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Effective Date: 
1/2008

Documents


Instructions

Updated: 1/2008

Purpose

  • To give advance notice to applicants and recipients who have transferred assets for less than the fair market value of the asset and/or waived rights to receive income or an inheritance.
  • To notify an applicant of the possible effect of the transfer on Medicaid services or eligibility.
  • To notify an applicant of the possible effect of excess home equity on Medicaid services or eligibility.
  • To notify an applicant of the opportunity to provide additional information about the transfer that may reduce the penalty period.
  • To notify an applicant about claiming undue hardship.
  • To notify an applicant of undue hardship criteria.
  • To notify an applicant that nursing facility staff may act on their behalf with written consent to submit the undue hardship claim.

Procedure

When to Prepare

Prepare Form H1226 by the third working day after determining the uncompensated value of assets transferred for less than fair market value, if unable to notify the individual verbally. If notifying the individual verbally, immediately send or give Form H1226.

Number of Copies

Prepare an original and one copy of Form H1226.

Transmittal

Send the original Form H1226 to the applicant's/recipient's mailing address or to the authorized representative. A self-addressed envelope is included to facilitate a response. File the copy in the case record. Do not routinely send a copy to the facility staff.

If the applicant or recipient has given the facility staff authorization to act for him in an undue hardship situation, Form H1226 can be sent to the authorized facility staff so that they can file an undue hardship claim.

Form Retention

Keep the copy of Form H1226 according to the retention requirements of the case record.

Detailed Instructions

Date — Self-explanatory.

Contact Name, Address, Fax Number and Telephone Number — Self-explanatory.

Case, EDG Number — Enter the case or EDG number.

Check the first box if the applicant/recipient resides in an institutional setting.

Medicaid will not pay — Enter the applicant's/recipient's name.

From/Through — Enter the penalty period.

Check the second box if the applicant/recipient resides in the community.

Medicaid will not pay — Enter the applicant's/recipient's name.

From/Through — Enter the penalty period. For home and community-based waiver services with a penalty period under DRA policy, do not enter penalty period dates.

Date of Earliest Transfer — Enter the date of the first transfer.

Type(s) of Asset Transferred — Enter the type(s) of asset(s) transferred.

Total Value of Transfer(s) — Enter the total value of all transfers.

Or, if the individual's home equity exceeds the limit:

Home Equity Value — Enter the home equity value.

Home Equity Limit — Enter the current home equity limit.

Check the first box if the applicant/recipient resides in an institutional setting.

Medicaid will not pay — Enter the applicant's/recipient's name.

Effective — Enter the date.

Check the second box if the applicant/recipient resides in the community.

Medicaid will not pay — Enter the applicant's/recipient's name.

Effective — Enter the date.

If we do not hear from you by — Enter the 10th day from date of notice.

Please call — Enter the contact's telephone number.

Undue Hardship

To submit an undue hardship claim — Enter the 10th day from date of notice. Note: The following is considered written consent for the nursing facility to submit the undue hardship claim:

  • Form H1826, Case Information Release; or
  • A written statement that is signed, dated and addressed from the applicant/recipient or authorized representative giving the nursing facility consent to submit the undue hardship claim on his behalf.