Regulations found at 55 Pa Code 1181.53 and 1187.31 provide that an applicant for MA LTC benefits must have a functional need for nursing care services. The Aging Services Policy and Procedure Manual Chapter IX Section IV states that the applicant’s functional need must be certified as meeting a specific level of care in order to be determined Nursing Facility Clinical Eligible (NFCE).

Regulations found at 55 Pa. Code § 1187.31 state that “the nursing facility shall ensure that before an MA applicant or recipient is admitted to a nursing facility, or before authorization for MA payment for nursing facility services in the case of a resident, the MA applicant, recipient or resident has been evaluated by the Department or an independent assessor and found to need nursing facility …show more content…
The first exception is: if a NF resident in need of Medical Assistance benefits has died before the assessment could be conducted. The second exception is circumstances in which the “individual has already been discharged from [the NF] and the assessment is for eligibility for MA during a time period that the individual was in the [NF].” The circumstances in this case meet the second exception to a face to face LCD, so a retrospective medical documentation and chart review is permitted in this case. The Aging Manual Chapter IX Section V provides a retrospective review should “be a rare occurrence as the Nursing Facility is required to contact the AAA for an assessment prior to a discharge” from the NF. Neither the representative from the CAO nor any of the representatives from Bucks County AAA provided any documentation to substantiate their reason not to grant an exception as indicated above therefore, the ALJ finds that the Bucks County AAA was incorrect to determine the Appellant NFI due to not assessing the Appellant’s level of care for a time when the individual was in the