An individual who needs help to pay for Long Term Care (LTC) services, or someone acting on the individual’s behalf, may complete an application. The individual may apply before or after admission to an LTC facility or before or after an assessment for a home and community based service (HCBS) program is completed.
55 Pa. Code § 125.84 55 Pa. Code § 171.81(a)
NOTE: Need is defined as an individual who has a medical condition requiring LTC services and lacks the financial assets to pay for those services.
Examples:
Mr. A. was discharged from the hospital and admitted directly to an LTC facility on October 20. Mr. A. has Medicare A, which will pay for the first twenty days of LTC services. He applied for MA LTC with a requested effective date of October 20. The CAO would authorize MA LTC effective October 20, if all other conditions of eligibility are met.
Mr. P. is admitted to an LTC facility on November 25 from the hospital. On January 10, he applied for MA LTC with a requested effective date of November 25. He had total resources of $9,500 on November 25. The CAO advised Mr. P. he was over the resource limit. He paid an outstanding hospital bill for $500 and purchased an irrevocable burial for $7,000 on January 30. He provided verification of the paid expenses to the CAO on February 6. The CAO would authorize MA LTC effective November 25, if all other conditions of eligibility are met.
Ms. T. is admitted to an LTC facility on September 3. On October 5, she applied for MA LTC with a requested effective date of September 3. Ms. T. had resources totaling $15,000. The CAO advised Ms. T. she was over the resource limit. She privately paid the LTC facility $7,400.00 on September 30. Her resources were reduced to within the resource limit. The LTC facility’s daily private pay rate is $200. $7,400 divided by $200 = 37 days. This covered the period from September 3 to October 9. The CAO would authorize MA LTC effective October 10, if all other conditions of eligibility are met, because she had available assets to pay for her LTC services.
Mrs. N. is admitted to a non-MA LTC facility on June 10. She applied for MA LTC with a requested effective date of June 10. The CAO will deny MA LTC and evaluate her eligibility in a non-LTC related MA category. She has no need for MA LTC, because the non-MA facility can not bill MA for payment of LTC services.
Mr. R. is admitted to an LTC facility on June 20. He applied for MA LTC with a requested effective date of June 20. Mr. R. had resources totaling $10,000. The CAO advised Mr. R. that he was over the resource limit. He spent $2,500 for taxes and other household expenses on July 6. The CAO would authorize MA LTC effective July 6, if all other conditions of eligibility are met.
An individual or an individual’s representative may complete an application for Long Term Care, Support and Services Form (PA600L). The PA 600L can be obtained from the local County Assistance Office (CAO) or the LTC service provider. An application may also be completed online. The Commonwealth of Pennsylvania Access to Social Services (COMPASS) is online at www.compass.state.pa.us or available by going to the Department of Public Welfare (DPW) website at www.dpw.state.pa.us and clicking on the COMPASS link under the 'PA Online Services' menu.
NOTE: The Application for Services in Your Home (PA 600WP) has not been approved for use in Non-Community Choice counties. The PA 600WP is used for individuals applying for LTC services under one of the HCBS programs. This application allows for post verification of income and resources. The use of the PA 600WP is restricted to the current Community Choice demonstration counties only. These counties are Allegheny, Chester, Cumberland, Dauphin, Delaware, Fayette, Greene, Lancaster, Montgomery, Perry, Philadelphia, and Washington.
In addition to an online application, a screening program is available through COMPASS. An individual wanting to determine potential eligibility for LTC may complete a short questionnaire for LTC services. The final determination of MA LTC will be made by the local CAO. 55 Pa Code § 121.3(b)(2)(ii)
NOTE: The COMPASS screening program only evaluates income and non-financial potential eligibility for MA LTC. It does not evaluate potential resource eligibility for MA LTC.
An application form is not needed if an individual reapplies within 60 days of the original application date for denials or within 60 days of the date of closing.
