Fill in Your Pa 600 L Sg Form Launch Pa 600 L Sg Editor Now

Fill in Your Pa 600 L Sg Form

The PA 600 L (SG) form is a crucial document for those seeking financial assistance for long-term care, supports, and services through Medicaid in Pennsylvania. It guides applicants through the process of applying for care in various settings, such as in a facility or through home and community waiver services. The form also emphasizes the importance of providing detailed information about one's income, resources, and any previous asset transfers, which could affect eligibility for benefits.

Launch Pa 600 L Sg Editor Now

Understanding the PA 600 L SG form, a vital document for those seeking Medical Assistance (Medicaid) in Pennsylvania for long-term care, supports, and services, requires navigating through a detailed application process. This form enables individuals or their representatives to apply for various types of assistance, including care within a facility and home and community waiver services. It is meticulously designed to capture essential information about the applicant's income, resources, and insurance, which are crucial for determining eligibility. The form provides spaces for indicating the type of service required and for disclosing any asset transfers or trusts established within the past 60 months, which could affect eligibility. Applicants are encouraged to complete the application with accurate details regarding their marital status, military service, and voting registration preference, as these may have implications on their application. Additionally, the form seeks information on medical insurance, real estate ownership, mobile homes, burial arrangements, and life insurance policies to ensure a comprehensive assessment of the applicant's financial status. Importantly, assistance from county assistance office staff is available for those who find the process challenging, underlining the state's commitment to supporting its residents in accessing necessary long-term care services.

Document Example

Medical Assistance (Medicaid)

Financial Eligibility Application for

Long Term Care, Supports and Services

You may also apply online at www.compass.state.pa.us

Check any that you are applying for:

¨Care in a Facility

¨ Home and Community Waiver Services Type/Name of Waiver/Service: ___________________________________________

¨Other __________________________________________________________________________________________________

*Please read the entire application form

*Print the requested information in the unshaded sections

*If you need help, another person can help you or you can get help from your county assistance office

You or any representative you choose may complete this application. Your representative can be your spouse, a friend, a relative, a person who has your power of attorney, or your medical provider. It should be someone who knows and can provide information about your income and resources. If you are married, information in some sections must be completed for both you and your spouse.

After the form is completed, bring it, have someone else bring it, or mail it to the county assistance office unless you are instructed otherwise. The county assistance office will tell you if a face to face interview is needed. You will need proof of identity and verification for other information on the form unless we already have

the information in our records. If you need help to obtain any information ask the county assistance office for help. You should attach verification to this form.

Persons who have given away assets (income or resources) within the past 60 months, or set up or transferred assets to a trust within the past 60 months prior to applying for Medical Assistance for long term care, supports and services may be ineligible for benefits. Because of this requirement, you may need to provide verification of assets owned during the past 60 months even though you may no longer own them. We will use your Social Security Number to get information about your assets for the 60 months prior to your application.

If the information is complete and you have provided the necessary verification (with this form, if possible), the county assistance office will notify you within

30 days of receiving your application if you are eligible, ineligible or if additional information is needed.

 

PROVIDER USE

 

 

 

NAME

 

NUMBER

 

 

 

ADDRESS

 

NUMBER

 

 

 

DATE OF ADMISSION

DATE OF OPTIONS ASSESSMENT

REQUESTED EFFECTIVE DATE

 

 

 

CONTACT NAME/TELEPHONE NUMBER/ADDRESS

CAO USE

CO.

DIST

RECORD NUMBER

FILE CLEARED BY

APPL. REG. NO.

 

 

 

 

 

WORKER I.D.

 

CASELOAD

 

 

 

 

 

 

¨ AUTHORIZED REASON

 

CATEGORY

 

 

 

 

 

¨ NOT AUTHORIZED REASON

 

DATE

 

 

 

 

 

1

PA 600 L (SG) 8/12

PLEASE CoMPLETE ThE FoLLowing inForMATion For ThE

PErSon rEquESTing MEdiCAL ASSiSTAnCE bEnEFiTS

LAST NAME

 

FIRST NAME

 

 

 

MIDDLE INITIAL

 

(JR., SR., I, ETC.)

 

 

 

 

 

 

 

 

 

 

 

CURRENT ADDRESS (IF IN A FACILITY, USE FACILITY ADDRESS)

 

CITY

STATE

 

ZIP CODE + 4

ADMISSION DATE

 

 

 

 

 

 

 

 

 

 

 

DATE MOVED TO THIS ADDRESS

TOWNSHIP

 

 

SCHOOL DISTRICT

 

AREA CODE AND TELEPHONE NUMBER

 

 

 

 

 

 

 

 

 

 

PREVIOUS ADDRESS (IF IN A FACILITY, GIVE YOUR HOME ADDRESS. IF YOU ARE MARRIED, GIVE YOUR SPOUSE’S ADDRESS.)

