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HomeMy WebLinkAbout09-3807r r IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA PRESBYTERIAN SENIOR LIVING d/b/a GREEN RIDGE VILLAGE, . Plaintiff, V. No. LESTER RUSSELL and AMY RUSSELL, Defendants. CIVIL ACTION - EQUITY TYPE OF PLEADING: COMPLAINT FILED ON BEHALF OF: Presbyterian Senior Living d/b/a Green Ridge Village, Plaintiff COUNSEL OF RECORD FOR THIS PARTY: Nicole M. Kerns Attorney I.D. No. 206827 (412) 281-3511 Marijane E. Treacy Attorney I.D. No. 84070 (412) 281-3535 SCHUTJER BOGAR LLC U. S. Steel Tower, Suite 3290 600 Grant Street Pittsburgh, PA 15219 Fax (412) 281-0530 Bradley Schutjer Attorney I.D. No. 75954 (717) 909-5921 SCHUTJER BOGAR LLC 417 Walnut Street, 4 h Floor Harrisburg, PA 17101 Attorneys for Plaintiff f 1 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA PRESBYTERIAN SENIOR LIVING D/B/A GREEN RIDGE VILLAGE, Plaintiff, V. No. LESTER RUSSELL and AMY RUSSELL, Defendants. CIVIL ACTION - EQUITY NOTICE YOU HAVE BEEN SUED IN COURT. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after this complaint and notice are served, by entering a written appearance personally or by attorney and filing in writing with the court your defenses or objections to the claims set forth against you. You are warned that if you fail to do so the case may proceed without you and a judgment may be entered against you by the court without further notice for any money claimed in the complaint or for any other claim or relief requested by the plaintiff. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE. Cumberland County Bar Association 32 South Bedford Street Carlisle, PA 17013 Telephone: (717) 249-3166 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA PRESBYTERIAN SENIOR LIVING DB/A GREEN RIDGE VILLAGE, Plaintiff, V. No, LESTER RUSSELL and AMY RUSSELL, Defendants. CIVIL ACTION - EQUITY AVISO USTED HA SIDO DEMANDADO/A EN CORTE. Si usted desea defenderse de las demandas que se presentan mas adelante en las siguientes paginas, debe tomar accion dentro de los proximos veiente (20) dias despues de la notificacion de esta Demanda y Aviso radicando personalmente o por medio de un abogado una comparecencia escrita y radicando en la Corte por escrito sus defensas de, y objeccionee a, las demandas presentadas aqui en contra suya. Se le advierte de que si usted falla de tomar accion como se describe anteriormente, el caso puede proceder sin usted y un fallo por cualquier suma de dinero reclamada en la demanda o cualquier otra reclamacion o remedio solicitado por el demandante puede ser dictado en contra suya por la Corte sin mas aviso adicional. Usted pued perder dinero o propiedad u otros derechos importantes para usted. USTED DEBE LLEVAR ESTE DOCUMENTO A SU ABOGADO INMEDIATAMENTE. SI USTED NO TIENE UN ABOGADO, LLAME O VAYA A LA SIGUIENTE OFICINA. ESTA OFICINA PUEDE PROVEERLE INFORMACION A CERCA DE COMO CONSEGUIR UN ABOGADO. SI USTED NO PUEDE PAGAR POR LOS SERVICIOS DE UN ABOGADO, ES POSIBLE QUE ESTA OFICINA LE PUEDA PROVEER INFORMACION SOBRE AGENCIAS QUE OFREZCAN SERVICIOS LEGALES SIN CARGO O BAJO COSTO A PERSONAS QUE CUALIFICAN. Cumberland County Bar Association 32 South Bedford Street Carlisle, PA 17013 Telephone: (717) 249-3166 I ) IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA PRESBYTERIAN SENIOR LIVING DB/A GREEN RIDGE VILLAGE, V. LESTER RUSSELL and AMY RUSSELL, Plaintiff, Defendants. No. 7 CIVIL ACTION - EQUITY COMPLAINT AND NOW, COMES, Plaintiff, Presbyterian Senior Living d/b/a Green Ridge Village ("Plaintiff'), by and through its attorneys, SCHUTJER BOGAR LLC, and files the following Complaint against Defendants Lester Russell ("Defendant Lester Russell") and Amy Russell ("Defendant Amy Russell") (collectively referred to as "Defendants") and in support thereof, states: 1. Plaintiff is a corporation organized and existing under the laws of the Commonwealth of Pennsylvania, with its principal offices located at 210 Big Spring Road, Newville, Pennsylvania 17241. 2. Defendant Lester Russell is an adult individual who currently resides at Plaintiffs skilled nursing facility located at 210 Big Spring Road, Newville, Pennsylvania 17241. 3. Defendant Amy Russell is an adult individual who currently resides at 11 Schoolhouse Road, Newville, Pennsylvania 17241. 4. On or about November 19, 2007, Defendant Lester Russell made application for admission to Plaintiff's skilled nursing facility located at 210 Big Spring Road, Newville, Pennsylvania 17241. 5. On or about November 19, 2007, Plaintiff and Defendant Lester Russell entered into a written Admission Agreement ("Agreement'), pursuant to which Plaintiff agreed to provide Defendant Lester Russell with skilled nursing services in exchange for his promise to pay a specific monetary fee from his income and resources, to assign his right to receive Medical Assistance benefits to Plaintiff in the event that he became insolvent and upon making application for Medical Assistance benefits, to assign his "Patient Pay" amount to the Plaintiff as estimated by the Cumberland County Assistance Office ("CAO") in accordance with 55 Pa. Code § 181.452(e). A true and correct copy of the Agreement is attached hereto as Exhibit "A." 6. Subsequent to Defendant Lester Russell's admission to Plaintiff's skilled nursing facility, no payment was made for services rendered to him because he allegedly became insolvent. As a result, an application for Medical Assistance benefits subsequently was filed. 7. The CAO approved the application for Medical Assistance benefits on or about April 27, 2009, with benefits awarded effective beginning February 1, 2008. A true and correct copy of the PA-162 Notice is attached as Exhibit "B." 8. The CAO also determined that the monthly income or "Patient Pay Liability" of Defendant Lester Russell, consisting of Social Security income, and a pension should be forwarded to Plaintiff as Defendant Lester Russell's contribution toward the cost of the care that Plaintiff has provided to him. See the PA-162, attached as Exhibit "B." 9. To date, an outstanding balance of $37,041.20 is due and owing to Plaintiff as a result of Defendant Lester Russell's failure to forward his entire monthly income to Plaintiff. 10. The foregoing amounts increase every month, as Defendant Lester Russell is a current resident in Plaintiff's skilled nursing facility. 11. To the extent of Plaintiff's knowledge and upon Plaintiff's information and belief, 2 Defendant Lester Russell's monthly social security and pension income have been going to his daughter, Amy Russell, who has been using the same for her own personal enjoyment. 12. The continued failure of Defendants to forward Defendant Lester Russell's entire monthly income places Defendant Lester Russell's eligibility for Medical Assistance benefits in jeopardy, as the longer Defendant Amy Russell retains and uses Defendant Lester Russell's monthly income for her own benefit and not to fulfill Defendant Lester Russell's obligations, the monthly income will be considered an accruing resource and Defendant Lester Russell may be determined to be in excess of the resource limit for Medical Assistance benefits. COUNTI BREACH OF CONTRACUSPECIFIC PERFORMANCE Plaintiff v. Defendant Lester Russell 13. The allegations contained in Paragraphs 1 through 12 are incorporated herein by reference as if fully set forth at length. 14. Pursuant to the Agreement, Defendant Lester Russell has an obligation to pay for the skilled nursing services that Plaintiff provided to him from his income and resources and to assign his Medical Assistance benefits and monthly "Patient Pay Liability" to Plaintiff in accordance with the terms and conditions of the Agreement. See Exhibit "A." 15. The law is clear that an "assignee stands in the shoes of the assignor and assumes the rights of the assignor." Horbal V. Moxham Nat'l Bank, 697 A.2d 577 (Pa. 1997). 16. Defendant Lester Russell breached the Agreement with Plaintiff by refusing to assign to Plaintiff his entire monthly income or "Patient Pay Liability" in accordance with both the terms and conditions of the Agreement and Defendant Lester Russell's Medical Assistance approval. See Exhibits "A" and "B." IT By failing to remit his income, Defendant Lester Russell is interfering with 3 Plaintiff's right to receive all of the income or "Patient Pay Liability" that has been contractually assigned to it. 18. Furthermore, if Defendant Lester Russell does not turn over his income or "Patient Pay Liability," he places his eligibility for Medical Assistance benefits in jeopardy, thereby directly interfering with Plaintiff's right to receive those Medical Assistance benefits that have also been contractually assigned to it. 19. The aforementioned breach of the Agreement has caused and continues to cause irreparable harm to Plaintiff because if Defendant Lester Russell does not turn over his entire monthly income or "Patient Pay Liability," his Medical Assistance benefits will be discontinued. 20. Upon information and belief, at all times material hereto, Defendant Lester Russell has been financially unable to fully compensate Plaintiff for the services that it has rendered to him and continues to render to him in accordance with the terms and conditions of the Agreement. 21. Accordingly, only a decree of specific performance will adequately protect the interests of Plaintiff and provide it with the benefits and/or protections promised under the Agreement. WHEREFORE, Plaintiff respectfully requests that this Court enter a decree ordering specific performance of the Agreement by Defendant Lester Russell. COUNT II VIOLATION OF UNIFORM FRAUDULENT TRANSFER ACT Plaintiff v. Defendant Lester Russell and Defendant Amy Russell 22. The allegations contained in Paragraphs 1 through 21 are incorporated by reference as if fully set forth at length. 23. Upon Plaintiff's information and belief and to the extent of its knowledge, 4 Defendant Lester Russell has transferred to his daughter, Defendant Amy Russell, his monthly social security and pension income, which was to be paid to Plaintiff for the cost of the care and services that it has rendered to Defendant Lester Russell. 24. Upon Plaintiff's information and belief and to the extent of its knowledge, said transfers of Defendant Lester Russell's income to Defendant Amy Russell, were intended to avoid making said income available to pay Plaintiff for the care and services that it rendered to him. 25. Defendant Amy Russell is a first transferee within the meaning of the Pennsylvania Uniform Fraudulent Transfer Act. 12 Pa.C.S.A. § 5104. 26. Plaintiff was a foreseeable creditor within the meaning of the Pennsylvania Uniform Fraudulent Transfer Act. 12 Pa.C.S.A. § 5104. 27. Defendant Amy Russell accepted the above-referenced transfers of Defendant Lester Russell's income, with full knowledge that said transfers were being made when Defendant Lester Russell was already insolvent and with the sole purpose of avoiding those monies being available to pay Plaintiff for the care and services that Plaintiff rendered to Defendant Lester Russell in accordance with the terms and conditions of the Agreement. [THE REMAINDER OF THIS PAGE LEFT BLANK INTENTIONALLY] 5 WHEREFORE, Plaintiff respectfully requests that this Court enter an order that voids the above-referenced transfers of income to Defendant Amy Russell and further orders that direct payment be made to Plaintiff. Respectfully submitted, S JER BOGAR LLC Dated: (o b8 Oct By; IQ f 0 (_ M PelAf Nicole M. Kerns Attorney I.D. No. 206827 (412) 281-3511 nkernsna,schutjerbo ar.com Marijane Treacy Attorney I.D. No. 84070 (412) 281-3535 mjtreacya,schutjerbo ar.com U.S. Steel Tower 600 Grant Street, Suite 3290 Pittsburgh, PA 15219 Fax (412) 281-0530 Bradley Schutjer Attorney I.D. No. 75954 (717) 909-5921 417 Walnut Street, 4t' Floor Harrisburg, PA 17101 Attorneys for Plaintiff 6 EXHIBIT "A" -..---.._. C aDNris NT LONG TERM CARE ADMISSION AGREEMENT 1. INTRODUCTION This Agreement is between kQS n "C R(J-S<.-",11 Resident, or 6 V nU VS S-4? . Residents Representative (referred to as Resident in the Agreement) and CU VVJ - Health Center, a licensed Long Term Care Facility (referred to as Health Center in this Agreement), for admission of Resident to the Health Center on laa 20. (Date) Resident requests occupancy of Room 10(14 , a room for occupancy of residents at a Daily Rate of $3 Resident may request a room change and the Health Center will make every effort to honor such requests as soon as possible. However, a room change may result in a change in the Daily Rate upon occupancy of the new room. In the event of an increase in the Daily Rate, the Health Center will provide thirty (30) days' notice of any change, thereby giving Resident sufficient time to request a room change (for example from a private to a semi-private room) or to transfer to another nursing facility. The Health Center agrees to accept payments from Medicare and other contracted third party payers for Resident's stay if Resident meets all qualifications required by Medicare or other third party payer. Resident agrees to pay daily co-payment and/or deductibles as designated by Medicare or other third party payers. If Resident qualifies for Medical Assistance CUX }, the Health Center agrees to accept the Patient Pay Liability (as defined below) as determined by the County Assistance Office with the balance of the payment for covered services coming from the MA Program. H. DEFINITIONS A. Daily Rate. The rate the Health Center charges a private pay resident for room and board, general nursing care, housekeeping services, linen services, nutrition management, limited in room storage of Resident's personal belongs, and recreational programs for each day a Resident is at the Health Center. Physician services are not included in the Daily Rate. .... ......... _.._..... B. Healthcare Surrogate. An adult who is appointed to make healthcare decisions for Resident when Resident becomes unable to make them for him/herself C. Medical .Director. The physician designated by the Health Center to be responsible for resident care policies and the coordination of medical care in the Health Center. D. Clinical Records. All records (excluding financial records) pertaining to a particular Resident that are prepared and maintained by Health Center. E. Patient Pay Liability. The. amount of personal funds, as determined by the Commonwealth County Assistance Office, that a Resident who is receiving MA must pay monthly to the Health Center in addition to the payment from the MA program. F. Personal Needs Services. Personal services such as telephone service, laundry, beauty and hair care (exclusive of routine assistance with grooming), and newspaper delivery provided by the Health Center to Residents for their convenience at Residents' expense. G. Private Pay Resident. A Resident who pays the Daily Rate and all other fees of the Health Center from his/her own resources (including private insurance and Medicare Part B) and who is not covered by or has exhausted Medicare Part A and MA coverage. H. Resident Funds. Personal funds of a Resident that the Resident has authorized in writing that the Health Center shall manage for the Resident. 1. Resident's Representative. A person who is responsible for making decisions on behalf of the Resident and has been so designated in writing by the Resident or a court of competent jurisdiction. If a Guarantor Agreement is attached to this Agreement, the Resident's Representative is only obligated to make payment from the Resident's personal funds. Reference in this Agreement to Resident . -2- shall also include, as appropriate, the Resident's Representative or other person authorized to act on Resident's behalf: J. Skilled Nursing Care. Professionally supervised nursing care and related medical and other health services provided to an individual not in need of hospitalization, but whose needs are above the level of room and board and can only be met in a long-term care nursing facility on an inpatient basis because of age, illness, disease, injury, convalescence or physical or mental infirmity. K. Specialty Care Services. Medical services ordered by a physician for a Resident that are not included in the Daily Rate. Medicare and Medicaid each include certain Specialty Care Services in the per diem rates, but neither include all such services. L. Transfer and discharge. Movement of a resident to a bed outside of the certified facility or unit whether that bed is in the same physical plant or not. Transfer and discharge do not refer to movement of a resident within the same certified facility. III. HEALTH CENTER OBLIGATIONS: The Health Center will: A. provide, as part of the Daily Rate, room and board, general nursing care, housekeeping services, linen services, nutrition management, limited in room storage of Resident's personal belongings, and recreational programs. General nursing care does not include private duty nursing. B. provide Specialty Care Services ordered by Resident's treating or attending physician. Although additignal fees for specialty services may be covered by third party payers, the Specialty Care Services identified on Exhibit A are not j included in the daily rate, and are billed at the rates set forth in Exhibit A. Any items ordered by a physician, which are not identified on the Exhibit A will be i provided at charges identified by the Health Center prior to the delivery of the service. -3- ;.....'