The individual applying for a Personal Care Supplement (or someone acting for the individual) must complete and sign one of the following applications:
For care in a Dom Care Home, an Application for Domiciliary Care Supplement (PA 1-D). The AAA completes the PA 1-D by indicating if the individual has a functional need for Dom Care services.
For care in a PCH, an Application for Personal Care Home Supplement (PA 761).The PCH completes the PA 761 by indicating if the individual is functionally disabled.
If the individual is not receiving SSI or is not eligible for SSI, he or she must also:
Write “SSI APPLICANT” in the upper-right corner of the PA 761 or PA 1-D.
Contact the Social Security Administration (SSA) by telephone to ask for SSI benefits, and to tell the SSA that he or she is also applying for a Personal Care Supplement.
NOTE: For the date of the SSI application, the SSA uses the date that the first contact for SSI benefits is made. The SSA must be told at that time that the individual is also applying for a Personal Care Supplement. If the individual's income is more than the regular SSI limit, the Personal Care Home or AAA may need to call the SSA to confirm that the individual is functionally disabled.
The Personal Care Home Operator is responsible to determine the individual is appropriate to reside in the Personal Care Home. The application process begins with the PCH. The operator of the home must take the following actions:
If the individual has been found eligible but has not yet received SSI benefits, obtain verification that the individual is eligible for SSI benefits.
If the individual is not already receiving SSI or has not applied for SSI,
Help the individual obtain verification of his or her income and resources.
Call the SSA to request SSI benefits and to tell them that the individual is also applying for a Personal Care Supplement.
Send the CAO all of the following information:
A completed application (PA 761).
Copy of the PCH license
The AAA is responsible to determine the individual is appropriate to reside in the Domiciliary Care Home. The application process begins with the AAA. The AAA must take the following actions:
If the individual has been found eligible but has not yet received SSI benefits, obtain verification that the individual is eligible for SSI benefits.
If the individual is not already receiving SSI or has not applied for SSI, AAA must take the following actions:
Help the individual obtain verification of his or her income and resources
Call the SSA to request SSI benefits and to tell them that the individual is also applying for a Domiciliary Care Supplement.
Send the CAO the following information:
A completed application (PA 1-D).
Certificate of compliance (Dom Care)
As soon as the CAO and the SSA decide the individual is eligible, help the individual find a PCH or Dom Care Home, if he or she needs help.
A Dom Care individual may enter a LTC facility for a short-term stay (90 days or less). The individual may receive their regular SSI benefit for expenses to maintain a home or living arrangement in the community. During this 3-month period the individual does not need to pay anything toward their cost of care.
The AAA will assist the Dom Care individual with the paperwork that must be sent to the SSA for the short-term stay. See the Long Term Care Handbook, Section 405.2, SSI Category for an explanation of continued SSI payments while in a LTC facility.
When the CAO receives the application and completed forms, the CAO must take the following actions:
Review all forms to be sure they are complete.
NOTE: The Department maintains a Personal Care Home Directory of all licensed PCHs in the State. If a certificate of compliance is not included with the application it can be found by accessing the PCH Directory online at the Department’s website, http://www.dhs.pa.gov/. A copy should be made for the case record.
Check the SDX Data Exchange 6 to verify whether the applicant is receiving SSI benefits and if the individual's current address is correct.
Individuals receiving HCBS while in a PCH (76) or Dom Care (75) facility need both waiver and facility type codes entered into eCIS.
NOTE: PCH residents are only able to participate in the following HCBS programs.
Adult Autism Waiver.
Adult Community Autism Program (ACAP).
Community Health Choices (CHC) Waiver: Individuals in PCH will not be enrolled in a CHC managed care plan unless they are receiving rehabilitation services. The Office of Long-Term Living monitors this population for eligibility.
OBRA: Only when an individual is in a PCH that meets additional specifications.
Person/Family Directed Support: Only individuals residing in a PCH with ten (10) or less residents with a move-in date for the PCH of 7/1/2008 or after (the move-in date applies to the PCH where the person is residing and may not be transferred to a new home).
