Bisel Logo Pennsylvania Medicaid — Long-Term Care

2014 Edition

AUTHOR: ROBERT C. GERHARD, III

Published: December, 2013 (2014 Edition)
(Prior Editions: 2004 1st Edition; 2006, 2007, 2008, 2009, 2010, 2011, 2012, 2013)
Most recent supplement/update: N/A
Library of Congress Number: 2004106829
ISBN: 1-887024-99-9

1 VOLUME, SOFT-COVER, PRICE: $183.50


Written by certified elder law specialist Robert C. Gerhard, III Esq. this reference book is a "must have" for anyone advising seniors and their families. This essential guide explains how Medicaid is used to finance long-term care in Pennsylvania. No other text discusses Pennsylvania's Medicaid rules in such detail. Precise citations are provided to applicable cases, statutes, and regulations.


TABLE OF CONTENTS

       

Chapter 1
INTRODUCTION
§ 1.1. Introduction and Overview of Medicaid
§ 1.2. Administration of Pennsylvania's Medical Assistance Program
§ 1.3. Medicare
  § 1.3.1. Introduction and Overview
  § 1.3.2. Medicare's Nursing Care Benefit
    (a) Limited Benefits for Skilled Nursing Facility Care
    (b) Three-Day Hospital Stay
    (c) Spell of Illness
    (d) Skilled Nursing Facility
    (e) Daily Skilled Nursing Care
    (f) Examples of Covered Skilled Care
    (g) Conclusion
§ 1.4. Medicaid Fraud and Abuse
  § 1.4.1. Fraudulent Applications
  § 1.4.2. Efforts to Criminalize Medicaid Planning
§ 1.5. PDA 601 Waiver and Community Choice Programs
Appendix 1A. Department of Public Welfare Admissions Notice Packet
Appendix 1B. Act 42 of 2005/House Bill 1168
Appendix 1C. Deficit Reduction Act of 2005
Appendix 1D. CMS Guidance on Deficit Reduction Act of 2005

Chapter 2
ELIGIBILITY FOR LONG-TERM CARE BENEFITS
§ 2.1. Introduction and Overview of Eligibility
§ 2.2. Excluded Resources
  § 2.2.1. Burial Spaces
  § 2.2.2. Burial Reserves
    (a) Irrevocable Burial Reserves
    (b) Revocable Burial Reserves
  § 2.2.3. Real Property Used as Principal Place of Residence
    (a) Substantial Home Equity
    (b) Reducing Substantial Home Equity
    (c) Effective Date
    (d) Exceptions to Substantial Home Equity Limit
    (e) Sale of Residence
  § 2.2.4. Real Property Not Excluded as a Home
  § 2.2.5. Motor Vehicle
  § 2.2.6. Life Insurance Policies
  § 2.2.7. Household Goods and Personal Effects
  § 2.2.8. Non-Business Property Essential to Self-Support
  § 2.2.9. Property Used in a Trade or Business Essential to Self-Support
  § 2.2.10. Resources Excluded by Federal Statute
  § 2.2.11. Disaster Relief Assistance
  § 2.2.12. Replacement Assistance
  § 2.2.13. Retroactive Payment under SSI and Title II of the Social Security Act
  § 2.2.14. German Reparation Payments
  § 2.2.15. Japanese-American and Aleutian Restitution Payments
  § 2.2.16. Agent Orange Settlement Payments
  § 2.2.17. Pension Funds Owned by Community Spouse
  § 2.2.18. Asset Disregard Under State Long-Term Care Partnership Program
§ 2.3. Non-excluded Resources
  § 2.3.1. Annuities
  § 2.3.2. Life Estate Deeds with Retained Powers (LERPs)
§ 2.4. Jointly Owned Resources
§ 2.5. Deeming of Resources
§ 2.6. Treatment of Income
  § 2.6.1. Patient Pay Liability
    (a) Introduction
    (b) Earned Income
    (c) Unearned Income
    (d) Exclusions from Income
    (e) Allocating Income Between Spouses
    (f) Calculation of Patient Pay Liability
§ 2.7. Treatment of Lump Sums
§ 2.8. Citizenship and Alienage Requirements
  § 2.8.1. Illegal and Ineligible Aliens
  § 2.8.2. Citizens and Aliens in Satisfactory Immigration Status
§ 2.9 Enforceability of Continuing Care Retirement Community Contracts
Appendix 2A. Operations Memorandum-Medicaid, OPS031102, November 2003
Appendix 2B. Request for Verification of Jointly Owned Resources
Appendix 2C. MA Bulletin Regarding $10,000 Lifetime Limit
Appendix 2D. DPW Medical Assistance Bulletin Regarding Federal Medicaid Citizenship and Identity Eligibility Requirements for Medical Assistance Nursing Home Applicants or Recipients

