The MA eligibility process starts when the AAA or HCBS program office receives a referral for HCBS or LTC facility services. The referral may come from a hospital, an LTC facility, physician, the CAO, etc.
After the LTC service provider makes a determination of functional need, the MA 51 or PA 1768 will be forwarded to the CAO. The person, person’s representative, or LTC service provider will submit an application for MA LTC benefits to the CAO.
NOTE: In full service AAA counties, the AAA will be responsible for completing the application and obtaining all necessary verification before forwarding the application/verification to the CAO for processing.
1. Date stamp the form upon receipt of the application in the CAO. The date stamp is the application date unless a provider, the AAA, or other agency submits the application.
NOTE: Current MA recipients are not required to submit a new application form. However, the CAO must complete a partial renewal. The partial renewal should include, but is not limited to, verification of intent to return home and any transfer of assets within the required look back period.
NOTE: An individual or individual’s representative can submit an application for MA LTC. However, MA LTC can not be authorized until functional need is verified by the PA 1768 or MA 51.
2. Enter the information from the application into CIS via the Application Processing (AP) and Case Initiation (CI) modes.
NOTE: Complete an Income Eligibility Verification System (IEVS) request for the individual.
3. Review the MA 51 or PA 1768 to establish the functional need for LTC services. Review the MA 103 from the LTC facility to provide notification of the date of admission or requested effective date of MA LTC.
4. Conduct a telephone or face-to-face interview with the applicant to review the application, if necessary. Instruct the applicant with a community spouse to list both the applicant and the spouse on the application. Income and resource information must be reported for both individuals.
5. Advise the applicant in writing if any additional verification is required and the date the verification must be provided by. The verification should be provided within 30 days of the receipt of the application to ensure a timely determination of eligibility.
6. Help the applicant to complete the application process and obtain verification if needed.
7. Determine eligibility/ineligibility for MA LTC within 30 days. If the CAO delays the decision, notify the applicant of the reason for the delay and indicate that it will extend the period an additional 15 days, for a total of 45 days. The reason for the delay in processing the application should be documented in the narrative as part of the case record. 55 Pa. Code § 125.84(e) 42 CFR § 435.911
Exception: If an individual is waiting placement in an LTC facility or an HCBS program because a bed or slot is not available, the application may be held pending for 120 days. See Section 404.53, Applications Held Pending.
NOTE: The MA LTC application period can be extended beyond 45 days when the delay is caused by unusual circumstances beyond the CAO’s control. A delay by a third party constitutes unusual circumstances. Other unusual circumstances include a delay by the individual and an administrative emergency beyond the CAO’s control.
8. Establish the effective date of MA LTC eligibility, if authorizing the application. The effective date of MA LTC eligibility is the date of the application or the date within the retroactive period when functional, nonfinancial, and financial eligibility is established. Do not authorize LTC facility services until the individual is admitted. Do not authorize eligibility for HCBS services until the appropriate program office has determined the individual has a functional need and qualifies for the HCBS services.
9. Review eligibility for MA if the individual is ineligible for an HCBS program or LTC facility services payment, and authorize benefits for persons who qualify.
10. Provide the individual with a Notice to Applicant, explaining the reason for the decision. Send a copy of the notice to the individual’s representative and the LTC service provider.
Updated March 12, 2012, Replacing June 30, 2011