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o The first month for which the institutionalized person has applied for LTC and has been found to meet all eligibility requirements except for the transfer of assets for less than full market value.

If the calculation of a restricted period of coverage results in a partial month at the end of the restricted period, the payability for the partial month will be prorated, using the following formula:

(Payability for full month) x (1 – (minus) the part of month not covered).

During the period of restricted Community Medicaid coverage, if the individual is otherwise eligible for Community Medicaid, the individual is eligible for all covered medical services except nursing facility services, equivalent care in a medical institution, and home and community-based services.

Example 1 Mr. Barth makes a transfer on January 2, 2006. The period of restricted coverage begins September 1. Example 2 Ms. Adams makes a transfer on March 31, 2010. She enters a nursing home in June, 2010 and applies for LTC on July 16, 2010. She is found otherwise eligible for LTC effective July 1, 2010. The period of restricted coverage begins July 1, 2010.

Once a period of restricted Community Medicaid coverage is established, the period may only be recalculated if the LTC applicant provides documentation within forty-five days after the LTC application that all or part of the total uncompensated value was returned to the applicant. In such a case, divide the remaining uncompensated value by the average cost of care to establish the adjusted period of restricted coverage.

Undue Hardship

Once a period of restricted eligibility is assigned, an applicant can claim undue hardship when a penalty will result in inability to get necessary medical services so that health or life would be endangered. Undue hardship also exists when imposing the penalty would result in deprivation of food, clothing, shelter or other necessities of life. Undue hardship does NOT exist when the penalty causes inconvenience, restricts a person’s lifestyle, or does not put a person at risk of serious deprivation.

Applicants can request an undue hardship waiver by calling Yvette Thomas on (202) 698-4247 within 15 days of the notice of restricted coverage.

Applicants need to provide the following information regarding eligibility for a Hardship waiver:

 the reason for the transfer;  attempts that have been made to recover the transferred asset;  notice of pending discharge from the nursing facility due to the denial of payment of LTC services;  notice of pending termination of community-based services due to denial of payment;  statement from doctor(s) saying that the inability to get LTC or community-based services would result in NOT getting medical services needed to prevent the endangerment of health or life;  proof that the restriction would result in an inability to get food, clothing or shelter;