Pennsylvania Medicaid (Medical Assistance) Long-Term Care Application Packet

PENNSYLVANIA MEDICAL ASSISTANCE (MEDICAID) — LONG-TERM CARE APPLICATION PACKET

TABLE OF CONTENTS

1. Purpose and Scope
2. Client and Household Information
3. Pennsylvania 2025/2026 Eligibility Standards
4. Program Selection — NF Medicaid, CHC Waiver, MNO-MA
5. Asset Inventory and Resource Test
6. Income Inventory and Patient Pay Liability
7. 60-Month Look-Back and Transfer Penalty Analysis
8. Spend-Down Strategy Memorandum
9. Primary Residence Treatment
10. Filial-Support Exposure Notice (23 Pa.C.S. § 4603)
11. Required Forms and Documentation Checklist
12. Filing Instructions and County Assistance Office
13. Authorized Representative Designation
14. Estate Recovery Notice
15. Sources and References

1. PURPOSE AND SCOPE

This packet supports an application for Pennsylvania Medical Assistance (Medicaid) long-term care benefits for the applicant identified below, including (check all that apply):

• ☐ Nursing Facility (NF) Medical Assistance — institutional care
• ☐ Community HealthChoices (CHC) waiver — home- and community-based services (HCBS)
• ☐ Medically Needy Only — Medical Assistance (MNO-MA) with spend-down
• ☐ Medicare Savings Program (QMB / SLMB / QI) — premium and cost-sharing only
• ☐ Aging Waiver / OBRA Waiver (legacy — now consolidated into CHC for most adults 21+)

2. CLIENT AND HOUSEHOLD INFORMATION

3. PENNSYLVANIA 2025/2026 ELIGIBILITY STANDARDS

4. PROGRAM SELECTION — NF MEDICAID, CHC WAIVER, MNO-MA

4.1. Nursing Facility Medical Assistance. Applicant resides in a Medicaid-certified nursing facility, requires nursing-facility level of care (NFLOC) as documented on Form MA-51 signed by a physician, and meets categorical financial eligibility under 55 Pa. Code Chapter 178 (resources) and Chapter 181 (income).

4.2. Community HealthChoices (CHC) Waiver. Applicant requires NFLOC but elects to receive services in the community. Functional eligibility is determined by the Independent Enrollment Broker (IEB) through Maximus (1-877-550-4227). Financial eligibility mirrors NF-MA. Once approved, applicant selects one of three CHC-MCOs (AmeriHealth Caritas CHC, PA Health & Wellness, or UPMC CHC).

4.3. Medically Needy Only — Medical Assistance (MNO-MA). Applicant whose income exceeds the categorically needy standard but who has incurred medical expenses sufficient to "spend down" net countable income to the MNO income limit during a six-month period. Governed by 55 Pa. Code Chapter 183.

4.4. Selection rationale (drafter's note): [________________________________]

5. ASSET INVENTORY AND RESOURCE TEST

Total countable resources: $[________________________________]

Exempt / non-countable resources (one home if intent to return; one vehicle; household goods; irrevocable funeral trust; term life or whole life with face value ≤ $1,500 per person; specially designated burial space): [________________________________]

6. INCOME INVENTORY AND PATIENT PAY LIABILITY

Patient Pay Liability calculation (NF resident):

Gross monthly income − $45 personal needs allowance − applicable health insurance premiums (Medicare Part B, Part D, Medigap) − MMMNA diverted to community spouse (if any) − allowable family allowance = Patient Pay Liability of $[____________] per month payable to the facility.

7. 60-MONTH LOOK-BACK AND TRANSFER PENALTY ANALYSIS

7.1. Look-back start date: [__/__/____] (date of application or institutionalization, whichever later, minus 60 months).

7.2. Disclosed transfers within the look-back period:

7.3. Total uncompensated transfers: $[____________]

7.4. Penalty period calculation: Total uncompensated transfers ÷ statewide divisor ($399.80/day for 2025; $421.20/day for 2026) = [____] days of ineligibility, beginning the later of (a) the date the applicant is otherwise eligible and receiving institutional care, or (b) the date of the disqualifying transfer.