If the individual is receiving SSI benefits, the CAO will authorize the personal care supplement by taking the following actions:
Complete the Authorization for State Supplement for Persons in a Domiciliary Care Facility/Personal Care Home Form (PA 747).
Forward the SSA copy of the PA 747 to the SSA.
Authorize the individual in the Electronic Client Information System (eCIS) using the appropriate category, program status code and facility code (See Section 391.42, Category, Program Status Code, and Facility Code).
Send a manual PA-FS 162 with the PA 162F letting the individual know that he or she will begin receiving the Personal Care Supplement (See Section 391.43, Completing the Client Notice).
Send a copy of the PA 747 and the Notice to Applicant to AAA.
NOTE: If the PA 747 is being used to authorize the personal care supplement in a PCH, write “PERSONAL CARE HOME” in the upper-right corner.
NOTE: eCIS will not allow entry of a program status code designating eligibility for the personal care supplement (60 or 62) until eligibility for the supplement is showing on Data Exchange 6. The CAO must wait until the SDX Data Exchange shows the Personal Care Supplement as being received before Program Status Code 60 or 62 can be entered into CIS.
If the individual is not yet receiving SSI benefits because the SSA has not yet determined eligibility for SSI benefits or the application status is unknown, the CAO must take the following actions:
Complete the Authorization for State Supplement for Persons in a Domiciliary Care Facility/Personal Care Home Form (PA 747).
Send a manual PA-FS 162 with the PA 162F letting the individual know that he or she will begin receiving the Personal Care Supplement (See Section 391.43, Completing the Client Notice).
After it is verified on the SDX Data Exchange that the SSA has approved SSI benefits, authorize the individual in eCIS using the appropriate category, program status code and facility code (See Section 391.42, Category, Program Status Code, and Facility Code).
Send a copy of the PA 747 and the manual notice of eligibility:
To AAA for the Dom Care Supplement.
To the PCH for the Personal Care Supplement.
NOTE: eCIS will not allow authorization in an SSI category (A, J, M) until the SSA determines eligibility for SSI benefits. The CAO cannot authorize MA in an SSI category until eligibility for SSI is verified on the SDX Data Exchange.
If the Dom Care or PCH individual is in a facility for a short-term stay, 90 consecutive days or less, the AAA must provide documentation to the SSA for approval so the individual will continue to receive the full SSI benefits for the duration of the 90 day stay. The individual and the CAO will receive written notice from the SSA of the individual’s eligibility for the continued payments. The CAO must review the documentation and if all the information is provided, the individual will also be eligible for the HMD. The individual must continue to pay shelter expenses in the community while in the facility. The individual does not pay anything toward the cost of care during this 3-month period. See the Long Term Care Handbook, Section 405.2, SSI Category for the list of documents needed to be sent to the SSA for approval.
If the SSA determines that the individual is not eligible for SSI benefits, the SSA will return the PA 747 to the CAO. Notify AAA of the SSA’s decision for the Dom Care Supplement or the PCH for the Personal Care Supplement. If the individual needs or requests MA before the SSA makes its decision, explain the application process and give him or her a PA 600.
If an applicant for a PCH or Dom Care Supplement is being referred to SSA for a determination of SSI eligibility, the home operator and/or AAA will help the individual or representative with the application, if help is needed. SSA determines the date of the SSI application based on the date the initial contact regarding SSI was made. The first contact should be a telephone call to SSA requesting benefits.
It is important for the individual or representative to tell SSA that an application is also being submitted for the Personal Care Supplement. If the individual's income exceeds the normal SSI eligibility limit, AAA or the Personal Care Home may need to contact SSA by phone on the individual's behalf, to verify the individual's determination of functional disability. If a request is not made by phone, the date of initial contact is the date SSA receives the application. To avoid a loss of benefits, the CAO should advise the individual to make the request by phone.
NOTE: The individual must enter the facility within 30 days of SSA’s decision.
If the individual's countable net income is more than the federal SSI benefit rate but less than the federal benefit rate plus the Supplement, SSA will issue an SSI check for the amount of the supplemental benefits for which the individual is eligible. SSA allows a $20 income disregard.
Updated January 31, 2022, Replacing May 12, 2020