468.3 Payment Toward the Cost of LTC Facility Services- Step 2

If a resident in an LTC facility is eligible for MA LTC in Step 1, the CAO must determine whether the person qualifies for payment toward the cost of LTC facility services.

The CAO must determine how much income the resident has after deducting allowable expenses (see Section 468.31). If the amount is less than the monthly MA payment rate for the LTC facility, DHS must pay the difference.

For a partial month, the MA payment rate is the daily rate for the specific LTC facility times the number of days the resident is in the facility.

55 Pa. Code § 181.453

NOTE:  There is one MA per diem rate for each LTC facility, regardless of the services provided.

If an individual is requesting MA LTC in the same calendar month he was admitted and the admission date is after the first day of the calendar month then the CAO will only count the income that is actually available.     

55 Pa. Code § 181.451(b)

Example: Stanley has applied for MA LTC payments. His monthly income and expenses are as follows:

Step 1: Determining Eligibility

Because Stanley’s six-month income after deductions is less than $2,550, he is eligible for MNO benefits.

Step 2: Determining Payment

Because Stanley has more income then he needs to pay his medical expenses he is not eligible for payment from DHS.

NOTE: The CAO will monitor the case to ensure the extra income that is not needed to pay for LTC services, when added to existing resources does not exceed the resource limit.

468.31 Deductions from Gross Income

The CAO must allow the following deductions from a resident’s income:    

• Personal Needs Allowance (PNA).    

• Guardian fees.

Guardian fees are an allowable deduction from the cost of care if the fees are ordered by a court. The CAO must verify the court order.

The amount of the guardian fee that is allowable as a deduction effective 1/1/2023 is $300.00 per month or the court authorized monthly fee, whichever is less. The deduction cannot be more than $300.00 per month, even if the court ordered higher fees. The actual amount of the guardian fee included in the court-order must be entered in eCIS. eCIS will correctly use either the actual amount entered or $300.00 as the deduction, whichever is less.

Exception: Fees paid to a representative payee cannot be deducted.

• Community Spouse Monthly Maintenance Needs Allowance (CSMMNA).

• The resident must pay a lower CSMMNA if he or she needs the money to pay for medical or remedial expenses. See Section 468.34, Community Spouse Monthly Maintenance Needs Allowance.

• Maintenance allowance for dependents who live with a spouse in the community.       

• Maintenance allowance for a dependent child or a child who is disabled when there is no spouse in the community.    

• Medical and remedial expenses.    

• Medical and remedial expenses are deducted by the LTC facility when the LTC facility submits the claim for payment. If the individual’s income after allowing the CSMMNA is not enough to pay medical expenses, the individual must reduce the amount of the CSMMNA to pay the medical and remedial expenses.

• Home Maintenance Deduction (HMD).    

• An individual is eligible to receive the HMD if a doctor says the individual is expected to remain in the LTC facility for six months or less from the date of admission. The individual must have a home to return to, and he or she must be responsible for the bills. See 468.38, Home Maintenance Deduction.

• Court-ordered child support.

The CAO must not allow deductions for federal or state taxes, union dues, alimony, expenses related to obtaining the income, or medical insurance premiums for the person’s spouse.

55 Pa. Code § 181.452  applies to the entire section

468.32 Personal Needs Allowance (PNA)

The CAO must deduct a PNA of $45.00 per month to be used by the person for clothing and other personal needs while he or she is in the LTC facility.

NOTE: An individual who (a) is a resident of an Intermediate Care Facility for persons with intellectual disabilities (ICF/ID),or Intermediate Care Facility for Other related Conditions (ICF/ORC),  (b) is not receiving SSI benefits, and (c) has earnings from therapeutic activities (sheltered workshop) arranged by the institution will receive a PNA based on his or her earnings. See LTC Handbook Chapter 486 for information about the graduated PNA for residents of Intermediate Care Facilities who have income from a sheltered workshop.

55 Pa. Code § 181.452(d)(1)  applies to the entire section

468.33 Medical Expenses

An individual may receive a deduction for medical expenses that are not paid by someone else. The expense must be the individual’s financial responsibility. There is no limit to the number of times the individual may incur a specific medical expense. The LTC facility must deduct costs for medical services from the individual’s payment toward the cost of LTC facility care.      

The deduction is allowed in the calendar month in which the bill is paid. The LTC facility must deduct the expense when it bills DHS and the  individual.

