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Send a DMA-5110, Request for Medical Assistance Coverage For Institutional Services and Disclosure Of Annuities, to the beneficiary and a DHB-5097/DHB-5097S Request For Information. Send a DMA-5112, Informational Notice Regarding Annuities and Medicaid Eligibility, to the issuer of the annuity. The annuity that is a resource still must meet the requirement related to the State of North Carolina Medicaid Program being named as a remainder beneficiary. If it does not meet this requirement, it is a non-allowable transfer. Refer to MA-2240, Transfer of Assets. However, it is likely that since the annuity is a countable resource, the a/b or the a/b’s spouse will be ineligible due to excess resources and transfer of assets sanction will not apply. If an annuity purchased on or after November 1, 2007, is not a resource, it must be evaluated for transfer of assets under the rules in MA-2240, Transfer of Assets. H. Term Life Policies (including burial insurance policies, accident policies with death benefits) 1. Most term life policies do not generate a cash surrender value (CSV). a. If a term life insurance policy generates a CSV, include the face value in the total face value of policies which generate a CSV to determine if the CSV is a countable resource. Refer to XII.B. above. b. If the term life insurance does not generate a CSV, do not include the face value of the policy in determining the total face value of all policies that generate a CSV. 2. Verify any dividends paid by the policy. See XII.I.2.a. below for budgeting. I. The Single Premium Pure Endowment These policies pay a benefit in a balloon payment only to those persons who survive a certain period of time. The endowment portion is similar to an annuity. The purchase of a Single Premium Pure Endowment policy is an uncompensated transfer. Refer to MA-2240, Transfer of Assets. J. Verification 1. Examine life insurance policies (if available) and document: a. The name of the Insurance Company b. Policy number c. Name of the insured (on whose life the policy is written) d. Owner of the policy 92