Post on 16-Sep-2020
transcript
EMILY S. ANDERSON
MA-LTC Basics 08/20/12- Health Care Training 1
Case Summary: Emily (age 89) is a widow requesting MA payment of LTC services for residence in the Bethany Care Center, a Long-Term Care Facility (LTCF). Prior to moving into the nursing facility, Emily lived in her own home with her daughter, Patricia. Patricia is Emily’s authorized representative. Emily was diagnosed with Alzheimer’s disease three years ago. Patricia and her siblings decided that they wanted to keep their mother in her home as long as possible. Patricia agreed to become Emily’s primary caretaker, so she retired early and moved in with her mother in her mother’s home. Patricia has lived in her mother’s home and has been her primary caretaker for the last 3 years. Unfortunately, on the second of last month Emily fell and broke her hip while at home. Emily was admitted to Abbott Northwestern Hospital on LM/02/YY. She had a PAS completed on LM/11/YY indicating her need for an institutional level of care. Emily began receiving skilled nursing facility services in the hospital on LM/12/YY. Emily was placed at Bethany Care Center on LM/15/YY. She is not expected to be discharged.
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DHS-3531-ENG 5-17
MINNESOTA HEALTH CARE PROGRAMS (MHCP)
Application for Medical Assistance for Long-Term-Care Services (MA-LTC)
Office Use Only
DATE RECEIVED CASE NUMBER WORKER NUMBER
■Answer all questions the best you can.■ Return the form right away.■We will contact you if we need more information.
1. Information for the person living in or planning to live in a long-term-care facility or requesting
services to help the person live at home or other settings in the community
FIRST NAME
EmilyMI
SLAST NAME
AndersonDATE OF BIRTH
GENDER
Male Female
MARITAL STATUS
Legally separated Divorced Never married Married Widowed
Do you have a Social Security number (SSN)?
Yes No
IF YES, WHAT IS YOUR SSN?
Do you have a guardian or conservator? Yes No
Are you a veteran or the spouse of a veteran?
Yes No
Are you blind, or do you have a physical or mental health condition that limits your ability to work or perform daily activities? Yes No
Are you pregnant?
Yes No N/A
Have you had a long-term-care consultation?
Yes No Don't know
What language do you speak most of the time?
EnglishDo you need an interpreter?
Yes No
OPTIONAL INFORMATION
→
RACE (check all that apply)
White Black or African American American Indian or Alaska Native Asian IndianChinese Filipino Japanese KoreanVietnamese Other Asian Native Hawaiian Guamanian or ChamorroSamoan Other Pacific Islander Other
HISPANIC OR LATINO ETHNICITY (check all that apply)
Mexican Mexican American Chicano or Chicana Puerto Rican Cuban Other
2. Are there other family members living with you? Yes – fill in below No
Name (First, MI, Last)Date of birth
(MM/DD/YYYY) Relationship to you
Patricia A Weber Daughter
CM/CD/CY
12/5/CY-89
800-11-xxxx
Rev. 6/12/2017 HC Training
Page 2 of 7 DHS-3531-ENG 5-17
3. If you or anyone in your family is an American Indian or Alaska Native, some income and
assets might not count toward your eligibility and you might not be required to pay premiums
or copays. Do you want to apply for these exceptions?
Yes No
4. Address and phone number
STREET ADDRESS WHERE YOU ARE CURRENTLY LIVING
2309 Hayes Street NECITY
MinneapolisSTATE
MNZIP CODE
55418COUNTY
HennepinMAILING ADDRESS (if different) CITY STATE ZIP CODE COUNTY
PHONE NUMBER
612-781-2691Do you plan to make Minnesota your home?
Yes No
Do you currently have medical benefits from another state?
Yes No
Are you currently in a long-term-care facility? Yes – fill in the following No
LONG-TERM-CARE FACILITY NAME
Bethany Covenant HomeDATE MOVED INTO THIS FACILITY (MM/DD/YYYY)
STREET ADDRESS BEFORE MOVING TO THIS FACILITY
871 St. Clair AveCITY
St. PaulSTATE
MNZIP CODE
55105COUNTY
Ramsey
If you have a home, do you plan to return there? Yes No
OPTIONAL INFORMATION
→
What is your living situation? (choose one)
I live in a hospital, nursing home, treatment facility or detox center.I have my own housing (rent, pay a mortgage or share housing costs with a roommate).l live with family or friends because of economic hardship.I live in an emergency shelter.I live in a service provider’s housing (foster home or group home).UnknownI live in a jail, prison or juvenile detention facility.I live in a hotel or motel.I decline to answer.I live in a place not meant for housing (anywhere outside, a vehicle, an abandoned building, a bus or train station, or an airport).
5. Are you a U.S. citizen or U.S. national? Yes No
6. Do you want someone to act on your behalf as an authorized representative?
Yes – complete Appendix B No
(You can give a trusted person permission to talk about this application with us, see your information and act for you on matters related to this application, including getting information about your application and signing your application on your behalf.)
LM/15/YY
Page 3 of 7 DHS-3531-ENG 5-17
7. Do you want help from MA to pay for medical bills from the past three months?(The start date for MA can go back up to three months from your application date if you have medical bills from that time and meet the MA requirements.)
Yes – fill in below No
How many months?
One Two Three
You must provide proof of your medical expenses, income and assets in each of the months for which you are requesting coverage. Refer to the types of proof listed after each of the following questions for examples of acceptable proof for the income and assets you had.
8. How much cash do you or your spouse have on hand, in a safety deposit
box, at home and at the facility where you live?$ 0.00
9. Do you or your spouse have savings or checking accounts, money market accounts or
certificates of deposit?
Yes – fill in below No
Owner name(s) Type of account Bank name and address Account number
Emily Savings People's Credit Union 7890123456
Emily Checking People's Credit Union 7890123456
You must provide proof of these assets. Proof may be recent account statements or a written statement from your bank showing the current balance or value of accounts.
10. Do you or your spouse have stocks, bonds or retirement accounts? Yes No
11. Do you or your spouse own or co-own houses, condominiums, summer or winter homes,
cabins, mobile homes, time-shares, rental properties, any real estate, or life estate interests or
remainder interests in real property?
Yes – fill in below No
Owner name(s) Type of property Property address
Do you or your spouse
live here all year?
Emily Residential 871 St. Clair Ave, St. Paul, 55105 Yes No
You must provide proof of these assets. Proof may be real property tax statements, warranty deeds, quit claim deeds, life estate or other real property agreements or documents showing the amounts owed against the property.
12. Do you or your spouse own or co-own promissory notes, contracts for deed or other property
agreements?
Yes No
13. Do you or your spouse have any vehicles in your name? Include cars, trucks, vans, motorcycles, motorhomes, campers, boats, snowmobiles, all-terrain vehicles, etc.