Exception: The LTC facility must deduct a medical expense over several months if the expense exceeds the individual's income.

Example: Chad has to make a $200.00 payment toward the cost of LTC services each month. He needs a hearing aid, which will cost $600.00. The LTC facility must deduct $200.00 from Chad’s payment each month to cover the expense. Chad will not pay anything towards the cost of his LTC facility services for three months.

NOTE:  The CAO must split health insurance premiums over the number of months the payment covers.

Example: An individual pays $240.00 every three months for Blue Cross. The CAO must allow a deduction of $80.00 a month.

If a supplemental Medicare insurance premium is paid for both spouses, only the portion that covers the MA LTC recipient can be used as a medical deduction. The CAO must use 50 percent of the premium as the medical deduction if it cannot determine the exact amount.

Example: Each month, $120.00 is deducted from the individual’s pension check for supplemental insurance. This covers both husband and wife. The husband is in an LTC facility. The individual can use $60.00 as a medical deduction.

The LTC facility will deduct the following medical expenses if the individual paid for them in the month of application or renewal or if the individual will pay for them during the coverage period:

• Medicare and other health insurance premiums, including enrollment fees, deductibles, or co-insurance charges.

NOTE:  If the individual chooses a Medicare D plan that has a premium higher than the low-income subsidy (benchmark) for Pennsylvania, the LTC facility will encourage the  individual to choose a plan that does not require a premium. See Appendix A for the current low-income subsidy amount.

• Expenses for medical or remedial care that is accepted under state statutes or regulations but is not covered by MA.  These medical services are known as "fee for service" items. See Appendix C for a list of covered services and "fee for service" items. The CAO can determine whether an item is covered by checking the DHS fee schedule or contacting the LTC facility.      

NOTE: “Not covered” includes expenses for medical or remedial care that is accepted under state rules but is given by a medical provider who does not accept the ACCESS card. “Medical services” include dues paid to an ambulance company.

• Co-payments required by DHS’s co-payment program.

The co-payment deduction is subject to the co-payment fee established by DHS. See the Medical Assistance Handbook, Chapter 338, Appendix D for co-payment rates for medical services.    

The LTC facility will not deduct payments for medical services or items that are included in the LTC facility’s per diem rate. See Chapter 438, Benefits and Billing.

The cost of diapers must never be considered a medical expense deduction and used to reduce the individual’s payment toward the cost of  care. The cost of supplies needed by a resident for incontinence care is included in the LTC facility’s per diem rate. If the LTC facility normally uses cloth diapers but the resident needs disposable diapers for medical reasons, the LTC facility must give disposable diapers to the resident. The cost of disposable diapers must be included on the LTC facility’s cost report so that the facility can be paid for them.

If the resident does not have a medical need for disposable diapers but prefers disposable diapers, the LTC facility must give the resident disposable diapers. However, the extra cost for disposable diapers must be charged to the resident’s personal care account. The LTC facility may only charge the resident the difference between the cloth diapers and the disposable diapers.

Exception: The LTC facility must deduct the cost of any item that is specifically prescribed by a physician, such as a brand-name medication or item.

55 Pa. Code § 181.452(d)(5)  applies to the entire section

468.34 Community Spouse Monthly Maintenance Needs Allowance (CSMMNA)

The CAO will deduct a spousal allowance from the IS's income for the needs of the person’s CS. The IS must agree, in writing, to make the allowance available to the CS. The CAO must deduct only the amount actually given to the CS. If the CS has dependents who live in the same household, the CAO must apply the provisions of Section 468.36,  Allowance for Dependents Living with a Community Spouse.

A CS who is not living with the individual when he or she enters an LTC facility or applies for MA LTC may be entitled to a CSMMNA if the CAO receives:

• A written request by the CS for a spousal allowance.

• A written agreement by the IS to give a spousal allowance from the  individual’s income.

The CAO will  follow these steps to determine a CSMMNA:

1. Verify that the institutionalized spouse has a spouse residing in the community who lived with the IS before he or she entered the LTC facility. A spouse who lived in a hospital, an LTC facility, or an intermediate care facility does not qualify for the CSMMNA.

