You qualify for Medical Assistance (MA) and payment of Home and Community Based Services (HCBS) in the _____ Waiver for a limited period from ___ to ___. You qualify for these benefits with a monthly spend-down. This means you must incur $___in medical expenses each month to be eligible for the rest of the calendar month. See the Spend-down section for more details on what medical expenses were used. A MA benefit card (PA ACCESS card) will be sent to you unless you were given one before.
The Service Provider/Coordinator will notify you when your HCBS will begin.
62 P.S. § 441.8; 55 Pa. Code §§ 141.71, 178.1, 181.1, 181.13
You qualify for Medical Assistance (MA) and payment of Home and Community Based Services (HCBS) in the Living Independence for the Elderly (LIFE) Program effective _________. You qualify for these benefits because you have medical expenses that are used to spend-down your income. This means you must incur and pay $______ in medical expenses each month to be eligible. See the Spend-down section for the amounts of each medical expense you are responsible to pay the provider. The Service Provider/Coordinator will notify you when your HCBS will begin.
62 P.S. § 441.8; 55 Pa. Code §§ 141.71, 178.1, 181.1, 181.13
You qualify for Medical Assistance (MA) and payment of Home and Community Based Services (HCBS) in the _____ Waiver. You qualify for these benefits because you have medical expenses that are used to spend-down your income. See the Spend-down section for more details on what medical expenses were used. A MA benefit card (PA ACCESS card) will be sent to you unless you were given one before.
The Service Provider/Coordinator will notify you when your HCBS will begin.
62 P.S. § 441.8; 55 Pa. Code §§ 141.71, 178.1, 181.1, 181.14
Reminder: Notice templates are available in the “Long-Term Care Forms” folder on DocuShare.
Updated September 30, 2019, Replacing March 12, 2012