Yes No
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14. Do you or your spouse have an interest in a trust or annuity? Yes No
15. Do you or your spouse have life insurance? Yes – fill in below No
Owner name(s) Policy number Insurance company name and address
Emily 636130 Liberty Life Insurance Company
Emily 623120 Liberty Life Insurance Company
You must provide proof of these assets. Proof may be a copy of your life insurance policy.
16. Do you or your spouse have a prepaid burial account or burial trust? Include revocable andirrevocable accounts, insurance-funded burials, annuity-funded burials, Cremation Society agreements, burial spaces,burial space items and other funds designated for burial.
Yes – fill in below No
Owner name(s) Type of burial asset Company or bank name and address
Emily Irrevocable Burial Trust Nelson's Funeral Home
Emily Burial Plot Fort Snelling National Cemetery
You must provide proof of these assets. Proof may be copies of the life insurance policy, burial contracts or other documents showing the current value of the assets.
17. Do you or your spouse have assets currently used for self-employment or in a business in
which you or your spouse has an interest?
Yes No
18. Do you or your spouse own or co-own any other assets you have not listed?
Yes No
19. Do you or your spouse live in a continuing care retirement community? Yes No
20. Did you or your spouse create a trust in the last 60 months? Yes No
21. Did you or your spouse buy an annuity, life estate in another person's home, a promissory
note, loan or mortgage in the last 60 months?
Yes No
22. Did you or your spouse not accept items or income you could have taken, such as an
inheritance or a pension, in the last 60 months?
Yes No
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23. Did you or your spouse sell, trade or give away items or income in the last 60 months?
Yes No
24. Are you working, or do you expect to work in the next month? Include temporary and seasonal work.Yes No
25. Are you self-employed, or do you expect to be self-employed next month?
Yes No
26. Did you get money this month or do you expect to get money next month from sources other
than work?Include: ■ Social Security ■ Spousal support ■ Unemployment ■ Interest
■ Supplemental Security Income (SSI) ■ Workers' compensation ■ Veterans' benefits ■ Dividends■ Retirement or pension payments ■ Public assistance payments ■ Rental income ■ Trusts■ Payments from a contract for deed ■ Annuities ■ Any other payments
Yes – fill in below No
Type of income Amount How often received? Has this income ended?
RSDI $ 1,200.00 Monthly Yes NoIF YES, END DATE (MM/DD/YYYY)
Pension $ 950.00 Yes NoIF YES, END DATE (MM/DD/YYYY)
You must provide proof of this income. Proof may be award letters, copies of checks, tax forms, court orders, or other documents.
27. Expenses
If you are blind or have a disability, do you have work expenses? Yes No Not applicable
If you have a legal guardian or conservator, do you pay a fee? Yes No Not applicable
Do you have court-ordered child or medical support payments taken from your income? Yes No
Do you have court-ordered spousal maintenance payments taken from your income? Yes No
You must provide proof of these expenses. Proof may be court orders or paystubs.
28. Do you have medical expenses? Include health insurance premiums, pharmacy co-pays, doctor office co-paysand all unpaid medical bills.
Yes – fill in below No
LIST EACH MEDICAL EXPENSE
Abbott Northwestern Hospital - $1316 for 2017 Medicare Part B Premium - $109 1/1/17 Medicare Blue RX Premier Premium - $92.00 1/1/17 Gentle Eye Care - $300 LM/01/YY Walgreens prescriptions - $20 each for 3 expenses = $60 (LM/01/YY)
You must provide proof of these expenses. Proof may be receipts of pharmacy co-pays, unpaid medical bills, or notices of health insurance premiums.
Monthly
Page 6 of 7 DHS-3531-ENG 5-17
29. Are you getting medical care for an accident or injury that happened in the last six years?
Yes – fill in below No
TYPE OF ACCIDENT OR INJURY
Fell and broke my hip at home.DATE HAPPENED (MM/DD/YYYY) Is there a lawsuit?
Yes No
You must provide proof of your medical injury. Proof may be information about your injury, third-party insurance claims, or worker's compensation payments or benefits.
30. Did you buy, exchange, or add a rider to a long-term-care insurance policy on or after
July 1, 2006?
Yes No
31. Do you have Medicare, other health coverage or long-term-care insurance now or have you
had coverage in the last three months?
Yes – fill in below No
COVERAGE TYPES
Medicare Medicare supplemental policy Medical insurance Hospital only HMO Prescription drugDental Vision Long-term care Other
POLICYHOLDER'S NAME
Emily AndersonINSURANCE COMPANY NAME START DATE (MM/DD/YYYY) END DATE (MM/DD/YYYY)
POLICY NUMBER LIST EVERYONE WHO IS COVERED BY THIS POLICY
Emily AndersonMONTHLY PREMIUM
$ 201.00
Is this health insurance through an employer or union? Yes No
You must provide proof of your health care coverage. Proof may be front and back copies of your health insurance cards, documentation of monthly premium amounts, written documentation of coverage from the health insurance provider or copies of paid medical bills.
32. Do you have a spouse? Yes No
33. Do you want to give part of your income to any of the following family members?■ A child under 21■ A child 21 years old or older whom you list as a dependent on your tax forms■ A parent or sibling whom you list as a dependent on your tax forms
Yes No
LM/02/YY
Medicare A & B/BCBS Medicare Blue RX Premier (Part D) 12/1/CY-24
Worker Notes:
Emily and daughter (her AREP) came in today for an interview. Emily was hospitalized on LM/02/YY after she fell in her home that same day. She began receiving skilled nursing facility services in the hospital on LM/12/YY. She moved to BEthany Care Center on LM/15/YY.
Prior to hospitalization, Emily lived in her own home. She was diagnosed with Alzheimer's Disease 3 years ago. Her daughter moved in with her on 3/17/CY03 to provide care - this is verified.
Emily's husband was a veteran. Emily was referred to VA during the interview to pursue VA Aid & Attendance.
Emily attended a managed care presentation after her interview.
Appendix B – Authorized Representative Designation
You can choose an authorized representative.
You can give a trusted person permission to talk about this application with us, see your information and act for you on matters related to this application, including getting information about your application and signing your application on your behalf. This person is called an "authorized representative." If you ever need to change your authorized representative, contact your county or tribal agency. Contact information for county agencies is listed in Attachment C.
A legally appointed representative for someone on this application must submit proof with the application.
1. NAME OF AUTHORIZED REPRESENTATIVE (First Name, Middle Name, Last Name)
Patricia A WeberRELATIONSHIP TO YOU, IF ANY
Daughter2. ADDRESS
871 St. Clair Ave3. APARTMENT OR SUITE NUMBER
4. CITY
St. Paul5. STATE
MN6. ZIP CODE
551057. PHONE NUMBER
612-789-37018. ORGANIZATION NAME 9. ID NUMBER (if applicable)
By signing, you allow this person to sign your application, get official information about this application and act for you on all future matters with this agency.