NOTE:  A CS who lives in a personal care home (PCH), domiciliary care facility (DCF), assisted living facility or other residential setting is considered to be living at home if he or she lived with the IS before the IS entered the LTC facility. Because the PCH, DCF and most assisted living facilities charge one  fee that  includes items that are not shelter, the CAO must not use the whole amount as a shelter expense. It must use only the actual amount of the rent. The PCH, DCF, or assisted living facility must be able to identify the shelter portion of the payment.   If the actual rent amount cannot be identified, the CAO may make an eligibility determination using zero for the rent amount. A spouse who lives in a hospital, an LTC facility, or an ICF is considered institutionalized and does not qualify for the CSMMNA.

2. Determine whether the CS incurs excess shelter costs for the residence where he or she lives.

Start by verifying the actual monthly shelter cost.

a. Use rent, mortgage payments (principal plus interest of all mortgage payments, including second and third mortgages), sales or lease purchase agreement, maintenance charges for condominium or cooperative residences, trailer lot rent, taxes, and property insurance.  If the CS takes out a mortgage or home equity loan and uses the home as collateral, use the monthly payment to the financial institution.  Use a monthly average for expenses that are not paid every month.

b. Use either the SNAP heating standard, the non-heating standard, the homeless standard, the limited Shelter Utility Allowance (SUA), or the phone standard (if the phone is the only utility cost) found in Appendix A.  See Section 468.35, Choosing a Utility Standard.    

  55 Pa. Code § 181.452(d)(2)  

NOTE:  If utilities are included in rent or condominium fees, do not include an allowance for utilities. Do not include an allowance for utilities when the CS lives in a PCH, DCF, assisted living facility, or other residential setting. Count only the rent portion of the PCH, DCF or assisted living facility monthly fee.

Next, subtract the excess shelter standard found in Appendix A from the total shelter and utility costs to determine the excess shelter costs.

Example: Adam is a resident of Spring Garden Nursing Home. His wife Angela lives in their

house. Adam receives $2,000.00 in Social Security income each month. Angela

receives $1,496.40 in Social Security income each month.

3. Add the excess shelter costs to the Minimum Monthly Maintenance Needs Allowance (MinMMNA) found in Appendix A. The total shelter cost/maintenance allowance is the amount needed to keep the CS from becoming impoverished.

NOTE:  The amount cannot exceed the Maximum Monthly Maintenance Needs Allowance (MaxMMNA) found in Appendix A.

4. Compute the CS’s total countable gross earned and unearned income. The CAO must count interest from the protected share of resources of the CS. Use the current rate of return for a one-year certificate of deposit established by DHS, which is currently 1.5%.

If the CS has a protected share of resources that is less than the minimum protected share found in the LTC Handbook Chapter 440, Appendix A then the CAO must only determine the interest on the actual resources the CS owns.

Example:  The CS can protect $10,000.00 in resources.

Do not count income listed in Section 450.5. Do not count Temporary Assistance for Needy Families (TANF) or General Assistance (GA) benefits, but count Supplemental Security Income (SSI) benefits. If the spouse in the LTC facility receives income that is excluded and gives that money to the CS, consider that income to be a contribution, and count it as income for the spouse.

Exception: This does not apply to VA Aid and Attendance benefits.

See Appendix D for a sample form for requesting income and shelter information from the CS.

5. Subtract the CS’s total countable income (from step 4) from the Shelter

cost/maintenance allowance (from step 3), up to the limit.

If the CS’s gross income in step 4 is as much as, or more than, the Shelter cost/maintenance allowance in step 3,  then the CS does not need any income from the IS. Do not allow a CSMMNA deduction.

If the CS’s income in step 4 is less than the Shelter cost/maintenance allowance in step 3, go on to step 6 to determine the CSMMNA.       

6.  Determine whether the IS has income available to meet the needs of the CS:

If the result exceeds $0, go to step 7.       

7.  Determine how much income the IS can contribute monthly to support the CS.  

If the available income of the IS in step 6 is greater than or equal to the income needed to meet the CSMMNA in step 5 then the IS may transfer the full amount of the CSMMNA to the CS.

In this example, the IS has $1,806.50 available income. The IS has enough income to provide the CS with the full CSMMNA each month.

Income must be transferred first. When the IS does not have enough available income to meet the CSMMNA additional resources can be protected to generate income for the CS. Additional resources can be protected only if there is not enough income.

8. If the IS does not have enough monthly income to contribute to the CS to bring

the total income of the CS (figured in step 4) plus the IS contribution (figured in

step 7) equal to the Shelter cost/maintenance allowance (figured in step 3), the CS can

use additional resources to generate income.

9. If the couple has non-protected resources and not enough income to transfer to the CS, additional resources can be protected to generate income.

a. Obtain a written request from the individual or the individual’s representative, and

follow the steps in LTC Handbook 440.922.

NOTE:  An MA LTC application must be completed for an appeal to be filed.

b. Upon receipt of the signed order from the Bureau of Hearings and Appeals (BHA),

add the projected income from the additional resources to the CS’s total countable

gross income (figured in step 4).

10. Subtract the CS’s total countable income (step 4 and, if it applies, step 7) from his or her Shelter cost/maintenance allowance (figured in step 3), up to the limit. The result is the CSMMNA. If the CS’s income equals or is more than the Shelter cost/maintenance allowance (figured in step 3), do not allow a deduction.

11. Have the IS or his representative sign the Certification of Payment of Income form (PA 1847). By signing this form the IS agrees to make the allowance available to the CS.     

12. Deduct the amount given to the CS from the income of the IS when determining the payment toward the cost of LTC facility services.

NOTE:  The deduction may not be more than the MaxMMNA found in Appendix A.

13. Notify the individual, CS, individual's representative (if any) and the LTC facility

of the amount of the CSMMNA and tell them that they have the right to file an appeal.

Example: Gregory is a resident at the Spring Garden Nursing Home. His wife Kelly lives in their house. Gregory receives $2,200 in income each month. The CAO determines the amount of income Kelly needs each month to prevent impoverishment as follows:

The CAO must deduct $1,427.00 from Gregory’s income of $2,200.00 if he agrees to give the money to Kelly. Gregory must pay $728.00 (after the $45.00 PNA deduction) toward the cost of his LTC facility services.

NOTE:  The CAO must review the spousal allowance at each renewal and whenever the CS reports a change in income or expenses. If the amount of the allowance changes, the person or representative must agree, in writing, to give the new amount to the CS by completing the Certification of Payment of Income form (PA 1847). The CAO does not have to change the spousal allowance and the person’s payment toward cost of care because of changes in the CS’s income. It can project a monthly average for six months based on income from the last six months and any expected changes.

14. At renewal, review and verify the CS’s needs, income, and resources as follows:

• Count the projected income to the CS from the protected share of resources and from the additional protected resources used to generate monthly income.

• The CAO must always include as income the original amount protected from resources, even if the resources that were to generate income are used up.

Example: At application, it is found that the CS is short $300.00 a month after the IS’s income is transferred to her. The couple has $30,000.00 in unprotected resources. They obtain three annuity quotes and file an appeal to protect additional resources to generate the $300.00 a month. That amount is considered income in all future case adjustments (for example, COLA), even if the resources that were to generate income are spent.

NOTE:  The CS is not required to buy the annuity. However, if the CS buys an annuity, it must meet all of the following requirements:

• • The annuity must be guaranteed.

  • The annuity must pay out principal and interest in equal monthly payments over the CS’s lifetime; with no deferral and no balloon payments.

  • The number of payments must reflect the CS’s life expectancy according to insurance estimates. See LTC Handbook Chapter 440, Appendix D for life expectancy tables.

  • The DHS must be named as the beneficiary in the first position in the event the CS dies before the guaranteed period of the annuity, not to exceed the amount of all medical assistance spent for the IS. The DHS must be named as the beneficiary in the second position after the CS, minor child, or dependent child.

• Count the interest from the protected share as income for the CS. Use the current rate of return established by DHS.

15. The spousal allowance may exceed the limit only if:    

• Either spouse shows, at a fair hearing before the BHA, that the CS needs more income than the CSMMNA allows. The CAO must review the amount established by the BHA order at each renewal or whenever a change indicates that the amount is no longer needed; or

• There is a court support order for a higher amount.     

NOTE:  A support order is different from alimony. To get a support order, the couple must still be married.    

The deduction for the CS ends at the beginning of the month after one of the following happens:

• The CS is admitted to an LTC facility.

• The CS dies.

• The IS is discharged for more than 30 days (not including hospital or therapeutic leave days).

• The couple is divorced.

55 Pa. Code § 181.452(d)(2)  applies to the entire section

468.35 Choosing a Utility Standard

If the CS has utility expenses other than a phone, the CAO must include either a heating, non-heating, or limited standard when determining the CS’s shelter costs. If the CS is homeless, the CAO must allow the homeless standard. See Appendix A for the amount of each SUA.

The CAO must allow the heating standard if the CS:

• Receives a LIHEAP payment between October 1 and September 30, even if the CS does not have expenses for heating or cooling.