 

AREA CODE AND TELEPHONE NUMBER

 

 

 

 

 

 

 

 

 

 

 

Do you want an interpreter?

Yes

No

If yes, what language? _______________________________________________________________________________________________ __

Do you need your notices in Spanish? ¿Necessita sus avisos en Español?

Yes

No

Have you ever applied for or received cash or medical benefits or participated in the Supplemental Nutrition Assistance Program (SNAP), formerly known as food stamps, in another county in Pennsylvania or in another state?

Yes

No

If yes, what State? _______________________________

What county? __________________________________

How long? ____________________________________

Record Number ________________________________

Have you ever applied for or received benefits using a different Social Security Number? If yes, what is the number? ________________________

Yes

No

Have you previously lived in a nursing facility?

Yes

No

If yes, provide name: __________________________________________________________________________________________________

Address: ____________________________________________________________________________________________________________

Dates: ______________________________________________________________________________________________________________

2

PA 600 L (SG) 8/12

Complete all information in this section for yourself, your spouse if you are married, and any dependent children or siblings.

1 *Attach an additional sheet of paper if you have more dependents.

RELATIONSHIP

LAST NAME

FIRST NAME

MI JR/SR ALIAS/MAIDEN NAME BIRTH DATE SEX *RACE

SSN

 

 

 

 

 

SELF

SPOUSE

DEPENDENT

*For Race: Your benefits will not be affected if you do not wish to answer. Please use one of the following codes:

1. Black 2. Hispanic 3. North American Indian or Alaskan Native 4. Asian or Pacific Islander 5. White (Not Hispanic) 6. Other

2Please answer and sign:

Are you a U.S. Citizen?

Yes

No

If No, check one:

Permanent Resident

Temporary Resident

Refugee

Illegal Alien

Alien #:_______________________________________________________Country of Origin: ______________________________Date of Entry:______________________

Sign to declare your citizenship or alien status as marked above:

SignatureDate

Name and address of sponsor if you have one: ___________________________________________________________________________________________________ ____

_____________________________________________________________________________________________________________________________________________

3Marital Status

Please check one:

Married

Single

Widowed

Divorced

Separated

If you checked widowed, what was the date of your spouse’s death?____________________ Name:_______________________________________________________

If you checked separated, what was the date of separation?____________________ Please complete item #1 above for spouse.

4Military Status

Veteran’s Name_______________________________________________

Please check one:

Veteran

Active Military

National Guard

Reserves

Widow/Spouse or Dependent Child of a Veteran

Branch of Service____________________________ Date Entered__________________Date Left__________________Claim No.____________________________________

3

PA 600 L (SG) 8/12

5

Voter registration (Optional)

 

 

 

If you are not registered to vote where

you live now, would you like to apply to register to vote here today?

Yes

No

IF YOU DO NOT CHECK EITHER BOX, YOU WILL BE CONSIDERED TO HAVE DECIDED NOT TO REGISTER TO VOTE AT THIS TIME.

To register, you must: 1) Be at least 18 on the day of the next election; 2) Be a citizen of the United States for at least one month PRIOR TO THE NEXT ELECTION;

3) Reside in Pennsylvania and the voting district at least 30 days prior to the next election.

Applying to register or declining to register to vote will not affect the amount of assistance that you will be provided by this agency.

If you would like help filling out the voter registration application form, we will help you. The decision whether to seek or accept help is yours. You may fill out the application form in private. Please contact the county assistance office if you would like help. If you believe that someone has interfered with your right to register or to decline to register to vote, your right to privacy in deciding whether to register or in applying to register to vote, or your right to choose your own political party or other political preference, you may file a complaint with the Secretary of the Commonwealth, PA Department of State, Harrisburg, PA 17120. (Toll-free telephone number 1-877-VOTESPA.)

COUNTY ASSISTANCE OFFICE STAFF WILL COMPLETE THIS BOX BASED UPON YOUR RESPONSE ABOVE

Given to Client __/__/__

 

Sent to voter registration __/__/__

Declined, not interested __/__/__

 

Not a U.S. citizen __/__/__

 

Mailed to Client __/__/__ Declined, already registered __/__/__

6

if you are receiving or have received long term care, supports and services, how were your expenses being paid?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7

do you have unpaid medical bills?

Yes

no if you are requesting Medical Assistance for these bills, attach copies.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8

MEdiCAL inSurAnCE inForMATion

(Including Long Term Care Insurance)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INSURANCE

INSURANCE COMPANY

 

 

AGREEMENT/

GROUP NAME

EFFECTIVE

PREMIUM

PAID HOW

 

POLICY HOLDER NAME

 

 

 

 

 

 

 

DATE OF

 

 

 

 

 

 

 

COMPANY/MEDICARE

ADDRESS

 

 

POLICY NUMBER

NUMBER

COVERAGE

AMOUNT

OFTEN

 

AND ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4

PA 600 L (SG) 8/12

Add an additional sheet of paper if more space is needed. Please label what question number you are answering on any additional pages.

