Asset Assessment for Medical Assistance for Long-Term-Care Services (MA-LTC)

Transcription

1 DHS-3340-ENG 6-16 Minnesota Health Care Programs Asset Assessment for Medical Assistance for Long-Term-Care Services (MA-LTC) Who is this form for? This form is for married people who received or expect to receive 30 uninterrupted days of long-termcare (LTC) services. What is this form for? This form will help you and your spouse decide which assets your spouse can keep and how many assets you will need to spend, if any, before you are eligible for Medical Assistance for LTC services (MA-LTC). You can ask to complete an asset assessment (this form) for planning purposes anytime you expect to receive 30 uninterrupted days of LTC services. LTC services include stays in an LTC facility (LTCF) or services through the Alternative Care (AC) program or one of the Home and Community-Based Services (HCBS) waiver programs: Brain Injury (BI) Community Alternative Care (CAC) Community Access for Disability Inclusion (CADI) Developmental Disabilities (DD) Elderly Waiver (EW) What do I need to do with this form? 1. Read the Important Information page (page B) at the end of this form. Tear off this page and keep it. 2. Answer all the questions on the form. If you need more space, write the number of the question and the answer on a separate piece of paper. Include it with the form. 3. Attach proofs. Proofs we need are on page A at the end of the form. 4. Mail or take the form to your county agency. Questions? If you have questions or need help, call your county agency. You can ask to meet with a worker. If you are 60 years old or older, you can also call the Senior LinkAge Line at Or, if you have a disability, you can call the Disability Linkage Line at

2 or Attention. If you need free help interpreting this document, call the above number. مالحظة: إذا أردت مساعدة مجانية لترجمة هذه الوثيقة اتصل على الرقم أعاله. kmnt smkal. ebig~k tuvkarcmnyyk~ gkarbke bäksarenheday²tkit«fâ sumehaturs&bítamelxxageli. Pažnja. Ako vam treba besplatna pomoć za tumačenje ovog dokumenta, nazovite gore naveden broj. Thov ua twb zoo nyeem. Yog hais tias koj xav tau kev pab txhais lus rau tsab ntaub ntawv no pub dawb, ces hu rau tus najnpawb xov tooj saum toj no. ໂປຣດຊາບ. ຖ າຫາກ ທ ານຕ ອງການການຊ ວຍເຫ ອໃນການແປເອກະສານນ ຟຣ, ຈ ງໂທຣໄປທ ໝາຍເລກຂ າງເທ ງນ. Hubachiisa. Dokumentiin kun bilisa akka siif hiikamu gargaarsa hoo feete, lakkoobsa gubbatti kenname bibili. Внимание: если вам нужна бесплатная помощь в устном переводе данного документа, позвоните по указанному выше телефону. Digniin. Haddii aad u baahantahay caawimaad lacag-la aan ah ee tarjumaadda qoraalkan, lambarka kore wac. Atención. Si desea recibir asistencia gratuita para interpretar este documento, llame al número indicado arriba. Chú ý. Nếu quý vị cần được giúp đỡ dịch tài liệu này miễn phí, xin gọi số bên trên. LB (3-13) ADA1 (9-15) For accessible formats of this publication or assistance with additional equal access to human services, write to DHS.info@state.mn.us, call , or use your preferred relay service.

3 *DHS-3340-ENG* DHS-3340-ENG 6-16 Minnesota Health Care Programs Asset Assessment for Medical Assistance for Long-Term-Care Services (MA-LTC) Office Use Only DATE RECEIVED CASE NUMBER WORKER NUMBER Fill in the information asked for below. FIRST NAME MI LAST NAME DATE OF BIRTH SEX M F SOCIAL SECURITY NUMBER PHONE NUMBER COUNTY STREET ADDRESS CITY STATE ZIP CODE SPOUSE S FIRST NAME MI LAST NAME DATE OF BIRTH SEX M F SOCIAL SECURITY NUMBER PHONE NUMBER COUNTY SPOUSE S STREET ADDRESS (if different) CITY STATE ZIP CODE Answer the following questions about assets you and your spouse own. Include assets you or your spouse owns with another person. 1. 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? $ 2. Do you or your spouse have savings or checking accounts, money market accounts or certificates of deposit? No Yes fill in below Type of Account Bank Name and Address Account Number See required proofs on Page A. If you need more space, write the question number and the answer on a separate piece of paper. 1

4 3. Do you or your spouse have a postsecondary fund under section 529 of the Internal Revenue Code on behalf of a child of either or both of you who is under the age of 25? No Yes fill in below Beneficiary s Name and Date of Birth Company or Bank Name and Address Account Number 4. Do you or your spouse have stocks, bonds or retirement accounts? No Yes fill in below Type of Investment Company or Bank Name and Address Account Number 5. Do you or your spouse own a tax-deferred retirement account? No Yes fill in below Type of Investment Company or Bank Name and Address Account Number 6. 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? No Yes fill in below Type of Property Property Address Do you or your spouse live here all year? Yes No Yes No 7. Do you or your spouse own or co-own promissory notes, contracts for deed or other property agreements? No Yes fill in below Type of Asset See required proofs on Page A. If you need more space, write the question number and the answer on a separate piece of paper. 2

