Fill in Your Pa 1572 Form

Guide to Filling Out Pa 1572

When it's time to prepare for long-term care, understanding how to document and protect your resources is crucial. The Pennsylvania Resource Assessment Form, PA 1572, plays a pivotal role for couples when one partner requires care within a nursing facility or is eligible for Home and Community-Based Services (HCBS) and the other resides in the community. This form determines how much of the couple's resources can be protected for the community spouse's use and what must be spent down for the institutionalized spouse to qualify for Medical Assistance. Filling out this form accurately is the first step in navigating the financial aspects of long-term care, ensuring that both spouses' needs are considered under the law. Below are the steps to complete this form, geared to provide clarity and aid throughout the process.

1. Start by gathering all necessary financial documents. This includes bank statements, stock certificates, life insurance policies, deed to real estate, vehicle titles, and any other documents proving ownership and value of assets as of the date of admission to the nursing facility or the date of assessment for HCBS.
2. Provide the general information required at the top of the form, including LAST NAME, FIRST NAME, M.I. (middle initial), DATE OF BIRTH, SOCIAL SECURITY NO., ADDRESS (street and city), COUNTY, STATE, ZIP CODE, NAME OF LTC (long-term care) SERVICE PROVIDER, and TELEPHONE NO. of the LTC service provider. Don't forget to include the DATE OF ADMISSION OR HCBS ASSESSMENT.
3. Repeat step 2 for the spouse’s information, ensuring all their personal details are correctly entered.
4. Under the resources section, list each resource, selecting the appropriate two-digit code from the list provided on the back of the instructions page. For each resource, you must indicate the owner(s), document the last name, first name, and middle initial of the owner(s), and provide the total value, amount owed, and net value. Remember, the form requires documentation of the value as of the date of admission or assessment for HCBS.
5. For life insurance policies, fill in the required information below the resources section. This includes NAME OF INSURED, INSURANCE COMPANY, POLICY NUMBER, NAME OF BENEFICIARY, FACE VALUE, CASH VALUE (as of the date of admission to the facility or assessment for HCBS), and a documented column to tick YES or NO if it’s been documented.
6. Use the notes/information section if you need extra space or have additional information to include. You can also list any prior admission to a facility or assessment for HCBS with the necessary details.
7. If the individual has a legal representative, fill in the section regarding legal representation accordingly. Include the NAME, TELEPHONE NUMBER, STREET ADDRESS, CITY, STATE, ZIP CODE, and RELATIONSHIP OF RESIDENT to the legal representative.
8. Review the checklist to ensure all required information is provided and all necessary documentation to verify your resources is attached. Photocopies of verification for each resource listed must be included with the form. Do not send original documents.
9. Sign the form, indicating your relationship to the individual in need of LTC services, and date it. Your signature affirms that all the information provided is accurate to the best of your knowledge.
10. Mail or deliver the completed form and all attached documentation to the county assistance office where the nursing facility is located, or where you are receiving HCBS. The LTC Service Provider or your local telephone book can provide the address.

Once the form and supporting documents are submitted, the county assistance office will process the Resource Assessment. You, your spouse, and, if applicable, your legal representative will be notified in writing of the resources that can be protected and the amount that must be spent down for eligibility for Medical Assistance. This clear and thorough approach ensures that you have taken the necessary steps to secure your financial situation while navigating the complexities of long-term care arrangements.

What is the purpose of the PA 1572 Resource Assessment Form?

The PA 1572 Resource Assessment Form is designed to determine the amount of a married couple’s total resources that can be protected for the spouse living in the community, and how much must be spent before the individual in a nursing facility or eligible for Home and Community Based Services (HCBS) can qualify for Medical Assistance benefits.

Who needs to complete the PA 1572 form?

This form needs to be completed by couples when one spouse is in a nursing facility, other medical institution, or has been assessed as eligible for Home and Community Based Services (HCBS), while the other spouse lives in the community.

Is completing the PA 1572 form the same as applying for Medical Assistance?