_ ....... ................ ............. .._....--------.-..._........ ..............._....._........._....._......_..._....__...._..__.._.__._ --------- ..---..----.--- - -- C. provide Personal Needs Services, at Resident's expense (at the rates set forth on the Fee Schedule attached as Exhibit A) and at Resident's request, including but not limited to: 1. Beauty/Barber Services 2. Newspaper delivery and personal reading materials 3. Local and Long Distance Telephone Services 4. Cable Services, depending on cable provider 5. Personal laundry, dry cleaning and mending b. Personal clothing. D. provide safekeeping of Resident Funds, if authorized in writing by the Resident, and make those funds available, at Resident's request, during normal business hours. I . Resident may manage his/her financial resources if (s)he wishes. 2. Residents may keep a limited amount of funds at the Health Center, the maximum amount, which is specified from time to time by the Health Center. 3. Requests for withdrawals in excess of $50.00 require advance notice to assure availability of cash at the Health Center. Resident Funds shall be retained in compliance with State and Federal regulations. Resident Funds exceeding $50.00 shall be placed in an interest bearing account. A written quarterly statement of these funds shall be provided to Resident. Resident agrees to return signed copy to facility if required. E. provide refunds of unused advance payments and Resident Funds within thirty (30) days after deductions for payment of any outstanding bills or other amounts due the Health Center after Resident's discharge or death. In the event of i Resident's death, refunds will be made to the authorized representative of Resident's estate. 1 -4- F. assist Resident in applying for and obtaining private insurance and/or public benefits to cover the cost of the Residents care. G. transfer or discharge Resident out of the Medicare or Medicaid certified portion of the Health Center only for medical reasons, for Resident's welfare, because the safety or health of individuals in the Health Center is endangered, because the Resident has failed, after reasonable notice, to pay for a stay at the Health Center, or with the voluntary consent of Resident. Except in emergency situations, at least thirty (30) days' notice will be provided to Resident and Resident's Representative to assure that the transfer is safe and orderly. The Health Center reserves the right and discretion to move Resident to another room or bed within certified parts of the Health Center consistent with the safety, care and welfare needs of the Resident. H. arrange for Resident's transfer or discharge upon the order of Resident's personal physician when helshe deems it necessary to receive services the Health Center is not qualified to provide or at Resident's request. I. honor Resident's Rights as outlined in the Department of Public Welfare t Admissions Notice Packet (1vU 401). 7. to the extent permitted by law, hold Resident responsible to pay for any damages or injuries caused by Resident to other persons, residents or staff. To the extent permitted by law, Resident shall indemnify and hold the Health Center harmless from any claims, actions or proceedings against the Health Center resulting from Resident's actions or omissions. Health Center will be responsible for loss of or damage to Resident's personal property by Health Center staff. K. provide Resident with a iocXced drawer or box for Resident's valuables or for medications retained for self-administration. Resident may self-administer medications only in certain circumstances and may not have medications in i his/her room without physician authorization. -5- L. provide Resident with a choice of pharmacy if Resident does not wish to utilize the pharmacy provider designated by the Health Center. With this choice, pharmacy must provide medications in compliance with all applicable laws and under a delivery system that is consistent with the one used by the Health Center, must provide a monthly written profile of all drugs provided to the Health Center's consultant pharmacist, and must be delivered from the provider pharmacy in tamper proof containers, directly to the Health Center's licensed nursing staff. M, provide Resident with a choice of attending physician who will provide medical care during the Resident's stay at the Health Center and who shall comply with the Health Center's rules, regulations, policies and procedures and all applicable laws and credentialling standards. Resident may also designate an alternate attending physician in the event that the primary attending physician is unavailable. In the event that Resident's attending physician(s) are unavailable, the Resident authorizes Health Center's Medical Director or other physician designated by the Health Center to issue appropriate orders. 1[V, RESIDENT OBLIGATIONS The Resident agrees to. A. by signing this Agreement, Resident certifies that (s)he is competent, and has never been adjudged incompetent, and is entering into this Agreement of his/her own free will. 1. In the event Resident has been adjudged incompetent, Resident's healthcare surrogate will attest, in a separate document that (s)he has the legal authority to act on behalf of the Resident. B. provide tho Health Center with all information about Resident's health status and ' financial resources. Failure to accurately identify resources and income, or the submission of false information may amount to a violation of law and may result i in the termination of this Agreement by and at the option of the Health Center. s • -6- C. provide the Health Center with a copy of all current insurance cards. Resident will provide the Health Center with cbanges in insurance coverage or financial status in a timely manner, and will update the information provided to the Health Center from time to time, as requested. Resident understands that making incomplete or inaccurate disclosures will be considered a breach of this Agreement. D. authorize the Health Center to provide care and treatment to Resident consistent with the terms of this Agreement and to carry out the orders of the Resident's treating or attending physician or of the physician designated by the Health Center. Resident also authorizes the Health Center to obtain all necessary clinical and/or financial information. from the hospital or nursing facility from which Resident may be transferring. E. authorize the Health Center to make Resident's Clinical Records available to Health Center staff and agents. Resident also authorizes the release of the Resident's Clinical Records to any other health care provider from whom Resident receives treatment, to third-party payors of health services, and to any managed care organization NCO) in which Resident may be enrolled. Resident also authorizes the release to the Health Center of records prepared and maintained by any third-parry payor of health care services pertaining to health care services rendered to the Resident by the Health Center. Resident also acknowledges receipt of the "Release for Electronic Transmission of Minimum Data Set" ('WS), which explains the MDS system of records using Resident data. Resident's Clinical Records will remain otherwise confidential, and shall not be made available to anyone other than Resident or authorized agents of the state or federal governments without the express written authorization of Resident or without a subpoena or other judicial order. F. cooperate fully with the Health Center and any third party payer to secure payment. Resident authorizes the Health Center to collect any payments made by third parties on Resident's behalf directly from the third party payer. Resident . -7- also authorizes the Health Center to make claims, file appeals or grievances, and take other actions necessary and appropriate to secure receipt of third-party payments to reimburse the Health Center for its charges for the stay and care of Resident to the fullest extent'permitted by law. Provided that Resident may, but shall not be required to authorize the Health Center to pursue grievances or appeals on Resident's behalf under Pennsylvania's Quality Health Care Accountability and Protection Act, to the fullest extent permitted by law and as security for payment of the Health Center's charges, Resident hereby assigns to the Health Center all of Resident's rights to any third-party payments now or subsequently payable for services rendered by or provided under arrangement through the Health Center. G. pay the Daily Rate established for the accommodation requested. Payment is due 30 days in advance, and Resident agrees to make full payment by the first of each month. Collection procedures are initiated after thirty (30) days of unpaid balances. Interest shall be charged on unpaid balances. 1. If the Health Center. initiates any legal actions to collect payments due from Resident under this Agreement, Resident shall be responsible to pay all attorney's fees add costs incurred by the Health Center in enforcing Resident's financial obligations under the Agreement. 2. This Agreement shall'. serve as an assignment to the Health Center of as much of Resident's.. property as equals the amount of any unpaid obligations under this Agreement, and this assignment shall be an obligation of Resident's estate that may be enforced against Resident's estate. Resident's estate shall be liable to and shall pay to the Health { Center an amount equivalent to any unpaid obligations of Resident under this Agreement. This liability shall apply whether or not Resident is occupying the Health Center at the time of Resident's death. H. pay for additional items, services and equipment not included in the Daily Rate as identified by the Fee Schedules, attached as Exhibit A. -9- the Daily Rate except when Resident requests room change, changes in charges for Specialty Care Services or Personal Needs Services, or changes in billing procedures, and agree that the changes will be effective upon the date designated by the Health Center. I understand that the Resident may continue to live at the Health Center as long as Resident continues to pay the Daily Rate. Resident may be discharged for non. payment of incurred charges or transferred for the benefit of the Resident or others, as set forth in Section M(H) of this Agreement. K. acknowledge that non-payment of the Daily Rate for a private room will result in a room change. L. acknowledge that the Health Center has the discretion, with thirty (30)' days' notice, to transfer Resident ' to another room or bed within the Health Center consistent with the safety, care and welfare needs of Resident. The Health Center also has the discretion, upon thirty (30) days' advance notice, to transfer or change Resident's roommate; if any, at any time consistent with the needs of the Health Center. M. terminate this Agreement upon written notice to the Health Center, but if Resident leaves for any reason other-than a medical emergency or death, Resident must give reasonable advance written notice to the Health Center. N. notify the Health Center at least two months before the Resident has insufficient resources, funds or income to meet his/her financial obligations and to apply for MA benefits timely. If Resident is no longer able to pay the Daily Rate and is not eligible for MA, Resident agrees to vacate the Health Center. 0. pay co-payments and/or ddductibles for services covered by the Medicare Program or other third party payer, and pay the Health Center within thirty (30) days of receipt of services'-for those services not covered by the Medicare Program or other third party payer. -9- P. pay for items and services requested by Resident and not covered by MA within thirty days of receiving the non-covered service. Q. to the extent otherwise permitted by law, assume responsibility for any damages or injuries caused by acts or Qmissions of the Resident to other persons, residents or staff". R. comply with reasonable rules, regulations, policies and procedures that the Health Center establishes from time to time and makes available to Residents, subject to reasonable accommodation ok Resident's individual needs and preferences. The Health Center's rules, regulations, policies and procedures are for purposes of internal management and shall not be construed as imposing contractual obligations on the Health Center and are subject to change from time to time. S. acknowledge receipt of the Resident Handbook, a document that provides Residents with Health Center rules, regulations, policies and procedures. T. acknowledge receipt of information on Advance Directives in the absence of providing the Health Center with an existing Advance Directive or Living Will. U. provide the Health Center with a copy of any and all Durable Powers of Attorney, Guardianships, and/or Advance Directives pertaining to the Resident. V. acknowledge that (s)he has read and understands the terms of this Agreement, that the terms have been explained to them by a representative of the Health Center, and that (s)he has had an opportunity to ask questions about the Agreement. V. MEDICARE AND MEDICAID The Health Center is certified to participate in the Medicare and Medicaid Programs. The Health Center's participation in these piograms is subject to termination by either the Health Center or the responsible government entity. The Permsylvania Department of Public Welfare (DPW) is responsible for administering benefits under the Medicaid Program and the Centers for 1 Medicare and Medicaid Services (CMS) is responsible for administering the Medicare program through an intermediary. The Resident acknowledges that the Health Center is not responsible -10- for and has made no representations regarding the actions or decisions of DPW, CMS or the Medicare intermediary in administering these programs. A. LUdlme If Resident is eligible for benefits under the Medicare Program, Resident understands that certain skilled nursing and related health care services may be covered by Medicare. The Health Center will bill Medicare Part A on behalf of the Resident for skilled nursing services and payment will be made by Medicare Part A directly to the Health Center for services received by Resident. When the Health Center notifies-Resident that the nursing services being provided to the Resident no longer qualify as a skilled service, -the Resident may request that the Health Center bill Medicare anyway. If Medicare denies coverage, Resident agrees to be responsible for the charges incurred on the Medicare Part A non-covered days. The following describes coverage under the Medicare Part A Program: 1. Medicare Part A covers from one (1) to one hundred (100) days at the Health Center. Coverage is not guaranteed and is limited to the unused days in the Resident's benefit period. Conditions stipulated by Medicare must be met for coverage to begin and remain in force. 2. The Medicare Part A Program pays for all covered charges from day one (1) through day twenty (20) ifthe criteria for skilled service is met. 3. The Medicare Part ,A. Program pays a portion but not all of the charges from day twenty-one (21) through day one hundred (100). The Resident is responsible for and shall pay any co-insurance or deductible amounts as determined by the Medicare Part A program. Depending on the circumstances, this payment may be made by personal health insurance, MA, or personal funds. 