10. YOUR SIGNATURE 11. DATE (MM/DD/YYYY)
Authorized Representative Signature
By signing, I agree to be an authorized representative for this household. I understand my responsibilities including keeping information about the people applying on this application private.
I would like to get information by email at:
AUTHORIZED REPRESENTATIVE SIGNATURE DATE (MM/DD/YYYY)
Emily Anderson CM/01/CY
Patricia Weber CM/01/CY
__
PHYSICIAN CERTIFICATION Instructions on reverse
▲
1
PROVIDER INFORMATION LTC MALTC Provider’s Name Provider Phone # NPI Own Reference # Today’s Date
Street Address Attending Physician’s Name Physician's NPI
City/State/Zip Date Physician Signed Order Date of this Admission Anticipated Discharge Date (See back)
3 4
11
8
22
20.
21.
ICF-MR SCREENING ONLY
Date person screened ________________________ Was it prior to this admission? l Yes l No If no, attach reason why.
➤ NOTICE: Anyone who misrepresents essential information requested by this form may upon conviction be subject to fine and imprisonment under Federal and State law.
5
11a
2
6
9
2a
7
10
12
16
18
RECIPIENT INFORMATION Recipient Medical Recipient Name (Last, First, Initial) Assistance Number Birthdate Sex 13 If applying, 13A 14 15 place X in box ➙Primary Diagnosis/Reason for Admission DIAG Code 17
Secondary Diagnosis DIAG Code 19
ADMISSION INFORMATION
Date of Recommended Level of Care:. ........................SNF l NF Only l ICF-MR l RTC lFirst Admission (“X” one) 23 24 25 Psychiatric 26
Length of Stay: ....................................... 30 days or l 31 to 90 l 91 to180 l over 180 l (“X” one) less 27 days 28 days 29 days 30
Admitted from: ............................Acute-Care Hospital l Home l RTC l Other SNF or NF l ICF/MR l (“X” one) 31 32 33 34 35
31a If Box 31 is checked indicate: Name of hospital __________________________________________________________________
Date of hospital admission __________________ Date of hospital discharge __________________
PHYSICIAN’S SIGNATURE
I certify (or I certify that a physician has certified) that the recipient named above requires long term care services and that the services are being provided under a written plan of care.
X ________________________________________________________________
35. AUTHORIZED SIGNATURE AND DATE
LOCAL COUNTY AGENCY USE ONLY
_______________________36. Date this form received by Local County Agency
____________________________________________36a. Name of county
____________________________________________ 37. LOCAL COUNTY AGENCY SIGNATURE AND DATE
____________________________________________ 38. DATE FORM RETURNED TO LTC FACILITY
PREADMISSION SCREENING FOR SNFs and NFs
Was person screened prior to this admission? lYes lNo
a. If yes, date screened _______________________ and name of agency that did screening ________________________________________________
b. No screening required: l transfer from another MN SNF/NF or certified MN Board and Care Home (BCH)
ladmit from hospital <30 day stay expected
lother reason, (explain) ______________________________________________________________________________
c. Screening after admit: l stay exceeded 30 days l emergency admit
lother reason (explain) _____________________________________________________________________________
DHS-1503-ENG 9-08
INSTRUCTIONS
This form must be completed by the LTC facility within 72 hours (not including weekends or holidays) after the admission of a Medical Assistance (MA) recipient or MA applicant.
Type or print all items except numbers 35 and 37.
1. Leave blank.
2., 2a, 6., 9. Long-term care (LTC) facility name, telephone and address.
3. Long-term care facility’s NPI.
4. Optional – may use medical record number or other number.
5. Date the form is being completed.
7. Name of attending physician.
8. Physician’s NPI, if available.
10. Date physician signed orders for this admission or if physician signed DHS-1503, date physician signed line 35. For an MA recipient, date must be prior or equal to the date in box 11.
11. Enter the date of admission or readmission to the facility.
11a. Enter the date the physician anticipates resident will be discharaged from this (current) admission. This box is for use by the local county agency worker to determine budgeting method.
12. Recipient’s name.
13. Recipient’s Medical Assistance identification number. If an MA applicant leave blank, the Local County Agency will complete.
13a. If a MN Health Care Programs (MHCP) applicant, place an X in this box. If an MHCP recipient, leave blank.
14. Recipient’s birth date.
15. Recipient’s sex – use F for female and M for male.
16. Primary diagnosis or reason for admission.
17. Enter ICD-9-CM code for primary diagnosis.
18. Secondary diagnosis for admission; if none, leave blank.
19. Optional – if used, enter ICD-9-CM code for secondary diagnosis.
20. If yes, complete 20a. If yes, but the date of screening listed here is more than 60 days before this admission, the person must be screened again. Contact your county screener. If no, check most appropriate reason in 20b or 20c. For use of "other," please refer to Chapter 27 of MHCP Manual.
21. Must be completed for each admission, including admissions from a RTC (Regional Treatment Center) to a community ICF-MR, or transfer from one community ICF-MR to another ICF-MR or readmission of person previously discharged. If not screened prior to admission, attach reason or reasons why.
22. Enter date the individual first entered the facility either as a recipient, applicant or as private pay (including Medicare eligibles).
23 - 26. Check one box only. Note: SNF refers to a Medicare certified level of care (skilled nursing care), NF-Only refers to a Medicaid-only certified level of care (i.e. such as a certified Board and Care Home-BCH), and RTC psychiatric is only used in Regional Treatment Centers for certified psychiatric beds.
27 - 30. Check one. Length of stay means the anticipated amount of time the person will be at the facility. This is to be estimated from the date in box 11.
31 - 35. Check one box only. Note: Use home option when other choices do not apply. RTC refers to any previous RTC stay, regardless of bed type or level of care in an RTC.
31a. Complete only if person was hospitalized.
35. Signature of physician or authorized person and date signed (authorized person attests to the fact that facility maintains documentation of physician signature on file in resident's record).
36. Enter the date form is received by the Local County Agency or date stamp upon receipt.
36a. Enter the county name.
37. Signature of Local County Agency representative and date signed.
38. Enter the date DHS-1503 is completed, signed and returned to the LTC facility.
Distribution: LTC facility sends the completed form to the Local County Agency and retains a photocopy. Local County Agency retains a photocopy and returns original signed/dated copy to the LTC facility for the resident's record.
__
PHYSICIAN CERTIFICATION Instructions on reverse
▲
1
PROVIDER INFORMATION LTC MALTC Provider’s Name Provider Phone # NPI Own Reference # Today’s Date
Street Address Attending Physician’s Name Physician's NPI
City/State/Zip Date Physician Signed Order Date of this Admission Anticipated Discharge Date (See back)
3 4
11
8
22
20.
21.
