PMN19329404 – Revised MA 51, Medical Evaluation Form for Long-Term Care Facility
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 the Independent Enrollment Broker (IEB) or appropriate program office will complete a (PA 1768 ) to verify that an assessment of the individual’s functional eligibility or ineligibility has been completed.
For LTC facility services, Aging Well or its designated subcontractor, currently the local AAA, will receive a Medical Evaluation form (MA 51) from the individual’s attending physician and will complete the Functional Eligibility Determination (FED) form. Aging Well will complete the FED 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: Aging Well does not complete the FED form for an individual whose benefits are stopped and who reapplies within one year from the date of the prior FED, unless a change in the prior decision is indicated. If requested, Aging Well 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, Aging Well will complete the full FED.
Examples:
Elvis 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. Elvis does not apply for MA LTC until August 15. Elvis has not left the facility. The CAO will use the MA 51 received on June 1 to determine functional eligibility for MA LTC. Aging Well 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.
Norma was admitted to an LTC facility on July 1, 2018, and was discharged home on August 15, 2018. An MA 51 was received in the CAO on July 5, 2018, certifying a functional need for LTC services effective July 1, 2018. Norma is re-admitted from the hospital on May 31, 2019. 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 Aging Well.
Carol was admitted to an LTC facility on January 1, 2019, and discharged home on March 15, 2019. An MA 51 was received by the CAO on January 5, 2019, certifying a functional need for LTC services effective January 1, 2019. Carol is readmitted from home by her family on September 1, 2019. The LTC facility physician does not feel that Carol needs LTC services. The LTC facility will contact Aging Well and provide a new MA 51 for a (FED). Aging Well will complete the FED 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.
NOTE: The FED is not required by the CAO to process LTC MA. The CAO is not to deny or delay LTC MA benefits due to not receiving a FED. The CAO is to continue to request the MA 51 to determine functional eligibility for LTC MA. Questions 21 and 22 of the MA 51 must be completed ad signed by Aging Well or the appropriate DHS program office (OLTL, OMHSAS or ODP) to certify the individual's medical need for LTC facility services.
The CAO will use the application date to decide when someone qualifies for MA LTC.
The date of application is the earliest of the following:
The date on which a signed paper application form is received and date stamped in the CAO.
The earliest date the applicant signs the paper form if it is submitted by the Aging Well or another MA provider.
The date the attending physician certifies a functional need for LTC services, if the individual is already receiving MA prior to requesting payment of LTC services See Section 404.27
The date on which an online application is transmitted electronically through COMPASS by the person. COMPASS applications that are submitted online may not immediately have a signed signature page. See Section 304.19 in the MA handbook.
The date of first treatment or admission if the COMPASS application is submitted by an MA provider.
NOTE: The MA provider must still submit the COMPASS application within four calendar months total of the date of the first treatment or admission in order to comply with retroactive coverage rules. See Section 304.15 in the MA handbook.
Example: The facility's business office electronically submits an unsigned COMPASS application for Wanda on 12/15 and requests LTC MA effective 9/3. As long as a signed signature page is provided within 30 days of the COMPASS submission (See Section 304.19 in the MA handbook) and all other financial /functional eligibility conditions are met as of the requested begin date, the CAO may authorize LTC MA services effective 9/3.
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.
Example: Allen 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 489 HCBS Waiver 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 an 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 Residence.
If an 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 facility and HCBS agency listed on the PA 1768.
NOTE: The CAO cannot issue a notice before it decides if an individual qualifies for HCBS.
Exception: When the CAO receives a PA 1768 documenting functional eligibility for HCBS and listing 'Nursing Home Transition (NHT)' in the comments section for a financially eligible individual, the CAO will enter the waiver code in eCIS and send an HCBS eligibility notice before the individual is discharged from the LTC facility. See Operations Memorandum 19-01-05 for NHT instructions.
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 Aging Well, the 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.
PMN19402468 - Long-Term Care (LTC) Facility, Living Independence for the Elderly (LIFE) Provider, and CAO Procedures when LIFE Members Transition to or from an LTC Facility
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.
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: Connie was admitted to an LTC facility on January 1, 2019. An MA 51 was received at the CAO, signed by the physician on February 5, 2019, certifying a functional need for LTC services. An application for MA LTC was received with a requested effective date of January 21, 2019. Unless the physician signs a prescription or statement of functional need back to January 21, 2019, the CAO will authorize MA LTC effective February 5, 2019, if all other conditions of eligibility are met.
Aging Well will receive the MA 51 from the individual’s attending physician, recommending the type of care needed. The Aging Well 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, Aging Well will complete the assessment and forward it to the appropriate program office for a decision on eligibility for LTC services. For all other individuals, Aging Well 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 Aging Well will not determine functional eligibility for HCBS or LTC facility services for individuals residing in intermediate care facilities 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 and narrate any contacts to obtain the form. Verbal verification does not negate the LTC facility’s responsibility to provide the MA 103. When the MA 103 is received it must be scanned to the case record. The CAO can update the case without the MA 103 if collateral contact was made and narrated. After the appropriate case updates were made the CAO should contact the LTC facility one more time to request the completed MA 103 and narrate all contact information.