5 8. Do you or your spouse have any vehicles in your name? Include cars, trucks, vans, motorcycles, motor homes, campers, boats, snowmobiles, all-terrain vehicles, etc. No Yes fill in below Type of Vehicle Year, Make, Model 9. Do you or your spouse have an interest in a trust or annuity? No Yes fill in below Type 10. Do you or your spouse have life insurance? No Yes fill in below Policy Number Insurance Company Name and Address 11. Do you or your spouse have a prepaid burial account or burial trust? Include revocable and irrevocable accounts, insurance-funded burials, annuity-funded burials, Cremation Society agreements, burial spaces, burial space items and other funds designated for burial. No Yes fill in below Type of Burial Asset Company or Bank Name and Address 12. 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? No Yes fill in below Type of Asset See required proofs on Page A. If you need more space, write the question number and the answer on a separate piece of paper. 3

6 13. Do you or your spouse own or co-own any other assets you have not listed? No Yes fill in below Type of Asset 14. Do you or your spouse live in a continuing care retirement community? No Yes I have attached all necessary proofs. I declare that I have read and understand the information on this form. I believe all the information entered on this form is true and correct. YOUR SIGNATURE SPOUSE S SIGNATURE DATE SIGNATURE OF PERSON ACTING ON YOUR BEHALF RELATIONSHIP DATE PERSON S ADDRESS PERSON S DAYTIME PHONE NUMBER See required proofs on Page A. If you need more space, write the question number and the answer on a separate piece of paper. 4

7 Page A Required Proofs Send proof of how much each asset listed on this form is worth. Proof can be any of the following: Bank accounts Bank statements or a written statement from the bank showing the balance or value of accounts. Stocks, bonds and retirement accounts Copies of bonds, stock ownership statements, retirement account statements or other documents showing the value. Real estate Property tax statement. Include documents showing the loan balance owed against the property. Promissory notes, contracts for deed or other property agreements Copies of promissory notes, contract for deed or other property agreement documents. Vehicles Documents showing the loan balance owed against the vehicle. Trusts and annuities Copies of trust documents, documents showing an accounting of the trust corpus for each trust, and annuity contracts. Life insurance Life insurance statements showing the face and cash surrender value. Burial contracts Burial contract and statement of goods and services from the company or funeral home that holds the contract. Self-employment assets Documents showing the value of assets. Include documents showing the loan balance owed against each asset. Continuing care retirement community entrance fee Documents showing the available amount of the entrance fee. Other assets Documents showing the value of assets. Include documents showing the loan balance owed against each asset. If you want a county worker to help you get the proofs, you can sign a release of information form. The form will allow others to release proofs to the worker. Send copies of proofs. Do not send original documents. Keep this page. A

8 Page B Important Information What is an asset assessment? An asset assessment determines the total value of assets you and your spouse own. We use the information on the asset assessment form to help you decide the assets your spouse can keep. As of June 1, 2016, your spouse is able to keep the maximum amount of assets for a community spouse that is allowed under federal law and is in effect at the time of your application for long-term-care services. We will not count the assets your spouse can keep toward your asset limit for Medical Assistance for long-term-care services (MA-LTC). When should I complete an asset assessment? You can ask to complete an asset assessment anytime you expect to receive 30 uninterrupted days of LTC services. What assets should I list on the asset assessment? List these: Assets in your name Assets in your spouse s name Assets in both your and your spouse s names Also list assets that you or your spouse owns jointly with a person or people other than each other. Does my home count as an asset when completing the asset assessment? Usually, your home does not count as an asset for an asset assessment. Other assets that do not count include these: Personal property and household goods One vehicle Capital assets needed to operate a trade or business Money set aside for a burial space and burial space items for you, your spouse and other members of your immediate family Retirement annuities funded by a pension fund or retirement plan unless you can get all or part of the funds Certain assets if you are an American Indian What assets count? Counted assets include but are not limited to these: Cash Bank accounts (savings, checking, money market, and credit union accounts; certificates of deposit; etc.) Stocks and bonds Individual retirement accounts (IRAs) and other retirement accounts College 529 savings plans Cash surrender value of life insurance policies if the face value of all policies is more than $1,500 Contracts for deed Certain trust funds Life estate interests Annuities in the accumulation phase If you have more than one vehicle, the other vehicle(s). Vehicles include cars, vans, motor homes, motorcycles, trucks, campers, etc. Boats, trailers, machinery, snowmobiles, all-terrain vehicles, etc. Lake homes, cabins, summer and winter homes, time-shares, life estates, etc. You must tell us about all assets you and your spouse own or co-own. A worker will determine whether an asset counts. What happens after I complete the asset assessment form? Give the completed form to your county agency. A worker will look at the information on the form and determine the amount of assets you may need to spend before you can be eligible for MA-LTC. