A partial renewal is a review of specific eligibility factors that can change. A partial renewal is required based on anticipated increase in resources, anticipated changes such as the sale of the home, changes to spousal allowances, or when a MA recipient applies for MA LTC.
A partial renewal will not change the due date for a complete renewal of eligibility.
No specific form is required for a partial renewal. The form to be used, if any, will be appropriate to the circumstances being reviewed. An interview is not required. A PA 4 must be obtained if needed to request third party verification of income or resources.
NOTE: When determining the individual’s payment toward the cost of nursing facility services (STEP 2), the CAO will complete a calculation of interest income every 12 months. The CAO is not required to recalculate interest income at the time of the partial renewal if 12 months have not elapsed since the last recalculation.
To complete a partial renewal, the CAO will:
1. Contact the individual or representative to inform the client or representative what information or verification is needed.
2. When the information is received, determine financial eligibility and decide whether there is a change in the contribution toward the cost of LTC facility services. If the individual is ineligible, provide an Advance Notice prior to closure.
3. If the individual or representative fails to respond to the request for information, provide an Advance Notice advising of ineligibility for continued MA.
4. Telephone or write the individual or representative if he fails to provide verification. LTC facility service payments may continue if the facts presented by the individual or representative are consistent and reasonable and a plan is made to obtain the verification. Allow up to 30 calendar days for the client to provide verification. 55 Pa. Code 133.84 (d)
When resources are close to an individual's resource limit, the CAO must set an alert to review resource balances. The following criteria should be used:
|
Time Frame |
NMP - Limit $8,000 $2,000 + $6,000 disregard |
MNO Limit - $ 2,400 |
|
60 days if resources are |
$7,900 - $8,000 |
$2,300 - $2,400 |
|
3 months if resources are |
$7,800 - $7,899 |
$2,200 - $2,299 |
|
6 months if resources are |
$7,500 - $7,799 |
$1,900 - $2,199 |
NOTE: Only resources subject to frequent change (i.e., bank and patient fund accounts) need to be verified every 60 days.
A partial renewal will also be completed when the following occurs:
Property is sold.
An MA recipient applies for payment of LTC services.
An MA LTC recipient moves to another county in Pa.
A partial renewal includes but is not limited to verifying; intent to return to resident property, transfers for less than FMV, medical needs, income, resources, etc.
The renewal date on CABUDG/ Budget Authorization should be updated at each income and resources review. A complete renewal is not necessary in order to update the renewal date. The renewal date on CABUDG/Budget Authorization is changed to reflect the due date of the next review.
The CAO is responsible for:
1. Review case alerts to establish which individuals are due for review.
2. Mail any appropriate forms to the individual or representative. A face-to-face interview is not required. The type and value of each resource must be identified by the individual or representative and verification of each resource must be provided to the CAO, if available. Information regarding the company/bank name, address, and account number/policy number must be included.
3. Request a PA 4, if needed.
4. Complete an IEVS Status Inquiry and review the information available on the Detail and History screens for Exchange 5. See “Using IEVS” for complete IEVS procedures.
5. Request third party verification for unreported or conflicting resource information from IEVS Exchange 5. The institution which holds the funds must verify the resource. For example, only the financial institution can verify an irrevocable burial reserve. A burial agreement presented by the funeral home is not acceptable verification.
Resources that change frequently, such as the resident’s account held by the LTC facility and other bank accounts, will be verified with each review.
Resources, such as life insurance, burial funds, vehicles, and real property, need to be verified once a year.
NOTE: Due to confidentiality, special handling of the PA 76 form is required when verifying information identified by IEVS Exchange 4 and 5. See “Using IEVS” Chapter 1, page 5, “Third Party Verification” and Verifying IRS Information.”
6. Review exempt resources such as irrevocable burial reserves and resident property to be sure that the exempt decision meets the necessary policy conditions. For example, verify the irrevocability of the burial reserve, not just the amount.
7. Review all information provided by the client or representative. Resolve new or conflicting information by contacting the individual or representative and requesting third party verification as needed.
8. When there is a delay in securing verification due to a third party and the individual or representative is cooperating, continue benefits and review the process in securing documentation and cooperation every two weeks. The IMCW should not pend verification indefinitely. A more aggressive plan, made with the cooperation of the individual or representative, may be necessary.
9. Once the review is complete, set an alert for the next review based upon the criteria for partial renewal in Section 476.31. if necessary.
Recipients or Representative Responsibilities
1. Cooperate by providing the information necessary to complete the review.
When there is a COLA, the CAO will review income eligibility factors that decide the individual’s payment toward the cost of LTC facility services. See Chapter 468. The CAO will conduct IEVS income reviews in compliance with procedures outlined in “Using IEVS.” IEVS Exchanges #1, 3 and 4 should be reviewed as part of the normal COLA process.
The CAO will:
1. Follow the policy specified in Chapter 472, “Mass Changes.”
2. Verify individual income and Medicare Part B premiums.
3. If a maintenance allowance is provided, verify income and shelter expenses of the community spouse, dependents, or child with disability as required in Sections 468.34, 468.35 , 468.36, and 468.37
4. Recompute interest income, if necessary, based upon previously reported resources.
5. Inform the LTC facility to deduct the individual’s expenses for medical services and insurance premiums as part of the billing to the Department of Public Welfare (DPW). See Section 468.33
6. Establish the individual’s contribution toward the cost of LTC facility services and provide an Advance Notice (either manual or CIS/eCIS generated) if the individual’s contribution increases. Do not include specific medical expenses and insurance premiums in the calculation and notice.
7. Update the renewal due date in CIS/eCIS according to case circumstances.
Issued May 1, 2012