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:
Doris was admitted to an LTC facility on January 1, 2018. An MA 51 was received by the CAO on January 5, 2018, certifying a functional need for LTC services effective January 1, 2018. Doris applies for MA LTC on February 15, 2018. Doris has never been discharged from the facility. A new MA 51 is not required.
Carla was admitted to an LTC facility on January 1, 2018. An MA 51 was received by the CAO on January 5, 2018, certifying a functional need for LTC services effective January 1, 2018. Carla is discharged home on April 15, 2018, and MA LTC was discontinued. Carla is readmitted from the hospital on September 9, 2018. 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 Aging Well.
Sue was admitted to an LTC facility on January 1, 2018, and discharged home on March 15, 2018. An MA 51 was received by the CAO on January 5, 2018, certifying a functional need for LTC services effective January 1, 2018. Sue is readmitted from the hospital on February 15, 2019. A new MA 51 and FED must be completed because more than 365 days have passed.
If the Aging Well, 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 unless OLTL states in the comments section of the PA 1768, "OLTL to generate notice". This process will enable the individual to ask for a fair hearing. The CAO must contact the assessing agency with the date and time of the appeal hearing as soon as it is received. The assessing agency must attend the hearing to explain how the NFI determination was made. 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 CHC waiver. 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:
PA Independent Enrollment Broker
P.O. Box 61560
Harrisburg, PA 17106
Or
Fax to: (717) 540-6203
The Authorization for Release of Information Form (PA 4) is not required as a condition of MA LTC eligibility.
If the individual or the individual’s representative provides information to determine MA LTC eligibility, the CAO will not require the individual or the individual’s representative to sign the PA 4.
If the individual or individual’s representative is unable to provide information to determine MA LTC eligibility 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 . The CAO will send the individual or the individual’s representative a PA 4 and request the individual or the individual’s representative “sign and return” the form within 10 days. If the PA 4 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, 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.
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. Aging Well or the 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. If the category is followed by two numbers, this is known as a program status code (PSC).
The following categories are eligible for MA benefits:
A, J, M, D, C, PC, MG, TC, TU, PH, PD, PM, PW, PI, TD, PJ, TJ, PA, and TA.
If an individual in a TJ or TA category has a PSC of 65 or 67, the individual is eligible for payment of the Medicare B premium (Buy-In) only and is not an MA recipient. Individuals eligible in a PA, PJ, or PM category with a PSC 86 are also only eligible for payment of the Medicare Part A premium, not full MA.
The PG category represents the Healthy Horizons cost-sharing program. Individuals eligible in the PG category can be eligible for payment of Medicare Part A and/or Part B premiums, the payment of Medicare deductibles and coinsurance, but are not full MA recipients.
An individual, who is eligible in a buy-in only category, must submit an entire application for MA LTC.
NOTE: An individual receiving state blind pension in a “B” or "SBP" category is not receiving MA and must submit an application for MA LTC if payment is needed.
404.271 Application for a Recipient
The following actions will be taken when a MA recipient (non-SSI) requests LTC facility services:
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 Service Provider notifies the CAO via an MA 103 / MA 51 that the individual will now be receiving LTC services or PA 1768 that the client is in need of HCBS services.
3. The CAO will enter a facility code in CIS to end the HMO/MCO enrollment, when notification of receipt of LTC services is received. The CAO should not enter the waiver code until HCBS eligibility is established.
4. The CAO will review the MA 103 /MA 51 or PA 1768 to establish the functional need for LTC or HCBS 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.
Partial renewals require that only certain pages of the PA 600L; with needed questions highlighted, be sent to all involved parties for completion with the pending verification list. Send the following pages containing the listed information in the PA600 L to active MA recipients requesting LTC or HCBS services:
Instructions for completion of the application and information about the look back for asset transfer.
Date of admission and Requested Effective Date completed by the provider only.
All pages requesting Resource Information for Applicant and Spouse
Real Estate
Mobile Home
Burial Arrangements
Life Insurance
Automobiles, Recreational Vehicles, Trucks, Motorcycles
Other Resources
Asset Transfers
Closed Accounts
Lump Sums
Shelter Expense
Rights and Responsibilities with signature
Power of Attorney and Representative information. This should only be sent if the information was not already reported to the CAO, verified and included on the eCIS MA Provider screen.
NOTE: Previous versions of the PA 600 L are still valid and can be used until the supply has been depleted.
6. Run eligibility.
7. Send a notice to the individual explaining the reason for the decision. Send a copy of the notice to the individual, individual's representative, and LTC service provider.
