The individual applying for a Personal Care Supplement (or someone acting for the individual) must complete and sign one of the following applications:
For care in a Dom Care Home, an Application for Domiciliary Care Supplement (PA 1-D).
For care in a PCH, an Application for Personal Care Boarding Home Supplement (PA 761).
If the individual is not receiving SSI or is not eligible for SSI, he or she must also:
Write “SSI APPLICANT” in the upper-right corner of the PA 761 orPA 1-D.
Contact the Social Security Administration (SSA) by telephone to ask for SSI benefits, and to tell the SSA that he or she is also applying for a Personal Care Supplement.
NOTE: For the date of the SSI application, the SSA uses the date that the first contact for SSI benefits is made. The SSA must be told at that time that the individual is also applying for a Personal Care Supplement. If the individual's income is more than the regular SSI limit, AAA may need to call the SSA to confirm that the individual is functionally disabled.
When the application process begins with the PCH or Dom Care Home, the operator of the home must take the following actions:
If the individual has not had a medical exam within the past 60 days, arrange for the individual's doctor to examine the individual and fill out a Medical Evaluation Form (MA 51).
NOTE: If the individual is not getting SSI and needs Medical Assistance (MA) to pay for the exam, AAA must tell the individual to submit a completed PA 600 to the CAO.
If the individual has been found eligible but has not yet received SSI benefits, obtain verification that the individual is eligible for SSI benefits.
If the individual is not eligible for SSI benefits the operator must take the following actions:
Help the individual obtain verification of his or her income and resources.
Call the SSA to request SSI benefits and to tell them that the individual is also applying for a Personal Care Supplement.
Send AAA all of the following information:
A completed application (PA 761 or PA 1-D).
MA 51.
Copy of the PCH or Dom Care Home’s certificate of compliance.
Proof of eligibility for SSI.
When AAA receives an application for a personal care supplement, it must take the following actions:
Stamp the application with the date, and make sure all forms are complete. Hold the application until the SSA decides whether the individual is functionally disabled.
NOTE: If the individual does not turn in the needed forms, notify the individual that the application cannot be processed until he or she does so.
If the individual has not had a medical exam within the past 60 days, have the individual (or the individual's representative) arrange for the individual's doctor to examine the individual and complete a Medical Evaluation Form (MA 51).
NOTE: If the individual is not an SSI recipient needs Medical Assistance (MA) to cover the cost of the exam, AAA will refer the individual to the CAO for an application for MA. A PA 600 is required.
Complete a Level of Care Determination (LCD) if one has not been completed or if the MA 51 indicates a change from an earlier assessment.
If the individual is not already receiving SSI or has not applied for SSI, AAA must take the following actions:
Instruct the individual to go to the SSA to apply for SSI benefits.
If the individual's income is more than the regular SSI limit, call the SSA to confirm that the individual is functionally disabled.
Complete the AAA Level II Client Determination Report and send a copy to the applicant.
Send the CAO all of the following information:
AAA Level II Client Determination Report.
MA 51.
Certificate of compliance.
As soon as the CAO and the SSA decide the individual is eligible, help the individual find a PCH or Dom Care Home, if he or she needs help.
NOTE: AAA has a list of Dom Care Homes, but, generally, it is the individual's (or their representative’s) duty to find a PCH. A list of licensed PCH providers is available from the Department’s regional licensing offices. See Appendix C for the addresses and telephone numbers of the regional offices.
When the CAO receives the application and completed forms, the CAO must take the following actions:
Review all forms to be sure they are complete and that the MA 51 was signed by the doctor within 60 days of the application date.
NOTE: The Department maintains a Personal Care Home Directory of all licensed PCHs in the State. If a certificate of compliance is not included with the application it can be found by accessing the PCH Directory online at the Department’s website, www.dhs.state.pa.us. A copy should be made for the case record.
Check the SDX Data Exchange 6 to verify whether the applicant is receiving SSI benefits and if the individual's current address is correct.