9Complete the following resource information for you and your spouse (if you are married): A. real Estate None

LOCATION

OWNER

VALUE

$

INCOME PRODUCING

RESIDENT

YES

NO

YES

NO

 

 

 

 

WHO LIVES IN THE PROPERTY?

IS THE PROPERTY LISTED FOR SALE? IF YES - DATE LISTED

YES

NO

IF FOR SALE GIVE

s

REALTOR’S NAME AND TELEPHONE NUMBER * REMEMBER TO REPORT THE PROPERTY SALE TO US.

ARE YOU PLANNING TO RETURN TO THE PROPERTY?

YES

NO

DO YOU OWN ANY OTHER REAL ESTATE?

YES

NO

b. Mobile home None

LOCATION

 

OWNER

YEAR AND MODEL

 

 

 

 

IS THE MOBILE HOME LISTED FOR SALE?

YES

NO

C. burial Arrangements

None

 

 

 

VALUE

INCOME PRODUCING

RESIDENT

 

 

 

$

YES

NO

YES

NO

 

WHO LIVES IN THE MOBILE HOME?

 

 

 

 

 

 

REALTOR’S NAME AND TELEPHONE NUMBER

 

 

 

 

 

 

 

 

 

 

IF YES GIVE

 

 

 

 

 

 

 

s

 

 

 

 

 

 

BANK/INSURANCE COMPANY NAME AND ADDRESS

 

 

 

 

ACCOUNT NUMBERS

 

 

 

 

 

 

 

 

 

 

 

 

 

FUNERAL HOME

 

 

 

 

 

 

 

 

 

VALUE OF ACCOUNT

DATE ESTABLISHED

 

 

 

 

 

 

 

 

$

 

 

 

CAN MONEY BE WITHDRAWN BEFORE DEATH OF INDIVIDUAL?

YES

NO

 

CAN INTEREST BE WITHDRAWN?

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

DO YOU OWN ANY BURIAL SPACES?

YES

NO

IF YES

 

s

 

NUMBER

 

 

 

 

 

 

GIVE LOCATION

 

OF SPACES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

d. Life insurance

None

 

 

 

 

 

 

 

 

 

 

COMPANY NAME

POLICY NUMBER

FACE VALUE

CURRENT CASH VALUE

WHO OWNS THE POLICY?

5

PA 600 L (SG) 8/12

E. Automobiles, recreational Vehicles, Trucks, Motorcycles None

NAME OF OWNER(S)

YEAR

MAKE

MODEL

LICENSED?

PLATE NUMBER

 

 

ACCOUNT

F. bank Accounts (Checking, Savings, irA, etc.) List all accounts that include applicant’s and/or spouse’s name and money. None

BANK NAME/BRANCH

ACCOUNT TYPE

ACCOUNT NUMBER

CURRENT BALANCE

NAME(S) ON ACCOUNT/OWNER

g. Stocks, bonds (including u.S. Savings bonds), Trusts, Mutual Funds, cash on hand, etc. None

NAME ON INVESTMENT

TYPE ACCOUNT

ACCOUNT NUMBER

CURRENT ACCOUNT VALUE

 

 

NAME(S) ON ACCOUNT/OWNER

10

within the past 60 months, have you or your spouse closed, given away, sold or transferred any assets such as: a home, land, personal

 

property, life insurance policies, annuities, bank accounts, certificates of deposit, stocks, irA, bonds or a right to income?

Yes

No

 

within the past 60 months, have you or your spouse transferred any assets into a trust?

Yes

No

If yes to either question, explain circumstances (attach extra paper if needed)_______________________________________________________________________________

_____________________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________________

TYPE OF RESOURCE(S)

MARKET VALUE

AT TIME

OF TRANSFER

s

$

DATE OF TRANSFER

OR CLOSING

6

PA 600 L (SG) 8/12

11 if you closed or depleted any accounts because you paid for nursing services, list these accounts.

TYPE OF RESOURCE

LOCATION

ACCOUNT NUMBER

OWNER(S)

DATE OF CLOSING

12

have you or your spouse received or does either of you expect to receive any income/asset/settlement/lump sum/inheritance?

Yes

If yes, describe:

AMOUNT $

 

 

 

DATE EXPECTED

 

No

13 income information for the applicant:

INCOME SOURCES

SOCIAL SECURITY

VETERANS BENEFIT AID AND ATTENDANCE

PENSIONS

WORKER’S COMPENSATION

RAILROAD RETIREMENT

BLACK LUNG

ANNUITY (COMPANY)

PAYMENTS FROM A TRUST

INTEREST/DIVIDEND (SOURCE)

OTHER INCOME

TO WHOM ARE THE

s

CHECKS SENT? (GUARDIAN,

 

REPRESENTATIVE PAYEE)

 

IDENTIFY INVESTMENT TYPE/NAME

GROSS INCOME AMOUNT

HOW OFTEN PAID

______________________________________

_________________________

____________________

______________________________________

_________________________

____________________

______________________________________

_________________________

____________________

______________________________________

_________________________

____________________

______________________________________

_________________________

____________________

______________________________________

_________________________

____________________

______________________________________

_________________________

____________________

______________________________________

_________________________

____________________

______________________________________

_________________________

____________________

______________________________________

_________________________

____________________

 

 

ADDRESS

 

 

 

 

 

 

 

 

7

PA 600 L (SG) 8/12

Complete this section if you have a spouse or dependent. Skip this section if you are not married or do not have a dependent.

