When an individual applies for MA LTC Services, the LTC service provider will complete an assessment of the individual’s functional need for services.
For HCBS services, the appropriate program office will complete a (PA 1768) to verify that an assessment had been completed of the individual’s functional eligibility or ineligibility need for LTC services.
For LTC facility services, the AAA will receive a Medical Evaluation form (MA 51) from the individual’s attending physician and will complete the Level of Care Determination (LCD) form. The AAA will complete the LCD within five working days if the referral is from an LTC facility, three working days if the referral is from a hospital, or ten working days if the referral is from a person living in the community.
NOTE: The AAA does not complete the LCD form for an individual whose benefits are stopped and who reapplies within one year from the date of the prior LCD, unless a change in the prior decision is indicated. If requested, the AAA will complete a “paper review” if information indicates a change in the individual’s medical condition. A "paper review" is a review of medical information, which may include a new MA 51. If the review indicates a change in the individual’s need for LTC facility services, the AAA will complete the full LCD.
Examples:
Mr. E. was admitted to an LTC facility on June 1. An MA 51 was received in the CAO on June 10 certifying a functional need for LTC services effective June 1. Mr. E. does not apply for MA LTC until August 15. Mr. E. has not left the facility. The CAO will use the MA 51 received on June 1 to determine functional eligibility for MA LTC. AAA will not complete a new evaluation of functional need as the form is valid indefinitely because there has been no discharge from the LTC facility.
Ms. N. was admitted to an LTC facility on July 1, 2014, and was discharged home on August 15, 2014. An MA 51 was received in the CAO on July 5, 2014, certifying a functional need for LTC services effective July 1, 2014. Ms. N. is re-admitted from the hospital on May 31, 2015. The CAO will use the MA 51 received on July 5, 2014, to determine functional eligibility for the second admission, because the admission was within 365 days of the first admission.
NOTE: If the individual is requesting a home maintenance deduction (HMD) on the second admission, the physician must certify the individual will be discharged within 180 days from the date of admission for the second time. The physician can complete a new MA 51 or sign a statement. The MA 51 does not need to be reviewed by AAA.
Ms. C. was admitted to an LTC facility on January 1, 2014, and discharged home on March 15, 2014. An MA 51 was received by the CAO on January 5, 2014, certifying a functional need for LTC services effective January 1, 2014. Ms. C. is readmitted from home by her family on September 1, 2014. The LTC facility physician does not feel that Ms. C. needs LTC services. The LTC facility will contact AAA and provide a new MA 51 for a Level of Care Determination (LCD). AAA will complete the LCD and forward the new MA 51 to the CAO. The CAO will use the new MA 51 to determine eligibility for MA LTC.
The MA 51 or PA 1768 will be forwarded to the local CAO upon completion.
The CAO will use the application date to decide when someone qualifies for MA LTC. The date of application is either:
the date on which a signed application form is received and date stamped in the CAO.
the earliest date the applicant signs the form if it is submitted by the AAA or other provider.
the date the attending physician certifies a functional need for LTC services, if the individual is receiving MA prior to asking for payment for LTC services; or
the date on which an online application is transmitted electronically through COMPASS by the person.
the date of first treatment or admission if the COMPASS application is submitted by an MA provider.
NOTE: The MA provider must submit the COMPASS application within four calendar months of the date of the first treatment or admission.
55 Pa. Code § 123.82 55 Pa. Code § 141.81(g)
An individual must submit an application to the CAO in the county where the individual is physically residing. The MA 51/PA 1768 is completed by the LTC Service Provider in the county where the individual is physically located, (i.e., where he or she lives, is hospitalized, or is staying with someone for care). If the individual is temporarily outside of the county where he or she will be physically residing, the LTC service provider will forward the necessary forms and information to the appropriate CAO. 55 Pa. Code § 125.84 (b)
Example: Mr. A. is currently in a hospital located in Dauphin County. When he is discharged, he will be moved to an LTC facility in Lancaster County. The LTC service provider in Dauphin County is responsible for completing the assessment for functional need and forwarding the MA 51/PA 1768 to the Lancaster CAO.