NOTE:  The CAO must not use the heating standard if the CS lives in a public housing unit or other rental housing that has central utility meters and pays only for "excess" heating or cooling costs, unless the CS receives a LIHEAP payment.

• Has heating and cooling costs that are billed separately from the rent or mortgage.

NOTE:  Cooling costs must be for central or room air conditioning, not for fans.

• Is responsible for heating or cooling costs, even on an irregular basis.

The CAO must use the non-heating standard if the CS has utility costs other than heating, cooling, or telephone.  This standard is used as a deduction when the CS is responsible for two or more utilities used for purposes other than heating or cooling.

The CAO must use the limited standard if the CS has one utility expense that is not a telephone or a heating or cooling expense.

The CAO must use the homeless standard if the CS is homeless and has or will have any shelter costs during the month.

If the CS’s only utility expense is for a telephone, the CAO must use the phone standard.

NOTE:  When a CS lives with others and shares expenses, the CAO must not use part of the SUA. Each household that shares utility expenses must get the full SUA. (For more information see the (SNAP Handbook, Chapter 560.832.)    

55 Pa. Code § 181.452(d)(2)(iii)  applies to entire section

468.36 Allowance for Dependents Living with a Community Spouse

The CAO must deduct an allowance for dependent family members who live with the CS and are considered a tax dependent under the Internal Revenue Code (IRC). If there is more than one dependent, the CAO must compute the allowance separately for each dependent. The dependent allowance is deducted even if the CS does not qualify for the CSMMNA.    

Allowances can be given for the following dependents:

• A child of either spouse who is not married, is not the head of the household, and is under age 19; or under age 24 if the child is a full-time student.

• A disabled child of any age.

• A parent of either spouse.

• A dependent sibling, including half-brothers, half-sisters, and adopted siblings.

NOTE:  The CAO must not allow a deduction for a dependent grandchild. The CS is not legally responsible for the grandchildren. The CS could get TANF cash assistance for them without using the CS’s income.

To set the maintenance allowance for a dependent living with a CS, the CAO must follow these steps:

1. Determine the dependent’s income according to Chapter 450, Income. (Allow the exclusions in Section 450.52, Income Exclusions of a Spouse or Dependent – STEP 2.)

2. Exclude the earned income of a student up to $1,930.00 for a calendar month in 2021, ($1,900.00 in 2020) but not more than $7,770.00 for the calendar year 2021, ($7,670.00 for 2020.)

3. Subtract the total countable income from the Dependent Living With Spouse Allowance found in Appendix A.      

4. If the dependent’s income is as much as or more than the allowance, do not allow a deduction. If the dependent’s income is less than the allowance, compute 1/3 of the difference between the allowance and the income (1/3 of the remainder in step 3.)     

Example: Gregory from the previous example has a younger brother who was living at home with him and Kelly when he entered the nursing facility. He claimed his brother as a dependent on his federal income taxes. The brother receives a pension of $416.00 each month.

The CAO will allow a deduction of $579.67 from Gregory’s income for his dependent brother in addition to the $1,427 allowed for Kelly.

5. Subtract the PNA, spousal allowance and dependent allowance from the LTC facility resident’s income when determining the cost of LTC facility services.

The CAO must subtract the dependent maintenance allowance from the IS’s remaining available income (the IS’s income minus the PNA, spousal allowance and any medical expense deduction).

6. Notify the individual, CS, individual's representative (if any) and the LTC facility of the amount of the dependent deduction and tell them they have the right to file an appeal.

55 Pa. Code § 181.452(d)(3)  applies to entire section

468.37 Allowance for a Dependent Child or a Child Who is Disabled When There is No Spouse in the Community

The CAO must deduct an allowance for a dependent child or a child who is disabled in the community when there is no CS. The CAO must allow the deduction if the individual claims or may claim the child as a tax dependent under the rules of the IRC.     

A dependent child is one who is not married, is not the head of the household, and is under age 19; or under age 24 if the child is a full-time student.

A disabled child is a child of any age who is or could be considered disabled by the Social Security Administration (SSA) and is claimed or may be claimed as a tax dependent by the individual for tax purposes under the IRC.

If the child who is disabled receives an SSI payment, the allowance will reduce the child’s SSI benefit. The CAO must explain to the individual that the child can keep SSI medical coverage by limiting the amount of the allowance.

