Page 1932

West Virginia Income Maintenance Manual Chapter 24

West Virginia Income Maintenance Manual Page 7 Chapter 24 Long Term Care

24.4.1.C Nursing Facility Coverage Group and SSI-Related/Monthly Spenddown Group If the applicant is currently residing in the nursing facility, is not eligible as a QMB client, and is not eligible to receive full coverage Medicaid without a spenddown, he must apply for Medicaid eligibility in the Nursing Facility coverage group or SSI-Related/Monthly Spenddown group. 24.4.1.C.1 Application Forms The following application forms may be used: • DFA-2; • WV PATH; • DFA-MA-1, Application for Long Term Medicaid and Children with Disabilities Community Service Program; or • DFA-SLA-1 or DFA-SLA-2, Single-Streamlined Application (SLA) with supplement DFA- SLA-S1. The DFA-RR-1 is required with the DFA-2. 24.4.1.C.2 Complete Application The application is complete when the client or his authorized representative signs a DFA-2, WV PATH application, DFA-5, DFA-MA-1, or SLA which contains, at a minimum, the client's name and address. 24.4.1.C.3 Date of Application The date of application is the date the applicant submits a DFA-2, WV PATH application, DFA- MA-1, or SLA, in person, by electronic transmission, or by mail, which contains, at a minimum, his name, address, and signature. When the application is submitted by mail or fax, the date of application is the date that the form with the name, address, and signature is received in the local office.

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Page 1932

Official source

West Virginia Income Maintenance Manual Chapter 24

West Virginia Income Maintenance Manual Page 7 Chapter 24 Long Term Care

24.4.1.C Nursing Facility Coverage Group and SSI-Related/Monthly Spenddown Group If the applicant is currently residing in the nursing facility, is not eligible as a QMB client, and is not eligible to receive full coverage Medicaid without a spenddown, he must apply for Medicaid eligibility in the Nursing Facility coverage group or SSI-Related/Monthly Spenddown group. 24.4.1.C.1 Application Forms The following application forms may be used: • DFA-2; • WV PATH; • DFA-MA-1, Application for Long Term Medicaid and Children with Disabilities Community Service Program; or • DFA-SLA-1 or DFA-SLA-2, Single-Streamlined Application (SLA) with supplement DFA- SLA-S1. The DFA-RR-1 is required with the DFA-2. 24.4.1.C.2 Complete Application The application is complete when the client or his authorized representative signs a DFA-2, WV PATH application, DFA-5, DFA-MA-1, or SLA which contains, at a minimum, the client's name and address. 24.4.1.C.3 Date of Application The date of application is the date the applicant submits a DFA-2, WV PATH application, DFA- MA-1, or SLA, in person, by electronic transmission, or by mail, which contains, at a minimum, his name, address, and signature. When the application is submitted by mail or fax, the date of application is the date that the form with the name, address, and signature is received in the local office.