medicaid application documentation

MedicaidApplication

DocumentationMatthew T. Kikta, Esquire

Necessary FormsPA 600L: Medicaid Application

MA 51: Medical Verification

PA 4: Release of Information

PA 1572: Resource Assessment

PA 162: Notice to ApplicantCopyright 2019 Gray Elder Law, LLC

FORM PA 600L –Medicaid Application

Completed by Applicant,

Agent, or other 3rd party

Determines “open” date

90 Day Retroactive filing

Copyright 2019 Gray Elder Law, LLC

Verification

60 Months of Financial Records

Personal Records

Gross Income Verification

Exhibit List to Client:


Exhibit List


Identifying Information:Copy of applicant’s birth or baptism certificate: (If not available, have the social security office send you a letter verifying date of birth.)A copy of applicant’s Social Security card.

Health Insurance Information:Copies of Medical Insurance card(s) including Medicare and any supplemental health care and/or prescription drug coverage for applicant.Invoices for these policies demonstrating the premium costs and frequency of payment.

Income Information:A copy of applicant’s current Social Security award letter, if availableA copy of any monthly pension/retirement benefit checks applicant may receive, or a 1099 statement for current year illustrating the gross amount he/she received for that tax year in retirement benefits Information verifying any other income received by applicant. As an example, this could include income from oil wells, rental properties, etc.

Bank Accounts: Copies of statements for the past 60 months (or inception) through the present (or liquidation) for any bank accounts applicant may have had in joint or sole name, including checking, savings, money markets, credit unions, annuities, etc. If these assets were liquidated or transferred in the last 60 months, please provide documentation as to where the proceeds from these assets were placed. For each account, please provide an explanation for all transactions over $500 as well all corresponding documentation (i.e. copies of checks, receipts for payment, proof of deposit to another account, etc.)

IRAs: Statements for the past 60 months through the present for any IRA accounts. If liquidated, please provide proof of this liquidation. For each account, please provide an explanation for all transactions over $500 as well all corresponding documentation (i.e. copies of checks, receipts for payment, proof of deposit to another account, etc.)

Exhibit List Stocks, bonds, annuities, mutual funds and certificates: If applicant owned any of these types of assets jointly or solely in the past 60 months, please provide statement copies or copies of the bonds or stock certificates. If these assets were liquidated, please provide documentation as to when these assets were liquidated and where the proceeds from these assets were deposited.

Federal Income Tax Returns for past five years.

Burial trust fund, burial plot: If applicant has funded a funeral arrangement, a letter is needed verifying the current value of the irrevocable burial account.

Life insurance: A letter from the insurance company for each life insurance policy applicant owns stating the current face and cash value, death benefit and named beneficiaries on the policies

Real Property:A copy of the deeds to any properties owned by applicant within the last 60 months. A copy of the most recent property taxes for any properties owned by applicant.Documentation verifying the monthly amount paid for home owner’s insurance on any property owned by applicant.Copies of utility bills for any properties owned by applicant (gas, electricity, water, telephone).

Copies of all unpaid medical bills.

Prior Gifts: please provide documentation verifying any gifts given by applicant in the last five years. Please include thefollowing information:

The amount that was given.Which account the gift was made from and in what form (cash, check, transfer).The date the gift was given.The person the gift was given to and their relationship to applicant.


Exhibit ListFor any vehicles owned by applicant, please provide the following information:

Type of vehicle (ex. car, van, truck, etc.)Make ModelYearLicensed (yes or no); if yes, please provide license #StateOwner/joint ownersAmount owedCurrent value

Spenddown Information: Please provide invoices/estimates/receipts for any item/service resources are spent down on.

Documentation showing value for any other asset owned by applicant such as additional real estate, time share interests, unclaimed property, or assets anticipated to be received in the next six months such as proceeds from a law suit or inheritedassets.

List of household expenses, i.e. rent, utilities, medical care, medical supplies, etc. (if applicable).


