Pennsylvania Medicaid - Long-Term Care (includes book + NEW interactive ebook)
2025 Edition
AUTHOR: ROBERT C. GERHARD, III
1 Volume, Soft-cover
Includes book + NEW interactive Ebook (link provided at checkout)
Published: January 2025 (2025 Edition)
(Prior Editions: 2004 1st Edition; 2006 - 2024)
Most recent supplement/update: N/A
Library of Congress Number: 2004106829
ISBN: 1-887024-99-9
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
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Chapter 1 INTRODUCTION |
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| § 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. | Aging 601 Waiver and Community Choice Programs | |||
| Appendix 1A. | Department of Human Services 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 | |||
| Appendix 1E. | Statements of Policy and Operations Memoranda | |||
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Chapter 2 ELIGIBILITY FOR LONG-TERM CARE BENEFITS |
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| § 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 | |||
| § 2.2.19. | Federal Income Tax Refunds | |||
| § 2.2.20. | Crime Victim Compensation | |||
| § 2.2.21. | Restitution of Misused SSA Benefits | |||
| § 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. | Reasonable Limits, 62 P.S. §441.4(a) | |||
| Appendix 2D. | DPW Medical Assistance Bulletin Regarding Federal Medicaid Citizenship and Identity Eligibility Requirements for Medical Assistance Nursing Home Applicants or Recipients | |||
| Appendix 2E. | Life Expectancy Tables | |||
| Appendix 2F. | Irrevocable Burial Limits by County | |||
| Appendix 2G. | DPW Policy Clarification, Rental Property Excluded | |||
| Appendix 2H. | DPW Policy Clarification PMN15842440, Sale or Transfer of Resident Property by Community Spouse, June 27, 2011. | |||
| Appendix 2I. | U.S. Department of Health and Human Services, Administration for Children & Families, Transmittal No. TANF-ACF-PI-2011-01. | |||
| Appendix 2J. | Federal Tax Refund Exclusions Update | |||
| Appendix 2K. | VA Pension and Aid and Attendance Rates | |||
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Chapter 3 SPOUSAL IMPOVERISHMENT PROTECTIONS |
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| § 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 | |||
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Chapter 4 ACHIEVING RESOURCE ELIGIBILITY |
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| § 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) | Basic Calculation of Ineligibility Period | |||
| (b) | Start Date of the Ineligibility Period | |||
| § 4.3.6. | Operation of Transfer Penalties Illustrated | |||
| (a) | Pre-DRA gift | |||
| (b) | Post-DRA gift, calculation of penalty period | |||
| (c) | 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 | |||
| (j) | Legal Fees Expanded to Obtain Medicaid Benefits | |||
| § 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. | 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. | SI 01140.120 Life Estate and Remainder Interest Tables | |||
| Appendix 4E. | Weatherbee v. Richman Opinion | |||
| Appendix 4F. | Operations Memorandum—Transfer of Assets to a Disabled Child | |||
| Appendix 4G. | Zahner v. Pennsylvania Department of Human Services Opinion | |||
| Appendix 4H. | DHS Special Needs Trust Fact Sheet | |||
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Chapter 5 MEDICAL ASSISTANCE APPLICATION PROCESS |
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| § 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 | |||
| § 5.2.4.1. | Additional Requirements for Veterans | |||
| § 5.2.5. | Medical Eligibility | |||
| § 5.2.5.1. | Application for the Aging Waiver Program | |||
| § 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 | |||
| § 5.2.12. | Quality Control Reviews | |||
| 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. | Functional Eligibility 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 | |||
| Appendix 5K. | DPW Policy Clarification PMN15842440, Lottery Win by Community Spouse, March 15, 2010 | |||
| Appendix 5L. | Citizenship and Identify Information | |||
| Appendix 5M. | Steps to Apply for Waiver | |||
| Appendix 5N. | Physician’s Certification Form | |||
| Appendix 5O. | Voluntary Withdrawal Form | |||
| Appendix 5P. | Aging Waiver Referral Form | |||
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Chapter 6 MEDICAL ASSISTANCE ESTATE RECOVERY PROGRAM |
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| § 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 | |||
| (d) | Exemption for Medicare Cost-Sharing Benefits | |||
| § 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 | |||
| (a) | Unpaid Patient Pay Liability | |||
| (b) | Unpaid Fees for Guardianship Proceedings | |||
| § 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 | |||
| Appendix 6H. | Federal Poverty Level Chart | |||
| Appendix 6I. | Agreement to Encumber Real Property | |||
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Chapter 7 APPEALS |
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| § 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 and Stipulated Agreements | |||
| § 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. | DHS Fair Hearing Pamphlet | |||
| Appendix 7C. | Sample Notice, Final Administrative Action | |||
| Appendix 7D. | Petition for Review by Commonwealth Court | |||
| Appendix 7E. | Example Stipulated Settlement Adjudication | |||
| Appendix 7F. | Notice of Mediation Telephone Appointment | |||
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TABLE OF CASES INDEX |
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