4. The Medicare Part A Program covers the following services: room and board, linens, meals, most prescription medications, therapy services, most medical supplies, non private duty nursing services, most recreational services, most social services, and most personal hygiene items provided -11- by the Facility. (Note: only the type and brand of personal hygiene items provided by the Health Center are included.) 5. Some items and services not covered by the Medicare Part A Program include, but are not limited to: personal clothing, eyeglasses, hearing aids, services of a beautician or barber, guest meals, special or alternative meals not required for therapeutic purposes or as a nutritional substitute, services not deemed medically necessary, and personal telephone service. The Fee Schedule for items and services provided to Medicare Part A eligible Residents that are not. covered by Medicare Part A is attached as EAibit A. 6. Bed hold days are not covered by the Medicare Part A Program. (See Section VII.) 7. Residents covered by Medicare Part A should not go out on overnight leave as this may distliialify them from further coverage by Medicare Part A- 8. Residents may be covered for therapy and other ancillary services under the Medicare Part B Program. The Health Center or provider approved by Health Center will bill Medicare Part B directly for these services. The Residents are responsible for the annual deductible and the co-insurance payment for Medicare-Part B covered services. 9. Resident is responsible to pay the Health Center for services and supplies not covered by the Medicare Program. 10. In the event that Medicare coverage is changed by law, those changes will control and take precedence over any contrary provision in this Agreement. B. Medicare Managed Care The Health Center participates as a 'provider of skilled nursing services under some, but not all Medicare MCOs. -12- 1. Requirements for eligibility for Medicare payments, deductibles and co- insurance may be different from those discussed in Section V(A). Pre- authorization of services is required by Medicare MCOs, and if the Resident chooses to • have services which the MCO refuses to pre- authorize, Resident shall pay the Health Center for those services. If the MCO refuses coverage on the grounds that it does not consider an item or service to be medically necessary, Health Center or MCO will provide an Advance Beneficiary Notice of that determination. The Health Center will communicate directly with Resident's Medicare MCO to obtain authorization for continued Medicare managed care coverage. 2. The Health Center will accept payment from the Medicare MCO as payment in full only for those services and supplies covered by the Medicare MCO. Resident is responsible for any copayments or other costs assigned to Resident or not covered by the MCO under the specific terms of the managed care plan. 3. Resident acknowledges that an MCO for which the Health Center is not an authorized provider may not approve payment for services provided by the Health Center, so that Resident may be required to pay the Health Center directly. Resident also acknowledges that the Health Center is not responsible for and has made no representations regarding the actions or decisions of any MCO for which the Health Center is an authorized provider, including decisions relating to a denial of coverage or refusal to pay on behalf of the Resident. 4. The Health Center reserves the right to stop its participation in any MCO at any time and in its sole discretion. To the extern practicable, the Health Center will provide advance notice to Residents enrolled in a particular managed care plan or insurance program of its decision to stop participation in that managed care plan or insurance program. --13- C. Medical Assistance Pro Erann 1. Residents who qualify for coverage under the MA Program must apply for and be approved for these services at the County Assistance Office. It is Resident°s responsibility to pursue MA coverage. Until approval of MA coverage is obtained, the Health Center will consider Resident to be a Private Pay Resident.. • 2. Resident will be required to usd the Patient Pay Liability to pay the Health Center for the Resident's stay in conjunction with the MA Program. Periodic adjustments in the Patient Pay Liability are made by the County Assistance Office and when issued, will supersede all previous determinations. Resi4ent shall arrange, if possible, for the designation of the Health Center for direct deposit of any Social Security or related benefits or any other'income sources of the Resident in an amount not to exceed the Patient Pay Liability. 3. MA program coverage includes the following: room and board, prescription and non-prescription medications, meals, linen service, nursing services, incontinence care, social services, recreational activities, personal laundry, a hair cut every six (6) weeks, a shampoo and set every two (2) weeks, one permanent per year, and personal hygiene items provided by the Health Center. (Note that only the type and brand of personal hygiene items provided by the Health Center are included.) The MA Program limits the frequency of coverage for the purchase of eyeglasses, hearing aids, and dentures. 4. The Health Center will not charge, solicit, accept or receive monies from or on behalf of Resident for bed hold days covered by MA Program, except for the Patient Pay Liability, to cover the cost of Resident's stay or as a condition of admitting a Resident under the MA Program. 5. Some items and services not covered by the MA Program include, but are not limited to: personal telephone service, personal clothing, guest meals, brand name personal hygiene items, and additional services provided by a -14- ? ............... .....?..................._..... beautician other than those listed above. Resident is responsible for charges incurred for these services at the rates listed on the Fee Schedule attached as Exhibit A in addition to the patient pay liability amount. 6. Residents receiving MA coverage are permitted to keep the amount that has been designated as the Resident's personal needs allowance for personal spending. Personal funds may be given to the Health Center for safekeeping (see Health Center Obligations in Section III). 7. The MA Program provides for bed hold days for limited periods of time during Resident's stay. a) Up to fifteen days bed hold days are allowed when Resident is transferred to a hospital, b) Up to thirty ' days bed hold days are allowed annually for intermittent therapeutic leave from the Health Center. c) The bed hold days referenced above are based upon the law in effect at this time, and may be subject to change if the governing state law is changed. 8. The Health Center provides equal access to its services to all individuals, regardless of payor source. VI. THIRD-PARTY PAYMENTS A. If Resident is or becomes eligible to receive financial assistance or reimbursement from any third parties (such 'as private insurance, employee benefit plans, MA, Medicare, managed care coverage, supplemental medical or other health insurance, supplemental security income insurance, or old-age survivors' or disability insurance), the Health Center reserves the right to collect such payments directly from the third party. Resident shall cooperate fully with the Health Center and each third-party payor to secure payment, and Resident shall designate the Health Center, to the extent permitted by law, as the recipient of direct deposit for receipt of Federal Social Security benefits or any other Federal or State government assistance, reimbursement, or benefits to the extent of all amounts due the Health Center. -15. B. Resident authorizes the Health Center to make claims and to take necessary actions to secure receipt of third party payments to reimburse the Health Center for its charges for the stay and care of Resident. To the fullest extent permitted by law, as security for payment of the Health Center's charges, Resident agrees to assign to the Health Center Resident's rights to any third-party payments now or subsequently payable to satisfy all charges due under this Agreement. Resident shall endorse and turn over to the Health Center any payments received from third party payor to the extent necessary to satisfy the charges under this Agreement. C. In the event of any denial of coverage by the Resident's insurance company, Resident shall pay the facility for all non-covered services retroactive to the date of the initial delivery of services. VIL READMISSION - BED HOLD POLICY A. A Health Center representative shall communicate with Resident regarding his/her desire to continue to occupy the Health Center bed during hospitalization or therapeutic leave. Verbal consent shall be given to the Health Center representative who shall document this consent in the clinical record. Written consent shall be obtained following the verbal consent. See Fee Schedule (Exhibit A) for bed-hold rates. B. Bed holds for Residents enrojled in the MA Program are subject to the provisions of Section 5(C)(7). C. Resident's belongings shall be removed from the Health Center within 24 hours if Resident does not execute a bed hold authorization. Belongings not removed in a timely fashion may be packed and stored. VIII. CML RIGHTS COMPLIANCE All Presbyterian Homes, Inc. facilities, including the Health Center, are open to all in need of services and are not restricted to members of the Presbyterian Church. The Health 16- Center does not discriminate on the basis of race, color, religion, national origin, age, ancestry, sec, handicap or disability. IX. REGULATION The Health Center and Resident recognize that Health Center is licensed by the Pennsylvania Department of Health and is regulated by the DPW. The Health Center and Resident recognize that Health Center is also regulated by CMS of the United States Department of Health and Human Services. Both parties recognize that regulatory changes may alter the conditions of this agreement. X. GRIEVANCE PROCEDURE . If Resident believes that Resident is being mistreated in any way or Resident's rights have been or are being violated by staff or another resident, on in any other way, Resident may submit a complaint to the Health Center's Director of Nursing and/or Administrator, and follow the Health Center's grievance procedure as'described in the Resident Handbook. The Health Center's grievance procedure does not preclude Residents from pursuing grievances with appropriate regulatory agencies. n ARBITRATION Any controversy, dispute or disagreement arising out of, or relating to this Agreement, or concerning any rights arising thereunder or the breach thereof shall be settled exclusively by arbitration, which shall be conducted at the. Health. Center in accordance with the American Health Lawyers Association Alternative Dispute Resolution Service Rules of Procedure for Arbitration. Judgment on the award rendered by the arbitrator shall be binding on both parties and may be entered in any court havrng'• jurisdiction thereof Provided, however, that this arbitration clause is not intended to limit or supersede hearing rights that are guaranteed to a resident under the Medicare or MA programs or an applicable state law. XH. GOVERNING LAW This Agreement shall be governed $y and construed in accordance with the laws of the Commonwealth of Pennsylvania. The Agreement shall be binding upon and inure to the benefit -17- of each of the undersigned parties and their respective heirs, personal representatives, successors and assigns. XIM SEVERABILITY The various provisions of this Agreement shall be severable one from another. If any provision of this Agreement is found by a court or administrative body of proper jurisdiction to be invalid, the other provisions shall remain in full force and effect as if the invalid provision had not been a part of this Agreement. . XTV. ENTIRE AGREEMENT This Agreement represents the entire understanding between the parties, and supersedes all previous representations, understandings -or agreements, oral or written, between the parties. XV. MODIFICATIONS The Health Center has the right to modify unilaterally the terms of this Agreement to the extent necessary to conform to subsequent changes in law or regulation. To the extent practicable, the Health Center will give Resident and Resident's Representative thirty (30) days advance written notice of any such modifications. XVI. WAIVER OF PROVISIONS The Health Centex Executive Director reserves the right to waive any obligation of Resident under the provisions of this Agreement in its sole and absolute discretion. No term, provision or obligation of this Agreement shall be deemed to have been waived by the Health Center unless and except to the extent that 'suck waiver is in writing by the Health Center. Any waiver by the Health Center shall not be deemed a waiver of any other term, provision or obligation of this Agreement, and the other obligations of Resident and this Agreement shall remain in full force and effect. -18- Signatures This Agreement and any addenda to this Agreement constitute the entire Agreement and understanding between the Health Center and the Resident with respect to the subject matter of this Agreement and supersede all prior Agreements and understandings. There are no Agreements, understandings, restrictions, warranties, or representations between the Health Center and the Resident other than those set forth in this Agreement, or incorporated in this Agreement by reference. This Agreement may be amended only by a document in writing signed by the Resident and the Administrator or Executive Director, and no act or omission of any employee or agent of the Health Center shall alter, change or modify any of the provisions of this Agreement. d or or Executive Director Resident Ai Resident Representative Witness t?d`,l9/05 Date / f '-'/ e'QT Date V Date /l Date -19- EXHIBIT "B" CUMBERLAND CAO MEDICAID . P.O. Box 599 ELIGIBLE 33 WESTMINSTER DRIVE: NOTICE CARLISLE PA 17013-0599 CAO RETURN ADDRESS CSLD 0004 *09200000000* NICOLE KERNS/SCHUTJER BOGA 600 GRANT STREET 32ND FLOOR, SUITE 3290 PITTSBURGH PA 15219 Notice ID: 94215840 PAGE 1 OF 1 21 01061410 0 TJN 5 00 WORKER: A ABELSON TELEPHONE: (800) 269-0173 MAIL DATE: 04/27/2009 NOT: 985 OPT: G TYPE: E IF YOU DO NOT UNDERSTAND OUR DECISION OR HAVE ANY QUESTIONS, PLEASE CONTACT YOUR NCMKER IMEDIATELY. You have been determined eligible for benefits effective 02/01/2008 to 02/29/2008. You are eligible for Medically Needy Only Medicaid coverage including Services in a Long-Term Care (LTC) Facility. A PA ACCESS card will be issued unless you have previously received one. You will be required to make a monthly payment towards your cost of care. Details of this monthly payment toward your cost of care are found in the LTC section. Contact the CAD if you have questions or changes to report. When contacting the CAD, please provide your record number which is located on the top and bottom of this notice. Citation: 55 Pa. Code 141.81, 178.1, 181.1. 