PA 600 L (AS) 9/18

Medical Assistance (Medicaid) Financial EligibilityApplication for Long Term Care, Supports and Services

Check any that you are applying for:Care ina facilityHome and Community Waiver Services – Type/Name of Waiver/Service: Other:

• Please read the entire form.

• Print the requested information in the unshaded sections.

• If you need help, another person can help you or you can gethelp from your county assistance office.

• Please review any information printed on this form. If any already printed information is incorrect or has changed, strike out the printed information and provide updated information. Please review all questions that do not have a printed response and provide a response unless the instructions tell you that you can choose not to answer.

You or any representative you choose may complete this application. Your representative can be your spouse, a friend, a relative, a person who has your power of attorney, or your medical provider. It should be someone who knows and can provide information about your income and resources. If you are married, information in some sections must be completed for both you and your spouse.

After the form is completed, bring it, have someone else bring it, or mail it to the county assistance office unless you are instructed otherwise. The county assistance office will tell you if an interview

is needed. You will need proof of identity and verification for other information on the form unless we already have the information in our records. If you need help to obtain any information ask the county assistance office for help. You should attach verification to this form.

Persons who have given away assets (income or resources) within the past 60 months, or set up or transferred assets to a trust within the last 60 months prior to applying for Medical Assistance for long term care, supports and services may be ineligible for benefits. Because of this requirement, you may need to provide verification of assets owned during the past 60 months even though you may no longer own them. We will use your Social Security number to get information about your assets for the 60 months prior to your application.

If the information is complete and you have provided the necessary verification (with this form, if possible) thecounty assistance office will notify you within 30 days of receiving your application if you are eligible, ineligible, or if additional information is needed.

This is an application for Medical Assistance benefits. If you need help translating it, please contact your county assistance office, CAO. Translation services will be provided free of charge.Esta es una solicitud de beneficios de Asistencia Médica. Si necesita ayuda con la traducción comuníquese con la Oficina de Asistencia del Condado (CAO) que le corresponde. Los servicios de traducción son gratuitos.

اذإتنكةجاحبٮلإ . اذهبلطلوصحللٮلععفانمةدعاسملاةيبطلا.CAO ةدعاسميفھتمجرت،ٮجريلاصتلاابتكمبةنوعمكتعطاقم

تامدخمدقتس. ان◌ً اجمةمجرتلا

You can also apply online at:www.compass.state.pa.us.

Page 1

Indicate appropriate type of care.


Admission date vs. “date moved to this address”

Contact info—can use child/agent’s phone

Verification: Prior MA award letter

Different Social Security number info

Billing statement from Skilled Nursing Facility for prior admissions


• Do not complete areas for Provider (SNF) or CAO use.

• Applicant, Agent, or 3rd Party Rep must sign Page 2 regarding citizenship.


Complete all information for applicant, spouse, and

dependents.

Separated without divorce decree = married

Military Status

Voter Registration

Verification:

Proof of Birth (License, birth cert., baptismal record)

Copy of Social Security Card

Marriage License

If Vet, discharge papers (DD-214). Copyright 2019 Gray Elder Law, LLC

Forms of Payment—Medicare, LTCI, private

payment.

Check “yes” and state the date of financial eligibility to begin penalty. Verification: SNF invoices, Rx bills, & medical expenses.

List all health insurance including Medicare Part B premium, Medigap premium, Rx coverage, & LTCI for applicant and spouse. Verification: photocopies of insurance cards and invoices.


Residence

Include other owners, liabilities, and rent. Always check “resident” and “Yes” for intent to return home. Verification: Deed, mortgage, & statement of county assessed value.


