Medical Assistance and Payment of Long Term Care Services

General Information

Long term care (LTC) services include both Home and Community Based Services (HCBS) and LTC Facility services (also known as nursing facilities). A person who has a medical need for an LTC service may apply for Medical Assistance (MA) and payment of Long Term Care (LTC) services. A person must meet all financial and non-financial eligibility requirements for MA LTC. You can apply for benefits online using COMPASS, the online resource for cash assistance, the Supplemental Nutrition Assistance Program (SNAP), help with child care, health care coverage, home heating assistance (LIHEAP), school meals, SelectPlan for Women and long-term living services or complete the Medical Assistance (Medicaid) Financial Eligibility Application for Long Term Care, Supports and Services and mail or give it to your local county assistance office. The county assistance office will then determine MA LTC eligibility.


Note: The following Medical Assistance LTC eligibility criteria do not apply to the Adult Community Autism Program (ACAP).  See Medical Assistance General Eligibility Requirements for additional information.


Non-Financial Eligibility

A person must:

  • Have a medical need for long term care services. A doctor must complete a form telling us of the medical need. This form is then reviewed by a Department approved assessing agency. The assessing agency will tell the county assistance office  if long term care services are needed.
  • Be a U.S. citizen or a qualified non-citizen
  • Be a resident of Pennsylvania
  • Have a Social Security number

Financial Eligibility

The financial eligibility factors are:

  • Income
  • Resources

NOTE: Any transfer of assets (income and resources) for less than fair market value in a five-year period prior to applying for Medical Assistance Long Term Care could affect eligibility for payment of long term care services.. See additional information under "Transfer of Assets" below.

Income

Most income is counted, including:

  • Social Security
  • Pensions
  • Interest and dividends from savings and investments
  • Rental Income
  • Withdrawals from an IRA

Income Limits (for one person)

  • For Non Money Payment (NMP) categories the limit is 300% of the Federal Benefit Rate (FBR), which changes annually. For 2013, the individual income limit is $2,130.
  • For Medically Needy Only (MNO) categories the limit is $2,550 (semi-annual net income)
    • If your income exceeds 300% of the FBR limit, the anticipated cost of long term care facility services for a 6-month period is an allowable medical expense deduction to reduce monthly income.

Resources

Examples of resources that are counted:

  • Bank accounts
  • Stocks, bonds and mutual funds
  • IRA and Keogh accounts
  • Non-resident property
  • Cash value of life insurance - if the face value of all policies is greater than $1500 per person (the first $1000 of cash value is excluded)

Examples of resources not counted:

  • The Home
    • If the value of the home is less than or equal to $525,000 and you intend to return to the home or are residing in the home.
    • If a spouse or dependent resides in the home.
  • One motor vehicle
  • All burial spaces/plots including those with a marker
  • Revocable and irrevocable burial reserves subject to specified limits

Resource Limits (for one person)

  • If your income is below or equal to 300% of the FBR (currently $2,130), the resource limit is $2,000 with an additional $6,000 resource disregard.
  • If your income is above 300% of the FBR (currently $2,130), the resource limit is $2,400.
  • Many individuals pay for long term care with personal funds and eventually reduce their resources to the Medical Assistance long term care limits.

    NOTE: The resources of a parent who is applying for or receiving Home and Community Based Services and is living with their child who is under the age of 21 are excluded.

Transfer of Assets (Income and Resources)

Any asset that was transferred, sold or given away within the past 60 months (look back period) must be reviewed by the county assistance office, when a person applies for Medical Assistance long term care. An asset includes both income and resources. The look back period is determined by the date a person is admitted to a long term care facility or assessed eligible for Home and Community Based Services and has applied for Medical Assistance long term care.   

The county assistance office will review the asset transfer to determine if fair market value (FMV) has been received. FMV is the amount that a person can receive for selling the item on the open market. If FMV is not received, a period of ineligibility, known as a penalty period, is established. During the penalty period DHS will not pay for long term care services. The uncompensated value (UV) of the asset is used to figure the penalty period. UV is the difference between the FMV and the amount received for the asset. The penalty period is figured by dividing the UV by the average daily private pay rate for long term care services. The penalty period begins on the date a person is eligible for Medical Assistance long term care.

Special Rules for Married Couples (Spousal Impoverishment)

Special Medical Assistance rules apply to couples to ensure that the spouse who remains in the community (known as the "community spouse") is not impoverished when one spouse (known as the "institutionalized spouse") is admitted to a long term care facility or assessed eligible for Home and Community Based Services. All resources owned by the institutionalized spouse and the community spouse (CS) are reviewed to determine the portion of the resources (called the “spousal share” or the “protected share”) that the CS may keep.The spousal share is one-half of the couple’s total countable resources, but no less than $23,184 (for 2013) and no more than $115,920 (for 2013). These minimum and maximum figures are revised annually. You can file a Resource Assessment Form (PA 1572) to determine the spousal share. A couple should file this form when one of them enters a long term care facility or is assessed eligible for Home and Community Based Services.

 The CS is not required to pay for the institutionalized spouse’s long term care services. The CS is allowed to keep all of his/her own income, regardless of the amount, and that income is not included in determining the institutionalized spouse’s eligibility for Medical Assistance long term care. If the institutionalized spouse is in a long term care facility, the CS may be eligible for a community spouse monthly maintenance needs allowance (CSMMNA). The county assistance office will use the CS’s income and shelter costs to determine the amount of the CSMMNA. If the institutionalized spouse has enough income to pay the CSMMNA, the institutionalized spouse’s income must be used first. However if a shortfall still exists after the institutionalized spouse gives all of his/her available income, an additional amount of resources exceeding the protected share of the couple’s resources can be made available to the CS to generate additional monthly income up to the CSMMNA. In addition, if the community spouse needs more income in excess of the CSMMNA because of exceptional circumstances that result in significant financial duress, you may request an increase in the CSMMNA. An application must be submitted for Medical Assistance long term care and a hearing requested.

What Medical Assistance Long Term Care Pays For

  • If an individual receiving Home and Community Based Services meets all eligibility requirements, Medical Assistance long term care pays for the long term care services received at home and in the community. For additional information see the page entitled Long Term Care Services . 
  • If an individual receiving long term care facility services meets all eligibility requirements, Medical Assistance long term care pays the difference between the long term care facility’s charge for providing care and the individual’s monthly payment toward cost of care.