The Department of Human Services (DHS) will help pay the cost of Long Term Care (LTC) services for anyone who is both medically and financially eligible. LTC providers evaluate and give care for individuals with illnesses, injuries or disabilities that have a medical need for LTC services. The LTC service provider is responsible for telling an individual and their family that they may apply for Medical Assistance (MA) and payment of Long Term Care (LTC) services.
The Pennsylvania Department of Aging, through the local Area Agency on Aging (AAA) office, the Independent Enrollment Broker (IEB) or the Home and Community-Based Services (HCBS) provider decides whether an individual's medical condition requires LTC services.
The AAA reviews medical information provided by the individual's doctor and reports its decision to the CAO. If the AAA decides that LTC services are not needed, it may recommend care in a Personal Care Home (PCH) or Domiciliary (DOM) Care Facility or some other community care arrangement. (See the Medical Assistance Eligibility Handbook, Chapter 391, Personal Care Supplement, for the eligibility requirements for PCH and DOM Care programs.)
Before an individual can get HCBS services, the appropriate program office or IEB must evaluate the individual’s medical need by completing a Home and Community-Based Services (HCBS) Eligibility/Ineligibility/Change Form (PA 1768).
The CAO decides whether an individual can get financial help to pay for LTC services. This is a two-step process:
Step 1—The CAO decides whether an individual can receive payment of LTC services.
Step 2—The CAO decides how much the individual must pay for LTC facility services.
NOTE: There is no payment for the cost of HCBS services.
An individual applying for or receiving MA and payment of LTC services must meet all of the requirements of this handbook and the following chapters of the Medical Assistance Eligibility Handbook:
LTC facilities include the following:
State or private Intermediate Care Facilities for individuals with Intellectual Disabilities (ICF/ID)
Private Intermediate Care Facilities for persons with other related conditions (ICF/ORC)
County LTC facilities
Private LTC facilities
State-operated psychiatric after-care units
55 Pa. Code § 125.84 (a) (5) 42 CFR § 483.1
NOTE: Psychiatric after-care units are licensed, long-term care facilities located on the grounds of Public Institutions for Mental Diseases. South Mountain Restoration Center is the only state-operated long-term care facility.
Federal law requires DHS to recover the cost of LTC services from the estates of deceased individuals who were 55 or older when they received the services. Costs that may be recovered include, but are not limited to, payments for the following:
Public or private LTC facility services
HCBS
Hospital services
Prescription drugs
The LTC service provider must tell the representative that if the individual received medical assistance for long term care services after age 55, then DHS has the right to recover those payments from the resident’s estate. The representative must contact the Estate Recovery Program, P.O. Box 8486, Harrisburg, Pennsylvania 17105-8486, telephone 800-528-3708 or (717) 772-6604.
If the individual had a will, the executor must contact the Estate Recovery Program to secure a statement from DHS for a claim for MA LTC payments paid for the individual’s care.
If the individual did not have a will:
A surviving spouse, relative, creditor, or any other interested individual may file for "Letters of Administration" from the Register of Wills in the county where the resident died or in the county where the resident lived before entering the LTC facility. Whoever receives the "Letters of Administration" can gather the resident’s assets and handle the estate.
When the resident’s estate does not exceed $4,000, Pennsylvania law permits a LTC facility to pay a licensed funeral director up to $3,500 for funeral expenses. Any remaining money may be paid to the individual’s spouse, children, parents, or siblings.
If no one has been named to handle the individual’s estate, all funds remaining in the patient care account that have not been distributed pursuant to Estate Recovery Program or that exceed the $4,000 limit must be returned to DHS.
If the LTC service provider has no records or information regarding relatives, heirs, or creditors, the provider must contact DHS at the following address:
Department of Human Services
Estate Recovery Program
P.O. Box 8486
Harrisburg, Pennsylvania 17105-8486
1-800-528-3708 or (717) 772-6604
NOTE: The CAO must refer all contacts concerning an individual’s estate to the Estate Recovery Program at the address above.
PROMISe is the claims processing system that supports both MA and non-MA programs. PROMISe requires a Waiver or Facility code in eCIS to authorize payment to LTC service providers. The absence of a Waiver or Facility code may cause the payment to the service provider to be rejected.
NOTE: All LTC; Domiciliary and skilled-level care Facility, Money Follows the Person (MFP), personal Care HOME (PCH), and Waiver Indicators can be viewed in the TFWC Table in CIS System Reference Inquiry.
Updated March 28, 2017, Replacing April 8, 2016