14 income information for the spouse and/or dependent:

INCOME SOURCES

IDENTIFY INVESTMENT TYPE/NAME

GROSS INCOME AMOUNT

HOW OFTEN PAID

SOCIAL SECURITY

______________________________________

_________________________

 

____________________

VETERANS BENEFIT AID AND ATTENDANCE

______________________________________

_________________________

 

____________________

PENSIONS

______________________________________

_________________________

 

____________________

WORKER’S COMPENSATION

______________________________________

_________________________

 

____________________

RAILROAD RETIREMENT

______________________________________

_________________________

 

____________________

BLACK LUNG

______________________________________

_________________________

 

____________________

ANNUITY (COMPANY)

______________________________________

_________________________

 

____________________

PAYMENTS FROM A TRUST

______________________________________

_________________________

 

____________________

INTEREST/DIVIDEND (SOURCE)

______________________________________

_________________________

 

____________________

OTHER INCOME

______________________________________

_________________________

 

____________________

15 Shelter expense:

MONTHLY RENT/MORTGAGE

$ _____________________

BASIC TELEPHONE

$_______________________

SALES OR LEASE PURCHASE AGREEMENT

$ _____________________

GAS

$_______________________

PERSONAL CARE OR DOMICILIARY CARE RENTAL CHARGE

$ _____________________

ELECTRIC

$_______________________

MAINTENANCE CHARGES FOR CONDO OR CO-OP RESIDENCE

$ _____________________

HEATING FUEL

$_______________________

LOT RENT FOR MOBILE HOME

$ _____________________

WATER

$_______________________

PROPERTY TAXES - ANNUAL AMOUNT

$ _____________________

SEWER

$_______________________

HOMEOWNERS INSURANCE - ANNUAL AMOUNT

$ _____________________

GARBAGE

$_______________________

Do you pay for heating and/or air conditioning separate from your rent?

Yes

No

 

 

8

PA 600 L (SG) 8/12

 

righT To nondiSCriMinATion

We may not discriminate on the basis of age, sex, race, color, ancestry, disability, religious creed, national origin, sexual preference, life-style, union membership, political belief, or because you applied for and/or received assistance before. If you feel you have been discriminated against by the Department or anyone providing services for the Department, you may file

a verbal or written complaint with the Department or the county assistance office. The Department or county assistance office will then forward the complaint to the appropriate Federal or State agency.

righT To APPEAL

You have the right to ask for a Departmental hearing to appeal a decision of or failure to act by the Department which affects your benefits or that you feel is unfair or incorrect. You may file the appeal at the county assistance office. At the appeal hearing, you may represent yourself or someone else, such as a lawyer, friend, or a relative may represent you.

righT To An AgEnCY ConFErEnCE

If you appeal, you may have an agency conference before the hearing.

righT To A wriTTEn noTiCE

We will give you a written notice explaining your benefits. If we deny, change, suspend, or stop benefits, we will explain the reason on the notice. You have 30 days from the date of the notice to ask for a hearing if you disagree with the action taken and/or the reasons given.

righT To ConFidEnTiALiTY

We keep information you give confidential and use it only to administer the programs you apply for and may be eligible for. Any person knowingly violating any of the rules and regulations of this Department made in accordance with this article shall be guilty of a misdemeanor, and upon conviction thereof, shall be sentenced to pay a fine, not exceeding one hundred dollars ($100), or to undergo imprisonment, not exceeding six months, or both (62 P.S. Section 483).

ESTATE rECoVErY

If you are age 55 or older and receive medical assistance to pay for nursing facility services, home and community-based waiver services and any related hospital and prescription drug service, you will be required to repay the cost of these services from your probate estate. You may call the MA Estate Recovery Program at 800-528-3708.

ChAngES

If you are not sure if you must report a particular change, you should report the change. You can report to a member of the county assistance office staff in person, by telephone, or by mail.

uSE oF ThE PA ACCESS CArd

You may use the PA ACCESS card for services only during the period you are eligible. You must use the card only for the person who is eligible and you may get only services that are needed and reasonable.

rESPonSibiLiTY To ProVidE SSns

You must provide a Social Security Number (SSN). If you do not have an SSN, you must apply for one. Refusal or failure to provide an SSN may result in disqualification. If you have a community spouse, he or she must also supply an SSN. We use the SSN to verify identity, administer our programs, prevent duplication in state and federal programs, for computer matches with other programs, and to get information about income and resources to determine eligibility for and/or the amount of your benefits (42 U.S.C. Section 1320b-7).

