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Undue hardship letter (F-10187).

Undue Hardship Waiver Request form (F-10193). See Process Help Section 12.18.6 Undue Hardship for information on how these forms are sent. If the situation requires an IM worker to manually send these forms, the forms must be mailed the same day or, at the latest, within 24 hours after CWW or the IM worker mails the Notice of Denial of Benefits/Negative Change in Benefits (F-16001) informing the applicant or member that long-term care services will be terminated or denied. 22.4.3 Valid Request A completed Undue Hardship Waiver Request form (F-10193) must be submitted to the IM agency. A written and signed request that fulfills the minimum request requirements listed in SECTION 22.4.5 REQUIRED DOCUMENTATION is also acceptable. The long-term care facility in which the applicant or member is residing may also file an undue hardship request on behalf of the institutionalized person. However, the long-term care facility must have the applicant or member’s, or his or her authorized representative's, power of attorney's, or legal guardian’s written permission, using the Undue Hardship Waiver Request form, to file the undue hardship request. The long-term care facility can also represent the institutionalized person in any subsequent fair hearing activity involving an undue hardship request or denial, as long as the facility has the applicant's or member's (or his or her authorized representative's, power of attorney's, or legal guardian’s) written permission to do so. This can also include the facility requesting a fair hearing. Note: A long-term care facility could include a nursing home, CBRF, or IMD (see SECTION 27.1 INSTITUTIONS). 22.4.4 Effective Date of Approved Undue Hardship Waivers IM agencies are required to process any valid request for an undue hardship waiver, whether the request is submitted timely or untimely. Completed requests must be scanned into the ECF and case comments entered documenting the receipt of the undue hardship request. 22.4.4.1 Timely Request—Received Within 20 Calendar Days After Notification Is Mailed If the valid request for an undue hardship waiver is received by the IM agency within 20 calendar days of the undue hardship letter (F-10187) mailing date, and the request is approved, the effective date of the waiver will be as follows: • For divestment, the entire divestment penalty period will be waived. • For all others, the effective date will be the date initial eligibility would have begun, including any requested backdated months. Example 1: Amy receives a notice dated February 10 that her January 20 application for HCBW Medicaid is denied and she will have a 100-day divestment penalty period beginning January 20. Amy submits an undue hardship request to the IM agency that is received on February 15. The undue hardship request is approved by the IM agency and Amy’s penalty period is waived. Amy is eligible for HCBW Medicaid beginning on the enrollment date provided to the IM agency by the ADRC.