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NC FAST automatically generates and mails the appropriate form based on the age of the applicant and the Medicaid program approved.

4. No signature is required for Estate Recovery forms.

5. The appropriate Estate Recovery form is determined by the age of the applicant and the Medicaid program approved.

a. Group 1 includes individuals under the age of 55 who must receive DHB-5051/DHB-5051sp, Your Estate May be Subject to Medicaid Recovery.

b. Group 2 includes individuals aged 55 or older, who must receive DHB-5052/DHB-5052sp, Your Estate is Subject to Medicaid Recovery.

c. Individuals who are eligible for SA automatically meet the eligibility requirements for Medicaid, regardless of age or living arrangement (adult care home or in home). Each SA a/b must receive DHB- 5052SA/DHB-5052SA-sp, State/County Special Assistance Applicant Medicaid Estate Recovery Notice.

B. Notification Procedures – at Recertification:

If notification forms regarding estate recovery are provided at application and documented on the case a second notification is not necessary at recertification unless the individual has turned age 55 since the last recertification or application.

C. Under age 55 – Facility Stay:

1. When an individual under the age of 55 enters a medical facility, it must be determined if the stay will be temporary or permanent/indefinite.

2. DHB-5051/DHB-5051sp, Your Estate May be Subject to Medicaid Recovery provides notice to the a/b explaining that they may be subject to estate recovery and that a determination must be made whether the a/b is considered living in a facility on a permanent or indefinite basis.

3. Do not delay approval of the application while making the determination of whether the stay is permanent or indefinite (refer to III.D., below).

4. If the placement is found to be permanent or indefinite, mail the DHB-5053, Your Estate Is Subject to Medicaid Recovery, which explains the decision and appeal rights.

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