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West Virginia Income Maintenance Manual Chapter 24

West Virginia Income Maintenance Manual Page 52 Chapter 24 Long Term Care

• Depriving the individual of medical care to the extent that the individual’s health or life would be endangered; or • Depriving him of the ability to obtain food, clothing, shelter or other necessities of life. ➢ Notice of Right to Request an Undue Hardship Waiver (DFA-NL-UH-1) and the Fair Hearing Request Form (DFA-FH-1) When the Worker determines the individual is otherwise eligible for LTC services except for one or more of the asset policies listed above to which an undue hardship provision applies, he gives the individual the Notice of Right to Request an Undue Hardship Waiver (DFA-NL-UH-1) and the Fair Hearing Request form (DFA-FH-1) at the time of the eligibility decision, which provides him the opportunity to request a waiver of the denial due to undue hardship. The individual, his authorized representative or a nursing facility staff member with the client’s permission, can use these forms to apply for an undue hardship waiver. ➢ Application for an Undue Hardship Waiver (DFA-UH-5) The Application for an Undue Hardship Waiver (DFA-UH-5) must be attached to the DFA-NL- UH-1. The DFA-UH-5 is the application for the waiver. It must be completed and returned to the Worker within 13 days of notice of the eligibility decision. Upon receipt, the Worker immediately mails, emails, or faxes it to the Bureau for Medical Services (BMS) Policy Unit for distribution to the Undue Hardship Waiver Committee. The DFA-UH-5 must include a signature of the individual for whom the waiver is filed when the LTC facility is completing the request. It must include an explanation of any efforts made to resolve the asset issue that resulted in the LTC services denial. Documentation that supports these attempts must be attached. Details regarding the individual’s undue hardship must be explained. If the DFA-UH-5 is not returned complete and timely, no additional notice occurs and the negative eligibility decision and any penalty applied remains. An individual who resides in a facility and requests an Undue Hardship Waiver is eligible for payment of up to 30 bed-hold days from the date the DFA-UH-5 is received by the BMS Policy Unit until a decision is made by the Committee. The Committee has 60 days to make a decision concerning the Waiver request. Denial of payment of LTC services due to excessive home equity is not subject to payment of bed-hold days. ➢ Decision for Request of Undue Hardship Waiver Form (DFA-NL-UH-2) If the waiver request is not appropriate for the Committee, it is returned to the local office which made the eligibility decision. The individual is notified of the Committee’s decision via the