181.11, 181.452, 181.453 If you disagree with our decision, you have the right to appeal. Tor a Complete explanation OT your rignt to appeal ano to a Tair nearing. IT you are currently receiving benefits and your oral request for a hearing is received in the County Assistance Office or your written request is postmarked or received on or before 05/10/2009 your assistance will continue pending the hearing decision, except when the change is due to State or Federal law. APPLICANT NAME AND ADDRESS LESTER E RUSSELL SWAIM HEALTH CENTER 210 BIG SPRING ROAD NEWVILLE PA 17241 CAJ DADDRESS CUMBERLAND CAO P.O. BOX 599 33 WESTMINSTER DRIVE CARLISLE PA 17013-0599 MIDPENN LEGAL SERVICES 401-405 LOUTHER STREET CARLISLE PA 17013 (717) 243-9400 Notice ID: 94215840 942'_5840 • THE FOLLOWING PERSON(S) ARE AFFECTED BY THE ACTION ON THE FRONT OF THIS NOTICE BNFT LINE FIRST NAME ACCESS/INDIVIDUAL NUMBER V PKG I LINE FIRST NAME ACCESS/INDIVIDUAL NUMBER V 01 LESTER 800176009 2 04 BNFT PKG THE FOLLOWING PERSON(S) INCOME OR FINANCIAL INFORMATION WERE INCLUDED IN THE DETERMINATION OF YOUR MEDICAID BENEFITS. Line Line Line Line Line Line Line Line GROSS INCOME Earned: Unearned: DEDUCTIONS Earned Income: Unearned Income: Dependant Care NET INCOME Individual Totals: Household Net Income: Additional Deductions: Medical Bills (as deduction): Patient Pay Amount: Total Household Net Income: Budget Income Limit This income covers a 06 month period. You are responsible for patient pay amount to providers as indicated below. Line Date Pay to: Provider Amount The following medical bills have been used as a deduction to calculate your eligibility for Medicaid benefits. The unpaid bills are your responsibility and will not be covered by Medicaid. Name of Provider Date of Service Amount Name of Provider Date of Service Amount PRIVATE PAY 02/01/2008 11329.20 MEDICARE B 02/01/2008 578.40 IF YOU WISH TO APPEAL, PLEASE COMPLETE AND RETURN THE BOTTOM PORTION OF THIS FORM. ----- DETACH HERE DETACH HERE Please check one of the boxes to show which type of hearing you want: ? I want a telephone Hearing. I and my witnesses and anyone helping me will be at this phone number: ? I want a Telephone Hearing. I and my witnesses and anyone helping me will be at the County Assistance Office (CAO). ? I want a Face to Face Hearing. I and my witnesses and anyone helping me will be in the hearing room with the Judge and the caseworker and CAO staff. ? I want a Face to Face Hearing. I and my witnesses and anyone helping me will be in the hearing room with the Judge. The caseworker and other staff will be on the phone from the CAO, if they decide not to come to the hearing room. PLEASE CHECK BELOW IF YOU NEED HELP BECAUSE OF A HEARING PROBLEM OR DISABILITY OR YOU NEED AN INTERPRETER: ? I have a hearing impairment or disability. I will need special help. ? I need an interpreter. There will be no cost to me. What language? CLIENT SIGNATURE TELEPHONE NO. DATE ADDRESS SIGNATURE CLIENT REP. ADDRESS TELEPHONE NO. DATE CUMBERLAND CAO LONG TERM CARE P.O. WX 599 ELIGIBLE 33 WESTMINSTER DRIVE NOTICE CARLISLE PA 17013-0599 CAO RETURN ADDRESS CSLD 0004 *10200000000* NICOLE KERNS/SCHUTJER BOGA 600 GRANT STREET 32ND FLOOR, SUITE 3290 PITTSBURGH PA 15219 Notice ID: 94215840 21 0106140 0 TJN 5 00 WORKER: A ABELSON TELEPHONE: (800) 269-0173 MAIL DATE: 04/27/2009 NOT: 985 OPT: G TYPE: E IF YOU DO NOT UNDERSTAND OUR DECISION OR HAVE ANY QUESTIONS, PLEASE CONTACT YOUR WWR INNEDIATELY. PAGE 1 OF 1 You have received a notice showing your eligibility for Medicaid. A person receiving benefits in a long-term care facility under the Medicaid program is required to contribute towards the monthly cost of Long Term Care. This computation is found on the reverse side of this notice. Citation: PA Code H 181.452 and 181.453 If you disagree with our decision, you have the right to appeal. See attached form for a complete explanation of your right to appeal and to a fair hearing. If you are currently receiving benefits and your oral request for a hearing is received in the County Assistance Office or your written request is postmarked or received on or before 05/10/2009 your assistance will continue p.ending the hearing decision, except when the change is due to State or Federal law. APPLICAN7 NAME AND ADDRESS LESTER E RUSSELL SWAIM HEALTH CENTER 210 BIG SPRING ROAD NEWVILLE PA 17241 CAO ADDRESS CUMBERLAND CAO P.O. BOX 599 33 WESTMINSTER DRIVE CARLISLE PA 17013-0599 MIDPENN LEGAL SERVICES 401-405 LOUTHER STREET CARLISLE PA 17013 (717) 243-9400 Notice ID: 94215840 94215840 W7410910MTHE FOLLOWING PERSON IS AFFECTED BY THE ACTION ON THE FRONT OF THIS NOTICE LINE FIRST NAME ACCESSIINDIVIDUAL NUMBER 01 LESTER 800176009 2 ?? THE FOLLOWING AMOUNTS WERE USED TO COMPUTE YOUR MONTHLY CONTRIBUTION TOWARDS YOUR COST OF A-a 1TA\ Calculation of Gross Monthly Income Calculation of Contribution toward Cost of Care Begin Date 02/01/2008 Begin Date 02/01/2008 Earned Income '` Gross Monthly Incom e; Wages, Salary .00 Total Earned Income .00 Self Employment .00 Total Unearned Income 2429.60 Rental Income .00 Income available first month .00 Other .00 Deductions , Total Earned 00 Personal Needs Allowance 45.00 Income: Unearned Income 04" - r Guardianship Fee .00 Social Security 1474.40 Total Allowance for Spouse / .00 Dependant SSI .00 Home Maintenance .00 Veteran's Benefits 00 Contribution towards 2384.60 . Cost of Care: The LTC facility will deduct the following medical expense from your Pension 955.20 contribution towards Cost of Care Railroad Benefits .00 Medicare Premium 96.40 Workmen's Comp .00 Other Insurance Premium .00 The LTC facility may deduct additional medical bills Black Lung .00 including supplemental health insurance premiums, provided they are verified. Annuity/Trust .00 Payment Interest / Dividend .00 Other (Rental, etc.) .00 Total Unearned Income: 2429.60 IF YOU WISH TO APPEAL, PLEASE COMPLETE AND RETURN THE BOTTOM PORTION OF THIS FORM. ----- DETACH HERE DETACH HERE Please check one of the boxes to show which type of hearing you want: ? I want a telephone Hearing. I and my witnesses and anyone helping me will be at this phone number: ? I want a Telephone Hearing. I and my witnesses and anyone helping me will be at the County Assistance Office (CAO). ? I want a Face to Face Hearing. I and my witnesses and anyone helping me will be in the hearing room with the Judge and the caseworker and CAO staff. ? I want a Face to Face Hearing. 1 and my witnesses and anyone helping me will be in the hearing room with the Judge. The caseworker and other staff will be on the phone from the CAO, if they decide not to come to the hearing room. PLEASE CHECK BELOW IF YOU NEED HELP BECAUSE OF A HEARING PROBLEM OR DISABILITY OR YOU NEED AN INTERPRETER: ? I have a hearing impairment or disability. I will need special help. ? I need an interpreter. There will be no cost to me. What language? CLIENT SIGNATURE ADDRESS TELEPHONE NO. DATE SIGNATURE CLIENT REP. ADDRESS TELEPHONE NO. DATE CUMBERLAND CAO MEDICAID • P.O. Box 599 ELIGIBLE 33 WESTMINSTER DRIVE NOTICE CARLISLE PA 17013-0599 CAO RETURN ADDRESS CSLD 0004 *07200000000* NICOLE KERNS/SCHUTJER BOGA 600 GRANT STREET 32ND FLOOR, SUITE 3290 PITTSBURGH PA 15219 Notice ID: 94215740 PAGE 1 OF 1 21 0106140 0 TJN 4 00 WORKER: A ABELSON TELEPHONE: (800) 269-0173 MAIL DATE: 04/27/2009 NOT: 985 OPT: G TYPE: E IF YOU DO HOT UNDERSTAND OUR DECISION OR HAVE ANY QUESTIONS, PLEASE CONTACT YOUR WORKER IMEDIATELY. You have been determined eligible for benefits effective 03/01/2008 to 03/31/2008. You are eligible for Medically Needy Only Medicaid coverage including Services in a Long-Term Care (LTC) Facility. A PA ACCESS card will be issued unless you have previously received one. You will be required to make a monthly payment towards your cost of care. Details of this monthly payment toward your cost of care are found in the LTC section. Contact the CAO if you have questions or changes to report. When contacting the CAO, please provide your record number which is located on the top and bottom of this notice. Citation: 55 Pa. Code 141.81, 178.1, 181.1, 181.11, 181.452, 181.453 If you disagree with our decision, you have the .y1 A cvniv1ow WAIJI rwupn V1 YOVr reum W aVLleai 8110 TO a Tair nearing. IT you are currently receiving benefits and your oral request for a hearing is received in the County Assistance Office or your written request is postmarked or received on or before 05/10/2009 your assistance will continue pending the hearing decision, except when the change is due to State or Federal law. APPLICANT NAME AND ADDRESS LESTER E RUSSELL SWAIM HEALTH CENTER 210 BIG SPRING ROAD NEWVILLE PA 17241 CUMBERLAND CAO P.O. BOX 599 33 WESTMINSTER DRIVE CARLISLE PA 17013-0599 MIDPENN LEGAL SERVICES 401-405 LOUTHER STREET CARLISLE PA 17013 (717) 243-9400 Notice ID: 94215740 c c c c c c c c r c 942'_5740 M91111MA"T THE FOLLOWING PERSON(S) ARE AFFECTED BY THE ACTION ON THE FRONT OF THIS NOTICE BNFT LINE FIRST NAME ACCESS/INDIVIDUAL NUMBER V PKG I LINE FIRST NAME ACCESS/INDIVIDUAL NUMBER 01 LESTER 800176009 2 04 BNFT V PKG .&..1LZJh-=* THE FOLLOWING PERSON(S) INCOME OR FINANCIAL INFORMATION WERE INCLUDED IN THE DETERMINATION OF YOUR MEDICAID BENEFITS. Line Line Line Line Line Line Line Line GROSS INCOME Earned: Unearned: DEDUCTIONS Earned Income: Unearned Income: Dependant Care NET INCOME Individual Totals: Additional Deductions: Medical Bills (as deduction): Patient Pay Amount: Total Household Net Income: Budget Income Limit This income covers a 06 month period. You are responsible for patient pay amount to providers as indicated below. Line Date Pay to: Provider Amount The following medical bills have been used as a deduction to calculate your eligibility for Medicaid benefits. The unpaid bills are your responsibility and will not be covered by Medicaid. Name of Provider Date of Service Amount ( Name of Provider Date of Service Amount PRIVATE PAY 02/01/2008 11329.20 MEDICARE B 02/01/2008 578.40 IF YOU WISH TO APPEAL, PLEASE COMPLETE AND RETURN THE BOTTOM PORTION OF THIS FORM. ----- DETACH HERE DETACH WERE Please check one of the boxes to show which type of hearing you want: ? I want a telephone Hearing. I and my witnesses and anyone helping me will be at this phone number: ? I want a Telephone Hearing. I and my witnesses and anyone helping me will be at the County Assistance Office (CAO). ? I want a Face to Face Hearing. I and my witnesses and anyone helping me will be in the hearing room with the Judge and the caseworker and CAO staff. ? I want a Face to Face Hearing. I and my witnesses and anyone helping me will be in the hearing room with the Judge. The caseworker and other staff will be on the phone from the CAO, if they decide not to come to the hearing room. PLEASE CHECK BELOW IF YOU NEED HELP BECAUSE OF A HEARING PROBLEM OR DISABILITY OR YOU NEED AN INTERPRETER: ? I have a hearing impairment or disability. I will need special help. ? I need an interpreter. There will be no cost to me. What language? CLIENT SIGNATURE ADDRESS TELEPHONE NO. DATE SIGNATURE CLIENT REP. ADDRESS TELEPHONE NO. DATE CUMBERLAND CAO LONG TERM CARE P.O. Box 599 ELIGIBLE 33 WESTMINSTER DRIVE NOTICE CARLISLE PA 17013-0599 CAO RETURN ADDRESS CSLD 0004 *08200000000* NICOLE KERNS/SCHUTJER BOGA 600 GRANT STREET 32ND FLOOR, SUITE 3290 PITTSBURGH PA 15219 Notice ID: 94215740 21 0106140 0 TJN 4 00 WORKER: A A13ELSON TELEPHONE: (800) 269-0173 MAIL DATE: 04/27/2009 NOT: 985 OPT: G TYPE: E IF YOU DO NOT UNDERSTAND OUR DECISION OR HAVE ANY QUESTIONS, PLEASE CONTACT YOUR NOMER IMEDIATELY. PAGE 1 OF 1 You have received a notice showing your eligibility for Medicaid. A person receiving benefits in a long-term care facility under the Medicaid program is required to contribute towards the monthly cost of Long Term Care. This computation is found on the reverse side of this notice. Citation: PA Code H 181.452 and 181.453 If you disagree with our decision, you have the right to appeal. See attached form for a complete explanation of your right to appeal and to a fair hearing. If you are currently receiving benefits and your oral request for a hearing is received in the County Assistance Office or your written request is postmarked or received on or before 05/10/2009 your assistance will continue pending the hearing decision, except when the change is due to State or Federal law. LESTER E RUSSELL SWAIM HEALTH CENTER 210 BIG SPRING ROAD NEWVILLE PA 17241 CAU ADDRESS CUMBERLAND CAO P.O. BOX 599 33 WESTMINSTER DRIVE CARLISLE PA 17013-0599 MIDPENN LEGAL SERVICES 401-405 LOUTHER STREET CARLISLE PA 17013 (717) 243-9400 Notice ID: 94215740 94215740 11 ?s?, THE FOLLOWING PERSON IS AFFECTED BY THE ACTION ON THE FRONT OF THIS NOTICE LINE FIRST NAME ACCESSIINDIVIDUAL NUMBER 01 LESTER 800176009 2 THE FOLLOWING AMOUNTS WERE USED TO COMPUTE YOUR MONTHLY CONTRIBUTION TOWARDS YOUR COST OF LONG TERM CARE1LTC)- Calculation of Gross Monthly Income Calculation of Contribution toward Cost of Care Begin Date 03/01/2008 Begin Date 03/01/2008 Earned Income Gross Monthly Income Wages, Salary .00 Total Earned Income .00 Self Employment .00 Total Unearned Income 2429.60 Rental Income .00 Income available first month .00 Other .00 Deductions h Total Earned Income: .00 Personal Needs Allowance 45.00 Unearned Income '., 4 n Guardianship Fee .00 Social Security 1474.40 Total Allowance for Spouse / Dependant .00 SSI .00 Home Maintenance .00 Veteran's Benefits .00 Contribution towards Cost of Care: 2384.60 Pension 955.20 The LTC facility will deduct the following medical expense from your contribution towards Cost of Care Railroad Benefits .00 Medicare Premium 96.40 Workmen's Comp .00 Other Insurance Premium .00 Black Lung .00 The LTC facility may deduct additional medical bills including supplemental health insurance premiums, Annuity/Trust Payment 00 provided they are verified. Interest / Dividend .00 Other (Rental, etc.) .00 Total Unearned Income: 2429.60 IF YOU WISH TO APPEAL, PLEASE COMPLETE AND RETURN THE BOTTOM PORTION OF THIS FORM. - DETACH HERE DETACH HERE Please check one of the boxes to show which type of hearing you want: ? I want a telephone Hearing. I and my witnesses and anyone helping me will be at this phone number: ? I want a Telephone Hearing. I and my witnesses and anyone helping me will be at the County Assistance Office (CAO). ? I want a Face to Face Hearing. I and my witnesses and anyone helping me will be in the hearing room with the Judge and the caseworker and CAO staff. ? I want a Face to Face Hearing. I and my witnesses and anyone helping me will be in the hearing room with the Judge. The caseworker and other staff will be on the phone from the CAO, if they decide not to come to the hearing room. PLEASE CHECK BELOW IF YOU NEED HELP BECAUSE OF A HEARING PROBLEM OR DISABILITY OR YOU NEED AN INTERPRETER: ? I have a hearing impairment or disability. I will need special help. ? I need an interpreter. There will be no cost to me. What language? CLIENT SIGNATURE ADDRESS TELEPHONE NO. DATE SIGNATURE CLIENT REP. ADDRESS TELEPHONE NO. DATE CUMBERLAND CAO MEDICAID • P.O. Vox 599 ELIGIBLE 33 WESTMINSTER DRIVE NOTICE CARLISLE PA 17013-0599 CAO RETURN ADDRESS CSLD 0004 *05200000000* NICOLE KERNS/SCHUTJER BOGA 600 GRANT STREET 32ND FLOOR, SUITE 3290 PITTSBURGH PA 15219 Notice ID: 94215640 PAGE 1 OF 1 IF YOU DO NOT UNDERSTAND OUR DECISION OR HAVE ANY QUESTIONS, PLEASE CONTACT YOUR NMTR IMMEDIATELY. You have been determined eligible for benefits effective 04/01/2008 to 04/30/2008. You are eligible for Medically Needy Only Medicaid coverage including Services in a Long-Term Care (LTC) Facility. A PA ACCESS card will be issued unless you have previously received one. You will be required to make a monthly payment towards your cost of care. Details of this monthly payment toward your cost of care are found in the LTC section. Contact the CAD if you have questions or changes to report. When contacting the CAD, please provide your record number which is located on the top and bottom of this notice. Citation: 55 Pa. Code 141.81, 178.1, 181.1, 181.11, 181.452, 181.453 If you disagree with our decision, you have the right to aDDeal. a1y"' ao pJ?WY1NLIV1? V? raur ?is?m to aDD@al a110 LO a Talr n@arlnsl. IT you are clrrently recelving benefits and your oral request for a hexing is received in the Canty Assistance Office or your written request is postmarked or received on or before 05/10/2009 your assistance will continue pending the hexing decision, ? except when the change is due to State or Federal law. ADDRESS 4PPLICANT NAME AND LESTER E RUSSELL SWAIM'HEALTH CENTER 210 BIG SPRING ROAD NEWVILLE PA 17241 ADDRESS CUMBERLAND CAO P.O. BOX 599 33 WESTMINSTER DRIVE CARLISLE PA 17013-0599 MIDPENN LEGAL SERVICES 401-405 LOUTHER STREET CARLISLE PA 17013 (717) 243-9400 Notice ID: 94215640 c c C C C C C C n Lf c f?A?tTttt tt tC?1 f1?? rfr?ir?e+r ?••..