BurialCheck “No” for $ or interest withdrawn before death to prove irrevocable status. Confirm county limit for burials. Plots, vaults, etc. not included in limit. Verification: Burial contract


(cont’d)

Life Insurance List all policies even if exempt. $1,000 exemption from cash value If aggregate face value = $1,500 or

less, exempt Can assign to fund burial account Make sure beneficiary is not “Estate of” Verification: Value statement showing

at least the face value and cash value


(cont’d)

Vehicles: Verification: title to all vehicles & value

(KBB)


Other Resources: Bank Accounts,

Stocks,Bonds: Verification: Last 60 months of statements

from currently held accounts Include values as of date of eligibility Include all assets owned by applicant or

spouse solely or jointly Can make an internal list of all transactions

above $500 a month to avoid surprises Be Prepared to be asked for statements past

“Open Date”Copyright 2019 Gray Elder Law, LLC

(cont’d)

Gifting/Spend-down: List uncompensated transfers in last 60

months. Do not include gifts $500 or under in one

month. Include exhibit with your own calculation of

any penalty period with dates of transfers. Document spend-down to show date of

eligibility and to clarify purchases that should not be penalized (ex.: reduction of assets by pre-need burials)


(cont.)

Closed Accounts: Include amount, date closed, and

outline the disposition of proceeds. Extra exhibit Verification: statements for previous

60 months.


Receipt of Funds: Only indicate “yes” if distribution is

expected or if spouse has recently died and applicant intends to claim elective share of estate.


(cont’d)

Applicant’s and/or Spouse’s Income: List all gross income including long term

care insurance and annuity payments. Verification: most recent Social Security

benefit statement, VA award letter, pension stub, annuity contract, long term care insurance contract, etc... May include prior year’s income tax

return.


(cont’d)

Shelter Expenses: List real estate taxes, homeowners

insurance, mortgage / rent, IL or PCH costs, etc... List average utility amounts Verification: real estate tax pay stubs,

homeowners insurance policy, mortgage / rental agreement, proof of facility cost, 3 months utility bills, etc...


PA 600 L (AS) 9/18Page 8

Your Rights and Responsibilities Read about your rights and responsibilities:

RIGHT TONONDISCRIMINATION

This institution is prohibited from discriminating on the basis ofrace, color, national origin, disability, age, sex and in some casesreligion or political beliefs.

Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print,audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied forbenefits.Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877‐8339. Additionally, program information may be made available in languages other than English.

To file a complaint of discrimination regarding a program receiving Federal financial assistance through the U.S. Department of Health and Human Services (HHS), write: HHS Director, Office for Civil Rights, Room 515‐F, 200 Independence Avenue, S.W., Washington, D.C. 20201 or call (202) 619‐0403(voice) or (800) 537‐7697 (TTY).

This institution is an equal opportunity provider.

RIGHT TO CONFIDENTIALITY

We will keep your information private. It will only be used to decide which programs you may be eligible for. The county assistance office (CAO), when requested, must provide federal, state and local law enforcement officials with the address, Social Security number (SSN) and photograph (if available) of an individual who is fleeing to avoid prosecution, custody or confinement for a felony or violating probation or parole.Anyperson knowingly violating any of the rules and regulations of this department shall be guilty of a misdemeanor and, upon conviction shall be sentenced to pay a fine, not exceeding one hundred ($100) dollars, or to undergo imprisonment, not exceeding six months, or both (62 P.S. section 483).

RIGHT TO A WRITTEN NOTICE

We will give you a written notice explaining your benefits. If we deny, change, suspend or stop benefits, wewill give you a written explanation of why. You have 30 days from the mailing date of the notice to ask for a hearing.

RIGHT TO APPEAL

You have the right to ask for a Department of Human Services (DHS) hearing to appeal a decision if you believe it is unfair or incorrect, or if DHS fails to act on your application for benefits. You may file the appeal at the CAO. If you appeal, you may also request an agency conference before the hearing. At the hearing you may represent yourself, or someone else, such as a lawyer, friend or relative may represent you.

RIGHT TO CLAIM GOOD CAUSE

If you apply for cash or Medical Assistance (MA) benefits, the law requires you to cooperate with establishing paternity and seeking support. You may be excused from these requirements if you prove it may be dangerous for you and/or your children.This is known as good cause. Unless a good cause exemption is established, you will be required to meet employment and training requirements. You will also be required to meet semi-annual reporting requirements unless good cause is granted.

