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(f) Period Under Consideration

Verification Requirements Specific to Long-Term Care (LTC) Eligibility

The DHR/ FIA 1052-LTC-Request for Information to Verify Eligibility form is sent by the CM to the A/R, specifying information or verifications need to determine LTC eligibility and giving the due date for receipt of the information. The following types of verifications are addressed on the form:

Application-The DHR/FIA CARES 9709 is used as the application form for Medical Assistance LTC eligibility Representative-The DES 2000-LTC-Physician’s statement of Incapacitation is no longer required to be completed and signed by the applicant’s physician, in order for a representative to sign the application and participate in the application process on the applicant’s behalf. Also, the DES 2004- Representative’s Statement is no longer required to be completed and signed by the applicant and the representative, in order to authorize a representative to act on the applicant’s behalf. Since the Medical Assistance program does not require a representative to be legally authorized by a court in order to act on the applicant’s behalf, it is not necessary to obtain verification of guardianship or powers of Attorney. Signatures on the CARES 9709 application are sufficient to authorize a representative acting on the applicant’s behalf. Consent to Release Information The DHR/FIA 704 form is used for applicants to consent to the release of information. For LTC applicants, the DES 2002 form is also signed by the A/R to authorize the long-term care facility (LTCF) to release information to the LDSS related to the LTC application. The DES 2005 form is signed by the A/R to authorize the LDSS to release information about the application to a designate LTCF. Medical Level of Care- In order for the LDSS to determine LTC eligibility, the applicant must be certified by DHMH’s utilization control unit (UCA):

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