To determine the allowance for a dependent child or disabled child when there is no CS, the CAO must follow these steps:

1. Determine the child’s income according to Chapter 450, Income. (Allow the exclusions in Section 450.52.)

2. Exclude the earned income of a student up to $1,930.00 ($1,900.00 in 2020) for a calendar month in 2021, but not more than $7,770.00 for the calendar year 2021 ($7,670.00 for 2020).

3. Subtract the child’s income from the appropriate limit found in Appendix A to determine the amount of the deduction:   

• For a dependent child, use the one-person NMP limit, Family Size Allowance (FSA), for the county where the child lives. If the child lives out of state, use Schedule 2 of the FSA. If there is more than one dependent child, set the allowance separately for each child.

• For a disabled child, use the Disabled/Blind Child Maintenance (SSI) limit.

4. Notify the individual, individual's representative (if any) and the LTC facility of the amount of the Dependent/Disabled Child Maintenance Allowance and that the individual has the right to file an appeal.

NOTE:  Allow a dependent child maintenance allowance deduction when determining the individual’s payment toward the cost of LTC facility services only if the amount is given to the child.  The individual must agree in writing to give the allowance by completing the Certification of Payment of Income, PA 1847. The CAO must deduct only the amount the individual actually gives the child.    

The CAO must verify the amount deducted, in writing, at the time of each application or renewal  and whenever the individual indicates, in writing, that the amount has changed.    

55 Pa. Code § 181.452(d)(4)  applies to entire section

468.38 Home Maintenance Deduction (HMD)

The CAO will allow a HMD to help maintain a home in the community if the individual is expected to return to the community within 180 days. The deduction can only be given to:

• A single individual, or

• A married individual when both spouses are institutionalized.

The individual’s doctor must show on the Medical Evaluation, MA51 that the individual is expected to return to the community within 180 days from the date of admission.      

The HMD is based solely on the doctor’s certification. It does not depend on the individual’s level of care, which is set by the AAA.

When determining the length of the HMD, the CAO will take into consideration:

• the date the individual was admitted to the LTC facility.

• the date the doctor certifies the individual will be leaving the LTC facility within 180 days.

Example: Ann is admitted to an LTC facility on January 10. She applies for MA LTC on January 30. On January 10, the doctor certifies that Ann will leave the facility in six months. Ann would be eligible for the HMD for the calendar month of January, and her eligibility would continue for six months (January through June.)  

Example: Colin is admitted to an LTC facility on May 12. He applies for MA LTC on August 5 with a requested effective date of July 1. On July 1 the doctor certifies that Colin will leave the facility within six months. Colin would be eligible for the HMD for the calendar month of July and continue through October (the sixth month after his month of admission.)

Example: A doctor evaluates Franklin for nursing facility care on March 13. The doctor completes and signs an MA 51 that shows Franklin is eligible for nursing facility care and certifies that Franklin will leave the facility within six months. The facility admits Franklin on April 15. Eligibility for the HMD cannot begin until admission to the facility. The period for HMD eligibility is April 15 through September 30.

Although the doctor may complete a new MA51 if the individual's condition has improved, a new MA51 does not allow the CAO to adjust the payment toward cost of care back to the original date payment of LTC facility services was authorized. If the new MA51 shows the individual's condition has now improved and the individual is able to return to the community, the CAO will act on the reported change and authorize a HMD for the remaining six month period from the initial admission date.  

Example: Samuel is admitted to an LTC facility on February 1. He owns his home and intends to return to it. His doctor certified his need for long-term care starting on February 1. The CAO approved MA LTC as of February 1 with no HMD. On April 1, the CAO receives a request for the HMD, and the doctor signs a new MA51 on that date. The MA51 says that Samuel's condition has improved and he is expected to return to the community. The CAO allows an HMD for April 1 through July 31. The CAO must update  the Long-Term Living screen and ensure a notice is generated to the individual, individual's representative and the LTC facility.

• The HMD may be given to MA-eligible persons in the psychiatric level of care at state-operated facilities, since post-eligibility rules apply to anyone receiving LTC services in a state-operated facility.

• If both spouses in an LTC facility will be returning home within six months, the CAO will assign the HMD to the spouse for which it would be most beneficial.  