ESTATE RECOVERY

If you are age 55 or older and receive MA to pay for nursing facility services, home and community-based waiver services and any related hospital and prescription drug service, you will be required to repay the cost of these services from your probate estate. You may call the MA Estate Recovery Program at1‐800‐528‐3708.

RIGHT TO CERTIF ICATE OF CREDITABLE COVERAGE

Federal law limits when health coverage may be denied or limited for a pre-existing condition. If you enroll in a group health plan that excludes treatment for a condition you already had, you can be credited for the time you received MA coverage. This may help you obtain coverage. Contact your caseworker to request this certificate.

RESPONSIB IL ITY TO PROVIDE INFORMATION

You must give true, correct and complete information. You must help in proving the information you give. Benefits may be denied ifyou fail to provide certain proof. If you cannot provide proof, you should ask the CAO to help you obtain it. If you are contacted by DHS or the Office of Inspector General, you must fully cooperate with those persons or investigators. If you are age 55 or olderand receive MA to pay for nursing facility services, home and community-based waiver services and any related hospital and prescription drug service, you may be required to repay the cost of these services from your probate estate. If you are applying for cash assistance, we may require you to sign an agreement to repay benefits that you, your spouse and your children have received.

RESPONSIB IL ITY TO PROVIDE SOCIAL SECURITY NUMBERS

For MA benefits, you must provide a SSN for each person for whom you are applying. If you do not have a SSN, you must apply for one. Not providing a SSN may result in not being able to receive benefits. Your SSN will be used for identity, for computer matches which verify income and resources, and to prevent duplication of state and federal benefits. A non‐citizen who is applying for emergency MA only is not required to provide a SSN. (42 U.S. C 1320b‐7)

RESPONSIB IL ITY TO USE THE PA ACCESS CARD LAWFULLY

Once you are eligible for benefits, you will be issued a PA ACCESS card. This card may only be used for the person who is eligible and only during the eligibility period. You may only use the card for services that are needed and reasonable.

RESPONSIB IL ITY TO REPORT CHANGES

If you qualify for benefits, you will be required to report changes in your circumstances to your caseworker or to the Customer Service Center. Types of changes reported would include people leaving or moving into the house, a new address, a new job for someone, if someone loses a job, birth of a child, new sources of income or changes to income. Your caseworker and notices you receive will cover the specifics in detail based on the programs and benefits you are eligible for. Failure to report required changes within the program guidelines could result in a loss of benefits, sanctions, or civil or criminal charges. You may report changes to the CAO in person, by phone, fax, mail or through a My COMPASS account.You may also report changes to the Customer Service Center at1‐877‐395‐8930, or for Philadelphia, 1‐215‐560‐7226 any time.

Affidavit

Applicant, Agent or 3rd Party Rep should sign and date at top in presence of a witness ONLY IF signing by “X”

Include signor’s address

Attorney should not sign the Affidavit

List Rep or Power of Attorney and address to receive all correspondence

Sign bottom ONLY IF withdrawing appCopyright 2019 Gray Elder Law, LLC

FORM PA 1572 –Resource Assessment

Married Applicants

Determines “Protected Share”

List exempt and countable assetsVerification of countable resources as of admission date

Written response from DHSCopyright 2019 Gray Elder Law, LLC

FORM MA 51-(Medical Verification)

Completed by Physician

Skilled Care Required (NFCE)


FORM PA 4 –(Authorization for

Release of Information)

Release of Information

Signed by Applicant, Agent, or Rep


FORM PA 162 –Notice to Applicant

Approval or Denial

Must give corresponding PA Code Sections if denied

Penalty Period Explanation

Patient Pay Calculations

Appeal Rights- 30 daysCopyright 2019 Gray Elder Law, LLC

Medicaid Application Tips

90 day retroactive filing

Clear documentation / paper trail

Periodic follow up with Caseworker

Communicate with Client, Facility,

and CAO to build good rapportCopyright 2019 Gray Elder Law, LLC

Thank you!Questions?

www.GrayElderLaw.com

[email protected]

954 Greentree RoadPittsburgh, PA 15220

412-458-6016

medicaid application documentation

Documents