No, completing the PA 1572 form is not the same as applying for Medical Assistance. It is a resource assessment to help protect as much of a couple's resources as legally possible under the special rules known as the Spousal Impoverishment Provisions. You are not obligated to apply for Medical Assistance by completing this form.

What should I do if I need help filling out the form?

If you need help completing the form, you can seek assistance from a spouse, family member, friend, attorney, or legal services agency. If you or your spouse are over 60, your local Area Agency on Aging can also provide assistance.

What happens after submitting the PA 1572 form?

After submitting the form along with the necessary verification of resources, an assessment will be completed to determine the amount of resources that can be protected for the community spouse and the amount that must be spent before applying for Medical Assistance. You, your spouse, and, if applicable, your legal representative will be notified in writing of the results.

Filling out the PA 1572 form, a Resource Assessment Form crucial for couples in which one spouse requires long-term care or home and community-based services, demands close attention to details. Common mistakes can hinder the process, possibly affecting eligibility and financial assessments. Here are nine mistakes people often make when completing this form:

1. Not listing all resources, whether jointly or individually owned, is a critical error. Every resource counts towards determining eligibility and the protected amount for the community spouse.

2. Failure to report the value of resources as of the date of admission to a nursing facility or the date of assessment for home and community-based services. The timing of valuation is essential for an accurate assessment.

3. Forgetting to attach photocopies of resource verifications can halt the process. The form requires documentary evidence for each listed resource to proceed with the assessment.

4. Omitting to fill out the life insurance section properly, which includes listing each policy's face value and cash value, could lead to an incomplete resource picture.

5. Incorrectly filling out the form by completing shaded areas that are meant to be left blank. This can lead to confusion and possibly incorrect data being submitted.

6. Not providing details for resources owned jointly with someone other than the spouse. This information is necessary to determine the applicant's share and, consequently, the resources eligible for protection.

7. Not indicating the two-digit resource code that best describes each resource. This facilitates the correct identification and categorization of resources.

8. Sending original documents instead of photocopies. Original documents are not returned, leading to a potential loss of important personal records.

9. Failing to sign the form, review the checklist, and ensure that all necessary verifications are attached. The form is incomplete without the applicant's signature and compliance with the checklist requirements.

Avoiding these mistakes not only smoothens the application process but also helps in securing the rightful benefits and protections under the law for the individual in need and the community spouse. It's advisable to seek help from a family member, friend, attorney, or legal services agency if any part of the form or its instructions is unclear.

When dealing with the intricate details of securing long-term care services, either in a nursing facility or through Home and Community Based Services (HCBS) for one member of a married couple, the PA 1572 form plays a critical role. This form ensures the equitable assessment and preservation of resources for the spouse living in the community. However, completing this form is just one step in a comprehensive process. To provide a complete picture of an individual's financial circumstances to the Medical Assistance program, several additional forms and documents often accompany the PA 1572 form. Understanding these supplementary materials is crucial for a seamless application process.

• Bank Statements: These documents offer a snapshot of the applicant’s financial situation, showing current balances in savings and checking accounts which is necessary for validating the information provided in the PA 1572 form.
• Investment Account Statements: To assess the value of stocks, bonds, mutual funds, IRAs, or annuities, the most recent statements from these accounts need to be attached to substantiate the financial disclosures on the PA 1572.
• Life Insurance Policies: Information on life insurance policies, including the cash surrender value (if applicable), helps determine countable resources.
• Property Deeds or Real Estate Valuations: For real property owned by the couple, deeds and recent market valuations are crucial to accurately assessing net worth.
• Vehicle Registration and Value Estimates: Documents for cars, boats, or other vehicles owned by the applicant, which help in determining current market value.
• Trust Documents: If the applicant has any trusts, the trust agreement and assets inventory list is necessary to understand the structure and assets held in trust.
• Burial Reserve Agreements: Both irrevocable and revocable burial reserve agreements are relevant in determining exempt resources.

Collecting and systematically submitting these documents along with the PA 1572 form is crucial for a comprehensive assessment by the Medical Assistance program. Each document serves to paint a full picture of the couple's financial situation, ensuring that the community spouse's resources are protected while fulfilling the necessary legal and procedural requirements for the applicant. Being thorough and diligent in this process helps in safeguarding assets according to the regulations while seeking eligibility for necessary care services.