NOTE: The HCBS programs identified in Chapter 389 HCBS Programs, are not located in every county. For example, individuals residing in McKean County cannot apply for the LIFE (Living Independence for the Elderly) program.
NOTE: The LTC service provider may complete the application and forward it to the CAO where the LTC facility is located or where the individual applying for HCBS physically resides.
If a individual who is admitted to an LTC facility or is requesting services provided by one of the HCBS programs in Pennsylvania is from another state, the individual will be considered a resident of PA. See Chapter 423, Residency, Discharge and Transfer.
If a individual transfers from one LTC facility to one in another county, or moves from one county to another county and continues to participate in one of the HCBS programs, eligibility continues while the CAO transfers the record to the new county. A new application is not required. See Section 423.63, Intercounty Transfer.
The PA 1768 is needed for verification that a decision of approval of functional eligibility for an HCBS program has been made in the gaining county and for terminating HCBS services in the losing county.
If an individual transfers from one LTC facility or HCBS program to another in the same county, a new application is not required. The CAO will review eligibility based on the new circumstances and issue a notice to the person and the LTC service provider.
If an individual transfers from an LTC facility to a HCBS program, a new application is not required. When the CAO receives a MA 103 verifying the facility discharge date and PA 1768 to verify HCBS, the CAO will issue a notice to the individual and LTC provider.
NOTE: The CAO cannot issue a notice before it decides if an individual qualifies for HCBS.
The applicant/representative must sign the application. If a representative signs for the applicant, the representative’s address and telephone number must also be provided. Online applications require the applicant or representative to submit a signed signature page if the applicant has access to a printer. If not, the CAO will print and mail a signature page upon receipt of the online application.
When the AAA, LTC facility, or other agency submits an application as a provider, the LTC service provider employee signs in the provider signature section.
NOTE: The applicant should be encouraged to sign with an “X” in the presence of a witness if unable to provide a signature. The individual witnessing the mark will sign his or her name and provide his or her address/phone number in the appropriate application section. 55 Pa. Code § 125.1(d)
The applicant must provide verification of functional need for LTC services before the CAO will authorize a payment. The functional need determination is the first step in the MA LTC eligibility process. The MA 51 is needed for LTC facility services, and the PA 1768 is needed for services provided under an HCBS program. The MA 51 must be completed and signed by a physician. The PA 1768 must be completed and signed by the HCBS service provider.
55 Pa. Code § 1187.31(4) 42 CFR § 480.40
NOTE: The date the physician signs the MA 51 is the certification of need date for LTC services. If the LTC facility is requesting payment for LTC services prior to this date, the physician can verify the need for LTC services back to the requested effective date via a signed prescription or other signed statement.
Example: Ms. C. was admitted to an LTC facility on January 1, 2011. An MA 51 was received at the CAO, signed by the physician on February 5, 2011, certifying a functional need for LTC services. An application for MA LTC was received with a requested effective date of January 21, 2011. Unless the physician signs a prescription or statement of functional need back to January 21, 2011, the CAO will authorize MA LTC effective February 5, 2011, if all other conditions of eligibility are met.
The AAA will receive the MA 51 from the individual’s attending physician, recommending the type of care needed. The AAA will complete an assessment to determine the individual’s need for LTC facility services. This assessment includes a review of the Preadmission Questionnaire for LTC facility services (PASARR-ID) or the completion of one if one has not been completed. The PASARR-ID identifies members of a target group with mental illness, mental retardation, or other related disabilities which require specialized services. The CAO will not receive a copy of the screening forms. This screening is completed for all admissions to an LTC facility. For individuals who are identified as members of the target group, AAA will complete the assessment and forward it to the appropriate program office for a decision on eligibility for LTC services. For all other individuals, AAA will indicate its decision on the MA 51, notify the individual, and provide the original signed MA 51 to the CAO. 55 Pa. Code § 1181.542(b)(4)(i)(D) 42 CFR § 483.112
NOTE: The AAA will not determine functional eligibility for HCBS or LTC facility services for individuals residing in ICFs/MR or in after care units of state mental hospitals.
