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• Proof that an undue hardship would exist if eligibility is terminated or denied or the divestment penalty period is applied (required for all four situations to which Undue Hardship policy may apply) as follows: • If the applicant or member is currently institutionalized, he or she must submit a copy of the notification from the long term care facility which states both of the following: ◦ The date of involuntary discharge ◦ An alternative placement location • Or other proof that if the undue hardship waiver is not approved, the applicant or member will: ◦ Not receive medical care resulting in his or hers health or life to be endangered ◦ He or she will not have food, clothing, shelter, or other necessities of life. • If the applicant or member is applying for HCBW, including FamilyCare, FamilyCare Partnership, PACE, or IRIS he or she must submit an estimate of the cost of the long term care services needed to meet his or her medical and remedial needs (as determined by the waivers case manager) and an estimate of costs for food, shelter, clothing, and other necessities of life.

These two estimates must be compared to the applicant, member, or couple’s income and assets. If the IM agency determines that the applicant or member does not have enough income and/or assets to pay for his or her long term care and other needs (i.e., food, shelter, etc.), consider the applicant or member’s health to be endangered. If the required documentation is not submitted with the request for an undue hardship waiver, send a written request for verification to the applicant or member, giving a verification due date of 20 calendar days from the date the request is mailed. If the applicant or member fails to submit the required verification within 20 calendar days after the request is mailed, deny the undue hardship waiver request and notify the applicant or member by sending a Notice of Denial of Benefits/Negative Change in Benefits (F-16001). The deadline to submit the required documentation may be extended for up to 10 calendar days if the individual communicates to the agency a need for additional time or assistance to obtain verification. 22.4.6 Determination Process Time Frame A decision about whether to approve or deny an undue hardship waiver must be made by the IM agency within 30 calendar days after receipt of the Undue Hardship Waiver Request form (F-10193). Send the applicant or member the appropriate manual Notice of Approval of Benefits/Positive Change in Benefits (F-16015) or Notice of Denial of Benefits/Negative Change in Benefits (F-16001) based on the IM agency’s decision. If the undue hardship request is denied, the Notice of Denial of Benefits/Negative Change in Benefits (F- 16001) must include the agency’s reason for the denial: "You have not provided proof that the denial of long term care services will create an undue hardship for you." The applicant or member has the right to make another subsequent request if and when his or her circumstances change. If an undue hardship waiver is approved, a new undue hardship request is not required to be completed at renewal unless there has been a change in the circumstances surrounding the original reason for the request. 22.4.7 Bed Hold Payments and Notifications (Divestment Only) When an undue hardship waiver request is received by an IM agency from an institutionalized individual, the IM agency must inform the institution that the request was received and that a bed hold