ICF-MR SCREENING ONLY
Date person screened ________________________ Was it prior to this admission? l Yes l No If no, attach reason why.
➤ NOTICE: Anyone who misrepresents essential information requested by this form may upon conviction be subject to fine and imprisonment under Federal and State law.
5
11a
2
6
9
2a
7
10
12
16
18
RECIPIENT INFORMATION Recipient Medical Recipient Name (Last, First, Initial) Assistance Number Birthdate Sex 13 If applying, 13A 14 15 place X in box ➙Primary Diagnosis/Reason for Admission DIAG Code 17
Secondary Diagnosis DIAG Code 19
ADMISSION INFORMATION
Date of Recommended Level of Care:. ........................SNF l NF Only l ICF-MR l RTC lFirst Admission (“X” one) 23 24 25 Psychiatric 26
Length of Stay: ....................................... 30 days or l 31 to 90 l 91 to180 l over 180 l (“X” one) less 27 days 28 days 29 days 30
Admitted from: ............................Acute-Care Hospital l Home l RTC l Other SNF or NF l ICF/MR l (“X” one) 31 32 33 34 35
31a If Box 31 is checked indicate: Name of hospital __________________________________________________________________
Date of hospital admission __________________ Date of hospital discharge __________________
PHYSICIAN’S SIGNATURE
I certify (or I certify that a physician has certified) that the recipient named above requires long term care services and that the services are being provided under a written plan of care.
X ________________________________________________________________
35. AUTHORIZED SIGNATURE AND DATE
LOCAL COUNTY AGENCY USE ONLY
_______________________36. Date this form received by Local County Agency
____________________________________________36a. Name of county
____________________________________________ 37. LOCAL COUNTY AGENCY SIGNATURE AND DATE
____________________________________________ 38. DATE FORM RETURNED TO LTC FACILITY
PREADMISSION SCREENING FOR SNFs and NFs
Was person screened prior to this admission? lYes lNo
a. If yes, date screened _______________________ and name of agency that did screening ________________________________________________
b. No screening required: l transfer from another MN SNF/NF or certified MN Board and Care Home (BCH)
ladmit from hospital <30 day stay expected
lother reason, (explain) ______________________________________________________________________________
c. Screening after admit: l stay exceeded 30 days l emergency admit
lother reason (explain) _____________________________________________________________________________
DHS-1503-ENG 9-08
INSTRUCTIONS
This form must be completed by the LTC facility within 72 hours (not including weekends or holidays) after the admission of a Medical Assistance (MA) recipient or MA applicant.
Type or print all items except numbers 35 and 37.
1. Leave blank.
2., 2a, 6., 9. Long-term care (LTC) facility name, telephone and address.
3. Long-term care facility’s NPI.
4. Optional – may use medical record number or other number.
5. Date the form is being completed.
7. Name of attending physician.
8. Physician’s NPI, if available.
10. Date physician signed orders for this admission or if physician signed DHS-1503, date physician signed line 35. For an MA recipient, date must be prior or equal to the date in box 11.
11. Enter the date of admission or readmission to the facility.
11a. Enter the date the physician anticipates resident will be discharaged from this (current) admission. This box is for use by the local county agency worker to determine budgeting method.
12. Recipient’s name.
13. Recipient’s Medical Assistance identification number. If an MA applicant leave blank, the Local County Agency will complete.
13a. If a MN Health Care Programs (MHCP) applicant, place an X in this box. If an MHCP recipient, leave blank.
14. Recipient’s birth date.
15. Recipient’s sex – use F for female and M for male.
16. Primary diagnosis or reason for admission.
17. Enter ICD-9-CM code for primary diagnosis.
18. Secondary diagnosis for admission; if none, leave blank.
19. Optional – if used, enter ICD-9-CM code for secondary diagnosis.
20. If yes, complete 20a. If yes, but the date of screening listed here is more than 60 days before this admission, the person must be screened again. Contact your county screener. If no, check most appropriate reason in 20b or 20c. For use of "other," please refer to Chapter 27 of MHCP Manual.
21. Must be completed for each admission, including admissions from a RTC (Regional Treatment Center) to a community ICF-MR, or transfer from one community ICF-MR to another ICF-MR or readmission of person previously discharged. If not screened prior to admission, attach reason or reasons why.
22. Enter date the individual first entered the facility either as a recipient, applicant or as private pay (including Medicare eligibles).
23 - 26. Check one box only. Note: SNF refers to a Medicare certified level of care (skilled nursing care), NF-Only refers to a Medicaid-only certified level of care (i.e. such as a certified Board and Care Home-BCH), and RTC psychiatric is only used in Regional Treatment Centers for certified psychiatric beds.
27 - 30. Check one. Length of stay means the anticipated amount of time the person will be at the facility. This is to be estimated from the date in box 11.
31 - 35. Check one box only. Note: Use home option when other choices do not apply. RTC refers to any previous RTC stay, regardless of bed type or level of care in an RTC.
31a. Complete only if person was hospitalized.
35. Signature of physician or authorized person and date signed (authorized person attests to the fact that facility maintains documentation of physician signature on file in resident's record).
36. Enter the date form is received by the Local County Agency or date stamp upon receipt.
36a. Enter the county name.
37. Signature of Local County Agency representative and date signed.
38. Enter the date DHS-1503 is completed, signed and returned to the LTC facility.
Distribution: LTC facility sends the completed form to the Local County Agency and retains a photocopy. Local County Agency retains a photocopy and returns original signed/dated copy to the LTC facility for the resident's record.
1
Date:
To:
Minnesota Health Care Programs
Medical Care ReceivedCase number:
Case name:
Worker name:
Worker phone number:
Fax number:
Agency name:
Agency address:
Why am I getting this letter?We are writing to ask you about your medical care. You asked for Medical Assistance to help pay for your long-term care services. You may pay less for your long-term care services if you have other medical expenses you need to pay.
What do I need to do?Fill out the enclosed form. Give us proof of each medical expense you list and how much of the bill was paid by insurance or someone else. Proof can be a copy of the bill and papers showing how much of the bill was paid by insurance or someone else. Return the completed form and proofs to your worker at the above address.
What will happen if I do not return the form and proofs?You may have to pay more for your long-term care services.
QuestionsCall your worker at the number listed above if you have questions.
*DHS-6059A-ENG*DHS-6059A-ENG 1-10
2
Agency UseDATE CASE NAME CASE NUMBER WORKER NAME OR WORKER NUMBER
Medical Care ReceivedAnswer the question below. Complete the information about your medical expenses
if you answer “Yes” to the question. Return this completed form to your worker.
Have you received medical care or had medical expenses since ?
l No
l Yes, I have received medical care or had medical expenses. Fill in the information about the medical care you received below. Include doctor and clinic visits, hospital stays, prescription drugs, transportation to get your medical care and all other medical services you received. Send copies of bills or receipts for each expense listed. Send proof of payments made by Medicare, other insurance or any other payments made on your behalf.
