointment date and time or the packet due date. The CAO can select any optional forms that may be needed.
Detail Process
The Detail Process lets the CAO view each case in detail. The Detail Process gives the CAO the chance to include future budgets in the current renewal process. The CAO may change the packet mailing address or the mailing date.
After the CAO processes the 001 alerts using the Quick Process or the Detail Process, the AR system pulls, prints, packages, and mails the renewal packets and automatically enters a narrative including the due date.
As a condition of continued eligibility, the individual or representative must:
1. Complete and sign the PA 600L.
2. Provide the information necessary to complete the renewal.
3. Provide the information needed to update the Third Party Liability File. The individual must provide information about medical resources within 30 calendar days after each renewal 55 Pa. Code § 133.73 55 Pa. Code § 133.84
When renewal information is not received from individual the CAO must:
1. Confirm that the renewal form and verification have not been received in the CAO by the renewal date. The worker must check the imaging repository, the reception area and mailroom areas of the CAO.
2. If there has been no contact from the individual to demonstrate that the individual is cooperating in providing the renewal information, close the MA budget for failure to provide information (reason 042) with a 15-day advance notice.
Reminder: The client must provide a signed renewal form or a signed application to determine ongoing eligibility for MA. If the renewal form or application was received in the CAO but was not signed the CAO must contact the individual through mail or phone to obtain a signed form.
For all programs, a new application form is NOT required only when all these conditions are met:
1. Individuals completed the required renewal form, but failed to provide pending information or verification.
2. Benefits were discontinued.
3. Individuals provided pending information or verification within 60 days of discontinuance.
Updated February 19, 2013, Replacing May 1, 2012