- 3S2?5550 12141101111101MM THE FOLLOWING PERSON(S) ARE AFFECTED BY THE ACTION ON THE FRONT OF THIS NOTICE BNFT LINE FIRST NAME ACCESS/INDIVIDUAL NUMBER V PKG I LINE FIRST NAME ACCESS/INDIVIDUAL NUMBER 01 LESTER 800176009 2 04 BNFT V PKG AX6 i THE FOLLOWING PERSON(S) INCOME OR FINANCIAL INFORMATION WERE INCLUDED IN THE DETERMINATION OF YOUR MEDICAID BENEFITS. Line Line Line Line Line Line Line Line GROSS INCOME Earned: Unearned: DEDUCTIONS Earned Income: Unearned Income, Dependant Care NET INCOME Individual Totals: Additional Deductions: Medical Bills (as deduction): Patient Pay Amount Total Household Net Income: Budget Income Limit This income covers a 06 month period. You are responsible for patient pay mount to providers as indicated below. Line Date Pay to: Provider Amount The following medical bills have been used as a deduction to calculate your eligibility for Medicaid benefits. The unpaid bills are your responsibility and will not be covered by Medicaid. Name of Provider Date of Service Amount I Name of Provider PRIVATE PAY 2/01 0 8 11329.20 MEDICARE B 02/01/2008 578.40 Date of Service Amount IF YOU WISH TO APPEAL, PLEASE COMPLETE AND RETURN THE BOTTOM PORTION OF THIS FORM. ----- DETACH HERE DETACH NERE ------ Please check one of the boxes to show which type of hearing you want: ? I want a telephone Hearing. I and my witnesses and anyone helping me will be at this phone number: ? I want a Telephone Hearing. I and my witnesses and anyone helping me will be at the County Assistance Office (CAO). ? I want a Face to Face Hearing. I and my witnesses and anyone helping me will be in the hearing room with the Judge and the caseworker and CAO staff. ? I want a Face to Face Hearing. I and my witnesses and anyone helping me will be in the hearing room with the Judge. The caseworker and other staff will be on the phone from the CAO, if they decide not to come to the hearing room. PLEASE CHECK BELOW IF YOU NEED HELP BECAUSE OF A HEARING PROBLEM OR DISABILITY OR YOU NEED AN INTERPRETER: ? I have a hearing impairment or disability. I will need special help. ? I need an interpreter. There will be no cost to me. What language? CLIENT SIGNATURE ADDRESS TELEPHONE NO. DATE SIGNATURE CLIENT REP. ADDRESS TELEPHONE NO. DATE CUMBERLAND Ca o LONG TERM CARE P.o. Box 599 ELIGIBLE 33 WESTMINSTER DRIVE NOTICE CARLISLE PA 17013-0599 CAO RETURN ADDRESS CSLD 0004 *06200000000* NICOLE KERNS/SCHUTJER BOGA 600 GRANT STREET 32ND FLOOR, SUITE 3290 PITTSBURGH PA 15219 Notice ID: 94215640 IF YOU DO NUT UNDERSTAND OUR DECISION OR RAVE ANY OUESTIONS, PLEASE CONTACT YOUR i11WRKER IMEDIATELY. PAGE 1 OF 1 You have received a notice showing your eligibility for Medicaid. A person receiving benefits in a long-term care facility under the Medicaid program is required to contribute towards the monthly cost of Long Term Care. This computation is found on the reverse side of this notice. Citation: PA Code §§ 181.452 and 181.453 If you disagree with our decision, you have the right to appeal. See attached form for a complete explanation of your right to appeal and to a fair hearing. If you are currently receiving benefits and your oral request for a hexing is received in the County Assistance Office or your written request is postmarked or received on or before 05/10/2009 your assistance will continue pending the hearing decision, except when the change is due to State or Federal law. LESTER E RUSSELL SWAIM HEALTH CENTER 210 BIG SPRING ROAD NEWVILLE PA 17241 CAO ADDRESS CUMBERLAND CAO P.O. BOX 599 33 WESTMINSTER DRIVE CARLISLE PA 17013-0599 MIDPENN LEGAL SERVICES 401-405 LOUTHER STREET CARLISLE PA 17013 (717) 243-9400 Notice ID: 94215640 o 0 0 0 0 0 N %D C. 94215640 =THE FOLLOWING PERSON IS AFFECTED BY THE ACTION ON THE FRONT OF THIS NOTICE LINE FIRST NAME ACCESSIINDIVIDUAL NUMBER 01 LESTER 800176009 2 THE FOLLOWING AMOUNTS WERE USED TO COMPUTE YOUR MONTHLY CONTRIBUTION TOWARDS YOUR COST OF LONG TERM CORF 11 TCI_ Calculation of Gross Monthly Income Calculation of Contribution toward Cost of Care Begin Date 04/01/2008 Begin Date 04/01/2008 Earned Income Gross Monthly Income H?'fHr' Wages, Salary b .00 Total Earned Income .00 Self Employment .00 Total Unearned Income 2429.60 Rental Income .00 Income available first month .00 Other .00 Deductions Total Earned Income: .00 Personal Needs Allowance 45.00 Unearned ncome ' ' , ow-l-l", u ardianship Fee 0 Social Security 1474.40 Total Allowance for Spouse / Dependant .00 SSI .00 Home Maintenance .00 Veteran's Benefits .00 Contribution towards Cost of Care: 2384.60 Pension 955.20 The LTC facility will deduct the following medical expense from your contribution towards Cost of Care Railroad Benefits .00 Medicare Premium 96.40 Workmen's Comp .00 Other Insurance Premium .00 Black Lung .00 The LTC facility may deduct additional medical bills including supplemental health insurance premiums, Annuity/Trust Payment 00 provided they are verified. Interest / Dividend .00 Other (Rental, etc.) .00 Total Unearned Income: 2429.60 IF YOU WISH TO APPEAL, PLEASE COMPLETE AND RETURN THE BOTTOM PORTION OF THIS FORM. ----- DETACH HERE DETACH HERE Please check one of the boxes to show which type of hearing you want: ? I want a telephone Hearing. I and my witnesses and anyone helping me will be at this phone number: ? I want a Telephone Hearing. I and my witnesses and anyone helping me will be at the County Assistance Office (CAO). ? I want a Face to Face Hearing. I and my witnesses and anyone helping me will be in the hearing room with the Judge and the caseworker and CAO staff. ? I want a Face to Face Hearing. I and my witnesses and anyone helping me will be in the hearing room with the Judge. The caseworker and other staff will be on the phone from the CAO, if they decide not to come to the hearing room. PLEASE CHECK BELOW IF YOU NEED HELP BECAUSE OF A HEARING PROBLEM OR DISABILITY OR YOU NEED AN INTERPRETER: ? I have a hearing impairment or disability. 1 will need special help. ? 1 need an interpreter. There will be no cost to me. What language? CLIENT SIGNATURE ADDRESS TELEPHONE NO. DATE SIGNATURE CLIENT REP. ADDRESS TELEPHONE NO. DATE CUMBERLAND CAO MEDICAID -P.O. BOX 599 ELIGIBLE 33 WESTMINSTER DRIVE NOTICE CARLISLE: PA 17013-0599 CAO RETURN ADDRESS ICSLD 0004 *03200000000* NICOLE KERNS/SCHUTJER BOGA 600 GRANT STREET 32ND FLOOR, SUITE 3290 PITTSBURGH PA 15219 Notice ID: 94215540 PAGE 1 OF 1 IF YOU DO HOT UNDERSTAND OUR DECISION OR HAVE MY QUESTIONS, PLEASE CONTACT YOUR NURKER IAMIATELY. You have been determined eligible for benefits effective 05/01/2008 to 05/31/2008. You are eligible for Medically Needy Only Medicaid coverage including Services in a Long-Term Care (LTC) Facility. A PA ACCESS card will be issued unless you have previously received one. You will be required to make a monthly payment towards your cost of care. Details of this monthly payment toward your cost of care are found in the LTC section. Contact the CAD if you have questions or changes to report. When contacting the CAD, please provide your record number which is located on the top and bottom of this notice. Citation: 55 Pa. Code 141.81, 178.1, 181.1, 181.11, 181.452, 181.453 If you disagree with our decision, you have the right to appeal. •..• o a.vnw.vav vxv?a?NUVn y? vvur scull LO aDDeal an0 LO a rair nearma. It you are currently receiving benefits and your oral request for a hearing is received in the County Assistance Office or your written request is postmarked or received on or before 05/10/2009 your assistance will continue pending the hearing decision, except when the change is due to State or Federal law. LESTER E RUSSELL SWAIM HEALTH CENTER 210 BIG SPRING ROAD NEWVILLE PA 17241 CAD ADDRESS CUMBERLAND CAO P.O. BOX 599 33 WESTMINSTER DRIVE CARLISLE PA 17013-0599 MIDPENN LEGAL SERVICES 401-405 LOUTHER STREET CARLISLE PA 17013 (717) 243-9400 Notice ID: 94215540 21 0106140 0 TJN 2 00 WORKER: A ABELSON APPEAL: 05/10/2009 TELEPHONE: (800) 269-0173 MAIL DATE: 04/27/2009 NOT: 985 OPT: G TYPE: E t 0 0 0 0 0 0 0 0 N 'i 0 w??rra u. arw I\u wrai?ww.. w,w? 94215540 THE FOLLOWING PERSON(S) ARE AFFECTED BY THE ACTION ON THE FRONT OF THIS NOTICE BNFT LINE FIRST NAME ACCESS/INDIVIDUAL NUMBER V PKG I LINE FIRST NAME ACCESS/INDIVIDUAL NUMBER 01 LESTER 800176009 2 04 BNFT V PKG THE FOLLOWING PERSON(S) INCOME OR FINANCIAL INFORMATION WERE INCLUDED IN THE DETERMINATION OF YOUR MEDICAID BENEFITS. Line Line Line Line Line Line Line Line GROSS INCOME Earne Unearned: DEDUCTIONS Earned Income: Unearned Income: Dependant Care NET INCOME Individual Totals: Household Net Income: You are responsible for patient pay amount to providers as indicated Additional Deductions: below: Medical Bills (as deduction): Line Date Pay to: Provider Amount Patient Pay Amount: Total Household Net Income: Budget Income Limit: This income covers a 06 month period. The following medical bills have been used as a deduction to calculate your eligibility for Medicaid benefits. The unpaid bills are your responsibility and will not be covered by Medicaid. Name of Provider Date of Service Amount I Name of Provider Date of Service Amount PRIVATE PAY 62751726-w- 11329.20 MEDICARE B 02/01/2008 578.40 IF YOU WISH TO APPEAL, PLEASE COMPLETE AND RETURN THE BOTTOM PORTION OF THIS FORM. ----- DF XH WM i UXH HERE Please check one of the boxes to show which type of hearing you want: ? I want a telephone Hearing. I and my witnesses and anyone helping me will be at this phone number: ? 1 want a Telephone Hearing. I and my witnesses and anyone helping me will be at the County Assistance Office (CAO). ? I want a Face to Face Hearing. I and my witnesses and anyone helping me will be in the hearing room with the Judge and the caseworker and CAO staff. ? 1 want a Face to Face Hearing. I and my witnesses and anyone helping me will be in the hearing room with the Judge. The caseworker and other staff will be on the phone from the CAO, if they decide not to come to the hearing room. PLEASE CHECK BELOW IF YOU NEED HELP BECAUSE OF A HEARING PROBLEM OR DISABILITY OR YOU NEED AN INTERPRETER: ? I have a hearing impairment or disability. I will need special help. ? I need an interpreter. There will be no cost to me. What language? CLIENT SIGNATURE ADDRESS TELEPHONE NO. DATE SIGNATURE CLIENT REP. ADDRESS TELEPHONE NO. DATE CUMBERLAND CAO LONG TERM CARE P.O. HOx 599 ELIGIBLE 33 WESTMINSTER DRIVE ]NOTICE CARLISLE PA 17013-0599 CAO RETURN ADDRESS CSLD 0004 *04200000000* NICOLE KERNS/SCHUTJER BOGA 600 GRANT STREET 32ND FLOOR, SUITE 3290 PITTSBURGH PA 15219 Notice ID: 94215540 IF YDU DO NOT UMOERSTAND OUR DECISION OR HAVE ANY QUESTIONS, PLEASE CONTACT YOUR WNTR INEDIATELY. PAGE 1 OF 1 You have received a notice showing your eligibility for Medicaid A person receiving benefits in a long-term care facility under the Medicaid program is required to contribute towards the monthly cost of Long Term Care. This computation is found on the reverse side of this notice. Citation: PA Code H 181.452 and 181.453 If you disagree with our decision, you have the right to appeal. See attached form for a complete explanation of your right to appeal and to a fair hearing. If you are currently receiving benefits and your oral request for a hearing is received in the County Assistance Office or your written request is postmarked or received on or before 05/10/2009 your assistance will continue pending the hearing decision, except when the change is due to State or Federal law. LESTER E RUSSELL SWAIM HEALTH CENTER 210 BIG SPRING ROAD NEWVILLE PA 17241 CAC ADDRESS CUMBERLAND CAO P.O. BOX 599 33 WESTMINSTER DRIVE CARLISLE PA 17013-0599 MIDPENN LEGAL SERVICES 401-405 LOUTHER STREET CARLISLE PA 17013 (717) 243-9400 Notice ID: 94215540 C) 0 0 0 0 0 0 0 N V 0 s 94215540 THE FOLLOWING PERSON IS AFFECTED BY THE ACTION ON THE FRONT OF THIS NOTICE LINE FIRST NAME ACCESS/INDIVIDUAL NUMBER 01 LESTER 800176009 2 THE FOLLOWING AMOUNTS WERE USED TO COMPUTE YOUR MONTHLY CONTRIBUTION TOWARDS YOUR COST OF LON[; TFRU CARP rl Tf`? Calculation of Gross Monthly Income Calculation of Contribution toward Cost of Care Begin Date 05/01/2008 Begin Date 05/01/2008 Earned Income ..? ,a+ Gross Monthly Income Y = Wages, Salary .00 Total Earned Income .00 Self Employment .00 Total Unearned Income 2429.60 Rental Income .00 Income available first month .00 Othe .00 r Deductions ! as£. I otal Earned Income: 00 Personal Needs Allowance 45.00 Unearned Income ? Guardianship Fee 00 Social Security 1474.40 Total Allowance for Spouse / Dependant .00 SSI .00 Home Maintenance .00 Veteran's Benefits .00 Contribution towards Cost of Care: 2384.60 Pension 955.20 The LTC facility will deduct the following medical expense from your contribution towards Cost of Care Railroad Benefits .00 Medicare Premium 96.40 Workmen's Comp .00 Other Insurance Premium .00 Black Lung .00 The LTC facility may deduct additional medical bills including supplemental health insurance premiums, Annuity/Trust Payment 00 provided they are verified. Interest / Dividend .00 Other (Rental, etc.) .00 Total Unearned Income: 2429.60 IF YOU WISH TO APPEAL, PLEASE COMPLETE AND RETURN THE BOTTOM PORTION OF THIS FORM. - DETACH HERE DETACH HERE Please check one of the boxes to show which type of hearing you want: ? I want a telephone Hearing. I and my witnesses and anyone helping me will be at this phone number: ? I want a Telephone Hearing. I and my witnesses and anyone helping me will be at the County Assistance Office (CAO). ? I want a Face to Face Hearing. I and my witnesses and anyone helping me will be in the hearing room with the Judge and the caseworker and CAO staff. ? I want a Face to Face Hearing. I and my witnesses and anyone helping me will be in the hearing room with the Judge. The caseworker and other staff will be on the phone from the CAO, if they decide not to come to the hearing room. PLEASE CHECK BELOW IF YOU NEED HELP BECAUSE OF A HEARING PROBLEM OR DISABILITY OR YOU NEED AN INTERPRETER: ? 1 have a hearing impairment or disability. I will need special help. ? I need an interpreter. There will be no cost to me. What language? CLIENT SIGNATURE ADDRESS TELEPHONE NO. DATE SIGNATURE CLIENT REP. ADDRESS TELEPHONE NO. DATE CT=ERIAND CAO MEDICAID • P.O. B'OX 599 ELIGIBLE 33 WESTMINSTER DRIVE NOTICE CARLISLE PA 17013-0599 CAO RETURN ADDRESS CSLD 0004 *01200000000* NICOLE KERNS/SCHUTJER BOGA 600 GRANT STREET 32ND FLOOR, SUITE 3290 PITTSBURGH PA 15219 Notice ID: 94215440 PAGE 1 OF 1 21 0106140 0 TJN 00 WORKER A ABELSON TELEPHONE: (800) 269-0173 MAIL DATE: 04/27/2009 NOT. 985 OPT. G TYPE: E IF YOU DO NOT UNDERSTAND OUR DECISION OR NAVE ANY QUESTIONS, PLEASE CONTACT YOUR NOWR IMIEDIATELY. You have been determined eligible for benefits effective 06/01/2008 to 06/30/2008. You are eligible for Medically Needy Only Medicaid coverage including Services in a Long-Term Care (LTC) Facility. A PA ACCESS card will be issued unless you have previously received one. You will be required to make a monthly payment towards your cost of care. Details of this monthly payment toward your cost of care are found in the LTC section. Contact the CAO if you have questions or changes to report. When contacting the CAO, please provide your record number which is located on the top and bottom of this notice. Citation: 55 Pa. Code 141.81, 178.1, 181.1, 181.11, 181.452, 181.453 If you disagree with our decision, you have the right to appeal. currently receiving benefits and your oralL ?equest or a hearing is received in he County Assistance Office or your written request is postmarked or received on or before 05/10/2009 your assistance will continue pending the hexing decision, except when the change is due to State or Federal law. LESTER E RUSSELL SWAIM HEALTH CENTER 210 BIG SPRING ROAD NEWVILLE PA 17241 CAO ADDRESS CUMBERLAND CAO P.O. BOX 599 33 WESTMINSTER DRIVE CARLISLE PA 17013-0599 MIDPENN LEGAL SERVICES 401-405 LOUTHER STREET CARLISLE PA 17013 (717) 243-9400 Notice ID: 94215440 AA?•T•?•? •rw w 942' 5440 THE FOLLOWING PERSON(S) ARE AFFECTED BY THE ACTION ON THE FRONT OF THIS NOTICE BNFT LINE FIRST NAME ACCESS/INDIVIDUAL NUMBER V PKG I LINE FIRST NAME ACCESS/INDIVIDUAL NUMBER 01 LESTER 800176009 2 04 BNFT V PKG `lAZj jX=- THE FOLLOWING PERSON(S) INCOME OR FINANCIAL INFORMATION WERE INCLUDED IN THE DETERMINATION OF YOUR MEDICAID BENEFITS. Line Line Line Line Line Line Line Line GROSS INCOME Earned: Unearned: DEDUCTIONS Earned Income: Unearned Income: Dependant Care NET INCOME Individual Totals: Additional Deductions. Medical Bills (as deduction): Patient Pay Amount Total Household Net Income: Budget Income Limit This income covers a 06 month period. You are responsible for patient pay amount to providers as indicated below. Line Date Pav to: Provider Amount The following medical bills have been used as a deduction to calculate your eligibility for Medicaid benefits. The unpaid bills are your responsibility and will not be covered by Medicaid. Name of Provider Date of Service Amount I Name of Provider PRIVATE PAY OT/U-172008 11329.20 MEDICARE B 02/01/2008 578.40 Date of Service Amount IF YOU WISH TO APPEAL, PLEASE COMPLETE AND RETURN THE BOTTOM PORTION OF THIS FORM. •----- DETACH HERE DETACH HERE Please check one of the boxes to show which type of hearing you want: ? I want a telephone Hearing. I and my witnesses and anyone helping me will be at this phone number: ? I want a Telephone Hearing. I and my witnesses and anyone helping me will be at the County Assistance Office (CAO). ? 