Within three days of an individual’s admission to an LTC facility, the facility administrator or designee must complete the Long Term Care Admission and Discharge Transmittal Form (MA 103) to provide notification of the individual’s need for services. The facility must forward the copy of the form labeled "County Assistance Office (CAO)" to the CAO within three working days of the individual’s admission.
For applicants who have been paying privately in an LTC facility, the MA 103 must indicate the date the facility is requesting MA LTC payment to begin. If the facility is forwarding the application form to the CAO, the MA 103 should be attached.
NOTE: If the CAO has completed the determination of MA LTC eligibility and the MA 103 is not in the CAO, the CAO will call the facility to verify the date of admission and requested date of payment for MA LTC services. The telephone contact and date should be included in the case record narrative. Authorization should not be delayed because the MA 103 is not received. The CAO will monitor receipt of the MA 103 after authorization. Verbal verification does not negate the LTC facility’s responsibility to provide the MA 103.
When an individual has been certified to have a functional need and transfers to an LTC facility in another county, functional need may be verified by current evaluations from the losing county. A new MA 51 is not required. The MA 103 is needed to verify that the individual continues to receive LTC services.
NOTE: The MA 51 is valid indefinitely if the information reflects the current functional need of the individual and the individual has not been discharged from the LTC facility, even if the individual has not applied for MA LTC. If an individual was found eligible for MA LTC and 365 consecutive days have not lapsed since MA LTC eligibility was discontinued, a new MA 51 is not required. A new MA 51 is required for an individual in an LTC facility whose MA eligibility has been discontinued for more than 365 consecutive days, regardless of whether the functional need remains unchanged.
Examples:
Ms. D. was admitted to an LTC facility on January 1, 2014. An MA 51 was received by the CAO on January 5, 2014, certifying a functional need for LTC services effective January 1, 2014. Ms. D. applies for MA LTC on February 15, 2015. Ms. D. has never been discharged from the facility. A new MA 51 is not required.
Ms. F. was admitted to an LTC facility on January 1, 2014. An MA 51 was received by the CAO on January 5, 2014, certifying a functional need for LTC services effective January 1, 2014. Ms. F. is discharged home on April 15, 2014, and MA LTC was discontinued. Ms. F. is readmitted from the hospital on September 9, 2014. A new MA 51 is not required, because 365 consecutive days have not lapsed since MA LTC was discontinued.
NOTE: If the individual is requesting a home maintenance deduction (HMD) on the second admission, the physician must certify the individual will be discharged within 180 days from the date of admission for the second time. The physician can complete a new MA 51 or sign a statement. The MA 51 does not need to be reviewed by AAA.
Ms. C. was admitted to an LTC facility on January 1, 2014, and discharged home on March 15, 2014. An MA 51 was received by the CAO on January 5, 2014, certifying a functional need for LTC services effective January 1, 2014. Ms. C. is readmitted from the hospital on February 15, 2015. A new MA 51 and Level of Care Determination (LCD) must be completed.
If the AAA the HCBS provider or IEB determines the individual does not have a functional need for LTC services, the individual and the CAO will be notified. If the individual does not have a functional need for LTC services, the individual will be told about other services in the community, such as care in a Personal Care Home (PCH) or domiciliary care facility. If the individual disagrees with the decision, the LTC service provider or CAO will tell the individual to complete and sign an application and forward it to the CAO. The CAO will send a denial notice to the applicant. This process will enable the individual to ask for a fair hearing. A representative of the LTC service provider will attend the hearing to explain the decision. The CAO will decide if the individual qualifies for MA such as Healthy Horizons.
