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West Virginia Income Maintenance Manual Chapter 24

West Virginia Income Maintenance Manual Page 79 Chapter 24 Long Term Care

Any time the client or his authorized representative is notified of any changes in the client's eligibility, the nursing facility administrator must also be notified. If more than one nursing facility is involved, each administrator must be sent a copy of the ES-NH-3. Below is a table of forms referenced in this chapter. It shows the form number, name, and description. The form number can vary on eligibility system generated notices. Form Name Description DFA-2 Application for Benefits Application for benefits that can be used by all eligibility groups DFA-5 Document for Protection of Application Date When the applicant has completed the application, and there is a technical failure that prevents printing the DFA-2, Form DFA-5 must be signed by the applicant. DFA-6 Request for Information Also called the “verification checklist;” used to inform the applicant of additional information needed. DFA-10 Appointment Letter for Office, Home, Phone Notifies the client of the scheduled appointment time and date. DFA-FH-1 Fair Hearing Request Form Notifies client of right to fair hearing, often sent with other forms. DFA-HS-3 Interagency Referral Form Notifies the Social Security Administration when an SSI recipient enters or leaves a nursing facility. DFA-LTC-5 Application for Long Term Care Services for Current Medicaid Recipients Gathers information regarding transferred assets, trusts, and annuities. DFA-MA-1 Application for LTC Medicaid and CDCSP A shelf document used to apply for the following Long Term Care (LTC) Medicaid categories: Nursing Facilities Services, Intermediate Care Facilities (ICF) for Individuals with Intellectual Disabilities, Aged and Disabled Waiver (ADW), Intellectual Disabilities and Developmental Disabilities (IDD) Waiver, Traumatic Brain Injury (TBI) Waiver, and Children with Disabilities Community Service Program (CDCSP). It must only be used for applicants that are not eligible for Medicaid coverage using the Modified Adjusted Gross Income (MAGI) methodology. DFA-NH-3 Notice of Contribution to the Cost of Care Along with any appropriate letter, notifies client of initial or changed required contribution. This