Type of medical expense Who gave you the medical care Date of this expenseDid or will insurance or anyone else pay part or all of this expense?
l Yes l No l Don’t know
l Yes l No l Don’t know
l Yes l No l Don’t know
l Yes l No l Don’t know
l Yes l No l Don’t know
l Yes l No l Don’t know
l Yes l No l Don’t know
l Yes l No l Don’t know
l Yes l No l Don’t know
l Yes l No l Don’t know
l Yes l No l Don’t know
l Yes l No l Don’t know
l Yes l No l Don’t know
l Yes l No l Don’t know
l Yes l No l Don’t know
l Yes l No l Don’t know
l Yes l No l Don’t know
l Yes l No l Don’t know
l Yes l No l Don’t know
Rev. 01/06/12 - Health Care Training
Dr. Marcia Flannigan CM/01/CY
NorthEast HealthCare Clinic
915 Broadway Ave. N.E.
Minneapolis, MN. 55418
Patricia Weber
871 St. Clair Avenue
St. Paul, MN 55105
CM/01/CY
Reference: Emily Anderson
To whom it may concern:
Emily Anderson was diagnosed with Alzheimer’s disease three years ago. It was
determined that Emily required daily, 24 hour care. Upon this diagnosis, Patricia Weber
moved into her mother’s home. It was the desire of the family to have Emily continue
living in her home and not be placed into a Long Term Care Facility.
While living in the home of Emily Anderson, Patricia Weber has provided continued
daily living support for her mother, Emily Anderson, which has delayed the placement of
Emily into a LTCF.
If you need additional information or clarification, please call me at (612) 555-5555.
Thank you,
Marcia Flannigan, MD Marcia Flannigan, MD
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Rev. 12/2/17 - Health Care Training
FDIC Insured New Deposit Insurance Limits - Congress has temporarily increased FDIC deposit insurance from $100,000 to $250,000 per depositor through December 31, 2009. Changes have also been made to other account types.
Peoples Credit Union 1300 Marshall Ave. N.E. Minneapolis, MN. 55418 612-555-5555 (1-800-736-7537)
Emily Anderson 871 St. Clair Avenue St. Paul, MN 55105
Peoples Credit Union Savings Emily Anderson Account Number: 7890123456 Activity Summary: Balance on LM/01/CY $650.00 Deposits $ Withdrawals $ Balance on LM/LD/YY $650.00 Peoples Credit Union Online Banking keeps getting better and better. With Peoples Credit Union online banking, you can keep track of your expenses, pay holiday bills, and enjoy the benefits of such free features as online check images, optional account alerts, and My Spending Report, a smart tool that collects and summarizes transactions from your People Credit Union Account(s). Check Card, Credit Card (s), and online Bill Pay. Go to www.peoplecreditunion.net and get started today. Peoples Credit Union Checking Emily Anderson Account Number: 7890123456 Activity Summary: Balance on LM/01/CY $ 516.40 Deposits $1949.00 Withdrawals $1936.07 Balance on LM/LD/YY
$528.93
Recent Transactions Date: CK Description Deposit Withdrawal LM/01 EFT Gentle Eye Care $300.00 LM/01 EFT Walgreens $60.00 LM/02 DEP Fidelity: Direct Deposit 950.00 LM/03 DEP Social Security: Direct Deposit 999.00 LM/10 8703 Wells Fargo Home Mortgage 550.00 LM/11 EFT Qwest 30.00 LM/11 EFT Xcel 125.00 LM/12 EFT Minneapolis Finance Department 50.00 LM/12 EFT Comcast 55.00 LM/13 EFT Rainbow Groceries 200.47 LM/17 8704 State Farm 565.60
Rev. 9/29/11 - Health Care Training
FDIC Insured New Deposit Insurance Limits - Congress has temporarily increased FDIC deposit insurance from $100,000 to $250,000 per
depositor through December 31, 2009. Changes have also been made to other account types.
Fidelity 1300 Marshall Ave. N.E.
Minneapolis, MN. 55418
612-555-5555
(1-800-736-7537)
Emily Anderson
871 St. Clair Avenue
St. Paul, MN 55105
Fidelity
Emily Anderson
Account Number: 8901234567
Payment Start Date: 12/5/CY-24
Activity Summary:
Balance on LM/01/YY $175,950.00
Monthly Payment on LM/02/YY $ 950.00
Emily’s Pension/Retirement Account is Employer Funded and she receives monthly periodic retirement
payments for the amount of $950.00. There is no cash-out option or lump sum available.
Rev. 09/29/11 - Health Care Training
Liberty Life Insurance Company
3800 Alamo Way
Austin, TX 58698
LM/ 01/ YY
871 St. Clair Avenue
St. Paul, MN 55105
Dear Emily S. Anderson,
Please find the information you requested about life insurance policy
#636130.
Type: Whole Life
Face Value: $1000.00
Cash Surrender Value as of LM/01/YY: $1,195.00
Beneficiary: Patricia Weber, daughter
Please contact me if you have additional questions.
Sincerely, Karol C. King
Karol C. King
Insurance Representative
LLLLII
Rev. 09/29/11 - Health Care Training
Number: 636130_____ Amount $ 1000.00_____
Rated Age: ___48____ Monthly Premium: $ ___4.14___
Whole Life
Liberty Life Insurance Co.
Home Office
Austin, Texas
MEMBER ISURED: Emily Anderson____________________________________________________
SUM INSURED: _____________$1,000.00___________________________________Dollars
Hereinafter called the Face Amount
BENEFICIARY: ____________Patricia Weber, related to the Member as Daughter_______________
In Consideration of the application herefor, a copy of which, signed by the Member, is attached hereto,
and the representations, conditions and agreements therein contained, and of the Conditions and
Provisions set forth on succeeding pages of this policy, all of which are hereby referred to and made a part
hereof as fully as if stated over the seal and signatures be.
Liberty Life Insurance Co. Home Office: Austin, Texas
Certified Copy of Request for Change of Beneficiary
(Original on File in Home Office)
Or Town ______St. Paul_______, State _____Minnesota____, Date ____February 13__ CY-40_____
Cert. No___636130_____of the Liberty Life Insurance Co., do hereby revoke the heretofore active designation
of beneficiary in said certificate and authorize and direct the Liberty Life Insurance Co. in the event of my death
the proceeds of insurance under said certificate be paid to the following beneficiaries:
$1000.00________ to ___________Patricia Weber________, related to me as Daughter_______________
_______________ to _________________________ ________, related to me as ______________________
Rev. 09/29/11 - Health Care Training
Number: 623120_____ Amount $ 10,000.00_____
Rated Age: ___68____ Monthly Premium: $ ___119.00___
Term Life
Liberty Life Insurance Co.