If AAA decided that the individual is not functionally disabled, send a Notice to the Applicant explaining why the application has been denied. Send a copy of the notice to AAA.
NOTE: The Notice to Applicant is the formal notice of the individual's right to ask for a fair hearing. If the individual appeals the AAA decision, notify AAA of the request and the date and time of the hearing. An individual from the Area Agency on Aging must attend the hearing to explain the decision, if an explanation is needed. 55 Pa. Code § 299.22 (d)
If the individual is functionally disabled and receiving SSI benefits, the CAO will authorize the personal care supplement by taking the following actions:
Complete the Authorization for State Supplement for Persons in a Domiciliary Care Facility/Personal Care Home Form (PA 747).
Forward the SSA copy of the PA 747 to the SSA.
Authorize the individual in the Client Information System (CIS) using the appropriate category, Program Status Code and Facility Code (See Section 391.42, Category, Program Status Code, and Facility Code).
Send a manual notice letting the individual know that he or she will begin receiving the Personal Care Supplement (See Section 391.43, Completing the Client Notice).
Send a copy of the PA 747 and the Notice to Applicant to AAA.
NOTE: If the PA 747 is being used to authorize the personal care supplement in a PCH, write “PERSONAL CARE HOME” in the upper-right corner.
NOTE: The Client Information System (CIS) will not allow entry of a program status code designating eligibility for the personal care supplement (60 or 62) until eligibility for the supplement is showing on Data Exchange 6. The CAO must wait until the SDX Data Exchange shows the Personal Care Supplement as being received before Program Status Code 60 or 62 can be entered into CIS.
If the individual is functionally disabled but is not yet receiving SSI benefits because the SSA has not yet determined eligibility for SSI benefits or the application status is unknown, the CAO must take the following actions:
Complete the Authorization for State Supplement for Persons in a Domiciliary Care Facility/Personal Care Home Form (PA 747.)
Send a manual notice letting the individual know that he or she will begin receiving the Personal Care Supplement (See Section 391.43, Completing the Client Notice).
After it is verified on the SDX Data Exchange that the SSA has approved SSI benefits, authorize the individual in the Client Information System (CIS) using the appropriate category, program status code and facility code (See Section 391.42, Category, Program Status Code, and Facility Code).
Send a copy of the PA 747 and the manual notice of eligibility to AAA.
NOTE: The Client Information System (CIS) will not allow authorization in an SSI category (A, J, M) until the SSA determines eligibility for SSI benefits. The CAO cannot authorize MA in an SSI category until eligibility for SSI is verified on the SDX Data Exchange.
If the SSA determines that the individual is not eligible for SSI benefits, the SSA will return the PA 747 to the CAO. Notify AAA of the SSA’s decision. If the individual needs or requests MA before the SSA makes its decision, explain the application process and give him or her a PA 600.
If an applicant for a PCH or Dom Care Supplement is being referred to SSA for a determination of SSI eligibility, the home operator and/or AAA will help the individual or representative with the application, if help is needed. SSA determines the date of the SSI application based on the date the initial contact regarding SSI was made. The first contact should be a telephone call to SSA requesting benefits
It is important for the individual or representative to tell SSA that an application is also being submitted for the Personal Care Supplement. If the individual's income exceeds the normal SSI eligibility limit, AAA may need to contact SSA by phone on the individual's behalf, to verify the individual's determination of functional disability. If a request is not made by phone, the date of initial contact is the date SSA receives the application. To avoid a loss of benefits, the CAO should advise the individual to make the request by phone.
NOTE: The individual must enter the facility within 30 days of SSA’s decision.
If the individual's countable net income is more than the federal SSI benefit rate but less than the federal benefit rate plus the Supplement, SSA will issue an SSI check for the amount of the supplemental benefits for which the individual is eligible. SSA allows a $20 income disregard.
Updated April 3, 2015, Replacing February 14, 2012