Applying for Medical Assistance (Funding for Nursing Home Care)
Most persons who need nursing home care have insurance coverage, which may pay for some or all of the nursing home care that they need for a limited amount of time. If the need for nursing home care continues after insurance coverage is exhausted, the person must then utilize his assets to pay for his care. When assets have been spent and the need for nursing home placement continues, he will then want to apply for Medical Assistance (MA) funding to pay for his care. Anyone who wishes to apply for medical assistance funding, should begin the process about two months before any other sources of payment are exhausted.
In Pennsylvania two government agencies work together to process applications for Medical Assistance. The local Area Agency on Aging first works with the applicant to determine medical appropriateness and then a determination of financial eligibility is made by the Department of Public Welfare (DPW). To qualify for medical assistance coverag in a nursing home, an applicant must be determined to be both medically appropriate for a nursing home and financially eligible.
Additionally Federal law requires that persons who are being newly admitted to nursing homes which accept medical assistance, whether or not MA will be paying for their care, be screened to identify certain conditions, such as serious mental illness, mental retardation or other conditions which may have caused a developmental disabililty and may require specialized services. Persons who are identified as having such a condition must have a more detailed evaluation performed prior to admission to the facility so that if necessary specialized services can be offered.
Frequently Asked Questions
- How is an application for MA initiated?
The applicant's doctor must complete a medical evaluation (MA51) form and submit it to the Area Agency on Aging, which covers the county where the applicant is located at the time he wishes to apply. The applicant should also, if possible, request that his physician complete a PASID form which can also be submitted to the Area Agency on Aging along with the MA51. Both of these forms are available through the Agency on Aging or should be available through the nursing home of choice.
The applicant will also need to complete a PA600 form detailing his financial status. The PA600 form is available through the nursing home or DPW and should be sumbitted via the nursing home to the DPW.
- What happens after an MA51 is submitted to the Area Agency on Aging?
The AAA will assure that the MA51 is fully completed and recently dated by the physician. As soon as possible an Agency on Aging assessor will schedule a visit to the applicant to collect information, cross-check data and present it for RN review and if necessary physican review. Unless certain conditions are identified, the Agency on Aging will forward its level of care determination directly to the DPW and will mail a copy to the applicant or his representative.
When certain conditions are identified, other government offices called, program offices, issue level of care decisions. Ultimately the DPW notifies the applicant of their financial determination.
- What must an applicant's condition be in order to qualify medically for nursing home care?
- To qualify medically for care in a nursing home, a consumer must have a medical need that requires the services of a trained professional on a daily basis. Trained professionals include Registered Nurses, Licensed Practical Nurses, Nurses' Aides with appropriate levels of professional supervision and therapists. In order to be eligible for nursing home care, the consumer must require care which is not available in a lower-level setting such as a boarding home. There is no way, other than through a face-to-face assessment by the Agency on Aging Options staff, to determine eligibility for admission to a MA nursing home bed. Level of care decisions are stringently monitored by the Department of Aging to assure that all determinations of "nursing home eligible" are supported by a daily medical need for professional services.
- Can applicants protect assets for a spouse who will remain at home?
- The Department of Public Welfare can supply forms which may be beneficial in protecting the assets of a spouse who will be remaining in the community. The DPW can be contacted directly at 724-543-1651 for details concerning spousal impoverishment.
- Is there any additional paperwork required?
- The nursing home chosen will also have its own application forms, etc. which will require completion.
Whether or not you qualify for nursing home care, there may be services available to you in the community through the Armstrong County Area Agency on Aging. The PDA Waiver Program allows Medical Assistance funds to be used to purchase in-home services as an alternative to placement and may be an option for you.