PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE OFFICE OF LONG-TERM LIVING OBRA Training for MA Forms (MA 408, MA 401) Janet Nerbecki April 2011 1 MA 408 April 2011 2 1
MA 408 cont d April 2011 3 MA 408 cont d April 2011 4 2
MA 408 cont d April 2011 5 MA 408 details The MA 408 is filled out as follows: Type or Print all items on the form in black ink Section I Enter the facility name and address, date, county code, facility MAID number, contact person, telephone number and fax number in the appropriate fields. Section II Check all appropriate boxes and enter date. Section III Enter the resident s name, SS#, MA recipient number, date of admission/change, and appropriate target group, in addition, place the date of the Program Office Letter of Determination in the appropriate box. Mail/fax MA 408 to the appropriate Field Operations Office. April 2011 6 3
MA 401 April 2011 7 MA 401 Cont d To Order copies of MA forms: http://www.dpw.state.pa.us/findaform/order medicalassistanceforms/index.htm April 2011 8 4
Questions? Ruth Anne Barnard, R.N., B.S.N. MDS/OBRA Coordinator for Field Operations rbarnard@pa.gov 717-214-3736 Field Operations Supervisor see list April 2011 9 5
NURSING HOME REFORM ACT OMNIBUS BUDGET RECONCILIATION ACT (OBRA) Target Resident (MI, MR, ORC) Reporting Form MA 408 (Must fill in Sections I, II, and III) SECTION I FACILITY INFORMATION Facility Name and Complete Address (may affix Facility stamp) Date County Code Service Provider ID - Service Location Number Contact Person Name Title Telephone Number Fax Number SECTION II TRACKING DATA - Check all that apply NEW ADMISSION Date CHANGE IN CONDITION Date A Target resident who is a new admission to a nursing facility and is Any change in individual s condition that affects target status, OR A not being accepted as a transfer from another nursing facility. Target individual admitted as an Exempted Hospital/Respite Care and is now in need of long-term nursing facility services. EXCEPTIONAL ADMISSION Date (described in Section V of the PA-PASRR-ID) Check one of the following: DISCHARGE Date Self explanatory. Indicate in Section III under comments, where Resident is an Exempted Hospital Discharge (30 days or less) Target individual is discharged to (i.e., home, PCH etc.). (See Change in Condition if individual goes to Long Term Care) Resident Requires Respite Care (14 days or less) EXPIRED (See Change in Condition if individual goes to Long Term Care) Self explanatory. Date Resident Requires Emergency Placement (30 days or less) (See Change in Condition if individual goes to Long Term Care) UNREPORTED TARGET Date Resident is in a coma or functions at brain stem level A resident who was not identified as a Target at admission. TRANSFER Date A Target resident who is transferred from one nursing facility to another. Indicated in Section III under comments, the facility and address the target individual is transferred to/from. SECTION III RESIDENT INFORMATION Social Security MA Recipient Admission Date of Program Office Name - Last, First, M.I. MI MR ORC Number Number Date Letter of Determination Comments NOTE: SEND OR FAX ORIGINAL WITHIN 48 HOURS TO: YOUR UMR FIELD OFFICE ENTER NAME AND ADDRESS OF UMR FIELD OFFICE FOR DPW USE ONLY Signature - UMR Representative DATE MA 408 3/04
