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West Virginia Income Maintenance Manual Chapter 24

West Virginia Income Maintenance Manual Page 6 Chapter 24 Long Term Care

Section 24.8 apply. These additional eligibility requirements for payment of nursing facility services apply to all Medicaid clients, including SSI, Deemed SSI, and Modified Adjusted Gross Income (MAGI) coverage group clients, and require the client to submit an additional application form for payment of nursing facility services. 24.4.1.B.1 Application Form All full coverage Medicaid clients who need Medicaid payment for nursing facility services must complete and return the Application for Long Term Care Services for Current Medicaid Recipients (DFA-LTC-5), at the initial application for nursing facility services. The DFA-LTC-5 is used to evaluate annuities, trusts, and resource transfers to determine if a transfer penalty applies. 24.4.1.B.2 Date of Application The date of application for payment of nursing facility services for current Medicaid clients is the date the applicant submits a DFA-LTC-5 in person, by electronic transmission, or by mail, which contains, at a minimum, his name, address, and signature. Payment for nursing facility services is not approved until the DFA-LTC-5 form is completed, signed, and returned to the local office. 24.4.1.B.3 SSI and Deemed SSI SSI and Deemed SSI Medicaid clients who need Medicaid payment for nursing facility services must complete the DFA-LTC-5 application form at initial application and annual redetermination. SSI and Deemed SSI clients were determined asset eligible for Medicaid by the Social Security Administration (SSA), however, the client must disclose information about transfer of resources, trusts, and annuities. Payment for nursing facility services is not approved until the DFA-LTC-5 form is completed, signed, and returned to the local office. When the DFA-LTC-5 form is not returned at the annual redetermination, the payment for long term care (LTC) services is closed after advance notice.