The PA 1572 form, utilized primarily in assessing resources for eligibility in Long Term Care (LTC) services under Medical Assistance programs, shares similarities with other forms in its purpose and requirements for document verification. One document it is akin to is the Medicaid application form, commonly used across various states for assessing financial eligibility for Medicaid benefits. Like the PA 1572 form, Medicaid application forms require detailed financial information and accompanying verification to assess an individual's resources and income. This includes bank statements, proof of income, and documentation of assets, paralleling the PA 1572's requirements for exhaustive resource verification, such as savings accounts, real estate ownership, and insurance policies. Both forms play a crucial role in determining access to essential healthcare and support services, emphasizing the comprehensive evaluation of an applicant's financial standing.

Another document similar to the PA 1572 form is the Supplemental Security Income (SSI) Resource Verification form. The SSI Resource Verification form is designed to document an individual's financial resources to determine eligibility for SSI benefits, which support people who have limited income and resources. Both the PA 1572 form and the SSI Resource Verification form require individuals to list assets such as cash, bank accounts, vehicles, and life insurance, along with the necessary proof to verify their value. The detailed documentation required by both forms ensures that eligibility decisions are made based on accurate and complete information about an individual's financial situation. Although serving different programs – with one focusing on medical assistance and the other on income supplementation – the core objective of determining financial eligibility through documented resources aligns them closely.

The PA 1572 form also shares similarities with the Asset Declaration form used in the application process for various welfare programs. Asset Declaration forms are crucial for programs that provide assistance based on financial need, such as food assistance or housing support. Applicants must disclose their financial resources, including property, savings, and investments, much like the PA 1572 form requires for LTC services eligibility. The verification of resources, accompanied by copies of financial documents like bank statements and property deeds, is a common requirement across these forms. The emphasis on transparency and the necessity for providing proof of resources underscores the importance of accurately assessing an applicant's financial capability to qualify for assistance, whether for healthcare, food, housing, or income support.

Filling out the PA 1572 form is an important process for couples when one partner requires Long Term Care (LTC) through Medical Assistance. The following tips can help ensure the process goes smoothly:

• Provide accurate information: Ensure all the details you provide are accurate to the best of your knowledge.
• Include all resources: List all resources regardless of ownership status. This includes those solely owned, jointly owned, or owned with others.
• Attach photocopies of proof: All resources must be verified with the appropriate documentation as specified in the form.
• Use the correct form version: Always use the most current version of the form to ensure compliance with recent guidelines.
• Seek help if needed: If you're unsure about any aspect of the form, don't hesitate to ask for assistance from a family member, friend, legal advisor, or your local Area Agency on Aging.
• Ensure the form is signed: Sign the form yourself and have your spouse or legal representative sign it if applicable.
• Check and double-check: Before submitting, review the form and the checklist provided to ensure no steps or documents are missed.
• Contact local offices for immediate needs: If Medical Assistance is needed promptly, reach out to your county assistance office or local Area Agency on Aging before filling out the form.

• Estimate resource values: Provide actual values based on the date of admission to a nursing facility or the date of assessment for HCBS, not estimates.
• Leave sections incomplete: Do not skip any sections or fail to provide the requested documentation.
• Send original documents: Originals may not be returned, so always send photocopies of required verifications.
• Ignore the shaded areas: Shaded areas are for official use only. Ensure you do not fill these sections out.
• Forget to list all resources: Failing to disclose all resources can affect the assessment.
• Postpone seeking assistance: If you're confused at any point, waiting too long to seek clarification can delay the process.
• Overlook changes in circumstances: Any changes in your financial situation should be communicated to the relevant authorities promptly.
• Disregard language assistance offers: If you need the form in another language or require an interpreter, contact the nursing facility or County Assistance Office immediately.
• Miss the submission deadline: Ensure you mail or deliver the completed form and necessary verifications by the required deadline.