Chapter 3
SPOUSAL IMPOVERISHMENT PROTECTIONS
§ 3.1. Introduction and Overview of Spousal Protections
§ 3.2. Monthly Maintenance Needs Allowance
§ 3.3. Community Spouse Resource Allowance
§ 3.4. Income-First vs. Resource-First Rule
  § 3.4.1. Resource-First Rule and the Hurly Appeal
    (a) Resource-First Rule Generally.
    (b) Calculation of Hurly Amount
  § 3.4.2. Modified Income-First Rule: Pennsylvania's Hybrid Approach
Appendix 3A. Hurly v. Houstoun Settlement Agreement
Appendix 3B. Sample MMNA, CSRA, and Hurly Calculations
Appendix 3C. "Hurly Multiplier" Table
Appendix 3D. Excerpts from I.R.S. Publication 1457 (7-1999), Table S, Single Life Factors Based on Life Table 90 CM, Interest at 3.0 Percent and Table K
Appendix 3E. Operations Memorandum—Changes to Spousal Impoverishment Procedures Related to Medicaid/Long-Term Care (LTC)
Appendix 3F. Historical Spousal Impoverishment Standards

Chapter 4
ACHIEVING RESOURCE ELIGIBILITY
§ 4.1. Introduction and Overview
§ 4.2. Spend-down
  § 4.2.1. Paying Off Debts
  § 4.2.2. Purchase Excluded Assets
  § 4.2.3. Repair Exempt Assets
  § 4.2.4. Conversion of Exempt Asset to Non-Exempt Status
§ 4.3. Transfer of Assets
  § 4.3.1. Introduction and Overview
  § 4.3.2. Fair Consideration
  § 4.3.3. Uncompensated Value
  § 4.3.4. Look-back Period
    (a) Pre-DRA Look-back Period
    (b) Post-DRA Look-back Period
  § 4.3.5. Ineligibility Period
    (a) Pre-DRA Ineligibility Period
    (b) Post-DRA Change in the Start Date of the Ineligibility Period
  § 4.3.6. Operation of Transfer Penalties Illustrated
    (a) Pre-DRA gift, calculation of penalty period
    (b) Post-DRA gift, application prior to January 1, 2007
    (c) Post-DRA gift, application after January 1, 2007
    (d) Illustration of Pre-DRA gift which is beyond the look-back, post-DRA application
    (e) Illustration of Pre-DRA gift which is not beyond the look-back, post-DRA application
    (f) Pre-DRA gift to trust falling within 60-month look-back
    (g) Pre-DRA and post-DRA, total monthly gifting under $500
    (h) Post-DRA, monthly gifts aggregated
    (i) Pre-DRA "Half-a-Loaf Gifting" Explained and Illustrated
  § 4.3.7. Exempt Transfers
    (a) Resident Property
    (b) Transfer of Assets Other than Resident Property
    (c) Timing of Exempt Transfers
    (d) Care-giver Exception for Transfer of Residence
    (e) Intent to Obtain Fair Market Value
    (f) Assets Transferred Exclusively for Purpose Other than to Qualify for Medical Assistance
    (g) Return of Gifted Assets
    (h) Undue Hardship
    (i) Purchase of Life Estate in Another's Home
  § 4.3.8. Withdrawal of Jointly Owned Assets
  § 4.3.9. Both Spouses in Nursing Home
  § 4.3.10. Transfers to Trusts
    (a) Introduction
    (b) Revocable Trusts
    (c) Irrevocable Trusts
    (d) Trusts for Disabled Persons
  § 4.3.11. Spousal Annuities
  § 4.3.12. Purchase of Promissory Notes, Loans, or Mortgages
Appendix 4A. HCFA Transmittal 64
Appendix 4B. Operations Memorandum—Transfer Penalties
Appendix 4C. Sample Special Needs Trust
Appendix 4D. Social Security Period Life Table