Example: Brian and Betty are both admitted to an LTC facility on June 1. They apply separately for MA LTC benefits to start on June 20. Their doctor certifies that both of them will be leaving the LTC facility within six months. The CAO contacts Brian and Betty to see which of them would like to receive the HMD. The couple selects Brian. The CAO authorizes benefits starting June 20 for both of them. Brian receives the HMD for the calendar months of June through November (six months). Betty does not receive the HMD.

For married individuals where there is a spouse in the community, the CAO will compute the cost of care for the IS based on the CSMMNA procedures laid out in 468.34 even if the HMD is more beneficial. If both spouses are institutionalized, then the HMD can be given.

Example: Andrea is a married individual applying for payment of LTC facility services. She is considered short-term and is maintaining a home in the community. Allen is also a nursing facility resident. Since Allen is institutionalized, Andrea is eligible for the HMD.

The CAO will maintain a separate case record for the other institutionalized spouse if he applies for or receives MA. If the other spouse returns to the community, then the CAO must add the spouse to the IS's case so that eligibility calculates the CSMMNA.

Note: Current policy for determining the length of the HMD applies for married individuals as well as single individuals. Once the HMD is set to expire, it must be terminated in eCIS.

A home is where the person lived before going into the LTC facility and where he or she plans to return. The individual may have owned or rented the home or may have shared costs with others. If the person pays any costs for the home, he or she can receive the HMD.

The HMD is the monthly SSI limit for one person. (See Appendix A for the current limit.) The individual is entitled to the amount no matter what the individual's actual home costs are.

A resident of a PCH can receive the HMD if a doctor certifies that the resident is likely to return there and the resident is paying the PCH to hold a bed while he or she is in the LTC facility. If the SSA determines that the SSI benefits will continue while the resident is temporarily residing in the LTC facility, the CAO must not count the SSI payments for the LTC care. If the individual has other income besides SSI, the individual can remain eligible in the SSI category, and the CAO can allow the HMD from the other income.

The deduction is limited to six months for each stay at an LTC facility.  CIS will create an alert to remove the deduction at the end of the six months.

Exception: If the resident is discharged from the LTC facility to his home and then returns to the facility, the individual is eligible for a new six-month period if a doctor says that the resident is likely to return home again within six months. This new period of HMD eligibility does not apply if the resident is admitted to a hospital from the LTC facility and then goes back to the LTC facility.

Income in the first month must be determined following the rules found in Section 450.25. Even if the initial month's income is spent and the individual does not pay anything toward the cost of LTC care, the HMD will begin with the month the doctor signs the MA51 and will continue for six months. There is no requirement when an individual is requesting a HMD to determine if the individual already used his or her income to pay shelter expenses.

Example: Donna was admitted to an LTC facility on June 15. On June 15 the doctor certifies that Donna will return home within six months. Because she verified that her June income was spent before she entered the LTC facility Donna does not pay anything toward her cost of care for June. Donna is eligible for the HMD for the six month period from June through November. Although she has no available income in June the HMD is only given through November, six months from the month the doctor certified she is short-term.

55 Pa. Code § 181.452(d)(6)  applies to entire section

468.381 Nursing Home Transition (NHT)

NHT was developed to assist individuals with a seamless transition from a LTC facility to the community while addressing their need for Home and Community-Based Services (HCBS). When it is determined that an individual in a facility is functionally able to be discharged to the community with HCBS, it is important to begin waiver services the day of discharge to ensure a safe discharge and avoid any gaps in coverage. 

NHT is different than other HCBS authorizations because with NHT the waiver code is entered in eCIS while the LTC facility code remains open ongoing. This allows the LTC facility to continue to be paid while the individual is residing in the facility and the waiver provider to be paid for waiver services the individual receives on the date the client is released from the facility.

When a facility resident and the individual’s service coordinator decide that the individual can safely transition to the community with HCBS, they will work with the Independent Enrollment Broker (IEB) or Administrative Entity (AE) to start services on the anticipated date of discharge from the facility.  A HCBS Eligibility/Ineligibility/Change Form (PA 1768) will be sent to the CAO at least two weeks prior to the anticipated date of discharge.  The service begin date on the PA 1768 will be a future date to match the date of anticipated discharge. 

NOTE: “Nursing Home Transition” or “NHT” must be indicated in the comment section of the PA 1768. If it is not indicated then NHT procedures do not apply.

NHT applies to all Office of Long-Term Living (OLTL) and Office of Developmental Programs (ODP) waivers, except for Living Independence for the Elderly (LIFE) (waiver code 96) and the Adult Community Autism Program (ACAP) (waiver code 51).    See Chapters 489.3 and 489.4 for a list of OLTL and ODP waivers.