1 want a Face to Face Hearing. I and my witnesses and anyone helping me will be in the hearing room with the Judge and the caseworker and CAO staff. ? I want a Face to Face Hearing. I and my witnesses and anyone helping me will be in the hearing room with the Judge. The caseworker and other staff will be on the phone from the CAO, if they decide not to come to the hearing room. PLEASE CHECK BELOW IF YOU NEED HELP BECAUSE OF A HEARING PROBLEM OR DISABILITY OR YOU NEED AN INTERPRETER: ? I have a hearing impairment or disability. I will need special help. ? I need an interpreter. There will be no cost to me. What language? CLIENT SIGNATURE ADDRESS TELEPHONE NO. DATE SIGNATURE CLIENT REP. ADDRESS TELEPHONE NO. DATE CUMBERLAND CAO LONG TERM CARE P.O. Box 599 ELIGIBLE 33 WESTMINSTER DRIVE NOTICE CARLISLE PA 17013-0599 CAO RETURN ADDRESS CSLD 0004 *02200000000* NICOLE KERNS/SCHUTJER BOGA 600 GRANT STREET 32ND FLOOR, SUITE 3290 PITTSBURGH PA 15219 Notice ID: 94215440 21 0106140 0 TJN 00 WORKER: A ABELSON TELEPHONE: (800) 269-0173 MAIL DATE: 04/27/2009 NOT. 985 OPT: G TYPE: E IF YOU DO NOT UNDERSTAND OUR DECISION OR HAVE ANY OUESHONS, PLEASE CONTACT YOUR WON(ER IMMEDIATELY. PAGE 1 OF 1 You have received a notice showing your eligibility for Medicaid A person receiving benefits in a long-term care facility under the Medicaid program is required to contribute towards the monthly cost of Long Term Care. This computation is found on the reverse side of this notice. Citation: PA Code §§ 181.452 and 181.453 If you disagree with our decision, you have the right to appeal. See attached form for a complete explanation of your right to appeal and to a fair hearing. If you are currently receiving benefits and your oral request for a hearing is received in the County Assistance Office or your written request is postmarked or received on or before 05/10/2009 your assistance will continue pending the hearing decision, except when the change is due to State or Federal law. LESTER E RUSSELL SWAIM HEALTH CENTER 210 BIG SPRING ROAD NEWVILLE PA 17241 ADDRESS CAO CUMBERLAND CAO P.O. BOX 599 33 WESTMINSTER DRIVE CARLISLE PA 17013-0599 MIDPENN LEGAL SERVICES 401-405 LOUTHER STREET CARLISLE PA 17013 (717) 243-9400 Notice ID: 94215440 0 o 0 0 0 0 0 0 N 0 94215440 PMOULOMMTHE FOLLOWING PERSON IS AFFECTED BY THE ACTION ON THE FRONT OF THIS NOTICE LINE FIRST NAME ACCESS/INDIVIDUAL NUMBER 01 LESTER 800176009 2 THE FOLLOWING AMOUNTS WERE USED TO COMPUTE YOUR MONTHLY CONTRIBUTION TOWARDS YOUR COST OF LONG TERM CeRF Il TC) Calculation of Gross Monthly Income Calculation of Contribution toward Cost of Care Begin Date 06/01/2008 Begin Date 06/01/2008 Earned Income '°° Gross Monthly Income kt +s Wages, Salary .00 Total Earned income .00 Self Employment .00 Total Unearned Income 2429.60 Rental Income .00 Income available first month .00 Other .00 Deductions Total Earned Income: .00 Personal Needs Allowance 45.00 Unearned Income Guardianship Fee 00 Social Security 1474.40 Total Allowance for Spouse / .00 Dependant SSI .00 Home Maintenance .00 Veteran's Benefits .00 Contribution towards 2384 60 Cost of Care: . Pension 955.20 The LTC facility will deduct the following medical expense from your contribution towards Cost of Care Railroad Benefits .00 Medicare Premium 96.40 Workmen's Comp .00 Other Insurance Premium .00 Black Lung .00 The LTC facility may deduct additional medical bills including supplemental health insurance premiums, Annuity/Trust provided they are verified. Payment 00 Interest / Dividend .00 Other (Rental, etc.) .00 Total Unearned Income: 2429.60 IF YOU WISH TO APPEAL, PLEASE COMPLETE AND RETURN THE BOTTOM PORTION OF THIS FORM. -- DETACH HERE DETACH HERE ---- Please check one of the boxes to show which type of hearing you want: ? I want a telephone Hearing. I and my witnesses and anyone helping me will be at this phone number: ? I want a Telephone Hearing. I and my witnesses and anyone helping me will be at the County Assistance Office (CAO). ? I want a Face to Face Hearing. I and my witnesses and anyone helping me will be in the hearing room with the Judge and the caseworker and CAO staff. ? I want a Face to Face Hearing. I and my witnesses and anyone helping me will be in the hearing room with the Judge. The caseworker and other staff will be on the phone from the CAO, if they decide not to come to the hearing room. PLEASE CHECK BELOW IF YOU NEED HELP BECAUSE OF A HEARING PROBLEM OR DISABILITY OR YOU NEED AN INTERPRETER: ? I have a hearing impairment or disability. I will need special help. ? I need an interpreter. There will be no cost to me. What language? CLIENT SIGNATURE ADDRESS TELEPHONE NO. DATE SIGNATURE CLIENT REP. ADDRESS TELEPHONE NO. DATE CUMBERLAND CAO MEDICAID " P.O. BOX 599 ELIGIBLE 33 WESTMINSTER DRIVE NOTICE CARLISLE PA 17013-0599 CAO RETURN ADDRESS CSLD 0004 *19200000000* NICOLE KERN'S/SCHUTJER BOGA 600 GRANT STREET 32ND FLOOR, SUITE 3290 PITTSBURGH PA 15219 Notice ID: 94216740 PAGE 1 OF 1 21 0106140 0 TJN 5 00 WORKER: A ABELSON TELEPHONE: (800) 269-0173 MAIL DATE: 04/27/2009 NOT. 985 OPT. G TYPE: E IF YOU DO NOT UNDERSTAND OUR DECISION OR NAVE ANY QUESTIONS, PLEASE COMACT YOUR N19R " IMMEDIATELY. You have been determined eligible for benefits effective 07/01/2008 to 07/31/2008. You are eligible for Medically Needy Only Medicaid coverage including Services in a Long-Term Care (LTC) Facility. A PA ACCESS card will be issued unless you have previously received one. You will be required to make a monthly payment towards your cost of care. Details of this monthly payment toward your cost of care are found in the LTC section. Contact the CAD if you have questions or changes to report. When contacting the CAD, please provide your record number which is located on the top and bottom of this notice. Citation: 55 Pa. Code 141.81, 178.1, 181.1, 181.11, 181.452, 181.453 .?. wa v?? v. z1g -m w auNaai ana Lo a fair nearing. IT you are currently receiving benefits and your oral request for a hearing is received in the County Assistance Office or your written request is postmarked or received on or before 05/10/2009 your assistance will continue pending the hearing decision, except when the change is due to State or Federal law. LESTER E RUSSELL SWAIM HEALTH CENTER 210 BIG SPRING ROAD NEWVILLE PA 17241 CAC ADDRESS CUMBERLAND CAO P.O. BOX 599 33 WESTMINSTER DRIVE CARLISLE PA 17013-0599 MIDPENN LEGAL SERVICES 401-405 LOUTHER STREET CARLISLE PA 17013 (717) 243-9400 Notice ID: 94216740 21 0106140 0 TJN 5 00 WORKER: A ABELSON APPEAL: 05/10/2009 TELEPHONE: (800) 269-0173 MAIL DATE: 04/27/2009 NOT. 985 OPT. G TYPE: E If you disagree with our decision, you have the right to armeal. 94216740 THE FOLLOWING PERSON(S) ARE AFFECTED BY THE ACTION ON THE FRONT OF THIS NOTICE BNFT LINE FIRST NAME ACCESS/INDIVIDUAL NUMBER V PKG I LINE FIRST NAME ACCESSIINDIVIDUAL NUMBER 01 LESTER 800176009 2 04 BNFT V PKG aIwILW&IL-M THE FOLLOWING PERSON(S) INCOME OR FINANCIAL INFORMATION WERE INCLUDED IN THE DETERMINATION OF YOUR MEDICAID BENEFITS. Line Line Line Line Line Line Line Line GROSS INCOME Earned.-- Unearned DEDUCTIONS Earned Income: Unearned Income: Dependant Care NET INCOME Individual Totals: Additional Deductions Medical Bills (as deduction): Patient Pay Amount: Total Household Net Income: Budget Income Limit: This income covers a 06 month period. The following medical bills have been used as a deduction to calculate your eligibility for Medicaid benefits. The unpaid bills are your responsibility and will not be covered by Medicaid. Name of Provider Date of Service Amount Name of Provider Date of Service Amount MEDICARE B 11/19/2007 578.40 PRIVATE PAY 11/19/2007 11329.20 IF YOU WISH TO APPEAL, PLEASE COMPLETE AND RETURN THE BOTTOM PORTION OF THIS FORM. ----- M7XH HERE DETACH HERE Please check one of the boxes to show which type of hearing you want: ? I want a telephone Hearing. I and my witnesses and anyone helping me will be at this phone number: ? I want a Telephone Hearing. I and my witnesses and anyone helping me will be at the County Assistance Office (CAO). ? I want a Face to Face Hearing. I and my witnesses and anyone helping me will be in the hearing room with the Judge and the caseworker and CAO staff. ? I want a Face to Face Hearing. I and my witnesses and anyone helping me will be in the hearing room with the Judge. The caseworker and other staff will be on the phone from the CAO, if they decide not to come to the hearing room. PLEASE CHECK BELOW IF YOU NEED HELP BECAUSE OF A HEARING PROBLEM OR DISABILITY OR YOU NEED AN INTERPRETER: ? I have a hearing impairment or disability. I will need special help. ? I need an interpreter. There will be no cost to me. What language? CLIENT SIGNATURE below. Line Date Pay to: Provider Amount You are responsible for patient pay amount to providers as indicated TELEPHONE NO. DATE ADDRESS SIGNATURE CLIENT REP. ADDRESS TELEPHONE NO. DATE CUMBERLAND CAO LONG TERM CARE ' P.O. BbX 599 ELIGIBLE 33 WESTMINSTER DRIVE NOTICE CARLISLE; PA 17013-0599 CAO RETURN ADDRESS CSLD 0004 *20200000000* NICOLE KERNS/SCHUTJER BOGA 600 GRANT STREET 32ND FLOOR, SUITE 3290 PITTSBURGH PA 15219 Notice ID: 94216740 21 0106140 0 TJN 5 00 WORKER: A A13ELSON TELEPHONE: (800) 269-0173 MAIL DATE: 04/27/2009 NOT: 985 OPT. G TYPE: E IF YOU DO NOT UNDERSTAND OUR DECISION OR HAVE ANY QUESTIONS, PLEASE CONTACT YOUR WORKER IMMEDIATELY. PAGE 1 OF 1 You have received a notice showing your eligibility for Medicaid. A person receiving benefits in a long-term care facility under the Medicaid program is required to contribute towards the monthly cost of Long Term Care. This computation is found on the reverse side of this notice. Citation: PA Code §§ 181.452 and 181.453 If you disagree with our decision, you have the right to appeal. See attached form for a complete explanation of your right to appeal and to a fair hearing. If you are currently receiving benefits and your oral request for a hearing is received in the County Assistance Office or your written request is postmarked or received on or before 05/10/2009 your assistance will continue pending the hearing decision, except when the change is due to State or Federal law. LESTER E RUSSELL SWAIM HEALTH CENTER 210 BIG SPRING ROAD NEWVILLE PA 17241 ADDRESS CAL CUMBERLAND CAO P.O. BOX 599 33 WESTMINSTER DRIVE CARLISLE PA 17013-0599 MIDPENN LEGAL SERVICES 401-405 LOUTHER STREET CARLISLE PA 17013 (717) 243-9400 Notice ID: 94216740 t c c i c c c c c c c cn e 94216740 THE FOLLOWING PERSON IS AFFECTED BY THE ACTION ON THE FRONT OF THIS NOTICE LINE FIRST NAME ACCESS/INDIVIDUAL NUMBER 01 LESTER 800176009 2 THE FOLLOWING AMOUNTS WERE USED TO COMPUTE YOUR MONTHLY CONTRIBUTION TOWARDS YOUR COST OF LONG TERM CARE (LTC)- Calculation of Gross Monthly Income Calculation of Contribution toward Cost of Care Begin Date 07/01/2008 Begin Date 07/01/2008 Earned Income sr Gross Monthly Income s ti' t Wages, Salary .00 Total Earned Income .00 Self Employment .00 Total Unearned Income 2429.60 Rental Income .00 Income available first month .00 Other .00 Deductions Total Earned Income: .00 Personal Needs Allowance 45.00 Unearned Income Guardianship Fee .00 Social Security 1474.40 Total Allowance for Spouse / Dependant .00 SSI .00 Home Maintenance .00 Veteran's Benefits .00 Contribution towards Cost of Care: 2384.60 Pension 955.20 The LTC facility will deduct the following medical expense from your contribution towards Cost of Care Railroad Benefits .00 Medicare Premium 96.40 Workmen's Comp .00 Other Insurance Premium .00 Black Lung .00 The LTC facility may deduct additional medical bills including supplemental health insurance premiums, Annuity/Trust Payment 00 provided they are verified. Interest / Dividend .00 Other (Rental, etc.) .00 Total Unearned Income: 2429.60 IF YOU WISH TO APPEAL, PLEASE COMPLETE AND RETURN THE BOTTOM PORTION OF THIS FORM. ----- DETACH HERE DETACH HERE ------ Please check one of the boxes to show which type of hearing you want: ? I want a telephone Hearing. I and my witnesses and anyone helping me will be at this phone number: ? I want a Telephone Hearing. I and my witnesses and anyone helping me will be at the County Assistance Office (CAO). ? I want a Face to Face Hearing. I and my witnesses and anyone helping me will be in the hearing room with the Judge and the caseworker and CAO staff. ? I want a Face to Face Hearing. I and my witnesses and anyone helping me will be in the hearing room with the Judge. The caseworker and other staff will be on the phone from the CAO, if they decide not to come to the hearing room. PLEASE CHECK BELOW IF YOU NEED HELP BECAUSE OF A HEARING PROBLEM OR DISABILITY OR YOU NEED AN INTERPRETER: ? I have a hearing impairment or disability. I will need special help. ? I need an interpreter. There will be no cost to me. What language? CLIENT SIGNATURE ADDRESS TELEPHONE NO. DATE SIGNATURE CLIENT REP. ADDRESS TELEPHONE NO. DATE CUMBERLAND CAO MEDICAID P.O. BbX 599 ELIGIBLE 33 WESTMINSTER DRIVE NOTICE CARLISLE PA 17013-0599 CAO RETURN ADDRESS CSLD 0004 *17200000000* NICOLE KERNS/SCHUTJER BOGA 600 GRANT STREET 32ND FLOOR, SUITE 3290 PITTSBURGH PA 15219 Notice ID: 94216640 PAGE 1 OF 1 IF YOU DD HOT UNDERSTAND OUR DECISION OR HAVE ANY QUESTIONS, PLEASE CONTACT YOUR OORKER IiNEDIATELY. You have been determined eligible for benefits effective 08/01/2008 to 08/31/2008. You are eligible for Medically Needy Only Medicaid coverage including Services in a Long-Term Care (LTC) Facility. A PA ACCESS card will be issued unless you have previously received one. You will be required to make a monthly payment towards your cost of care. Details of this monthly payment toward your cost of care are found in the LTC section. Contact the CAD if you have questions or changes to report. When contacting the CAD, please provide your record number which is located on the top and bottom of this notice. Citation: 55 Pa. Code 141.81, 178.1. 181.1, 181.11, 181.452, 181.453 If you disagree with our decision, you have the right to appeal. •v. o nwww v?N?