Page 12

12

c. Any requested documentation on the DHB-5056. Include the information regarding the qualified Long-Term Care Partnership policy. Refer to IV.C.3. above.

d. Attach a copy of the qualified Long-Term Care Partnership policy, if available.

6. Do not forward any forms or invoices to the clerk of court. All documentation is forwarded to the TPR unit.

7. If it is discovered that the beneficiary was eligible for Medicaid prior to October 1, 1994, and has had no break in eligibility since September 30, 1994, write “prior to 10/1/94” on the invoice and complete the DHB-5056.

a. The required fields are:

 name of beneficiary,  Medicaid ID #,  date of death,  county worker, and  date and telephone number of worker.

b. Circle YES for the first question.

c. Attach the Benefit History print out and send it to the TPR unit.

8. Mail the second copy of the invoice and the DHB-5054, Medicaid Estate Recovery Claim, to the individual who received the DHB-5051/DHB- 5051sp, DHB-5052/DHB-5052sp, DHB-5052SA/DHB-5052SA-sp or DHB- 5053 form.

9. If the applicant dies during the application process, send the DHB-5054 to the personal representative or family member of the deceased beneficiary. It is not necessary to send the notice and invoice via certified mail.

10. Maintain the third copy of the invoice with the local agency case.

D. Instructions for Supplemental Security Income (SSI) Beneficiaries

1. SSI cases are terminated by the Social Security Administration (SSA). When you learn of the death of a SSI beneficiary who has not been terminated by Social Security, report the date of death promptly via the DMA-5049, Referral to Local SSA Office.

DocuSign Envelope ID: FDC5A36F-C20D-40ED-8E94-3167F2A747A6 DocuSign Envelope ID: 9CB30F35-4CFE-41A3-8663-00DA59A946C6