7.5. Exceptions and rebuttal arguments:

• ☐ Transfer to spouse (no penalty)
• ☐ Transfer to a child under 21 or who is blind/permanently disabled
• ☐ Transfer to a sibling with equity interest who resided in home ≥ 1 year
• ☐ Transfer to a "caregiver child" who lived in the home ≥ 2 years and provided care that delayed institutionalization
• ☐ Transfer to a disabled-individual trust (d4A or d4C)
• ☐ Transfer for purpose other than to qualify for MA (rebuttal under 42 U.S.C. § 1396p(c)(2)(C))
• ☐ Asset returned in full (penalty rescinded)

8. SPEND-DOWN STRATEGY MEMORANDUM

The following lawful spend-down strategies are recommended (check each that has been completed or planned):

• ☐ Pre-pay funeral and burial through an irrevocable funeral trust
• ☐ Purchase or repair an exempt residence (if community spouse remains)
• ☐ Replace an aging vehicle (one vehicle is exempt)
• ☐ Pay down legitimate debts (mortgage, credit cards, medical bills)
• ☐ Make home modifications for accessibility (ramps, walk-in shower, stair lift)
• ☐ Purchase a Medicaid-compliant single-premium immediate annuity (SPIA) for the community spouse, naming Pennsylvania DHS as primary remainder beneficiary up to the amount of MA paid
• ☐ Establish a Special Needs Trust (d4A) for a disabled applicant under age 65
• ☐ Establish a Pooled Trust (d4C) sub-account
• ☐ Convert non-exempt resources to exempt income through a CSRA increase petition under 42 U.S.C. § 1396r-5(e)(2)(C)

Strategy narrative: [________________________________]

9. PRIMARY RESIDENCE TREATMENT

9.1. Home-equity cap. Pennsylvania applies the federal home-equity cap (currently approximately $752,000 for 2026 applications). Applicants whose home equity exceeds the cap are ineligible for nursing-facility MA unless the cap is inapplicable (community spouse, minor child, or blind/disabled child residing in the home).

9.2. Intent to return. A home occupied by the applicant immediately before institutionalization remains an exempt resource so long as the applicant signs a written Statement of Intent to Return Home, regardless of medical likelihood. PA does not impose a six-month limit on intent to return.

9.3. Caregiver-child transfer. A residence transferred to a child who (a) lived in the home for at least two years immediately before institutionalization and (b) provided care that delayed institutionalization is exempt from the transfer penalty. Document with caregiver affidavits and physician statement.

9.4. Estate recovery. Following the recipient's death, Pennsylvania DHS will pursue recovery against the probate estate (including any home that becomes part of the probate estate) for MA paid for nursing-facility, HCBS, and related services received at age 55 or older. See 55 Pa. Code Chapter 257 and Section 14 below.

9.5. Status of residence: [________________________________]

10. FILIAL-SUPPORT EXPOSURE NOTICE (23 Pa.C.S. § 4603)

10.1. Pennsylvania is one of a small number of states that actively enforces a filial-support statute. Under 23 Pa.C.S. § 4603, the spouse, child, or parent of an indigent person has a legal duty to financially support that person, and a creditor (including a nursing facility) may sue a relative directly for unpaid care.

10.2. Pittas exposure. In Health Care & Retirement Corp. of America v. Pittas, 46 A.3d 719 (Pa. Super. 2012), the Pennsylvania Superior Court affirmed a $92,943.41 judgment against an adult son for his mother's nursing-home bill, even though the son was not a power-of-attorney signatory and had not personally contracted for care.

10.3. Defenses. Section 4603(a)(2) excuses the relative who lacks "sufficient financial ability" to support the indigent person. A child is not liable for a parent who abandoned the child for ten years during the child's minority, § 4603(a.1).

10.4. Mitigation. A timely, complete MA application that ultimately results in approval — with retroactive eligibility back to the first month of the three-month retro period — typically eliminates the unpaid balance the facility could pursue under § 4603. Adult children with ongoing exposure during application processing should consult the engagement letter risk disclosure.

10.5. Acknowledged by: [________________________________] Date: [__/__/____]

11. REQUIRED FORMS AND DOCUMENTATION CHECKLIST

Forms (DHS / PA.gov):

• ☐ PA 600 — Pennsylvania Application for Benefits (or PA 600 L for long-term care)
• ☐ PA 600 L (AS) — Financial Eligibility Long-Term Care addendum
• ☐ MA 51 — Medical Evaluation form (signed by physician within 30 days)
• ☐ MA 103 — Resource assessment for married couples (institutional spouse / community spouse)
• ☐ Authorized Representative form (PA 1671 or signed AR designation)
• ☐ Annuity disclosure (if applicant or spouse owns an annuity) — DHS naming requirement
• ☐ CHC enrollment selection (if HCBS pathway)