~ ~ I i  ~ U U ~ ADMISSIONS NOTICE PACKET IMPORTANT INFORMATION FOR NURSING FACILITY RESIDENTS AND THEIR SPOUSES Important information for nursing facility residents and their spouses. If you need this information in another language or someone to interpret it, please notify the nursing facility or contact your local county assistance office. Language assistance will be provided free of charge. Información importante para los residentes en hogares de ancianos y sus esposos. Si usted necesita esta información en otro idioma o alguien que se la traduzca, favor de notificar al personal de la residencia o comunicarse con la oficina local de Asistencia del Condado (CAO). Asistencia lingüística será proveída gratis. Btmansxans mabgkrsenakgmnlklanbdak/nbdaykarngs mabb/ á M ~ ~ ë i u u i i I Thoâng tin quan troïng veà cô sôû döôõng laõo daønh cho thöôøng truù nhaân vaø vò phoái ngaãu. Neáu quí vò caàn thoâng tin naøy baèng moät thöù tieáng khaùc hay moät bbnrbsek. ì ebelakgk tvkarbtmanenhcapasaep getot á phieân dòch vieân, xin thoâng baùo cho cô sôû döôõng laõo hay lieân laïc vôùi Vaên ÉGkNamakeGaybkE begay smcrabmn M ël Kilanbd u ak/nbd u aykar i Phoøng Trôï Caáp Quaän Haït. Trôï giuùp veà ngoân ngöõ seõ ñöôïc cung caáp mieãn phí. É TakTgeTAkaryal i yevleh & rbs ßà elakgk. ~ CMnYykgkarbkE bng tv w U ȼɚɠɧɵɟ ɫɜɟɞɟɧɢɹ ɨɬɧɨɫɢɬɟɥɶɧɨ ɠɢɬɟɥɟɣ ɞɨɦɨɜ ɩɪɟɫɬɚɪɟɥɵɯ ɢ ɢɯ plegayeday²tkt«f. ɫɭɩɪɭɝ (ɫɭɩɪɭɝɨɜ). ȿɫɥɢ ɜɚɦ ɧɭɠɟɧ ɞɚɧɧɵɣ ɞɨɤɭɦɟɧɬ ɧɚ ɞɪɭɝɨɦ ɹɡɵɤɟ ɢɥɢ ɟɝɨ ɭɫɬɧɵɣ ɩɟɪɟɜɨɞ, ɨɛɪɚɳɚɣɬɟɫɶ ɜ ɞɨɦ ɩɪɟɫɬɚɪɟɥɵɯ ɥɢɛɨ ɜ ɦɟɫɬɧɨɟ Ȼɸɪɨ ɩɨɦɨɳɢ (County Assistance Office). ɉɨɦɨɳɶ ɩɟɪɟɜɨɞɱɢɤɚ ɩɪɟɞɨɫɬɚɜɥɹɟɬɫɹ ɛɟɫɩɥɚɬɧɨ. 䖭 ᰃথ 㒭 ݏ᠔ⱘሙ ঞ ⱘي䜡 䞡 㽕 䗮 ⶹDŽབᵰᙼ 䳔 㽕 ℸ 䗮 ⶹ 㗏 䆥 ៤ Ҫ 䇁 䳔 㽕 Ўᙼᦤկ 㗏 䆥 ˈ 䇋 䗮 ⶹݏ᠔ 㘨 LTD ᙼ᠔ऎⱘ џ໘(county䚵ওण Assistance Office)DŽ ᦤ ܡկ 䌍 䇁 㿔 णDŽ This information packet contains There are four (4) parts to this Admissions Notice Packet. important information about your rights PART 1 - Pages 2-6 Notice of Rights of Nursing Facility as a resident of a nursing facility, and Residents information about Medical Assistance Applies to Everyone (MA), a program which can help pay for PART 2 - Pages 7-8 Medical Assistance Payment for nursing facility care for people who cannot Nursing Facility Care Eligibility pay all of the costs of care by themselves. Requirements and Procedures Everyone should read this part - Even if you do not Federal law, 42 U.S.C. 1396r (c) (1) (B) need MA now. and (e) (6),requires the nursing facility to PART 3 - Pages 9-11 Protecting Resources and Income for give you this information. the Spouse Living at Home Even if you are paying for your nursing Applies if you have a spouse who is living in the community, i.e., is not in a nursing facility or medical facility care yourself, or if Medicare or institution. another insurance is paying, it is important PART 4 - Pages 12-15 Resource Assessment Form (PA 1572) for you to learn about MA before you might To be used by a couple when one of them is in a need it. nursing facility or other medical institution, and the other lives in the community. I certify that the notices required by 42 U.S.C. 1396r (c) (1) (B) and (e) (6) were provided to me at the time of my admission to: Note: A new 401 is needed for each admission. Name of Resident Resident s Social Security Number Name of Facility Date of Admission Signature of Resident OR Signature of Patient or Resident Representative Relationship to Resident Date Affix UMR stamp here FACILITY COPY MA 401 2/11 ( i )