PEnALTiES

If you do not report changes as required, your benefits may be reduced or stopped. If you purposely fail to give correct information or report changes, you may be fined and/or put in jail. Improper use of the PA Access Card for services may result in a fine, imprisonment or both.

rESPonSibiLiTY To ProVidE inForMATion You must give true, correct and complete information to the best of your ability. You must cooperate in documenting or verifying the information. If you cannot provide proof, you should ask the county assistance office to help. You must cooperate fully with quality control and with persons from the Department or

the Inspector General’s Office who are conducting investigations.

I UNDERSTAND:

My benefits may be reduced or I can be penalized for giving incomplete or false information or for not reporting changes that would affect my benefits.

Any person enriched as a result of a transfer of assets or income, which would have affected my eligibility, will be liable for repayment of those benefits issued incorrectly.

I am giving the state the right to seek, with or without legal action, payment from private or public health insurance or liable third party. The amount recovered will not exceed the amount paid by Medical Assistance.

The state has the right to review all records of medical service paid for by Medical Assistance.

Payment for medical services will be made directly to the provider, not to me. This includes payments from Medicare.

I received a copy of my rights and responsibilities, have read them or someone has read them to me, and I understand them.

I agree to provide or cooperate in getting any information needed to prove my statements.

I must report any changes in my circumstances within 10 days of the change.

I am responsible for any fraudulent statements made on this application even if the application is submitted by someone acting on my behalf.

The state operates a fraud control program under which local, state, and federal officials may verify the information I have given.

The state may obtain information about my circumstances from other persons or organizations, including computer matches and Immigration and Naturalization.

My Social Security Number will be used to obtain information to verify my circumstances and eligibility.

9

PA 600 L (SG) 8/12

AFFidAViT

I certify, subject to penalties provided by law, that the information I gave is true and correct and complete to the best of my knowledge.

I have read this application in full or someone has read it to me and I understand the questions asked. I have received a copy of and read my rights and responsibilities, or someone has read them to me, and I understand them.

APPLICANT OR AUTHORIZED REPRESENTATIVE SIGNATUREDATE I.D. VERIFIEDRELATIONSHIP TO APPLICANT

 

 

 

 

 

 

 

 

 

 

(

)

ADDRESS OF REPRESENTATIVE

 

CITY

 

 

STATE

 

ZIP CODE + 4

TELEPHONE NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WITNESS (IF SIGNED WITH AN X ABOVE)

DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

ADDRESS OF WITNESS

 

CITY

 

 

STATE

 

ZIP CODE + 4

TELEPHONE NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PROVIDER SIGNATURE (IF SUBMITTED BY PROVIDER)

DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Face to Face Interview With

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CAO OR OPTIONS

DATE

Telephone Interview With

 

 

 

 

 

Interview Waived

 

 

 

 

 

 

 

who is your representative or power of attorney?

Copies of notices will be sent to the person named.

LAST NAME, FIRST NAME, MIDDLE INITIAL

RELATIONSHIP TO APPLICANT

REPRESENTATIVE POWER OF ATTORNEY

ADDRESS

CITY

STATE

ZIP CODE + 4

TELEPHONE NUMBER

()

i wiSh To wiThdrAw MY APPLiCATion

/ /

SIGNATURE

DATE

10

PA 600 L (SG) 8/12

File Data

# Fact Detail Governing Law(s)
1 Name of Form PA 600 L (SG) N/A
2 Purpose Application for Medicaid Financial Eligibility for Long Term Care, Supports, and Services N/A
3 Alternative Application Mode Online at www.compass.state.pa.us N/A
4 Application Assistants Allowed from spouse, friend, relative, holder of power of attorney, or medical provider. N/A
5 Marital Information Requirement Information must be provided for both applicant and spouse, if married N/A
6 Verification of Assets Required for past 60 months; Applying includes checks on disposed assets and trusts. N/A
7 Decision Notification Timeline Within 30 days of application receipt N/A
8 Asset Transfer Disclosure Period Past 60 months prior to application date N/A
9 Voter Registration Assistance Optional assistance provided during application N/A
10 Requirement for Verification Applicant must provide proof of identity and other required information N/A

Guide to Filling Out Pa 600 L Sg

Once you have in your possession the form titled "Medical Assistance (Medicaid) Financial Eligibility Application for Long Term Care, Supports and Services" (PA 600 L SG), you are taking the first steps toward applying for different forms of long-term care and services under Medicaid. This form is vital for individuals seeking assistance for either in-facility care, home and community-based services, or other specific Medicaid-related services. It is structured to gather comprehensive information about the applicant, their financial situation, and their specific needs. It's important to provide detailed and accurate information to avoid any delays in the processing of the application. Following are the steps to complete the PA 600 L SG form accurately.