The applicant may be the individual, the individual’s spouse, a representative of the LTC facility, a medical provider, a representative of a hospital, or any other responsible party acting on behalf of the individual. A responsible party includes, but is not limited to, a legal guardian, an individual who has power of attorney, a friend, a relative, or anyone else who has indicated a concern for the well-being of the individual. 55 Pa. Code § 125.84(a)(5)
NOTE: The term applicant is used throughout this chapter to identify both the individual and a representative applying on behalf of the individual.
If a husband and wife are both applying for LTC services, each spouse must complete a separate application.
The individual for whom a payment for LTC services is requested must have a functional, non-financial, and financial need to be eligible for MA LTC.
The local Area Agency on Aging (AAA) completes a level of care assessment (also known as a functional need assessment) to determine if the individual meets the appropriate level of care required to receive LTC services. The individual has the right to appeal the level of care decision. See Section 404.24, Medical Forms for LTC Services for more information.
Upon admission to an LTC facility, the individual’s physician will complete a Medical Evaluation Form (MA 51). The MA 51 will be forwarded to AAA for completion of the level of care assessment. The original MA 51 will be sent to the local CAO upon completion of the level of care assessment by the AAA.
55 Pa. Code § 1187.31 55 Pa. Code § 1181.53
For HCBS, the appropriate program office or Independent Enrollment Broker (IEB) will evaluate the individual’s functional need for LTC services and complete an HCBS Eligibility/Ineligibility/Change Form (PA 1768) to indicate the individual’s eligibility or ineligibility for an HCBS program.
If AAA, the HCBS program office or IEB determines that the individual has a functional need for LTC services, the CAO will determine if the individual meets MA LTC non-financial and financial eligibility requirements. The LTC facility or HCBS provider will provide services based on the individual’s functional need for service.
The CAO will review the application to determine if the individual has any unpaid medical expenses during the retroactive period. The retroactive period is the period that begins the first day of the third calendar month prior to the month of application and ends the day before the date of application. See Section 404.21, Date of Application. 55 Pa. Code § 181.12(a)
An individual may receive retroactive payment for LTC services for an application that is submitted to the CAO after the date of medical assessment of need for an HCBS program or admission to an LTC facility. For a request of retroactive payment for LTC services, the CAO must obtain an MA 51 for LTC facility services or a PA 1768 for HCBS certifying a functional need for the days covered by the request for retroactive payment. See Section 404.24, Medical Forms for LTC Services.
An individual may also receive retroactive MA coverage for unpaid medical costs incurred before the individual had a functional need for payment of LTC services, if the individual meets all of the financial/non-financial eligibility requirements for non-LTC-related MA.
Each individual admitted to an LTC facility or applying for HCBS who has a spouse living in the community must have the resources of the couple (institutionalized spouse and spouse in the community) assessed to determine the amount of resources that may be protected for the spouse in the community. A resource assessment form (PA 1572) can be provided by the CAO or LTC service provider. 55 Pa. Code § 178.121
The resource assessment (RA) is based on the total countable resources owned by the couple on the medical assessment date for HCBS or the admission date to an LTC facility for a continuous period of at least 30 days or the day of admission to an LTC facility and the institutionalized spouse is applying for MA LTC. The medical assessment date is the date the individual has been determined to meet the functional eligibility requirements for HCBS by the appropriate program office or Independent Enrollment Broker (IEB). It is not the date that HCBS begins (referred to as the service begin date). The services provided by an HCBS program may start beginning the medical assessment date but normally start on later date.
The LTC facility must provide the individual with the Admissions Notice Packet (MA 401). If the individual is not applying for MA LTC at the time of admission to the LTC facility, the LTC facility must advise the individual to complete the RA form (Part IV of the (MA 401/PA1572). The individual being admitted to the LTC facility, spouse, or other individual acting on his or her behalf will complete the form and forward it to the CAO. The CAO will complete the assessment. If the individual applies for MA LTC at a later date, the CAO will use the information from the RA. 55 Pa. Code § 178.122
If the individual is applying for MA LTC at the time of admission to the LTC facility or functional assessment for HCBS, the CAO will complete the resource assessment as part of the application process. 55 Pa. Code § 178.123
See Chapter 440.91, Resource Assessment, for complete information about the resource assessment process.
Updated March 12, 2012, Replacing June 30, 2011