Adult Medicaid Manual MA-2285 – ESTATE RECOVERY

III. PROCEDURES

A. Notification Procedures

There are different notification requirements for individuals under the age of 55 and individuals age 55 or older. If notification forms regarding estate recovery are given at application and documented in the file a second notification is not necessary at redetermination, unless the individual has turned age 55. Medicaid is automatic for all Special Assistance (SA) facility recipients. Therefore, each Special Assistance, (SA) applicant/recipient, regardless of age, or his representative must sign the DMA-5052SA, State/County Special Assistance Applicant Medicaid Estate Recovery Notice. (Not applicable to SA/IH a/rs). They will have signed the DMA notice, since they must first qualify for Medicaid before being approved for SA/IH).

(III A.)

Notification for:

Group 1

Under age 55

Group 2

Age 55 or older

PLA/SA/CAP LTC

DMA-5051, possibly DMA-5053

DMA-5052/DMA-5052SA

1. A/r or his representative must sign the DMA-5051, Your Estate May Be Subject to Medicaid Recovery. This form is notice to the a/r explaining that he may be subject to estate recovery and that a determination must be made whether the a/r is considered living in a facility on a permanent or indefinite basis.

2. If the a/r or representative refuses to sign, document this on the DMA-5051, and in the case record.

3. Document in the case record that the notice was given or mailed to the a/r, and file a copy of the form in the case record.

4. Do not delay approval of the application while making the determination of whether the stay is permanent or indefinite.

5. If the placement is found to be permanent or indefinite, mail the DMA-5053, Your Estate Is Subject to Medicaid Recovery, which explains the decision and appeal rights.

6. File a copy of the DMA-5053 in the case record. No further action is required at this time.

1. A/r or his representative must sign the DMA-5052, Your Estate Is Subject To Medicaid Recovery, or the DMA-5052SA, State/County Special Assistance Applicant Medicaid Estate Recovery Notice, if the a/r is SA. Provide a signed copy of the DMA-5052, or the DMA-5052SA, to the applicant and/or his representative and retain one copy for the case file. This is a general notice that explains the a/r is subject to estate recovery.

2. If the a/r or representative refuses to sign, document this on the DMA-5052 or the DMA-5052SA and in the case record.

3. Document in the case record that the notice was given or mailed to the a/r, and file a copy of the form in the case record.

4. No further action is required at this time.

REVISED 05/01/11 – CHANGE NO. 09-11

(III)

B. Determination of “Permanent or Indefinite basis” for recipients under age 55 (Group 1 Above)

Living in a Medical facility on a permanent or indefinite basis means the individual under the age of 55 cannot reasonably be expected to be discharged to return home. This determination is based on documentary evidence. This does not mean an individual would never be able to return home. The county DSS is responsible for making the determination that the a/r cannot reasonably be expected to be discharged home. There are several ways to establish this.

1. Initial Determination

Review the FL-2/MR-2 or other documentary evidence:

Verify whether it contains a specific discharge plan/date or period of time that care in an institution is needed. Other documentary evidence includes the nursing facility’s plan of care, hospital discharge summary/planner’s report or a physician’s statement.

For example, an FL-2 may indicate placement required for 5 months to provide care and physical therapy for an individual who is recovering from a broken hip. This indicates a plan for discharge in 5 months. Therefore, the stay is not considered permanent or indefinite.

When the FL-2/MR-2 or other documentary evidence does not indicate a specific discharge plan/date:

The person is considered permanent or indefinite and cannot be reasonably expected to be discharged home.

When the FL-2/MR-2 or other documentary evidence indicates a specific discharge date to the home or reasonable plans for discharge:

1. Take no further action at this time.

2. Flag the case for review at the projected date of discharge or at the next review, whichever comes first.

Please see III.B.2 below for instructions.

REVISED 05/01/11 – CHANGE NO. 09-11

(III. B)

2. Determination at next review or flagged date

On the flagged date or next review:

1. Verify the recipient’s current living arrangement. If the individual was discharged to return home to live, his placement was not permanent and estate recovery does not apply.

2. No further action is required.

If the individual is still residing in the facility:

1. Consider that the individual cannot reasonably be expected to be discharged to return home unless documentation of specific plans and a date for discharge is provided from one of the sources listed in III.B.1.

2. Document the decision in the case record.

If no medical documentation of a specific discharge plan/date is provided or the individual is still residing in a facility at the time of the review:

1. Consider that the individual cannot reasonably be expected to be discharged to return home.

2. If the recipient in the medical facility dies before the determination has been made, assume the placement was permanent.

3. Document the decision in the case record.

C. Reconsideration Review of “permanent or indefinite status”

The recipient or his parent/guardian/responsible person acting on behalf of the

recipient may request reconsideration of the determination that the individual cannot reasonably be expected to be discharged to return home.

1. The recipient or his parent/guardian/responsible person acting on behalf of the recipient may request the reconsideration review in writing by completing the back page of the DMA-5053, Your Estate Is Subject to Estate Recovery.

2. The request is forwarded to the Department of Health and Human Services Hearings Office within 30 calendar days of the date of the notification.

3. If the request is forwarded to county DSS, the county must send the request, including evidence supporting the county’s decision, to the Department of Health and Human Services Hearings Office within 30 calendar days of receipt of the request for a reconsideration review.

REVISED 05/01/11 – CHANGE NO. 09-11

(III. C)

4. Within 30 calendar days of receipt of reconsideration review, the Hearings Office shall establish a reconsideration date and conducts a review of:

a. All evidence considered by the county DSS in making a determination of permanent institutionalization, and

b. Information provided to the Hearings Office, in writing or by telephone conference with the recipient or an individual acting on the behalf of the recipient.

5. The estate recovery administrator notifies the recipient or the individual acting behalf of the recipient in writing within 15 calendar days of the reconsideration review. If the recipient disagrees with the decision of the reconsideration review, he or she may appeal to the Office of Administrative Hearings (OAH) within 60 calendar days from receipt of the decision. If no appeal to OAH is filed the decision is final.