  1. Check the appropriate box at the very start of the form to indicate the type of assistance you are applying for (Care in a Facility, Home and Community Waiver Services, or Other) and specify the type/name of waiver/service if applicable.
  2. Read the entire form carefully to understand the requirements and instructions.
  3. Fill in the non-shaded sections with the requested information, which includes applicant details like name, current and previous addresses, contact information, and language preferences.
  4. If applicable, indicate if you require an interpreter or if you need your notices in Spanish.
  5. Answer questions about previous applications for cash, medical benefits, or participation in SNAP in other counties or states, including any use of different Social Security Numbers.
  6. Complete the section on household information for yourself, your spouse (if married), and any dependent children or siblings. Remember to attach an extra sheet if you have more dependents than the form accommodates.
  7. Determine and mark your citizenship or alien status, sign the form to declare this status, and fill in the details of your sponsor if you have one.
  8. Check your marital and military status, providing the necessary details as required.
  9. Decide if you want to register to vote and fill out that section accordingly.
  10. If you have received or are receiving long-term care, indicate how your expenses were or are being paid.
  11. State if you have any unpaid medical bills and attach copies if you're requesting Medical Assistance for these bills.
  12. Complete the section on medical insurance information, including any long-term care insurance that you may have.
  13. Fill out detailed information about your resources such as real estate, mobile homes, burial arrangements, and life insurance, including values, ownership, and whether these assets are listed for sale or generating any income. Add additional sheets of paper if more space is needed, clearly indicating the question number each response corresponds to.
  14. After ensuring all information is complete and accurate, attach any required verification to the form.
  15. Submit the completed form and attached verification to the county assistance office by mail or in person, unless instructed otherwise.

After submission, the county assistance office will review the information provided. They may request more information or a face-to-face interview to further assess your eligibility. Within 30 days of receiving your completed application and necessary verification, they will notify you of your eligibility status. It is essential to comply with any additional requests from the county assistance office promptly to ensure the timely processing of your application.

Your Questions, Answered

What is the PA 600 L (SG) form used for?

The PA 600 L (SG) form is an application specifically designed for individuals seeking financial eligibility for Medicaid in the context of long-term care, supports, and services in Pennsylvania. This includes care in a facility, home, and community-based waiver services, among other types of care. The form allows applicants to provide detailed information about their personal, financial, and medical circumstances to determine their eligibility for assistance.

Who can complete the PA 600 L (SG) form?

The form can be completed by the individual seeking medical assistance benefits or by a representative chosen by the individual. This representative can be a spouse, friend, relative, someone who holds the power of attorney, or a medical provider. It is essential that the person completing the form is knowledgeable about the applicant's income and resources to accurately fill out the required information. If married, sections of the form must be completed for both spouses to properly assess eligibility.

What documents are required to be submitted along with the PA 600 L (SG) form?

Applicants are required to submit proof of identity and other necessary verification documents related to the information provided on the form, unless such information is already available in the records of the county assistance office. Verification of assets owned in the past 60 months is particularly critical, especially if assets were transferred or given away, as this may impact eligibility for benefits. The county assistance office can offer assistance in obtaining any required information.

What happens after submitting the PA 600 L (SG) form?

Upon receiving a completed PA 600 L (SG) application and the necessary verification documents, the county assistance office will review the application to determine eligibility for Medicaid long-term care, supports, and services. The applicant will be notified within 30 days about whether they are eligible, ineligible, or if additional information is required to make a decision.

How can I apply for financial eligibility for Medicaid long-term care if I have previously transferred assets?

Applicants who have transferred assets or set up trusts in the 60 months prior to applying for Medicaid for long-term care may be subject to an ineligibility period. It is essential to disclose any such transfers on the PA 600 L (SG) form and provide detailed verification of these assets. The county assistance office will consider these transfers in the determination of eligibility under the Medicaid rules that address asset transfers and eligibility periods. If you are in this situation, it is advisable to provide as much information and documentation as possible to support your application.

Common mistakes

When filling out the PA 600 L SG form, which is used to apply for Medical Assistance (Medicaid) for long-term care, supports, and services, it's crucial to be meticulous to avoid mistakes that could delay or jeopardize the application process. Here are four common mistakes people make on this form:

  1. Not reading the entire application before starting. This form contains detailed instructions and specifies which sections to complete. Skipping this step can lead to incomplete or incorrectly filled sections.
  2. Ignoring the shaded sections. The form specifies that the information should be printed in the unshaded sections only. Filling out information in shaded areas can cause confusion and errors in processing the application.
  3. Failing to include information for both the applicant and the spouse. If the applicant is married, it's essential to provide details for both individuals in some sections. Omitting spouse’s information can lead to an incomplete application.
  4. Not attaching necessary verification documents. The application requires proof of identity and other information unless already available in the records. Missing attachments can lead to delays or denial of benefits.