«ruvn v? wu? ?wna ay a w... anu ly a lair nearlnm IT you are currently receiving benefits and your oral request for a hearing is received in the County Assistance Office or your written request is postmarked or received on or before 05/10/2009 your assistance will continue pending the hearing decision, except when the change is due to State or Federal law. APPLICANT NAME ANJID ADDRESS LESTER E RUSSELL SWAIM HEALTH CENTER 210 BIG SPRING ROAD NEWVILLE PA 17241 CAO ADDRESS CUMBERLAND CAO P.O. BOX 599 33 WESTMINSTER DRIVE CARLISLE PA 17013-0599 MIDPENN LEGAL SERVICES 401-405 LOUTHER STREET CARLISLE PA 17013 (717) 243-9400 Notice ID: 94216640 94216640 • THE FOLLOWING PERSON(S) ARE AFFECTED BY THE ACTION ON THE FRONT OF THIS NOTICE BNFT LINE FIRST NAME ACCESS/INDIVIDUAL NUMBER V PKG I LINE FIRST NAME ACCESSIINDI VI DUAL NUMBER 01 LESTER 800176009 2 04 BNFT V PKG :7,?R•le THE FOLLOWING PERSON(S) INCOME OR FINANCIAL INFORMATION WERE INCLUDED IN THE DETERMINATION OF YOUR MEDICAID BENEFITS. Line Line Line Line Line Line Line Line GROSS INCOME Earned: Unearned: DEDUCTIONS Earned Income: Unearned Income: Dependant Care NET INCOME Individual Totals: Household Net Income: You are responsible for patient pay amount to providers as indicated Additional Deductions: below: Medical Bills (as deduction): Line Date Pay to: Provider Amount Patient Pay Amount Total Household Net Income: Budget Income Limit This income covers a 06 month period. The following medical bills have been used as a deduction to calculate your eligibility for Medicaid benefits. The unpaid bills are your responsibility and will not be covered by Medicaid. Name of Provider Date of Service Amount I Name of Provider Date of Service Amount MEDICARE B 11/19/2007 578.40 PRIVATE PAY 11/19/2007 11329.20 IF YOU WISH TO APPEAL, PLEASE COMPLETE AND RETURN THE BOTTOM PORTION OF THIS FORM. ----- DETACH HERE DETACH HERE ------ Please check one of the boxes to show which type of hearing you want: ? I want a telephone Hearing. I and my witnesses and anyone helping me will be at this phone number: ? I want a Telephone Hearing. I and my witnesses and anyone helping me will be at the County Assistance Office (CAO). ? I want a Face to Face Hearing. I and my witnesses and anyone helping me will be in the hearing room with the Judge and the caseworker and CAO staff. ? I want a Face to Face Hearing. I and my witnesses and anyone helping me will be in the hearing room with the Judge. The caseworker and other staff will be on the phone from the CAO, if they decide not to come to the hearing room. PLEASE CHECK BELOW IF YOU NEED HELP BECAUSE OF A HEARING PROBLEM OR DISABILITY OR YOU NEED AN INTERPRETER: ? I have a hearing impairment or disability. I will need special help. ? I need an interpreter. There will be no cost to me. What language? CLIENT SIGNATURE ADDRESS TELEPHONE NO. DATE SIGNATURE CLIENT REP. ADDRESS TELEPHONE NO. DATE CUMBERLAND CAO LONG TERM CARE ' P.O. BbX 599 ELIGIBLE 33 WESTMINSTER DRIVE NOTICE CARLISLE PA 17013-0599 CAO RETURN ADDRESS CSLD 0004 *18200000000* NICOLE KERNS/SCHUTJER BOGA 600 GRANT STREET 32ND FLOOR, SUITE 3290 PITTSBURGH PA 15219 Notice ID: 94216640 IF YOU DO NOT UNDERSTAND OUR DECISION OR HME ANY QUESTIONS, PLEASE CONTACT YOUR NMM IMMEDIATELY. PAGE 1 OF 1 You have received a notice showing your eligibility for Medicaid. A person receiving benefits in a long-term care facility under the Medicaid program is required to contribute towards the monthly cost of Long Term Care. This computation is found on the reverse side of this notice. Citation: PA Code §§ 181.452 and 181.453 If you disagree with our decision, you have the right to appeal. See attached form for a complete explanation of your right to appeal and to a fair hearing. If you are currently receiving benefits and your oral request for a hearing is received in the County Assistance Office or your written request is postmarked or received on or before 05/10/2009 your assistance will continue pending the hearing decision, except when the change is due to State or Federal law. LESTER E RUSSELL SWAIM HEALTH CENTER 210 BIG SPRING ROAD NEWVILLE PA 17241 CA(D ADDRESS CUMBERLAND CAO P.O. BOX 599 33 WESTMINSTER DRIVE CARLISLE PA 17013-0599 MIDPENN LEGAL SERVICES 401-405 LOUTHER STREET CARLISLE PA 17013 (717) 243-9400 Notice ID. 94216640 C C C: c c c C C CC cc 94216640 0 '' THE FOLLOWING PERSON IS AFFECTED BY THE ACTION ON THE FRONT OF THIS NOTICE LINE FIRST NAME ACCESSIINDIVIDUAL NUMBER 01 LESTER 800176009 2 pixeififfe-im THE FOLLOWING AMOUNTS WERE USED TO COMPUTE YOUR MONTHLY CONTRIBUTION TOWARDS YOUR COST OF LONG TERM CARE ILTC)_ Calculation of Gross Monthly Income Calculation of Contribution toward Cost of Care Begin Date 08/01/2008 Begin Date 08/01/2008 Earned Income _ Gross Monthly Income Wages, Salary .00 Total Earned Income .00 Self Employment .00 Total Unearned Income 2429.60 Rental Income .00 Income available first month .00 Other .00 Deductions Total Earned Income: .00 Personal Needs Allowance 45.00 Unearned Income ,°' Guardianship Fee 00 Social Security 1474.40 Total Allowance for Spouse ! Dependant .00 SSI .00 Home Maintenance .00 Veteran's Benefits .00 Contribution towards Cost of Care: 2384.60 Pension 955.20 The LTC facility will deduct the following medical expense from your contribution towards Cost of Care Railroad Benefits .00 Medicare Premium 96.40 Workmen's Comp .00 Other Insurance Premium .00 Black Lung .00 The LTC facility may deduct additional medical bills including supplemental health insurance premiums, Annuity/Trust Payment 00 provided they are verified. Interest / Dividend .00 Other (Rental, etc.) .00 Total Unearned Income: 2429.60 IF YOU WISH TO APPEAL, PLEASE COMPLETE AND RETURN THE BOTTOM PORTION OF THIS FORM. ----- DETACH HERE DETACH HERE Please check one of the boxes to show which type of hearing you want: ? I want a telephone Hearing. I and my witnesses and anyone helping me will be at this phone number. ? I want a Telephone Hearing. I and my witnesses and anyone helping me will be at the County Assistance Office (CAO). ? I want a Face to Face Hearing. I and my witnesses and anyone helping me will be in the hearing room with the Judge and the caseworker and CAO staff. ? 1 want a Face to Face Hearing. I and my witnesses and anyone helping me will be in the hearing room with the Judge. The caseworker and other staff will be on the phone from the CAO, if they decide not to come to the hearing room. PLEASE CHECK BELOW IF YOU NEED HELP BECAUSE OF A HEARING PROBLEM OR DISABILITY OR YOU NEED AN INTERPRETER: ? I have a hearing impairment or disability. I will need special help. ? I need an interpreter. There will be no cost to me. What language? CLIENT SIGNATURE ADDRESS TELEPHONE NO. DATE SIGNATURE CLIENT REP. ADDRESS TELEPHONE NO. DATE CUMBERLAND CAO MEDICAID P.O. sox 599 ELIGIBLE 33 WESTMINSTER DRIVE NOTICE CARLISLE PA 17013-0599 CAO RETURN ADDRESS CSLD 0004 *15200000000* NICOLE KERNS/SCHUTJER BOGA 600 GRANT STREET 32ND FLOOR, SUITE 3290 PITTSBURGH PA 15219 Notice ID: 94216540 PAGE 1 OF 1 IF YOU DO HOT UNDERSTAND OUR DECISION OR HAVE ANY QUESTIONS, PLEASE CONTACT YOUR WORKER IIM OIATELY. You have been determined eligible for benefits effective 09/01/2008 to 09/30/2008. You are eligible for Medically Needy Only Medicaid coverage including Services in a Long-Term Care (LTC) Facility. A PA ACCESS card will be issued unless you have previously received one. You will be required to make a monthly payment towards your cost of care. Details of this monthly payment toward your cost of care are found in the LTC section. Contact the CAO if you have questions or changes to report. When contacting the CAO, please provide your record number which is located on the top and bottom of this notice. Citation: 55 Pa. Code 141.81, 178.1, 181.1, 181.11, 181.452, 181.453 y? a a.VIIIV?pap CJa M??IIO al V?1 ?? vvul nuns tD aDD6a1 ana LO a -- nearlnQ. IT YOU are currently receiving benefits and your oral request for a hearing is received in the County Assistance Office or your written request is postmarked or received on or before 05/10/2009 your assistance will continue pending the hearing decision, except when the change is due to State or Federal law. LESTER E RUSSELL SWAIM HEALTH CENTER 210 BIG SPRING ROAD NEWVILLE PA 17241 CAD ADDRESS CUMBERLAND CAO P.O. BOX 599 33 WESTMINSTER DRIVE CARLISLE PA 17013-0599 If you disagree with our decision, you have the MIDPENN LEGAL SERVICES 401-405 LOUTHER STREET CARLISLE PA 17013 (717) 243-9400 Notice ID: 94216540 21 0106140 0 TJN 3 00 WORKER: A ABELSON APPEAL 05/10/2009 TELEPHONE: (800) 269-0173 MAIL DATE: 04/27/2009 NOT: 985 OPT: G TYPE: E ?T + ? o c c c c 0 N Lr. 94216540 THE FOLLOWING PERSON(S) ARE AFFECTED BY THE ACTION ON THE FRONT OF THIS NOTICE BNFT LINE FIRST NAME ACCESS/INDIVIDUAL NUMBER V PKG I LINE FIRST NAME ACCESS/INDIVIDUAL NUMBER V 01 LESTER 800176009 2 04 BNFT PKG 75 ¦RsAM THE FOLLOWING PERSON(S) INCOME OR FINANCIAL INFORMATION WERE INCLUDED IN THE DETERMINATION OF YOUR MEDICAID BENEFITS. Line Line Line Line Line Line Line Line GROSS INCOME Earned: Unearned: DEDUCTIONS Earned Income: Unearned Income: Dependant Care NET INCOME Individual Totals: Additional Deductions: Medical Bills (as deductions Patient Pay Amount Total Household Net Income: Budget Income Limit This income covers a 06 month period. The following medical bills have been used as a deduction to calculate your eligibility for Medicaid benefits. The unpaid bills are your responsibility and will not be covered by Medicaid. Name of Provider Date of Service Amount I Name of Provider Date of Service Amount PRIVATE PAY 11/19/2007 11329.20 MEDICARE B 11/19/2007 578.40 IF YOU WISH TO APPEAL, PLEASE COMPLETE AND RETURN THE BOTTOM PORTION OF THIS FORM. - DETACH HERE DETACH HERE ------ Please check one of the boxes to show which type of hearing you want: ? I want a telephone Hearing. I and my witnesses and anyone helping me will be at this phone number: ? I want a Telephone Hearing. I and my witnesses and anyone helping me will be at the County Assistance Office (CAO). ? I want a Face to Face Hearing. I and my witnesses and anyone helping me will be in the hearing room with the Judge and the caseworker and CAO staff. ? I want a Face to Face Hearing. I and my witnesses and anyone helping me will be in the hearing room with the Judge. The caseworker and other staff will be on the phone from the CAO, if they decide not to come to the hearing room. PLEASE CHECK BELOW IF YOU NEED HELP BECAUSE OF A HEARING PROBLEM OR DISABILITY OR YOU NEED AN INTERPRETER: ? I have a hearing impairment or disability. I will need special help. ? I need an interpreter. There will be no cost to me. What language? CLIENT SIGNATURE below. Line Date Pay to: Provider Amount You are responsible for patient pay amount to providers as indicated TELEPHONE NO. DATE ADDRESS SIGNATURE CLIENT REP. ADDRESS TELEPHONE NO. DATE CUMBERAND CAO LONG TERM CARE 'P.O. BgX 599 ELIGIBLE 33 WESTMINSTER DRIVE NOTICE CARLISLE PA 17013-0599 CAO RETURN ADDRESS CSLD 0004 '16200000000* NICOLE KERNS/SCHUTJER BOGA 600 GRANT STREET 32ND FLOOR, SUITE 3290 PITTSBURGH PA 15219 Notice ID: 94216540 17 ,11,7; 21 0106140 0 TJN 3 00 WORKER: A ABELSON TELEPHONE: (800) 269-0173 MAIL DATE: 04/27/2009 NOT: 985 OPT: G TYPE: E IF YOU DO NOT UNDERSTAND OUR DECISION OR HAVE ANY OUESTIONS, PLEASE CONTACT YOUR WORM IMMEDIATELY. PAGE 1 OF 1 You have received a notice showing your eligibility for Medicaid. A person receiving benefits in a long-term care facility under the Medicaid program is required to contribute towards the monthly cost of Long Term Care. This computation is found on the reverse side of this notice. Citation: PA Code H 181.452 and 181.453 If you disagree with our decision, you have the right to appeal. See attached form for a complete explanation of your right to appeal and to a fair hearing. If you are currently receiving benefits and your oral request for a hearing is received in the County Assistance Office or your written request is postmarked or received on or before 05/10/2009 your assistance will continue pending the hearing decision, except when the change is due to State or Federal law. APPLICANT NAW. AND ADDRESS LESTER E RUSSELL SWAIM HEALTH CENTER 210 BIG SPRING ROAD NEWVILLE PA 17241 CUMBERLAND CAO P.O. BOX 599 33 WESTMINSTER DRIVE CARLISLE PA 17013-0599 MIDPENN LEGAL SERVICES 401-405 LOUTHER STREET CARLISLE PA 17013 (717) 243-9400 Notice ID: 94216540 c c c c c c c TICE540 rein" THE FOLLOWING PERSON IS AFFECTED BY THE ACTION ON THE FRONT OF THIS NO94216 LINE FIRST NAME ACCESS/INDIVIDUAL NUMBER 01 LESTER 800176009 2 j THE FOLLOWING AMOUNTS WERE USED TO COMPUTE YOUR MONTHLY CONTRIBUTION TOWARDS YOUR COST OF ?++?+ LONG TERM CORE Il Td`I Calculation of Gross Monthly Income Calculation of Contribution toward Cost of Care Begin Date 09/01/2008 Begin Date 09/01/2008 Earned Income T" Gross Monthl Income y * % Wages, Salary .00 Total Earned Income .00 Self Employment .00 Total Unearned Income 2429.60 Rental Income .00 Income available first month .00 Other .00 Deductions ` v Total Earned Income: .00 Personal Needs Allowance 45.00 Unearned ` <- Income '" Guardianship Fee o0 t, Social Security 1474.40 Total Allowance for Spouse / Dependant .00 SSI .00 Home Maintenance .00 Veteran's Benefits 00 Contribution towards . Cost of Care: 2384.60 Pension 955.20 The LTC facility will deduct the following medical expense from your contribution towards Cost of Care Railroad Benefits .00 Medicare Premium 96.40 Workmen's Comp .00 Other Insurance Premium .00 Black Lung 00 The LTC facility may deduct additional medical bills including supplemental health insurance premiums Annuit /T t , provided they are verified y rus Payment 00 . Interest / Dividend .00 Other (Rental, etc.) .00 Total Unearned Income: 2429.60 IF YOU WISH TO APPEAL, PLEASE COMPLETE AND RETURN THE BOTTOM PORTION OF THIS FORM. ---- DETACH HERE DETACH HERE Please check one of the boxes to show which type of hearing you want: ? I want a telephone Hearing. I and my witnesses and anyone helping me will be at this phone number: ? I want a Telephone Hearing. I and my witnesses and anyone helping me will be at the County Assistance Office (CAO). ? I want a Face to Face Hearing. I and my witnesses and anyone helping me will be in the hearing room with the Judge and the caseworker and CAO staff. ? I want a Face to Face Hearing. I and my witnesses and anyone helping me will be in the hearing room with the Judge. The caseworker and other staff will be on the phone from the CAO, if they decide not to come to the hearing room. PLEASE CHECK BELOW IF YOU NEED HELP BECAUSE OF A HEARING PROBLEM OR DISABILITY OR YOU NEED AN INTERPRETER: ? I have a hearing impairment or disability. I will need special help. ? I need an interpreter. There will be no cost to me. What language? CLIENT SIGNATURE ADDRESS TELEPHONE NO. DATE 51CiNATURE CLIENT REP. ADDRESS TELEPHONE NO. DATE CUMBE AND CAO MEDICAID ' P.O. oX 599 ELIGIBLE 33 WESTMINSTER DRIVE NOTICE CARLISLE PA 17013-0599 CAO RETURN ADDRESS CSLD 0004 *13200000000* NICOLE KER_p,1S/SCHUTJER BOGA 600 GRANT STREET 32ND FLOOR, SUITE 3290 PITTSBURGH PA 15219 Notice ID: 94216440 PAGE 1 OF 1 pal 21 0106140 0 TJN 2 00 WORKER: A ABELSON TELEPHONE: (800) 269-0173 MAIL DATE 04/27/2009 NOT: 985 OPT. G TYPE E IF YOU DO NOT UNDERSTAND OUR DECISION OR HAVE ANY QUESTIONS, PLEASE CONTACT YOUR Na?KER IMMEDIATELY. You have been determined eligible for benefits effective 10/01/2008 to 10/31/2008. You are eligible for Medically Needy Only Medicaid coverage including Services in a Long-Term Care (LTC) Facility. A PA ACCESS card will be issued unless you have previously received one. You will be required to make a monthly payment towards your cost of care. Details of this monthly payment toward your cost of care are found in the LTC section. Contact the CAO if you have questions or changes to report. When contacting the CAO, please provide your record number which is located on the top and bottom of this notice. Citation: 55 Pa. Code 141.81, 178.1, 181.1, 181.11, 181.452, 181.453 If you disagree with our decision, you have the ?•••r•o•o on?w?