The CAO will decide if an individual qualifies for MA LTC. If the individual is in an LTC facility, the individual will need to make a payment toward cost of care. The LTC facility will bill DPW based on the individual’s qualifying notice provided by the CAO. If an individual is eligible for MA LTC but the payment towards the cost of care is equal to or more than the MA LTC rate, DPW will not make a payment for LTC facility services. 55 Pa. Code § 181.11 55 Pa. Code § 181.12
The LTC facility may not charge more than the MA LTC rate as long as the individual remains eligible for MA LTC. This statement applies to services which are included in the LTC facility’s rate. 55 Pa. Code § 1181.51
Example: The XYZ Facility’s MA LTC rate is $180 per day. Their private pay rate is $230 per day. Mr. D has monthly income of $6,000. His income is less than the facility’s private pay rate ($6,900) and he qualifies for MA LTC. The facility may not charge him more than the MA LTC rate of $5,400 ($180 x 30).
NOTE: The CAO must review resources in cases where an individual does not pay their full income to the facility.
An individual residing in an LTC facility is also eligible for the same medical services provided to individuals receiving MA who reside in the community.
42 USC 1396(n)(c)(2)
Issued March 12, 2012