404.272 LTC Facility Applications for SSI Recipients (Categories A, J, M)
An individual who is receiving SSI only and is admitted to an LTC facility can keep getting an SSI payment of $30.00 and the maximum State Supplemental Payment (SSP) of $22.10. These payments should be used toward the individual’s Personal Needs Allowance (PNA) deduction of $60.00. SSI recipients will have a $0.00 cost of care after the PNA deduction, unless they have other countable income.
The following actions will be taken when an SSI recipient requests LTC facility services:
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 Service Provider notifies the CAO via an MA 103/ MA 51 that the individual will now be receiving LTC services.
3. Notify the Social Security Administration (SSA) of the applicant’s new address in a LTC facility and admission date via the PA 1781, also found in MAEH 387 Appendix C.
a. Scan to the record the information sent to SSA.
b. Include this information in the narrative.
4. AP the application for LTL as of the CAO receipt date of the request for LTC MA.
a. This may be in the form of a PA 600L, Long Term Care Admission and Discharge Transmittal (MA103), or a Medical Evaluation (MA51).
5. Verify that the applicant is a recipient of SSI benefits in an A, J, or M category.
a. Do not close the SSI category in eCIS if SSI is the only source of Social Security income.
6. Manually enter the appropriate LTC facility code through maintenance mode effective the admission date.
a. The “Explore LTL” field must be blank.
7. Run eligibility.
8. Send a pending list to the applicant and/or representative as needed to 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. SSI recipients requesting LTC MA must complete the pages of the PA 600 L listed in Section 404.271.
9. Review the status of the SSI payment in State Data Exchange (SDX), and review the open SSI record in CIS, within current application processing timeframes.
a. When SSA processes the facility address change, SSA will systematically change the program status code (PSC) from 00 to 45 in CIS.
10. Dispose of the application through AP when the PSC has been changed to 45, the SSI payment has been reduced to $30/month, and the individual is otherwise eligible.
11. Enter the 902Z TPL manually with a $0.00 cost of care effective the admission date.
12. Run Eligibility to trigger managed care enrollment updates.
13. Send a manual PA 162 indicating the effective date and cost of care to all applicable parties.
a. Scan the PA 162 to the record.
b. Narrate who was sent a PA 162.
NOTE: When the individual is discharged before the SSA processes the Federal Living Arrangement Code that causes the SSI budget’s program status code to update from 00 to 45, the caseworker will update the case with the facility information for the period of residence in the LTC facility, manually add the 902Z TPL for the period of the residence in the LTC facility and issue manual notices to all parties.
404.273 HCBS Applications for MA (Non-SSI Category) Recipients
The following actions will be taken when a MA recipient (non-SSI) requests HCBS:
1. The IEB or Program Office 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 IEB or Program Office provides the CAO a PA 1768 to verify functional eligibility for HCBS, the type of waiver the individual is applying for, and the assessment date.
3. AP the application for HCBS as of the CAO receipt date of the request for HCBS. This may be in the form of a PA 600L or a PA 1768.
4. Send a pending list to the applicant and/or representative as needed to complete a partial renewal which includes, but is not limited to, the transfer of assets within the required look-back period. MA recipients requesting HCBS must complete the pages of the PA 600 L listed in Section 404.271.
5. Enter disability information on the Disability screen in eCIS for any individuals under age 65 so that a waiver category is built.
6. Enter the waiver code and waiver begin date on the Waiver screen in eCIS.
Reminder: For the CHC waiver, the waiver begin date is the system process date. For all other waivers the begin date is either the service begin date or assessment date listed on the PA 1768.
7. Run eligibility.
8. Send the individual a notice, explaining the reason for the decision. Send a copy of the notice to the individual’s representative, the IEB, and if known, the HCBS provider.
404.274 HCBS Applications for SSI Recipients (Categories A, J, M)
The following actions will be taken when a SSI recipient requests HCBS:
1. The IEB or Program Office 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 IEB or Program Office provides the CAO a PA 1768 to verify functional eligibility for HCBS, the type of waiver the individual is applying for and the assessment date.
3. AP the application for HCBS as of the CAO receipt date of the request for HCBS. This may be in the form of a PA 600L or a PA 1768.
4. Send a pending list to the applicant and/or representative as needed to complete a partial renewal which includes, but is not limited to, verifying transfer of assets within the required look-back period. SSI recipients requesting HCBS must complete the pages of the PA 600 L listed in Section 404.271.
5 Enter the waiver code and waiver begin date on the Waiver screen in eCIS.
Reminder: For the CHC waiver, the waiver begin date is the system process date. For all other waivers the begin date is either the service begin date or assessment date listed on the PA 1768.
6. Run eligibility.
7. Send the individual a notice, explaining the reason for the decision. Send a copy of the notice to the individual’s representative, the IEB, and if known, the HCBS provider.
Updated December 23, 2024, Replacing September 14, 2020