Identity / citizenship:

• ☐ Birth certificate or U.S. passport
• ☐ State driver's license or PA non-driver ID
• ☐ Social Security card
• ☐ Marriage certificate / divorce decree / death certificate of prior spouse

Financial documentation (60 months back):

• ☐ Bank statements — every account, every month
• ☐ Brokerage and retirement statements
• ☐ Life insurance policies and current cash-value statements
• ☐ Annuity contracts and current values
• ☐ Deeds for real property; current mortgage balance; tax assessment
• ☐ Vehicle titles
• ☐ Burial reserves / pre-need funeral contracts
• ☐ Tax returns (last two years)
• ☐ Documentation of every gift, transfer, and loan ≥ $500

Income documentation:

• ☐ Social Security award letter (current year)
• ☐ Pension and annuity statements
• ☐ VA benefit letter
• ☐ Recent pay stubs (if working)
• ☐ Rental income ledgers and lease agreements

Medical / facility:

• ☐ MA-51 from attending physician
• ☐ Facility admission contract
• ☐ Most recent comprehensive care plan / MDS

12. FILING INSTRUCTIONS AND COUNTY ASSISTANCE OFFICE

12.1. County of filing. Long-term-care applications are filed at the County Assistance Office (CAO) for the county in which the applicant receives care. A facility-based applicant from another county still files in the facility's county.

12.2. Filing channels (choose one):

• ☐ COMPASS online (compass.state.pa.us)
• ☐ Paper PA 600 / PA 600 L mailed or hand-delivered to the CAO
• ☐ DHS Consumer Service Center for LTC: 1-866-550-4355 (telephone applications, available since June 2025)
• ☐ Authorized representative submission with PA 1671

12.3. Filing date matters. Medical Assistance is retroactive up to three months before the month of application if the applicant was eligible during the retro period. File at the earliest possible date.

12.4. Processing time. DHS regulations require disposition within 30 days for non-disability cases and 90 days for disability determinations. A Fair Hearing may be requested if no decision issues within statutory time.

12.5. CAO contact: Address [________________________________]; Phone [________________________________]; Caseworker [________________________________].

13. AUTHORIZED REPRESENTATIVE DESIGNATION

I, [APPLICANT NAME], designate [REPRESENTATIVE NAME] of [FIRM / ADDRESS] as my Authorized Representative under 55 Pa. Code § 125.84 to file and prosecute this Medical Assistance application; to receive all CAO correspondence, notices, and decisions; to provide and receive verifications; and to represent me in any Fair Hearing.

Applicant signature: [________________________________] Date: [__/__/____]

Representative signature: [________________________________] Date: [__/__/____]

14. ESTATE RECOVERY NOTICE

I acknowledge that under 42 U.S.C. § 1396p(b) and 55 Pa. Code Chapter 257, Pennsylvania DHS will seek recovery from my probate estate after my death for the amount of Medical Assistance paid on my behalf for nursing facility services, home and community-based services, and related hospital and prescription drug services received at age 55 or older. Hardship waiver procedures are available under 55 Pa. Code § 258.10.

Applicant or representative signature: [________________________________] Date: [__/__/____]

15. SOURCES AND REFERENCES

• Pennsylvania Department of Human Services — Medical Assistance — https://www.dhs.pa.gov/
• COMPASS online application — https://www.compass.state.pa.us/
• Pennsylvania Department of Aging — Community HealthChoices — https://www.aging.pa.gov/
• Pennsylvania Health Law Project (PHLP) — Medical Assistance Eligibility Manual — https://www.phlp.org/
• 55 Pa. Code Chapters 178, 181, 183, 187, 257 — https://www.pacodeandbulletin.gov/
• 23 Pa.C.S. § 4603 — Pennsylvania filial-support statute
• Health Care & Retirement Corp. of America v. Pittas, 46 A.3d 719 (Pa. Super. 2012)
• 42 U.S.C. § 1396p — federal transfer-of-asset and estate-recovery rules
• 42 U.S.C. § 1396r-5 — spousal-impoverishment rules
• DHS Consumer Service Center for LTC: 1-866-550-4355
• Independent Enrollment Broker (Maximus): 1-877-550-4227

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. A Pennsylvania-licensed elder law attorney must review and customize this document before use. Medicaid figures, citations, and program rules change periodically — always verify against current DHS and PHLP publications.