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West Virginia Income Maintenance Manual Chapter 24

West Virginia Income Maintenance Manual Page 80 Chapter 24 Long Term Care

Form Name Description is also sent to the nursing facility, BMS LTC Unit, and the client or his AR DFA-NL-A Notification Letter: Action Taken On Your Application Notice of decision at application. DFA-NL-B Notification Letter: Action Taken On the Benefits You Receive from the DOHS Notice of decision at redetermination. DFA-NL-C Notification Letter: Pending Change in the Benefits You Receive Notice of decision related to a change in benefits. DFA-NL-D Notification Letter: Action Taken on Your Request for an Assessment of the Assets Belonging to Both You and Your Community Spouse Informs client of results of an asset assessment, whether or not he has formally applied for Medicaid. DFA-NL-UH-1 Notification of Right to Request an Undue Hardship Waiver Sent with DFA-FH-1 and DFA-NL-UH-5. DFA-NL-UH-2 Decision for Request of Undue Hardship Sent with FH-1 to notify client of UH decision. DFA-UH-5 Application for Undue Hardship Waiver Application for undue hardship waiver. IM-NL-AC-1 Assets Computation and Asset Assessment Used to complete an asset assessment. IM-NL-LTC-1 Long Term Care Calculations Determines eligibility for Nursing Facility coverage group and contribution to cost of care. IM-NL-LTC-2 Determination of Community Spouse and Family Maintenance Allowance for LTC programs Calculates allowances for the community spouse and dependent family. Sent with applicable notice of decision form. OFS-LTCIP LTCIP Policy Verification LTC insurance partnership policy verifications for eligibility for LTCIP disregard.