The Office of Long Term Living uses an Independent Enrollment Broker (IEB), currently this is Maximus, to determine functional need for the 0192, Attendant Care, Independence, Commcare and OBRA waivers. Maximus decides functional need for new HCBS applicants only. Maximus is responsible to send the PA 1768 form to the CAO. When the CAO decides if an individual qualifies for MA LTC, a copy of the notice must be sent to:
Maximus
6385 Flank Drive Suite 400
Harrisburg, Pa 17112
Or
Fax to: (717) 540-6203
The Authorization for Release of Information Form (PA 4) or Authorization for Release of Information for Health Care Coverage (PA 4 LTC), for use by Community Choice Counties only) is not used to figure MA LTC. 55 Pa. Code § 201.4(1)(i)
If the individual or the individual’s representative provides information to figure MA LTC, the CAO will not require the individual or the individual’s representative to sign the PA 4 or PA 4 LTC.
If the individual or individual’s representative is unable to provide information to figure MA LTC and the collateral contact will not release the information to the CAO without the consent of the individual, the CAO will require the individual to sign a PA 4 or PA 4 LTC. The CAO will send the individual or the individual’s representative a PA 4 or PA 4 LTC and request the individual or the individual’s representative “sign and return” the form within 10 days. If the PA 4 or PA 4 LTC is not returned or is returned unsigned, the CAO will take action to deny MA LTC benefits with a Notice to Applicant or to close a recipient’s MA LTC benefits with an Advance Notice.
NOTE: The individual should be encouraged to sign with an “X” in the presence of a witness if unable to provide his or her signature.
NOTE: If a court appointed guardian or a individual who has power-of-attorney signs the PA 4 or PA 4 LTC, a copy of the guardianship or the power-of-attorney paperwork should accompany the form.
A relative, friend, or representative of an institution may complete an application for a deceased individual. The CAO will accept an application for a deceased individual if the death was not prior to the first day of the third month before the month of application. 55 Pa. Code § 123.72 55 Pa. Code § 123.82(ii)
If an individual who is receiving HCBS or is in an LTC facility dies before notification from the LTC service provider is received by the CAO, the CAO will accept and process the application. The AAA or HCBS provider will complete a "paper review" to determine the individual’s functional need for services.
NOTE: For applicants who expire prior to authorization for MA LTC, only resources available after funeral expenses have been paid are counted. If the remaining available resources are equal to, or less than, the MA LTC resource limit, MA LTC is authorized effective the date of requested coverage. State law requires that payment of funeral expenses receives priority over medical expenses in the distribution of a decedent’s estate. See Section 440.711, Excess Resources - Death prior to authorization, for more details. Title 20 § 3392 (Decedents, Estates and Fiduciaries Code)
An individual who is a current recipient of MA in a non-LTC related category is not required to complete an application for payment of LTC services. The following categories are eligible for MA benefits: A, J, M, D, C, PC, PU, TC, TU, PS, PH, PD, TD, PJ, TJ, PA, and TA. If the category is followed by two numbers, this is known as a program status code (PSC). If an individual in a PJ, PA, TJ, or TA category has a PSC of 65 or 67, the individual is eligible for payment (buy-in) of the Medicare B premium only and is not an MA recipient. An individual, who is eligible in a buy-in only category, must submit an application for MA LTC.
NOTE: An individual receiving state blind pension in a “B” category is not receiving MA and must submit an application for MA LTC if payment is needed.
1. The LTC Service Provider will verify eligibility for MA via the Eligibility Verification System (EVS).
NOTE: An individual who has an MA ACCESS card is not necessarily an active MA recipient. EVS must be checked to verify eligibility.
2. The LTC Service Provider notifies the CAO via an MA 103/MA 51 or PA 1768 that the individual will now be receiving LTC services.
3. The CAO will enter a facility or waiver code in CIS to end the HMO/MCO enrollment, when notification of receipt of LTC services is received.
4. The CAO will review the MA 103/MA 51 or PA 1768 to establish the functional need for LTC services and requested effective date of MA LTC.
5. The CAO will complete a partial renewal which includes, but is not limited to, verifying the intent to return to resident property and the transfer of assets within the required look-back period.
6. The CAO will determine eligibility for MA LTC and provide the individual with a notice, explaining the reason for the decision. Send a copy of the notice to the individual, individual’s representative, and LTC service provider.
Updated April 2, 2015, Replacing March 12, 2012