Home Office
Austin, Texas
MEMBER ISURED: Emily Anderson____________________________________________________
SUM INSURED: _____________$10,000.00___________________________________Dollars
Hereinafter called the Face Amount
BENEFICIARY: ____________Daniel Anderson, related to the Member as Son_______________
In Consideration of the application herefor, a copy of which, signed by the Member, is attached hereto,
and the representations, conditions and agreements therein contained, and of the Conditions and
Provisions set forth on succeeding pages of this policy, all of which are hereby referred to and made a part
hereof as fully as if stated over the seal and signatures be.
Liberty Life Insurance Co. Home Office: Minneapolis, Minnesota
Certified Copy of Request for Change of Beneficiary
(Original on File in Home Office)
Or Town ______St. Paul_______, State _____Minnesota____, Date ____April 13___ CY-20____
Cert. No___623120_____of the Liberty Life Insurance Co., do hereby revoke the heretofore active designation
of beneficiary in said certificate and authorize and direct the Liberty Life Insurance Co. in the event of my death
the proceeds of insurance under said certificate be paid to the following beneficiaries:
$10,000.00________ to _________Daniel Anderson________, related to me as Son_______________
_______________ to _________________________ ________, related to me as ______________________
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Ramsey County, MN Property Information Search Result
Taxpayer Name: Emily S Anderson
Address: 871 St. Clair Avenue Municipality: St. Paul
Values: Land Market $39,900 Building Market $179,600 Machinery Market
Total Market: $219,500 Land Limited $33,900 Building Limited $152,700
Total Limited: $186,600 Qualifying Improvements
Classifications: Property Type RESIDENTIAL
Homestead Status HOMESTEAD
Relative Homestead
Agricultural
Exempt Status
Rev. 09/15/09 - Health Care Training
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Rev. 09/15/09 - Health Care Training
Nelson Funeral Home 400 13th Ave. N.E. Minneapolis, MN 55418 612-386-3725
Irrevocable Funeral Trust Agreement For the benefit of ______Emily Anderson___________ (BENEFICIARY of Trust) “PURCHASER/BENEFICIARY” under this Agreement must be the Beneficiary of the Trust This Irrevocable Funeral Trust Agreement is made by and between the undersigned contract purchase and beneficiary of funeral services and/or merchandise (hereinafter “PURCHASER/BENEFICIARY”) and the funeral establishment as defined by and licensed pursuant to Minnesota Statute 149.08 and designated below as “TRUSTEE.” The purpose of this Irrevocable Funeral Trust Agreement is to set forth in advance certain arrangements regarding burial expenses and/or expenses for burial space items to be incurred on behalf of PURCHASER/BENEFICIARY. The services and merchandise hereunder shall be provided by TRUSTEE unless, prior to PURCHASER/BENEFICIARY’S death, PURCHASER/BENEFICIARY designates a different funeral establishment as TRUSTEE under this Agreement. In consideration of their mutual promises, and in accordance with Section 149.11 of the Minnesota Statutes as it may be amended from time to time, PURCHASER/BENEFICIARY and TRUSTEE agree as follows:
1. TRUSTEE. The following named funeral establishment shall serve as Trustee under this Agreement: Nelson Funeral Home_________________________________________________________ (Name of funeral establishment as it appears on its permit from the Minnesota State Commissioner of Health, hereinafter “TRUSTEE”) 2. Services and Merchandise. a) TRUSTEE will provide the following services (burial expenses): Funeral director/staff: $500.00, Transfer of remains: $100.00, Embalming: $800.00, Other preparation of the body: $300, Facility use for service: $200, Hearse for committal service: 100.00 (These funds are irrevocable to the maximum extent allowed by law) b) TRUSTEE will provide the following merchandise (burial space items): Casket: $2000.000, Vault: $800, obituary: $500.00, flowers $130.00 _________ 3. Deposit with Trustee. 2.a) the amount to be deposited by PURCHASER/BENEFICIARY with TRUSTEE under this Agreement for services described in Item 2.a) is $ 2000.00___________ 2.b) the amount to be deposited by PURCHASER/BENEFICIARY with TRUSTEE under this Agreement for Merchandise described in item 2.b is $3430.00_____ c.) The total amount to be deposited under this agreement is (2.a & 2.b): $5430.00__________ It is PURCHASER/BENEFICIARY’S intention that the amount to be held in trust is irrevocable up to an amount equivalent to the then-current allowable Supplemental Security Income (SSI) asset exclusions used for determining eligibility for public assistance. (Purchaser/Beneficiary, Please Note: You may deposit an amount or amounts with TRUSTEE which exceeds the asset exclusion limitations allowable under Supplemental Security Income (SSI). However, only those amounts up to
Rev. 09/15/09 - Health Care Training
the SSI Asset exclusion limitation may be designated as irrevocable. Any amounts deposited which exceed SSI Asset exclusion limitation swill not be irrevocable and may be withdrawn by you at any item). 4. Financial Institution/Interest. TRUSTEE shall deposit the amount set forth in Items 3.c) above into a separate designated trust account with an insured financial institution as defined in Minnesota Statue 49.01, subd 2 ( hereinafter “financial Institution”) pursuant to Minn. Stat 149.12. Such account shall be an insured account which shall bear interest at the then current interest rate offered by Financial Institution on savings accounts of the size of PURCHASER/BENEFICIARY’S deposit with TRUSTEE described in Item 3.c.) above. The interest on irrevocable trust funds is hereby declared:
Irrevocable Or (Purchaser/Beneficiary please check one of these boxes and initial here): X EM_______
Revocable 5. Account Names. The account to be opened by TRUSTEE with financial Institution as described in Item 4 above shall bear each and every of the following names: a) Purchaser and designated Beneficiary: ________________Emily Anderson___________________ b) Trustee funeral establishment: Nelson Funeral Home_________________________________________ c) Financial Institution: Peoples Credit Union___________________________________________________ This Agreement benefits and binds the devisees, heirs, successors, assigns, and personal representatives(s) of Purchaser/beneficiary, Trustee and Financial Institution. Signed at Minneapolis___________, Minnesota this 9th____ day of September_____ of 2001_______ Purchaser: Emily Anderson________ TRUSTEE: Nelson Funeral Home________________
By: John Nelson_______________________ Funeral Director
Current Month 01, CY Department of Veterans Affairs 7601 34th Avenue South Minneapolis, MN 55450-1199
SSN #: 800 - 11 - _____ Dear Emily S. __________: This letter is in response to your inquiry regarding your burial benefits through the Department of Veterans Affairs. You are eligible for the following burial benefits at Fort Snelling National Cemetery: • Burial Space • Opening and closing of the grave • Perpetual Care • Government headstone or marker You are not eligible for additional burial allowance benefits. If you have questions regarding these benefits please contact the Department of Veterans Affairs at 1-800-827-1000. Sincerely, S.S. Minnow
Rev. 09/15/09 - Health Care Training
Rev.12/02/16 - Health Care Training
Last Month 01, CY
Office of Public Inquiries
Windsor Park Building 6401 Security Blvd. Baltimore, MD 21235
Claim #: 800 - 11 - _____ A
Dear Emily S. Anderson: In response to your inquiry regarding your Social Security benefits, please see
the information below.
