Understanding the Medicaid Application Process In Pennsylvania

This blog post is the tenth chapter of a series entitled “How to Qualify for Medicaid in Pennsylvania.” This post focuses specifically on the Medicaid Application Process. Qualifying for Medicaid can be confusing and complicated, but this guide helps explain it easily. You can order a copy of the complete guide here.

A person eligible for Medicaid in Pennsylvania must file an application, and submit other required paperwork, in order to be approved for benefits.

The County Assistance Office (CAO) for the county where the nursing care is being furnished assigns the application to a caseworker, who processes the application and ultimately issues a determination approving or denying benefits.

An applicant who disagrees with the determination may appeal.

Medicaid Application

A person applying for benefits, or someone on his or her behalf such as a spouse, other relative, or agent under power of attorney, must complete a Pennsylvania Form 600L application. You can find the application in PDF format by logging onto www.dhs.pa.gov and searching for “600L.”

If the applicant is married, a Resource Assessment Form (PA 1572) needs to be filed in order to be approved for a community spouse resource allowance. The Resource Assessment Form lists assets owned by the applicant and spouse, valued as of the applicant’s date of nursing home admission.

The applicant’s physician must complete a Medical Evaluation Form (MA 51), giving details of the applicant’s diagnoses and care needs. The local Area Agency on Aging will complete a Functional Eligibility Determination (FED for short), formerly known as a Level of Care Determination. The FED is a determination about whether or not the applicant has the care needs to meet Medicaid’s medical eligibility requirements. An FED can be appealed.

The Area Agency on Aging and County Assistance Office may require additional forms as well.

An application should also be accompanied by photocopies of documents establishing eligibility, such as driver’s license and Social Security card, monthly bank statements throughout the look-back period, house deed, marriage certificate if there is a community spouse, and so on. Gathering supporting documentation can take a significant amount of time and produce hundreds of pages.

In many counties, the application is submitted directly to the local County Assistance Office, but that practice can vary by county.

Medicaid Application Pending

Once an application has been submitted, the applicant (who is presumably now qualified for benefits due to minimal assets) is not expected to pay for care at the nursing home’s usual private rate while the application is being processed.

Rather, the nursing home should be notified of the application so that it can mark the applicant’s account as “Medicaid pending.” The applicant should expect to pay the nursing home each month the “patient pay amount” (to be discussed in a subsequent blog post) while the application is being processed.

Processing the Application

A caseworker reviews the application and supporting materials to determine whether or not the applicant meets the requirements for eligibility.

The caseworker may request additional information or documentation, and may even ask for a personal interview with the person responsible for submitting the application.

It is not unusual to have a short timeframe, such as 10 days, to respond to a request from a caseworker.

Determination and Appeal

The County Assistance Office will issue a determination that informs the applicant whether or not the application is approved. If there is a community spouse, the caseworker will determine the community spouse resource allowance and monthly maintenance needs allowance.

If the application is denied, the determination notice should explain the reasons for denial.

An applicant (or someone authorized to act on his or her behalf) who disagrees with a determination may file an appeal with the County Assistance Office within 30 days of the determination.

The Pennsylvania Bureau of Hearings and Appeals will then schedule a “fair hearing” and assign the matter to an administrative law judge (ALJ for short). The person appealing (called the “appellant”) may choose to have the hearing by telephone or in person.

Fair Hearing Process

At the hearing, the ALJ will hear testimony from someone representing the County Assistance Office, usually the caseworker or a supervisor. The appellant (or someone on his or her behalf) may also testify.

Either side may present witnesses to testify, submit documents or other exhibits, and may be represented by legal counsel. All testimony is subject to cross-examination.

The ALJ will issue a written determination of findings and will rule on any legal issues. Either side may appeal the ALJ’s determination.

Medicaid Application Assistance

Nursing homes routinely assist residents and their families with preparing and submitting applications, and with providing medical evaluations and other forms.

Elder law firms also assist their clients with preparation of applications and representation during the approval process, fair hearing (if any), and appeals.