When navigating the complexities of Medicaid and long-term care planning, understanding the PA 1572 form is crucial for couples where one spouse requires care in a nursing facility or is eligible for Home and Community Based Services (HCBS), and the other resides in the community. However, there are several misconceptions surrounding this form that can lead to confusion and anxiety. Here are nine common misunderstandings and the truths behind them:

• Myth 1: The PA 1572 form is an application for Medical Assistance.

  Reality: This form is not an application for Medical Assistance but a Resource Assessment form designed to determine the amount of a couple’s resources that can be protected for the spouse living in the community.

• Myth 2: You must complete the PA 1572 form to receive any form of Medical Assistance.

  Reality: Completing this form is not a prerequisite for all types of Medical Assistance. It specifically aims to protect the resources of the community spouse when the other is in need of long-term care services.

• Myth 3: All resources owned by the couple are counted towards eligibility.

  Reality: Not all resources are counted in determining eligibility for Medical Assistance. Some assets, such as a primary residence under certain conditions, are not considered countable resources.

• Myth 4: The form must be completed and submitted by the individual in need of care.

  Reality: Assistance in completing the form can come from a spouse, family member, friend, attorney, or legal services agency. It's designed to be flexible to ensure the community spouse is not unduly burdened.

• Myth 5: Resources are valued at their current market value at the time of application.

  Reality: Resources should be valued as of the date of admission to the nursing facility or date of assessment for HCBS, not the date when the form is completed.

• Myth 6: Original financial documents must be sent with the PA 1572 form.

  Reality: Photocopies of resource verification documents are required, not originals, ensuring important documents remain with the applicants for their records.

• Myth 7: Once the form is completed, no further action is required until application for Medical Assistance.

  Reality: The form requires careful completion and submission with all necessary verification to the county assistance office. Follow-up may be necessary to clarify information or provide additional documentation.

• Myth 8: The resource assessment is only applicable at the initial stage of applying for long-term care services.

  Reality: The assessment of resources can be revisited if circumstances change, such as a significant change in the resources or needs of either spouse.

• Myth 9: Any money saved by the community spouse will affect the eligibility of the spouse in need of care.

  Reality: The PA 1572 form helps to lawfully protect a portion of the couple's resources for the community spouse, without penalizing the spouse who needs care.

Understanding the PA 1572 form and its role in the broader context of Medical Assistance planning can alleviate much of the concern couples may have when one partner needs long-term care. It’s important to approach this form with a clear understanding of its purpose and the protections it offers to ensure both the needs of the spouse requiring care and the financial security of the community spouse are properly balanced.

Completing the Resource Assessment Form, PA 1572, plays a crucial role for couples when one spouse requires long-term care, whether in a nursing facility or through Home and Community Based Services (HCBS), and the other spouse lives in the community. Here are seven key takeaways about filling out and using the PA 1572 form:

• The form is designed to assess the resources of married couples to determine how much can be protected for the spouse living in the community (community spouse) and how much may need to be spent prior to qualifying for Medical Assistance for long-term care services.
• Language assistance is provided free of charge for those who need the information in another language or require someone to interpret the form for them.
• Filling out the PA 1572 form will help ensure the maximum protection of your resources under the law. It is not an application for Medical Assistance, and completing it does not obligate you to apply.
• The form requires detailed information about the couple's resources, including bank accounts, savings, investments, real estate outside of residency, and more. It's essential to list all resources regardless of ownership status.
• Verification of all resources listed on the form is mandatory, and photocopies of documents verifying the resources must be attached. Original documents should not be sent as they will not be returned.
• The value of resources should reflect their status as of the date of admission to the nursing facility or the date of assessment for HCBS, not the date the form is filled out.
• Assistance in completing the form is available through various sources, including spouses, family members, friends, attorneys, or legal services agencies. For individuals or spouses over 60 years old, the local Area Agency on Aging can also provide help.

It's important to read and complete the form carefully, sign it, and review the checklist to ensure all necessary verification is provided. The completed form, along with the resource verification documents, should be mailed or delivered to the county assistance office where the nursing facility is located or where you are receiving HCBS. It is also advisable to get help from a legal representative or trusted family member if there are questions or concerns about how to properly complete the form or about any of the required information.