Begin Date: 12/05/CY-24
Current Year RSDI payment: $1,200.00 COLA increase: $0.00 for training.
Medicare Part A and B begin date: 12/01/CY-24
2017 Medicare Part D Plan: Medicare Blue RX Premier Deductions Made from RSDI Benefit Prior to Direct Deposit:
Part B premium: $ 109.00 (2017)
Part D premium: $ 92.00 (2017)
If you have questions regarding these benefits please contact the Social
Security Administration at 1-800-GET-HELP.
Sincerely, A. Federal Pencil-Pusher
Rev. 4/4/16- Health Care Training
Gentle Eye Care
Southdale Mall
Edina, Minnesota
Emily Anderson
LM/01/YY
1 Pair of Prescription Eye Wear: M+ Rimless Eyeglasses 1026 $ 99.20 Lenses $ 200.80
Total $ 300.00 Paid by Visa $ 300.00
LM/01/YY
Prescription 152362 Prescription 152363 Prescription 152364
$ 20.00 $ 20.00 $ 20.00
Total Paid By Visa
$60.00 $60.00
Thank you for shopping at Walgreens!
Rev. 4/4/16- Health Care Training
800 E. 28th St. Minneapolis, MN 55407 612-863-4000 CM/01/CY
Emily S. Anderson 871 St. Clair Avenue St. Paul, MN 55105
Date of Birth: 12/05/CY-89 Medicare ID Number: 890-11-____A
Date Description Amount LM/02/YY Medicare Part A
Hospitalization Co-Payment $1,288.00
Total Due $1,288.00
Abbott Northwestern Hospital is a part of Allina Hospitals & Clinics, a family of hospitals, clinics and care services in Minnesota and Western Wisconsin.
1
NAME CASE NUMBER PMI
AUTHORIZED REPRESENTATIVE CASE MANAGER l LTCF l CAC l CADI
l DD l EW l BI
APPLICANT REQUESTS MA-LTC
l DHS-3531 l DHS-5223 (CAF) with l DHS-3543
l DHS-3417 (HCAPP) with l DHS-3543
MA ENROLLEE REQUESTS LTC
l DHS-3543LTC ENROLLEE
l DHS-2128
DATE OF REQUEST RETRO REQUEST DATE MA-LTC BEGIN DATE
Institutional Level of Care
l LTCC/DD (DHS-5181) SCREENING DATE
l PAS (DHS-1503) SCREENING DATE LTCF PROVIDER NAME/NPI/DATES IN AND OUT
Community Spouse
No Yes NAME PMI
MA Eligibility Requirements
✔ Requirement Proof or Info Other/Notes
Basis of Eligibility Provided N/A
BASIS ELIGIBILITY TYPE
SSN Provided Exempt
l Citizen & Identity
l Immigrant
Provided Exempt
EXEMPTION REASON IMMIGRATION STATUS SPONSOR
Provided Exempt
U.S. ENTRY DATE
MN Residency Met Not Met
COUNTY OF FINANCIAL RESPONSIBILITY SERVICING COUNTY
OHC/TPL Provided N/A
l Medicare l A l B l D l MSP/Buy-In Eligible
PLAN NAME
l Other Coverage COST EFFECTIVE
Yes No
l LTC Insurance
l LTCP SubmittedPLAN NAME
l Accident DATE TYPE
Minnesota Health Care Programs
MA-LTC Case Checklist
*DHS-5590-ENG*DHS-5590-ENG 4-13
2
MA Eligibility Requirements
✔ Requirement Proof or Info Other/Notes
Medical Support Required N/A
REFERRAL TYPE
Medical Support Parental Fee
Household Size MA EFFECTIVE DATE MA-LTC EFFECTIVE DATE MSP
Asset Assessment Required N/A
ASSET ASSESSMENT EFFECTIVE DATE COMMUNITY SPOUSE ASSET ALLOWANCE
$
Asset attribution required? No Yes
Assets Required N/A
ASSET TOTAL FOR
$
ASSET TOTAL FOR
$
Income Provided N/A
MA-LTC Eligibility Requirements
✔ Requirement Proof or Info Other/Notes
Home Equity Limit
Provided N/A Exempt
FMV or EMV
$
ENCUMBRANCES
$
PROOF
Provided Not Provided
Annuity Provided N/A
DESIGNATE DHS THE PRB
Yes No
ANNUITY TRANSFER EVALUATION METHOD
N/A 1 2
TRANSFER
Yes No
Transfer Yes No
AMOUNT
$
PENALTY PERIOD MONTHS
BEGIN END PARTIAL MONTH
l STAT/TRAN Entered l MAXIS Case Note Entered l MMIS/RLVA
Income Calculation
SIS-EW Yes No BEGIN MONTH
Community Income Calculation
BEGIN MONTH END MONTH
LTC Income Calculation BEGIN MONTH END MONTH
l Needs Allowance l Home Maintenance Needs
l SIS-EW Maintenance Needsl Veteran’s
l PNA
l Community Spouse Allocation Community Spouse Income Verified Yes No
Community Spouse Expenses Verified Yes No
Made Available Yes No
l Family Allocation Family Member(s) Income Verified Yes No
Family Member(s) Expenses Verified Yes No
continued
3
Client Obligation and Service Delivery
Medical Spenddown l Monthly (AMM) ORIGINAL SPENDDOWN AMOUNT
$
RECIPIENT AMOUNT
$
SATISFACTION DATE (SMM ONLY)
BEGIN END
l Six-Month (SMM) ORIGINAL SPENDDOWN AMOUNT
$
RECIPIENT AMOUNT
$
SATISFACTION DATE (SMM ONLY)
BEGIN END
l Spenddown Not Met
LTC Spenddown (AIM or AMM)
BEGIN END ORIGINAL SPENDDOWN AMOUNT
$
RECIPIENT AMOUNT
$
Waiver Obligation (AWM)
BEGIN END ORIGINAL SPENDDOWN AMOUNT
$
RECIPIENT AMOUNT
$
Obligation Payment Option
Designated Provider Option Client Option Spenddown N/A
Service Delivery l Fee For Service MANAGED CARE EXCLUSION REASON(S)
l Managed Care NOTES
MSC+ MSHO SNBC
Actions
Communications l DHS-5181 l DHS-3050 l DHS-1503
Case and Person Note Entry
l Citizenship/Identity l Initial Approval/Denial
l Transfers l Burial Assets and Burial Fund Exclusion
l MMIS Managed Care l Other
Notices l Worker Comments entered (spenddown, etc)
l MHCP Asset Assessment Results (DHS-3340A/B)
l Division of Assets Notice sent, if applicable. (DHS-3340C)
l DHS-4915 sent, if applicable.
