450.1 General Policy

The County Assistance Office (CAO) will look at an individual’s total income to decide whether that individual can get Medical Assistance (MA) to help pay for Long-Term Care (LTC) services. The decision is a two-step process:            55 Pa. Code § 181.1

NOTE:  Deductions for bank fees and transportation costs do not count in finding gross income for MA LTC cases.

In both steps, the CAO will count only the income of the individual when deciding on eligibility for MA LTC and figuring the individual’s payment toward the cost of care. If the individual has a spouse or a dependent living in the community, the CAO will also look at the spouse's or dependent's income in step 2. The CAO may decide that the individual can pay less for LTC facility services because the individual needs to help support the spouse or dependent. See Chapter 468, Determining MA LTC Eligibility and Payment Toward Cost of Care, for more information.

The income that must be counted depends on the category of MA LTC for which the individual is eligible. (See Sections 450.3, 450.4, and 450.5).

Nonmoney Payment (NMP) Categories: PAN, PJN, or PMN

Step 1

The CAO will count gross monthly income to 300% of the current federal benefit rate. See Chapter 468, Appendix A. Some types of income that would not be counted for MA in the community must be counted when the individual lives in an LTC facility or is receiving Home and Community-Based Services (HCBS).        55 Pa. Code § 181.71

Example: Mr. H, age 70, lives in the community and gets Medical Assistance from a Healthy Horizons program. His rent rebates were not counted as income when he was accepted in the Healthy Horizons program. Mr. H enters an LTC facility in April. When deciding whether Mr. H can get MA LTC payments, the CAO counts his April rent rebate as income in step 1.

Step 2

The CAO will count the same income used in Step 1. See Section 450.51 and Appendix A for exclusions.

   55 Pa. Code § 181.304

MNO Categories: TAN or TJN

Step 1

The CAO will use the same exclusions and deductions for an individual who lives in the community when the individual is applying for MA LTC.

 55 Pa. Code § 181.452(3) I

Step 2

The CAO will count some income that was excluded and will not allow some deductions that are permitted in Step 1.

55 Pa. Code § 181.452(3)

The disposing of income, in addition to resources, may be considered a transfer of an asset. When income of the person or the person’s spouse is given or assigned to another person, such a gift or assignment may be considered a transfer of assets for less than fair market value. (For more information, see Section 440.8, Disposition of Assets.)          55 Pa. Code § 178.104

450.11 Potential benefits

The individual or the individual’s representative must apply for any benefits that can come from other sources. If the individual or representative does not apply for other benefits, without good cause, the individual cannot get MA LTC.          55 Pa. Code § 181.1(d)

Potential benefits include, but are not limited to the following:

NOTE:  Some VA benefits that are not connected to military service were increased under the Veterans Pension Act of 1959. The CAO cannot force anyone to apply for an increase in those benefits.        55 Pa. Code §181.302

NOTE:  Support payments are not considered a potential benefit. All support payments, whether voluntary or court ordered, are counted as unearned income.         55 Pa. Code § 181.104

The individual will apply for potential benefits within 30 days of applying for MA LTC.

The CAO will authorize MA LTC if all other requirements are met. If any potential income becomes available later, the individual will use it to pay DPW for services he or she already received.

450.12 Providing Proof of Income

The individual (or the individual’s representative) must report and prove all earned and unearned income for the individual applying for MA LTC. If the individual helps support a spouse or a dependent, the individual must also report, verify, and provide proof of the other individual’s income.

55 Pa. Code § 181.3

NOTE:  An individual will not be turned down for MA LTC for not being able to verify income, as long as he or she is cooperating.

The following are some things that can be used as proof of income:

NOTE:  Bank statements and benefit checks do not always show the gross amount of the income. Add any deductions, such as medical insurance or support payments.

The CAO will use the Income Eligibility Verification System (IEVS) to verify the income of the individual and the individual’s spouse. (See “Using IEVS” for complete information and instructions.)

Information available on IEVS includes:

NOTE:  Interest income reported to the IRS is a valuable tool for finding resources held by the individual and the individual’s spouse. It can also help the CAO tell who owns a resource.

450.13 Overpayments Due to Unreported Income

If the CAO finds out that an individual has more countable income than the individual first reported, it will complete an Overpayment Referral (OIG 189) form. and send it to the Office of Inspector General (OIG) by mail or fax.      55 Pa. Code § 255.4(c)(2)

NOTE:  Before contacting the OIG, the CAO must verify the income. Finding it listed on the IEVS is not enough proof.

55 Pa. Code § 255.84(d)

The OIG will decide whether to take legal action against the individual, try to get money back from the individual, or both. (See Supplemental Handbook, Chapter 910, Appendix A, Completing the Overpayment Referral Data Input Form (PA 189), ARRC Claim Change Form (PA 1001), and Overpayment Referral (OIG 189).       55 Pa. Code § 255.84(d)

See the Supplemental Handbook Chapter 910, Overpayment Recovery, for information on handling other overpayments.

The CAO will mail or fax the completed OIG 189 for LTC payments to the correct OIG regional office.

 

 

 

 

The OIG will send the CAO a completed Report on LTC Referral (OIG 613).

See the Supplemental Handbook Chapter 910, Overpayment Recovery, for regular processing of other overpayments.

Updated March 12, 2012, Replacing March 6, 2007