The CAO will send an Advance Notice advising the individual that an adverse action will be taken when:
Discontinuing MA.
Discontinuing LTC facility services payments.
Discontinuing HCBS.
NOTE: When payment of LTC facility services or HCBS is discontinued due to a transfer of assets for less than fair market value or excess home equity the CAO will need to send a manual advance notice. See Appendix D for the appropriate text and citations to be printed on the notice.
Increasing the amount the individual must pay toward the cost of LTC facility services. This includes ending the Home Maintenance Deduction (HMD) or decreasing the individual's deduction for the maintenance of a spouse or dependent in the community if the income of the spouse/ dependent increases.
NOTE: A notice is not required if there is no change in the individual's payment toward the cost of LTC facility services or for changes in medical expenses which are verified by the LTC facility and adjusted by the facility through the billing process.
Discontinuing Buy-In eligibility.
Changing the MA LTC category from Nonmoney Payment (NMP) to Medically Needy Only (MNO) 55 Pa. Code § 133.4(b)
In addition to the information listed in Section 477.1 which is contained on all notices, the Advance Notice will contain:
An explanation of the reason for the action, and the basis on which the decision was made; and
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 person 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).
The availability of continuing benefits if an action is appealed.
An Advance Notice will be mailed at least 10 calendar days prior to the effective date of the proposed action. The proposed adverse action will take effect a minimum of 15 days after the action is taken in e-CIS. The system will determine the effective date of the change in the LTC facility services payment or HCBS eligibility as follows and will enter the date on the notice: 55 Pa. Code § 133.4(b)(3)
Ineligibility due to failure to comply with a requirement- the date the 15 day advance notice expires.
Ineligibility due to resources- the date the 15 day advance notice expires.
Ineligibility due to income- the date the 15 day advance notice expires.
Ineligibility for payment of services in a LTC facility or HCBS due to an asset transfer for less than fair market value or excess home equity- the first day of the calendar month after the month in which 15 day advance notice expires.
Increase in the individual's payment toward the cost of LTC facility services- the first day of the calendar month in which the advance notice expires.
Change of category from NMP to MNO- the date the 15 day advance notice expires. The increased payment toward the cost of LTC facility services will be effective the first day of the calendar month in which the advance notice expires.
Because a LTC facility cannot submit for payment of LTC services until the month after services are received, 15 day advance notice is given if the change is processed 15 days prior to the end of the current month.
The CAO will determine this time period by counting 15 days from the processing date. This 15 day period gives the individual time to exercise the individual's right to appeal and to receive continued benefits pending the hearing decision. If the 15 day period expires on a weekend or holiday and the CAO receives a request for a hearing on the next business day, the CAO will consider the request to have been received timely.
Example 1: On 7/25, Mr. D's daughter reports that Mr. D received an increase in his monthly company retirement pension. The increase began with the pension check Mr. D received on 7/20. The increase was reported timely. The CAO sends an Advance Notice notifying Mr. D, his daughter, and the LTC facility that Mr. D's payment toward the cost of LTC facility services will increase effective 8/1, the first day of the calendar month in which the advance notice expired.
Example 2: On 8/5, Mr. B reports that he received an increase in his monthly retirement pension. The increase began with the pension check Mr. B received on 7/26. The increase was reported timely. The CAO sends an Advance Notice notifying Mr. B and the LTC facility that Mr. B’s payment toward the cost of LTC facility services will increase effective 8/1, the first day of the calendar month in which the advance notice expired.
Example 3: On 9/10 it is reported that Ms. G has a savings account valued higher than the MA LTC resource limit. On 9/15 the CAO processes this change in resources and sends an Advance Notice notifying Ms. G, her representative, and the LTC facility that Ms. G is no longer eligible for MA LTC effective 9/30, the date the 15 day advance notice expires.
Example 4: On 8/20 it is reported that Mr. A transferred his resident property to his son for less than fair market value. On 8/24 the CAO acts on this asset transfer. The CAO sends an Advance Notice notifying Mr. A, his representative, and the LTC facility that Mr. A remains eligible for MA but is no longer eligible for payment of LTC facility services effective 10/1, the first day of the calendar month after the month in which 15 day advance notice expires.
If the individual or the individual's representative requests a fair hearing within the 15 day period, the CAO will notify the LTC facility that benefits are to continue unchanged pending the results of the hearing. See the Supplemental Handbook Chapter 870, Appeal and Fair Hearing for more information.
Reminder: The CAO will not send a Confirming Notice upon completion of an action proposed on an Advance Notice.
The CAO will not use the Advance Notice as the first notice to the individual that he has a scheduled appointment or is to provide information to the CAO. The Advance Notice is used only after the individual fails to respond within an established time period. 55 Pa. Code § 133.4(b)
Updated February 19, 2013, Replacing May 1, 2012