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State of Maryland Medical Assistance Manual Revised April 2014

1000.12 Long- Term Care (LTC) and Forms and Notices

Once a form has been revised, older version are obsolete. Please verify you are using the correct form.

1. DES 501- Less Than 30 Day Stay Form

This form is used when the DHMH 257 is received by the LDSS showing a LTC stay less than 30 days. The form is sent to the Division of Recipient Eligibility Programs (DREP). A completed DHMH 257 must accompany the DES 501. If the recipient is enrolled in an MCO on the date of admission, the form cannot be processed because the MCO is responsible for the first 30 days of admission.

2. DES 601 A (LTC)- Spousal and Family Allowance Worksheet

This worksheet is used in determining the monthly maintenance allowance for a spouse or the monthly maintenance allowance for a family (see Section 1000).

3. DES 601 B (LTC)- Dependent Allowance Worksheet

This worksheet is used in determining the monthly maintenance allowance for a dependent child, when the institutionalized individual does not have a spouse living in the community (see Section 1000).

4. DES 602 (LTC)- Notice- Consideration of Resources in Continuing Eligibility

Notice indicating a couple’s total combined resources and the amounts attributed to the institutionalized individual and to the community spouse. It also advises the community spouse of the 90-day time frame to transfer certain resources of the institutionalized spouse into the community spouse’s name.

5. DES/LTC 811 -Transfer/Disposal of Assets Worksheet

This worksheet is used to determine when a penalty applies for disposal or transfer of assets. It is also used to calculate the amount of the penalty and the penalty period. If the client has an active penalty period, the CM must complete and fax the DES/LTC 813 to the Division of Recipient Eligibility Programs (DREP).

6. DES/LTC 812- Home Equity Value Worksheet

This worksheet is to be completed to evaluate the equity value of the home property. When the equity value exceeds the current home equity limit in Schedule MA-10, by any amount, the caseworker must complete and fax the DES/LTC 813 to the Division of Recipient Eligibility Program (DREP).

7. DES/LTC 813 -Manual MMIS Instructions for Screen 4/Screen 8

This form is sent to the Division of Recipient Eligibility Programs (DREP) when a penalty exists or the home equity value exceeds the current home equity limit. DREP