Page 2051

West Virginia Income Maintenance Manual Chapter 24

West Virginia Income Maintenance Manual Page 126 Chapter 24 Long Term Care

• If the client does not submit the appropriate Medicaid application form prior to the yellow DHS-2.FRM expiration date, the Worker checks the box indicating the application was not completed and faxes the form back to the UMC. 24.37.3.B Step Two: Receipt of the DOHS Referral Form for Medicaid Aged and Disabled Waiver Program (DHS-2.FRM) WHITE FORM The white DHS-2.FRM, along with the Notice of Decision letter, confirms to the Worker the client was determined medically-eligible and awarded a funded slot for the ADW program. 24.37.3.B.1 Expired White DHS-2.FRM If the white DHS-2.FRM form is expired, the Worker checks the box indicating it is expired and faxes the form back to the originating agency. Medicaid coverage for nursing facility services continues if all requirements are met. 24.37.3.B.2 White DHS-2.FRM with Missing Expiration Date If there is no expiration date on the white DHS-2.FRM, it should be faxed back to the originating agency, noting there is no expiration date. Medicaid coverage for nursing facility services continues if all requirements are met. 24.37.3.B.3 Current (Not Expired) White DHS-2.FRM If the white DHS-2.FRM is not expired: • The Worker approves eligibility in the ADW category upon notification the client has been discharged from the nursing facility. • The Worker checks the appropriate box on the white DHS-2.FRM indicating whether the client is eligible or ineligible for Medicaid ADW and faxes the form back to the originating agency.

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Page 2051

Official source

West Virginia Income Maintenance Manual Chapter 24

West Virginia Income Maintenance Manual Page 126 Chapter 24 Long Term Care

• If the client does not submit the appropriate Medicaid application form prior to the yellow DHS-2.FRM expiration date, the Worker checks the box indicating the application was not completed and faxes the form back to the UMC. 24.37.3.B Step Two: Receipt of the DOHS Referral Form for Medicaid Aged and Disabled Waiver Program (DHS-2.FRM) WHITE FORM The white DHS-2.FRM, along with the Notice of Decision letter, confirms to the Worker the client was determined medically-eligible and awarded a funded slot for the ADW program. 24.37.3.B.1 Expired White DHS-2.FRM If the white DHS-2.FRM form is expired, the Worker checks the box indicating it is expired and faxes the form back to the originating agency. Medicaid coverage for nursing facility services continues if all requirements are met. 24.37.3.B.2 White DHS-2.FRM with Missing Expiration Date If there is no expiration date on the white DHS-2.FRM, it should be faxed back to the originating agency, noting there is no expiration date. Medicaid coverage for nursing facility services continues if all requirements are met. 24.37.3.B.3 Current (Not Expired) White DHS-2.FRM If the white DHS-2.FRM is not expired: • The Worker approves eligibility in the ADW category upon notification the client has been discharged from the nursing facility. • The Worker checks the appropriate box on the white DHS-2.FRM indicating whether the client is eligible or ineligible for Medicaid ADW and faxes the form back to the originating agency.