The CAO will authorize HCBS, if otherwise eligible, by entering the appropriate waiver code and the waiver code begin date while the client is still residing in the facility and while the facility code remains open. The waiver code begin date must be the service begin date entered on the PA 1768.

NOTE:  The CAO must take action on a PA 1768 indicating NHT within five business days.

NOTE:  For NHT cases, the CAO will open all waivers, including the Community HealthChoices (CHC) Waiver, effective the service begin date found on the PA 1768, even when the begin date is in the future.

The individual will continue to receive LTC facility services with an open LTC facility code until the CAO either receives a MA 103 indicating discharge from the facility or a new PA 1768 verifying the client is no longer anticipated to receive HCBS.

If the PA 1768 verifying NHT is received after the CAO closes the LTC facility budget the client will need to reapply following the current application and reconsideration processes. If the individual is eligible for HCBS and the PA 1768 indicating NHT is received after the CAO ended LTC facility services the CAO will open HCBS retroactively effective the date of discharge from the facility. If the individual is eligible for the CHC Waiver the CAO must take the following action to ensure proper CHC MCO enrollment:

Email RA-PWEnrollmentUnit@pa.gov with the following information:

• Master Client Index (MCI) number of the recipient

• First and Last name of the recipient

• Retroactive effective date of opening

• Date data entry was completed by the CAO

The CAO will only follow NHT procedures when a PA 1768 notating NHT in the 1768 comments is received. If NHT is not listed on the PA 1768 the CAO will follow current procedures for processing HCBS.   

See the NHT section of the HCBS Procedural Desk Guide available at https://pagov.sharepoint.com/sites/DHS-OIM/Desk%20Guides/HCBS%20Procedural%20Desk%20Guide.docx for complete processing instructions.

468.3810 Home Maintenance Deduction (HMD) for NHT Participant

The CAO may allow a HMD for a resident of an LTC facility to transition to the community. The HMD can be used as a deduction for up to three months, even if the transition begins more than six months after the initial admission to the facility, if the following conditions are met:

• A doctor must certify that the individual’s condition has improved and the individual will be discharged to the community within the time frame for the requested HMD. The MA 51 verifying short-term must be signed by the doctor but questions 21 and 22 do not need to be completed because the individual was already verified as NFCE when admitted to the facility.

• An LTC transition coordinator must be actively helping the individual with the transition back to the community. The CAO must verify this by contacting the appropriate agency (for example, the Independent Enrollment Broker, AAA or Administrative Entity).

• The individual does not need to have an established residence in the community (for example, an apartment or real property) to be eligible for this deduction.

• The HMD begins in the calendar month in which the doctor certifies that the individual’s condition has improved and the person will be discharged home from the facility.

• The HMD will be allowed for up to three months in a row.

• If an individual received the HMD for up to six months when he or she was initially admitted to the LTC facility, the individual cannot receive an additional three months for the transition back to the community unless the individual had been discharged to the community between these time periods.

• If an individual received the HMD for less than six months when he or she was initially admitted, the individual would be entitled to an additional HMD for up to three months to transition back to the community. The HMD cannot be authorized for more than a total of six months for each admission to an LTC facility.

Example:

• It is now the end of July, and Stan is not quite ready to be discharged from Spring Hill. He is working with a nursing home transition coordinator, and his doctor states that he will be released within three months because of the continuing improvement in his condition. Stan is entitled to an HMD for up to six months for each admission. Because he has already received a HMD for four months (April through July), the CAO allows a HMD for the two-month period of August 1 through September 30.

• Elizabeth was admitted to Spring Hill LTC facility on May 1. Elizabeth owns her home and intends to return there. An application was received on November 1. It was signed and dated August 1, with a requested start date of May 1. All the required proof was received on November 21, including a signed MA51 verifying Elizabeth was expected to reside in the facility long-term. The CAO authorized MA LTC effective back to May 1 with no HMD. On December 7, the CAO received a new MA51 showing a need for short-term care and a request to adjust the HMD back to May 1. Elizabeth is not working with a nursing home transition coordinator. The CAO does not allow an HMD back to May 1, because the request did not come in within six months from the date of admission. The CAO denies the request for a transition HMD, because Elizabeth’s condition is not improving and she is not working with a nursing home transition coordinator.

Updated November 23, 2022, Replacing March 31, 2021