Form H1275, Request for Expanded Protected Resource Assessment

 

Instructions

Updated: 4/2009

 

Purpose

To allow the couple to request to expand their spousal protected resource assessment (SPRA) amount.

Procedure

When to Prepare

Complete Form H1275 when a resource assessment has been completed and the client is not eligible and requests an expansion of the SPRA.

Number of Copies

Complete an original and two copies if form is computer-entered. Complete an original and three copies if completed by hand.

Transmittal

Send the original to the client. Send one copy to the spouse.

Form Retention

Keep a copy of Form H1275 in the case record for three years after the case is denied.

Detailed Instructions

Client Name/Responsible Party — Enter the last name, comma, first name, space and middle initial. Do not exceed 22 characters. Shorten if necessary.

Date — Enter (in MMDDYY format) the date of Form H1274, Medicaid Eligibility Resource Assessment Notification.

Amount — Enter the amount of income the client is diverting to the community spouse.

Date — Enter (in MMDDYY format) the date the eligibility specialist provides the new expanded SPRA amount to the client.

Amount — Enter the amount of the new expanded SPRA.

Signature and Date — Signature of the client or responsible party and date (MMDDYY format).

Name of Eligibility Specialist — Enter the name of the eligibility specialist who expanded the SPRA.

Amount — Enter the amount of the new expanded SPRA.

Signature and Date — Signature of the eligibility specialist and date (MMDDYY format).