Addressing these mistakes ensures a smoother application process and helps applicants avoid unnecessary delays. It's also advised to seek help from the county assistance office if there are any doubts or difficulties in completing the form.

Documents used along the form

When applying for Medical Assistance (Medicaid) for Long Term Care, Supports, and Services through the PA 600 L (SG) form, it is often necessary to provide additional documentation to support the application. These documents help to verify the information submitted and ensure that applicants receive the support and services they qualify for. Understanding these related documents is crucial for a smooth application process.

  • Certified Copy of Birth Certificate: A certified copy of the applicant’s birth certificate is often required to verify the applicant’s age and citizenship. This document establishes the legal identity of the applicant.
  • Proof of Income: Documents such as recent pay stubs, social security benefit statements, or pension statements are needed to verify the income of the applicant (and spouse, if applicable). These documents are critical for determining financial eligibility for Medicaid.
  • Bank Statements: Recent bank statements (typically covering the last few months) from all checking and savings accounts are required to verify the current financial resources available to the applicant. This helps in assessing the applicant's financial situation and eligibility.
  • Proof of Insurance: Documentation of any existing medical insurance coverage, including Medicare, private health insurance, or long-term care insurance, is necessary. This information is used to coordinate benefits and understand what Medicaid needs to cover.

Collecting and submitting these documents alongside the PA 600 L (SG) form can significantly impact the application's outcome. It's important for applicants and their representatives to gather these materials as early as possible in the application process. Proper documentation ensures that the county assistance office can accurately assess eligibility and provide the necessary supports and services without undue delay.

Similar forms

The PA 600 L Sg form, known as the Medical Assistance (Medicaid) Financial Eligibility Application for Long Term Care, Supports, and Services, encompasses various sections that closely resemble other documents used within healthcare and social service applications in the United States. Due to the form’s multifaceted nature, individuals are required to provide detailed personal, financial, and medical information similar to what other applications demand. Specifically, the form parallels documents such as the Medicaid application for standard medical services, state-based Long-Term Care insurance applications, and applications for Home and Community-Based Services (HCBS) waivers. Each of these forms shares a primary goal: to assess the eligibility of an applicant for government-assisted healthcare programs, yet they cater to different needs within the healthcare system.

Similar to the PA 600 L Sg form, the standard Medicaid application requires applicants to provide extensive information about their household composition, income, and assets. However, the Medicaid application extends beyond long-term care, supporting a broader range of medical services for individuals and families. This resemblance underscores the emphasis on financial eligibility across Medicaid-related applications, yet distinguishes the PA 600 L Sg form by its focus on long-term care and supports. Both documents necessitate proof of identity, citizenship, or residency status, and detailed financial records, though the PA 600 L Sg form delves deeper into specifics regarding real estate, life insurance, and burial arrangements due to the long-term nature of the assistance applied for.

State-based Long-Term Care insurance applications share a close relation with the PA 600 L Sg form in terms of the targeted demographic—individuals seeking assistance for long-term care. These applications assess an applicant’s eligibility for insurance benefits that help cover the costs of long-term services, including in-home care, assisted living, and nursing home facilities. While insurance applications focus on the underwriting process, assessing risk, and determining premium rates, the PA 600 L Sg form’s purpose is to establish eligibility for Medicaid-funded services. Both sets of applications gather detailed information on the applicant’s medical conditions and care requirements to tailor the services or coverage to the applicant’s needs.

Applications for Home and Community-Based Services (HCBS) waivers, much like the PA 600 L Sg form, are designed for individuals who prefer to receive long-term care services in a home or community setting rather than institutionalized care. These forms usually require detailed information on the applicant's health condition, level of care needed, financial eligibility, and potential care strategies within the community. The similarity between HCBS waiver applications and the PA 600 L Sg form lies in their mutual objective to support individuals who require long-term care, emphasizing the applicant’s need for specialized waivers that allow for Medicaid to cover non-traditional services. Both documents play a crucial role in enabling access to necessary support systems outside of standard healthcare facilities.

Dos and Don'ts

When filling out the Pennsylvania PA 600 L SG form, an application for Medical Assistance (Medicaid) Financial Eligibility for Long Term Care, Supports, and Services, there are several important steps to follow and pitfalls to avoid ensuring the process goes smoothly and accurately. Here is some guidance:

  • Do read the entire application before beginning to fill it out to make sure you understand the types of information and documentation you will need to provide.
  • Don't rush through the form. Take your time to ensure all information is correct and complete. Incomplete or inaccurate information can delay the processing of your application.
  • Do print legibly in the unshaded sections of the form to ensure that your information can be clearly read by county assistance office staff.
  • Don't hesitate to seek help if you need assistance completing the form. You can get assistance from a friend, relative, medical provider, or someone who has your power of attorney, as well as from your county assistance office.
  • Do provide information for both you and your spouse if you are married, as required in some sections of the form.
  • Don't forget to include verification of your income, resources, and other necessary information with the form, if possible. This can expedite the eligibility determination process.
  • Do attach additional sheets of paper if you need more space to answer any questions. Make sure you label what question number you are answering on any additional pages.
  • Don't ignore the requirement to disclose if you or any representative has transferred assets in the last 60 months before applying for Medical Assistance. Failing to disclose such information could make you ineligible for benefits.
  • Do notify the county assistance office if your circumstances change after you have submitted the application. This can include changes to your income, resources, or family status.