Chapter 5
MEDICAL ASSISTANCE APPLICATION PROCESS
§ 5.1. Introduction and Overview of the Application Process
  § 5.1.1. Verifying Information
  § 5.1.2. Determining Spousal Share
  § 5.1.3. Identifying Effective Date
  § 5.1.4. Calculating Patient Pay Liability
§ 5.2. Application Process
  § 5.2.1. Forms
    (a) Application for Medical Assistance for Long Term Care, Supports, and Services (Form PA-600L)
    (b) Resource Assessment (Form PA-1572)
  § 5.2.2. Who May Submit Application
    (a) In General
    (b) Deceased Applicants
  § 5.2.3. Place of Filing
    (a) Pennsylvania Residents
    (b) Non-Pennsylvania Residents
  § 5.2.4. Eligibility Interview
  § 5.2.5. Medical Eligibility
  § 5.2.6. Release of Information
  § 5.2.7. Retroactive Authorization of Benefits and "180-day Rule"
  § 5.2.8. Issuance of Determination
    (a) Timetable for Determination
    (b) Favorable Determination
    (c) Unfavorable Determination and Appeals
  § 5.2.9. Redetermination
  § 5.2.10. Applications Held Pending
  § 5.2.11. Do's and Don'ts of the Application Process
Appendix 5A. Medical Assistance (Medicaid) Financial Eligibility Application for Long Term Care, Supports and Services (Form PA-600L)
Appendix 5B. Resource Assessment (Form PA-1572)
Appendix 5C. Application Checklist and Nursing Home Disclosure
Appendix 5D. Long Term Care Admission and Discharge Transmittal (Form MA-103).
Appendix 5E. Medical Evaluation (Form MA-51)
Appendix 5F. OPTIONS Determination Report
Appendix 5G. Authorization for Release of Information (Form PA-4)
Appendix 5H. Sample Determination Notice (Form PA/FS-162)
Appendix 5I. Certification of Transfer of Resources to Community Spouse
Appendix 5J. Certification of Payment of Income to Community Spouse or Child

Chapter 6
MEDICAL ASSISTANCE ESTATE RECOVERY PROGRAM
§ 6.1. Introduction
§ 6.2. Payments Subject to Estate Recovery
    (a) Nursing Facility Services
    (b) Home and Community-based Services
    (c) Related Hospital and Prescription Drug Services
§ 6.3. Property Liable to Repay the Department
    (a) All Probate Estate Property
    (b) Certain Life Insurance
    (c) Payments to Family and Funeral Directors
§ 6.4. Property Not Liable to Repay the Department
    (a) Joint Property
    (b) Certain Life Insurance
    (c) Trust Assets
    (d) Irrevocable Burial Reserves
    (e) Small Estates
    (f) Trusts for Disabled Persons
    (g) Hardship Waiver
    (h) Other Non-Probate Property
§ 6.5. Special Populations Exempt from Estate Recovery
§ 6.6. Requesting a Statement of Claim
§ 6.7. Insolvent Estates
  § 6.7.1. Claim vs. Lien
  § 6.7.2. Priorities of Estate Recovery Claim
  § 6.7.3. Family Exemption
  § 6.7.4. Funeral Expenses
§ 6.8. Liability of Personal Representative
§ 6.9. Liability of Purchasers/Transferees
§ 6.10. Postponement of Estate Recovery
  § 6.10.1. Real Estate
  § 6.10.2. Personal Property Over $10,000
  § 6.10.3. Cash and Cash Equivalent Assets Over $50,000
§ 6.11. Hardship Waivers
§ 6.12. Jurisdiction
§ 6.13. Unadministered Estates
Appendix 6A. Medical Assistance Estate Recovery Brochure
Appendix 6B. Medical Assistance Estate Recovery Pamphlet
Appendix 6C. Department of Public Welfare Request for Information
Appendix 6D. Statement of Claim Request Form
Appendix 6E. Undue Hardship Waiver Request Form
Appendix 6F. Letter from Department of Public Welfare Waiving Estate Recovery Under 55 PA Code § 258.10(f)
Appendix 6G. Letter from Department of Public Welfare Confirming No Estate Recovery

Chapter 7
APPEALS
§ 7.1. Introduction
§ 7.2. Fair Hearings
  § 7.2.1. Right of Appeal
  § 7.2.2. Policy and Purpose of Fair Hearing
  § 7.2.3. Timing of Appeal
  § 7.2.4. Appeal of Discontinuance of Benefits
  § 7.2.5. Procedure for Requesting a Hearing
  § 7.2.6. Who May Appeal
  § 7.2.7. Agency Conference
  § 7.2.8. Conduct of Hearing
  § 7.2.9. Final Administrative Action and Interim Assistance
  § 7.2.10. Hearing Abandoned
§ 7.3. Review and Appeal
  § 7.3.1. Introduction
  § 7.3.2. Administrative Review
    (a) Procedure
    (b) The Scope of Review
  § 7.3.3. Judicial Review
    (a) The Right of Review
    (b) The Standard and Scope of Judicial Review
    (c) Reconsideration During the Appellate Process
    (d) Procedures in the Commonwealth Court
    (e) Briefing and Argument
  § 7.3.4. Proceedings for Further Review
    (a) Reargument or Reconsideration
    (b) Review by the Supreme Court of Pennsylvania
    (c) Review by the Supreme Court of the United States
    (d) Review by Means of Civil Rights Actions Filed in the United States District Court
Appendix 7A. Request for Fair Hearing (Form PA-162)
Appendix 7B. DPW Fair Hearing Pamphlet
Appendix 7C. Sample Notice, Final Administrative Action
Appendix 7D. Petition for Review by Commonwealth Court

TABLE OF CASES
INDEX

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