Other l Lien Filed l RLVA Ineligibility Code Updated
l MMIS TPL Subsystem Updated DATE LTC SERVICES BEGIN:
l Create DAIL/WRIT (Division of Assets Review, Potential Benefits)
Eligibility Determination
l Basic MA Approved DATE
MA-LTC Approved MA-LTC Denied/Closed
DATE
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Actual Income = AFuture (Anticipated) Income = F (Circle One)
A or F A or F A or F A or F A or F A or FMonth of: Month of: Month of: Month of: Month of: Month of:
RSDI Income............................................................. 1 $+ $+ $+ $+ $+ $+
Deductions from RSDI (DisabledWidow/er, Widow/er, Pickle, DAC, etc.) 2 $- $- $- $- $- $-
Other Unearned Income (_______) Type(s) 3 $+ $+ $+ $+ $+ $+
Spousal/Parental Unearned Income............................ 4 $+ $+ $+ $+ $+ $+
COLA Disregard (January through June)..................... 5 $- $- $- $- $- $-
Other Deductions/Exclusions (PASS, CS, SSI, etc) ....... 6 $- $- $- $- $- $-
Net Unearned Income (1 + 3 + 4 - 2 - 5 - 6)................ 7 $ $ $ $ $ $
Gross Earned Income................................................ 8 $+ $+ $+ $+ $+ $+
Spousal/Parental Earned Income ............................... 9 $+ $+ $+ $+ $+ $+
Plan to Achieve Self Support (PASS) fromEarned Income.......................................................... 10 $- $- $- $- $- $-
Blind/Disabled Student Child Disregard...................... 11 $- $- $- $- $- $-
$ 65.00 Earned Income Disregard............................. 12 $- 65.00 $- 65.00 $- 65.00 $- 65.00 $- 65.00 $- 65.00
Impairment-Related Work Expense Deduction for Disabled only. Enter 0 if elderly or blind................... 13 $- $- $- $- $- $-
Other Earned Income Deductions/Exclusions($10 Infrequent Income, VISTA, etc.)........................... 14 $- $- $- $- $- $-
Earned Income Subtotal (8+9-10-11-12-13-14)........... 15 $ $ $ $ $ $
1/2 of Remaining Earned Income (15÷2)................... 16 $- $- $- $- $- $-
Work Expense Deduction for Blind only. Enter 0 if elderly or disabled.................................................... 17 $- $- $- $- $- $-
Net Earned Income (15-16-17).................................. 18 $ $ $ $ $ $
Net Monthly Income (7+18) (Truncate)......................... 19A
$B
$C
$D
$E
$F
$Monthly Income Standard(Household Size___)................................................. 20 $ $ $ $ $ $
Monthly Spenddown Balance*................................... 21 $ $ $ $ $ $
MA SIX-MONTH SPENDDOWN COMPUTATION
Net Semi-annual Income (Line 19 Total columns A -- F) $ ____________
Household Size ___________ = Income Standard (Standard H) $ ____________
Excess Semi-annual Income Six-Month Spenddown $ ____________
Comments:
CASE NAME
CASE NUMBER
INCOME CONSIDERED FOR: ELIG TYPE:
STANDARD:
ELIGIBILITY CONSIDERED DATE
FROM: TO: APPLICATION DATE WORKER
ELDERLY, DISABLED and BLINDINCOME COMPUTATION WORKSHEET
Method BMinnesota Department of Human Services
*If over income for six-month budget period, redetermine eligibility using Income Standard H.
4-05
Minnesota Health Care Programs (MHCP)
Spenddown WorksheetCASE NAME CASE NUMBER SPENDDOWN FOR SPENDDOWN PERIOD
FROM: TO:
H Bills (Non-Reimbursed Health Insurance)
Bill Type
DateInsurance Company Premium Amount Cumulative TotalMM DD YY
H
H
Total H Bills
M & P Bills (Non-Reimbursed Health Care Expenses Applied to First Day of Spenddown)
Bill Type
DateProvider Name Client Name Gross Bill Third Party
Payment Net Bill Cumulative TotalMM DD YY
– =
– =
– =
– =
– =
– =
– =
Total H, M and P Bills
R Bills (Day-by-Day Chronological Order of Reimbursable Health Care Expenses)
Bill Type
DateProvider Name Client Name Gross Bill Third Party
Payment Net Bill Cumulative TotalMM DD YY
R – =
R – =
R – =
R – =
R – =
R – =
R – =
Total H, M, P and R Bills
A. $ Stop when cumulative total is equal to or greater than the spenddown
B. $ Total expenses (truncate) incurred prior to (SATISFACTION DATE)
C. $ Recipient amount (Line A – Line B)
You are responsible for:1. All medical bills from through (DAY BEFORE SATISFACTION DATE), and 2. $ (RECIPIENT AMOUNT) of medical bills on (SATISFACTION DATE). Your Explanation of Medical Benefits notice will show who you owe.
Note: Document used/unused portion on bill copies and in case notes. Re-verify unused portion when calculating future spenddowns.
Medical Assistance (MA) Monthly spenddown 6-month spenddown
*DHS-1829-ENG*DHS-1829-ENG 8-09
LTC INCOME CALCULATION WORKSHEET
Case Name: Case Number: Calculation Month/Year: Gross Income Calculation Unearned Income Total
$
Excluded Unearned Income - $
Earned Income Total
+ $
Gross Income
= $
Deductions
Special Supplemental Security Income (SSI) Deduction
- $
Special Personal Allowance (Earned Income only)
- $
Medicare Premiums: Part A ______ Part B ______ Part D ______
- $
LTC Needs Allowance • Maintenance Needs Allowance (SIS-EW) • Home Maintenance Allowance (LTCF temporary stay) • Veteran’s Improved Pension • Clothing and Personal Needs
- $
Guardianship, Conservator and Representative Payee Fees
- $
Community Spouse Allocation
- $
Family Allocation
- $
Court-Ordered Child Support and/or Spousal Maintenance
- $
Health Insurance Premiums: Medicare Advantage Plans - Part C ________
- $
Remedial Care Expense
- $
Other Medical Expenses
- $
LTC Spenddown or Waiver Obligation Amount
= $
Note: SIS-EW Maintenance Needs Allowance and Home Maintenance Allowance may
change effective July 1 each year. The Clothing and Personal Needs allowance may change January 1 each year. See HCPM 22.45, Long-Term Care (LTC) Allowances, for the correct expenses amount. The Remedial Care Expense may change January and July 1 each year. See HCPM 22.50, Remedial Care Expense, for the correct expense amount.
Rev. 12/9/14– Health Care Training