By carefully following these dos and don'ts, you can help ensure that your application for Medical Assistance through the PA 600 L SG form is completed accurately, which can assist in processing your application more swiftly and efficiently.

Misconceptions

There are several misconceptions about the Pennsylvania Application for Long-Term Care, Supports, and Services, also known as the PA 600 L (SG) form. Addressing these misunderstandings is crucial for individuals and families navigating the complexities of applying for Medicaid coverage for long-term care.

  • Misconception #1: Only for Nursing Home Care
  • Many believe that the PA 600 L (SG) form is strictly for those seeking Medicaid coverage for nursing home care. However, it's also applicable to those seeking Home and Community-Based Services (HCBS) waivers, allowing individuals to receive care in their own home or community rather than a nursing facility.

  • Misconception #2: Solely the Applicant's Responsibility
  • There's a common misconception that only the individual applying for benefits can complete and submit the PA 600 L (SG) form. In truth, a designated representative, such as a family member, friend, or legal representative, can also assist with or complete the form on the applicant's behalf.

  • Misconception #3: Marital Information is Optional
  • Some applicants assume that providing information about their spouse is optional. This is incorrect. When married, applicants must include detailed information about their spouse, as Medicaid eligibility and asset assessments are determined based on the combined information of the applicant and their spouse.

  • Misconception #4: Asset Transfer Irrelevance
  • A significant misunderstanding is that transferring or giving away assets before applying won't impact eligibility. Assets transferred or given away within the 60 months before applying for Medicaid can affect eligibility. Applicants need to disclose these transactions when applying.

  • Misconception #5: Immediate Notification of Eligibility or Denial
  • There's a false expectation that applicants will be immediately informed about their eligibility or denial upon submission. The process can take up to 30 days for the county assistance office to review the application, verify information, and make a decision regarding eligibility.

  • Misconception #6: Application Availability Only in English
  • Another misconception is that the application is available only in English. The PA 600 L (SG) form and its instructions are accessible in multiple languages to accommodate non-English speakers, ensuring wider accessibility and understanding of the application process.

Understanding these misconceptions and clarifying the facts about the PA 600 L (SG) form can significantly assist individuals and families in effectively navigating the application process for Medicaid coverage for long-term care services.

Key takeaways

When approaching the process of filling out the Pa 600 L Sg form, also known as the Medical Assistance (Medicaid) Financial Eligibility Application for Long Term Care, Supports, and Services, there are several key takeaways that can help ensure a smooth and effective application process. These takeaways aim to provide clarity and aid in navigating through the complexities of the application to seek Medicaid assistance for long-term care.

  • Access the Application Online: Applicants can access and fill out the form online at www.compass.state.pa.us, which provides a convenient alternative to paper forms.
  • Assistance in Filling Out the Form: It is permissible for another person, such as a spouse, relative, friend, or legal representative, to complete the application on behalf of the applicant, ensuring that information about the applicant's income and resources is accurately provided.
  • Required Information for Married Applicants: If the applicant is married, specific sections of the form require information for both the applicant and their spouse, which is crucial for determining eligibility accurately.
  • Submission Processes: The completed form can be submitted by bringing it to the county assistance office, having someone else bring it in, or mailing it, unless instructed otherwise for specific cases.
  • Verification Necessity: Applicants must provide proof of identity and verification for other information requested on the form unless this information is already available in the records. It's recommended to attach necessary verification documents with the form submission.
  • 60-Month Look-back Period: Individuals who have transferred assets or income or established trusts within 60 months before applying may face eligibility issues. Verification of assets owned during this period is required, highlighting the need to prepare documentation reflecting asset history.
  • Processing Time and Notification: The county assistance office is responsible for notifying applicants within 30 days of receiving the application about eligibility, ineligibility, or if further information is needed, underlining the importance of timelines in the application process.
  • Comprehensive Information Requirement: The form necessitates detailed information regarding dependents, citizenship status, marital and military status, previous long-term care, medical insurance, and resources, emphasizing the need for thorough preparation before applying.
  • Voter Registration: The application includes the opportunity to register to vote, indicating that applying for Medicaid does not isolate applicants from civic participation, and choosing to register or not does not impact the assistance provided.

Understanding these key points before filling out the Pa 600 L Sg form can significantly enhance the efficiency and effectiveness of the application process for Medicaid's long-term care, supports, and services. It's critical for applicants or their representatives to compile relevant information, documentation, and fully comprehend the requirements and implications of the information provided within the application.

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