The CAO will send a completed Notice to the Applicant when:
An application for a LTC facility services payment or HCBS is approved. 55 Pa. Code §125.1(k)
The individual is eligible for a LTC facility services payment pending an available bed in a LTC facility (see Chapter 404.53, Applications Held Pending). 55 Pa. Code §125.1(k)
An application for MA is approved, but LTC facility services payment is denied. 55 Pa. Code §125.1(k)
An application for MA is denied. 55 Pa. Code §125.1(k)
An application has not been disposed of within 30 days and it is necessary to advise the individual that a decision will be made in 45 days.
An application for undue hardship waiver is approved or denied (see Appendices A, B and C for appropriate text and citations to be printed on the manual notice). 55 Pa. Code § 178.104(b)
An application is withdrawn by the individual. 55 Pa. Code §125.1(k)
The LOCA shows that the individual is not functionally in need of LTC facility services or HCBS but the individual wants to continue the application through the CAO. 55 Pa. Code §125.1(k)
NOTE: If the individual still wants to pursue the application for LTC services, the LTC Service Provider will advise the individual to complete page 1and sign the Application for Benefits and forward it to the CAO. This process will enable the individual to appeal the decision.
The CAO will use the same notice to provide the individual with information about eligibility for both MA and eligibility for LTC services. The notice is not required at renewal of eligibility. If, in the renewal process, the individual's eligibility or payment toward the cost of LTC facility services changes, the CAO will send a Confirming or Advance Notice, as appropriate. 55 Pa. Code § 133.4(a)
When an application for HCBS or LTC facility services payment is approved, the notice will contain the following information, in addition to the information found in Section 477.1:
The effective dates of MA and payment of LTC facility services or eligibility for HCBS. 55 Pa. Code §§ 1181.53(b)(6) & (7)
The individual's payment toward the cost of LTC facility services and the name of the LTC facility to which payment is to be made.
55 Pa. Code §§ 1181.53(b)(6) & (7)
NOTE: The CAO will list the individual's countable income and deductions given for:
Personal Needs Allowance (PNA).
guardian fees.
allowance for spouse/ dependent.
Home Maintenance Deduction (HMD).
Medicare premium.
The CAO must indicate on the notice to the LTC facility when the individual is being enrolled in the Buy-In program. As indicated on the notice, the LTC facility will deduct the Medicare premium from the individual's payment toward cost of care. The LTC facility will continue to deduct the Medicare premium until they receive a notice from the CAO that the Department of Public Welfare (DPW) has begun payment of the Medicare premium. IEVS Exchange #3, or Data Exchange #3 on the Workload Dashboard, will be posted with a detail screen when the Medicare payer is changed. The CAO will end the Medicare B premium effective the month Buy-In begins so that the cost of care is adjusted and a system notice is generated reflecting the changed cost of care. The LTC facility should not adjust the payment toward the cost of care until notice is received from the CAO.
To end the Medicare B premium in IVB and remove it from the notice, enter the appropriate end date on the Medical Expense screen.
An optional statement allowing the LTC facility additional deductions from the individual's payment toward the cost of LTC facility services for medical services or items not included in the per diem rate and not covered by the individual's medical card.
NOTE: The CAO will advise the individual or his representative to provide the LTC facility with verification of payment for medical services or items. This may include receipts for payment of medical insurance premiums. The LTC facility will deduct allowable medical and remedial expenses from the individual's payment toward cost of care when it bills DPW for LTC facility services.
The CAO will send a Notice to Applicant to notify the individual of eligibility/ ineligibility for retroactive MA and, if applicable, the amount of the individual's payment toward cost of LTC services or eligibility for HCBS. If the individual is applying for both LTC services and retroactive MA for medical expenses incurred prior to admission to the LTC facility or HCBS program, the CAO will send a notice for the retroactive period and a notice for the ongoing determination.
When an application for payment of LTC facility services or HCBS is denied, the notice will contain the following information, in addition to the information found in Section 477.1:
An explanation of the reason for the denial, and the facts and figures upon which the decision was based;
NOTE: An individual may be eligible for MA but not for a payment toward the cost of LTC facility services if the individual's income exceeds the MA rate of the LTC facility. In these cases, the CAO will advise the individual that the LTC facility may not charge more than the MA LTC payment rate for LTC facility services as long as the individual remains eligible for MA. This does not apply if the individual is ineligible for a LTC facility services payment due to the fair consideration provisions. The LTC facility must charge the private pay rate for an individual who is not eligible for a LTC facility services payment due to a transfer of assets made for less than Fair Market Value (FMV). 55 Pa. Code § 1181.51(b)
An explanation of the items that were needed for verification but were not provided and the steps taken by the CAO to help obtain the verification.
When the individual does not complete the application process, the CAO will send a notice rejecting the application.
Issued May 1, 2012