Page 2064

West Virginia Income Maintenance Manual Chapter 24

West Virginia Income Maintenance Manual Page 139 Chapter 24 Long Term Care

TRAUMATIC BRAIN INJURY (TBI) WAIVER 24.45 APPLICATION/REDETERMINATION The West Virginia Department of Human Services (DOHS) Referral Form for Medicaid Traumatic Brain Injury (TBI) Waiver Program, Initiate Financial Eligibility (DHS-2.FRM) must be presented to begin the TBI waiver financial eligibility determination process. The DHS-2.FRM form has two versions, one yellow and one white. • The yellow DHS-2.FRM instructs the Worker to determine financial eligibility. Financial eligibility is determined for the TBI waiver program before medical eligibility is initiated. • The white DHS-2.FRM, along with the Notice of Decision letter, confirms the client is medically-eligible and that a funded waiver slot is available for the TBI waiver program. The steps in the application process are outlined in Section 24.45.2 below. 24.45.1 GENERAL APPLICATION PROCEDURES 24.45.1.A Application Forms New applicants must apply for TBI waiver Medicaid using the DFA-MA-1, DFA-2, or DFA-SLA-1 and DFA-SLA-S1. Current Supplemental Security Income (SSI) and Deemed SSI clients must complete the DFA-LTC-5 form to evaluate for trusts, transfers, and annuities. An interview is not required. If a face-to-face interview is requested by the client or their authorized representative, the appointment must be scheduled within 10 calendar days of the date of the contact. The appointment may be scheduled after 10 calendar days only at the request of the client or his authorized representative. 24.45.1.B Complete Application The application is complete when the client or his authorized representative signs the appropriate application form which contains, at a minimum, the client's name, address and signature.