•••??? ?? ???? II4ni <o avoeai ano io a Lair nearing it you are currently receiving benefits and your oral request for a hearing is received in the County Assistance Office or your written request is postmarked or received on or before 05/10/2009 your assistance will continue pending the hearing decision, except when the change is due to State or Federal law. LESTER E RUSSELL SWAIM HEALTH CENTER 210 BIG SPRING ROAD NEWVILLE PA 17241 CAO .ADDRESS CUMBERLAND CAO P.O. BOX 599 33 WESTMINSTER DRIVE CARLISLE PA 17013-0599 MIDPENN LEGAL SERVICES 401-405 LOUTHER STREET CARLISLE PA 17013 (717) 243-9400 Notice ID: 94216440 21 0106140 0 TJN 2 00 WORKER: A ABELSON APPEAL: 05/10/2009 TELEPHONE (800) 269-0173 MAIL DATE 04/27/2009 NOT: 985 OPT: G TYPE: E ? o 0 0 0 0 0 0 N M 942'_5440 • THE FOLLOWING PERSON(S) ARE AFFECTED BY THE ACTION ON THE FRONT OF THIS NOTICE BNFT LINE FIRST NAME ACCESS/INDIVIDUAL NUMBER V PKG LINE FIRST NAME ACCESS/INDIVIDUAL NUMBER 01 LESTER 800176009 2 04 BNFT V PKG THE FOLLOWING PERSON(S) INCOME OR FINANCIAL INFORMATION WERE INCLUDED IN THE DETERMINATION OF YOUR MEDICAID BENEFITS. Line Line Line Line Line Line Line Line GROSS INCOME Earned: Unearned: DEDUCTIONS Earned Income: Unearned Income: Dependant Care NET INCOME Individual Totals: Additional Deductions: Medical Bills (as deduction): Patient Pay Amount Total Household Net Income: Budget Income Limit This income covers a 06 month period. The following medical bills have been used as a deduction to calculate your eligibility for Medicaid benefits. The unpaid bills are your responsibility and will not be covered by Medicaid Name of Provider Date of Service Amount Name of Provider Date of Service Amount MEDICARE B 1 1 / 7 578.40 PRIVATE PAY 11/19/2007 11329.20 IF YOU WISH TO APPEAL, PLEASE COMPLETE AND RETURN THE BOTTOM PORTION OF THIS FORM. ----- DETACH HERE DETACH WERE Please check one of the boxes to show which type of hearing you want: ? I want a telephone Hearing. I and my witnesses and anyone helping me will be at this phone number: ? I want a Telephone Hearing. I and my witnesses and anyone helping me will be at the County Assistance Office (CAO). ? I want a Face to Face Hearing. I and my witnesses and anyone helping me will be in the hearing room with the Judge and the caseworker and CAO staff. ? I want a Face to Face Hearing. I and my witnesses and anyone helping me will be in the hearing room with the Judge. The caseworker and other staff will be on the phone from the GAO, if they decide not to come to the hearing room. PLEASE CHECK BELOW IF YOU NEED HELP BECAUSE OF A HEARING PROBLEM OR DISABILITY OR YOU NEED AN INTERPRETER: ? I have a hearing impairment or disability. I will need special help. ? I need an interpreter. There will be no cost to me. What language? CLIENT SIGNATURE below. Line Date Pay to: Provider Amount You are responsible for patient pay amount to providers as indicated TELEPHONE NO. DATE ADDRESS SIGNATURE CLIENT REP. ADDRESS TELEPHONE NO. DATE CUMBERLAND CAO LONG TERM CARE P.O. BOX 599 ELIGIBLE 33 WESTMINSTER DRIVE NOTICE CARLISLE PA 17013-0599 CAO RETURN ADDRESS CSLD 0004 *14200000000* NICOLE KERNS/SCHUTJER BOGA 600 GRANT STREET 32ND FLOOR, SUITE 3290 PITTSBURGH PA 15219 Notice ID: 94216440 k WET 21 0106140 0 TJN 2 00 WORKER: A ABELSON TELEPHONE: (800) 269-0173 MAIL DATE: 04/27/2009 NOT: 985 OPT: G TYPE: E IF YOU DO NOT UNDERSTAND OUR DECISION OR HAVE ANY QUESTIONS, PLEASE CONTACT YOUR LAMER IMEDIATELY. PAGE 1 OF 1 You have received a notice showing your eligibility for Medicaid A person receiving benefits in a long-term care facility under the Medicaid program is required to contribute towards the monthly cost of Long Term Care. This computation is found on the reverse side of this notice. Citation: PA Code H 181.452 and 181.453 If you disagree with our decision, you have the right to appeal. See attached form for a complete explanation of your right to appeal and to a fair hearing. If you are currently receiving benefits and your oral request for a hearing is received in the County Assistance Office or your written request is postmarked or received on or before 05/10/2009 your assistance will continue pending the hearing decision, except when the change is due to State or Federal law. LESTER E RUSSELL SWAIM HEALTH CENTER 210 BIG SPRING ROAD NEWVILLE PA 17241 CUMBERLAND CAO P.O. BOX 599 33 WESTMINSTER DRIVE CARLISLE PA 17013-0599 MIDPENN LEGAL SERVICES 401-405 LOUTHER STREET CARLISLE PA 17013 (717) 243-9400 Notice ID: 94216440 94216440 THE FOLLOWING PERSON IS AFFECTED BY THE ACTION ON THE FRONT OF THIS NOTICE LINE FIRST NAME ACCESS/INDIVIDUAL NUMBER 01 LESTER 800176009 2 THE FOLLOWING AMOUNTS WERE USED TO COMPUTE YOUR MONTHLY CONTRIBUTION TOWARDS YOUR COST OF LONG TERM CARE (LTC). Calculation of Gross Monthly Income Calculation of Contribution toward Cost of Care Begin Date 10/01/2008 Begin Date 10/01/2008 Earned Income Gross Monthly Income k ; ti> .?. Wages, Salary .00 Total Earned Income .00 Self Employment .00 Total Unearned Income 2429.60 Rental Income .00 Income available first month .00 Other oo Deductions k #'z ' r ,A x= Total Earned Income: .00 Personal Needs Allowance 45. o0 Unearned Income ? r *}, .E ` f ' Guardianship Fee .00 Social Security 1474.40 Total Allowance for Spouse / Dependant .00 SSI .00 Home Maintenance .00 Veteran's Benefits .00 Contribution towards Cost of Care: 2384.60 Pension 955.20 The LTC facility will deduct the following medical expense from your contribution towards Cost of Care Railroad Benefits .00 Medicare Premium 96.40 Workmen's Comp .00 Other Insurance Premium .00 Black Lung .00 The LTC facility may deduct additional medical bills including supplemental health insurance premiums, Annuity/Trust Payment 00 provided they are verified. Interest / Dividend .00 Other (Rental, etc.) .00 Total Unearned Income: 2429.60 IF YOU WISH TO APPEAL, PLEASE COMPLETE AND RETURN THE BOTTOM PORTION OF THIS FORM. - DETACH HERE DETACH HERE Please check one of the boxes to show which type of hearing you want: ? 1 want a telephone Hearing. I and my witnesses and anyone helping me will be at this phone number: ? I want a Telephone Hearing. I and my witnesses and anyone helping me will be at the County Assistance Office (CAO). ? I want a Face to Face Hearing. I and my witnesses and anyone helping me will be in the hearing room with the Judge and the caseworker and CAO staff. ? I want a Face to Face Hearing. I and my witnesses and anyone helping me will be in the hearing room with the Judge. The caseworker and other staff will be on the phone from the CAO, if they decide not to come to the hearing room. PLEASE CHECK BELOW IF YOU NEED HELP BECAUSE OF A HEARING PROBLEM OR DISABILITY OR YOU NEED AN INTERPRETER: ? I have a hearing impairment or disability. I will need special help. ? I need an interpreter. There will be no cost to me. What language? CLIENT SIGNATURE ADDRESS TELEPHONE NO. DATE SIGNATURE CLIENT REP. ADDRESS TELEPHONE NO. DATE CUMBERLAND CAO MEDICAID P. n. f'bx 599 ELIGIBLE 33 WESTMINSTER DRIVE NOTICE CARLISLE PA 17013-0599 CAO RETURN ADDRESS CSLD 0004 *11200000000* NICOLE KERNS/SCHUTJER BOGA 600 GRANT STREET 32ND FLOOR, SUITE 3290 PITTSBURGH PA 15219 Notice ID: 94216340 PAGE 1 OF 1 A* Timmenogo""- 21 0106140 0 TJN 00 WORKER: A ABELSON TELEPHONE: (800) 269-0173 MAIL DATE: 04/27/2009 NOT: 985 OPT: G TYPE: E IF YOU DO HOT UNDERSTAND OUR DECISION OR HAVE ANY QUESTIONS, PLEASE CONTACT YOUR NWXER IMIEDIATELY. You have been determined eligible for benefits effective 11/01/2008 to 11/30/2008. You are eligible for Medically Needy Only Medicaid coverage including Services in a Long-Term Care (LTC) Facility. A PA ACCESS card will be issued unless you have previously received one. You will be required to make a monthly payment towards your cost of care. Details of this monthly payment toward your cost of care are found in the LTC section. Contact the CAD if you have questions or changes to report. When contacting the CAD, please provide your record number which is located on the top and bottom of this notice. Citation: 55 Pa. Code 141.81, 178.1, 181.1, 181.11, 181.452, 181.453 If you disagree with our decision, you have the for a complete explanation of your right to appeal and to a fair hearing If you are currently receiving benefits and your oral request for a hearing is received in the County Assistance Office or your written request is postmarked or received on or before 05/10/2009 your assistance will continue pending the hearing decision, except when the change is due to State or Federal law. ADDRESS LESTER E RUSSELL SWAIM HEALTH CENTER 210 BIG SPRING ROAD NEWVILLE PA 17241 CAO ADDRESS CUMBERLAND CAO P.O. BOX 599 33 WESTMINSTER DRIVE CARLISLE PA 17013-0599 MIDPENN LEGAL SERVICES 401-405 LOUTHER STREET CARLISLE PA 17013 (717) 243-9400 Notice ID: 94216340 94:215340 isawne THE FOLLOWING PERSON(S) ARE AFFECTED BY THE ACTION ON THE FRONT OF THIS NOTICE BNFT LINE FIRST NAME ACCESS/INDIVIDUAL NUMBER V PKG I LINE FIRST NAME ACCESS/INDIVIDUAL NUMBER V 01 LESTER 800176009 2 04 BNFT PKG RAMMMIll THE FOLLOWING PERSON(S) INCOME OR FINANCIAL INFORMATION WERE INCLUDED IN THE DETERMINATION OF YOUR MEDICAID BENEFITS. Line Line Line Line Line Line Line Line GROSS INCOME Earned: Unearned: DEDUCTIONS Earned Income: Unearned Income: Dependant Care NET INCOME Individual Totals: Household Net Income: Additional Deductions: Medical Bills (as deductions Patient Pay Amount Total Household Net Income: Budget Income Limit This income covers a 06 month period. You are responsible for patient pay amount to providers as indicated below. Line Date Pay to: Provider Amount The following medical bills have been used as a deduction to calculate your eligibility for Medicaid benefits. The unpaid bills are your responsibility and will not be covered by Medicaid. Name of Provider Date of Service Amount I Name of Provider Date of Service Amount PRIVATE PAY 11/19/2007 11329.20 MEDICARE B 11/19/2007 578.40 IF YOU WISH TO APPEAL, PLEASE COMPLETE AND RETURN THE BOTTOM PORTION OF THIS FORM. •----- DETACH HERE M7XH HERE Please check one of the boxes to show which type of hearing you want: ? I want a telephone Hearing. I and my witnesses and anyone helping me will be at this phone number: ? 1 want a Telephone Hearing. I and my witnesses and anyone helping me will be at the County Assistance Office (CAO). ? I want a Face to Face Hearing. I and my witnesses and anyone helping me will be in the hearing room with the Judge and the caseworker and CAO staff. ? I want a Face to Face Hearing. I and my witnesses and anyone helping me will be in the hearing room with the Judge. The caseworker and other staff will be on the phone from the CAO, if they decide not to come to the hearing room. PLEASE CHECK BELOW IF YOU NEED HELP BECAUSE OF A HEARING PROBLEM OR DISABILITY OR YOU NEED AN INTERPRETER: ? I have a hearing impairment or disability. I will need special help. ? I need an interpreter. There will be no cost to me. What language? CLIENT SIGNATURE ADDRESS TELEPHONE NO. DATE SIGNATURE CLIENT REP. ADDRESS TELEPHONE NO. DATE CUMBERLAND CAO LONG TERM CARE 1P.-O'. IrOX 599 ELIGIBLE 33 WESTMINSTER DRIVE NOTICE CARLISLE PA 17013-0599 CAO RETURN ADDRESS CSLD 0004 Notice ID: 94216340 PAGE 1 OF 1 21 0106140 0 TJN 00 *12200000000• WORKER: A ABELSON NICOLE KERNS/SCHUTJER BOGA 600 GRANT STREET TELEPHONE: (800) 269-0173 32ND FLOOR, SUITE 3290 MAIL DATE: 04/27/2009 PITTSBURGH PA 15219 NOT: 985 OPT. G TYPE E IF YOU DO NOT UNDERSTAND OUR DECISION OR HAVE ANY QUESTIONS, PLEASE CONTACT YOUR NORKER INNIEDIATEIY. You have received a notice showing your eligibility for Medicaid. A person receiving benefits in a long-term care facility under the Medicaid program is required to contribute towards the monthly cost of Long Term Care. This computation is found on the reverse side of this notice. Citation: PA Code H 181.452 and 181.453 If you disagree with our decision, you have the right to appeal. See attached form for a complete explanation of your right to appeal and to a fair hearing. If you are currently receiving benefits and your oral request for a hearing is received in the County Assistance Office or your written request is postmarked or received on or before 05/10/2009 your assistance will continue p.ending the hearing decision, except when the change is due to State or Federal law. APPLICANT AAME AND ADDRESS LESTER E RUSSELL SWAIM HEALTH CENTER 210 BIG SPRING ROAD NEWVILLE PA 17241 1 1, CAO ADDRESS CUMBERLAND CAO P.O. BOX 599 33 WESTMINSTER DRIVE CARLISLE PA 17013-0599 MIDPENN LEGAL SERVICES 401-405 LOUTHER STREET CARLISLE PA 17013 (717) 243-9400 Notice ID: 94216340 94216340 • THE FOLLOWING PERSON IS AFFECTED BY THE ACTION ON THE FRONT OF THIS NOTICE PiRiM LINE FIRST NAME ACCESSIINDI V [DUAL NUMBER 01 LESTER ' 800176009 2 X-ta THE FOLLOWING AMOUNTS WERE USED TO COMPUTE YOUR MONTHLY CONTRIBUTION TOWARDS YOUR COST OF 1 ANf: TFRU rARF 11 TrI Calculation of Gross Monthly Income Calculation of Contribution toward Cost of Care Begin Date 11/01/2008 Begin Date 11/01/2008 Earned Income < Gross Monthly Income p Wages, Salary r .00 Total Earned Income .00 Self Employment .00 Total Unearned Income 2429.60 Rental Income .00 Income available first month .00 Other .00 Deductions ": Total Earned 00 Personal Needs Allowance 45.00 Income: Unearned < Guardianship Fee . 00 Income Social Security 1474.40 Total Allowance for Spouse / .00 Dependant SSI .00 Home Maintenance .00 Veteran's Benefits 00 Contribution towards 2384.60 . Cost of Care: Pension 955.20 The LTC facility will deduct the following medical expense from your contribution towards Cost of Care Railroad Benefits .00 Medicare Premium 96.40 Workmen's Comp .00 Other Insurance Premium .00 Black Lung 00 The LTC facility may deduct additional medical bills . including supplemental health insurance premiums, provided they are verified. Annuity/Trust o 0 Payment Interest / Dividend .00 Other (Rental, etc.) .00 Total Unearned Income: 2429.60 IF YOU WISH TO APPEAL, PLEASE COMPLETE AND RETURN THE BOTTOM PORTION OF THIS FORM. ----- DETACH HERE DETACH HERE Please check one of the boxes to show which type of hearing you want: ? I want a telephone Hearing. I and my witnesses and anyone helping me will be at this phone number: ? I want a Telephone Hearing. I and my witnesses and anyone helping me will be at the County Assistance Office (CAO). ? I want a Face to Face Hearing. I and my witnesses and anyone helping me will be in the hearing room with the Judge and the caseworker and CAO staff. ? I want a Face to Face Hearing. I and my witnesses and anyone helping me will be in the hearing room with the Judge. The caseworker and other staff will be on the phone from the CAO, if they decide not to come to the hearing room. PLEASE CHECK BELOW IF YOU NEED HELP BECAUSE OF A HEARING PROBLEM OR DISABILITY OR YOU NEED AN INTERPRETER: ? I have a hearing impairment or disability. I will need special help. ? I need an interpreter. There will be no cost to me. What language? CLIENT SIGNATURE ADDRESS TELEPHONE NO. DATE SIGNATURE CLIENT REP. ADDRESS TELEPHONE NO. DATE 4 • 91 VERIFICATION The undersigned hereby verifies that the statements of fact in the foregoing Complaint are true and correct to the best of my knowledge, information and belief. I understand that any false statements therein are subject to the penalties contained in 18 Pa. C.S.A. § 4904, relating to unsworn falsification to authorities. Dated: Jeff Davi I Presbyterian' Ridge Village 4Mncial Officer, Living d/b/a Green Ell IALED-Offi E OF THE pEOTIHOINJTARY 2009 JUN -9 Pty 1' 51 cum - L fi ?LVA??J,S dTl' P `? NIAA ?d. $If, ?-d 4? (Ir I Oq 0 # aaotia i IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CASE NO.: 09-3807 AFFIDAVIT OF SERVICE Presbyterian Senior Living d/b/a Green Ridge Village vs. Lester Russell; Amy Russell Commonwealth of Pennsylvania County of Dauphin as. I, Timothy Hoot, a competent adult, being duly sworn according to law, depose and say that at 11:30 AM on 06/18/2009, I served Lester Russell at Green Ridge Village, 210 Big Spring Road, Newville, PA 17241 in the manner described below: ® Defendant(s) personally served. ? Adult family member with whom said Defendant(s) reside(s). Relationship is -_ ? Adult in charge of Defendant(s) residence who refused to give name and/or relationship. ? Manager/Clerk of place of lodging in which Defendant(s) reside(s). ? Agent or person in charge of Defendant's office or usual place of business. an officer of said Defendant's company. ? Other: a true and correct copy of Notice; Complaint issued in the above captioned matter. Description: Sex: Male - Age: 75 - Skin: White - Hair: Gray - Height: 5' 11" - Weight: 175 Swo n to and subs ribed before me on this X h day of T mothy H1h Y ZVU2009. Shinkowsvestigations 316 Fawn Ridge North Harrisburg, PA 17110 NO ARY PUBLIC (600) 276-0202 Atty File#: PHI-GR-009 - Our File# 7648 Law Firm: Schutjer Bogar, LLC - Pittsburgh Address: 600 Grant Street, Suite 3290, Pittsburgh, PA, 15219 Telephone: (412) 281-0965 COMMONWEALTH OF PENNSYLVANIA NOTARIAL SEAL Erin M. Johnson, Notary Public Lower Paxton Township, Dauphin County My commission expires November 18, 2012 FILED-a-'FICE 01 THE PP-OTHONIO -A?Y 2909 JUL -I Pil 12: E 2 11 CUMH IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CASE NO.: 09-3807 AFFIDAVIT OF SERVICE Presbyterian Senior Living d/b/a Green Ridge Village VS. Lester Russell; Amy Russell / C';1 ns ,? O Commonwealth of Pennsylvania Cu C..._ County of Dauphin so. e ?. r rr?? I, Timothy Hoot, a competent adult, being duly sworn according to law, depose and say that at r P n ' 06/2012009, I served Amy Russell at 11 Schoolhouse Road, Newville, PA 17241 in the manne described be C ?_ fr -i ? Defendant(s) personally served. ny rn ® Adult family member with whom said Defendant(s) reside(s). Relationship is Esteban Andrade- Spouse. Adult in charge of Defendant(s) residence who refused to give name and/or relationship. Manager/Clerk of place of lodging in which Defendant(s) reside(s). Agent or person in charge of Defendant's office or usual place of business. ? Other: an officer of said Defendant's company. a true and correct copy of Notice; Complaint issued in the above captioned matter. Description: Sex: Male - Age: 32 - Skin: White - Hair: Black - Height: 5' 06" - Weight• 140 X Sworn to and subs ribed before me on this Timothy t day of 20(4. Shinkow y Investigations 316 Fawn Ridge North Harrisburg, PA 17110 (800) 276-0202 NOTARY UBLIC Atty File#: PHI-GR-009 - Our File# 7649 Law Firm: Schutjer Bogar, LLC - Pittsburgh Address: 600 Grant Street, Suite 3290, Pittsburgh, PA, 15219 Telephone: (412) 281-0965 jMl"BALTH OF PENNSYLVANIA NOTARIAL SEAL stn M. Johnson, Notary Public Lower Paxton Township, Dauphin County AM!ji.NMt&im November 18, 2012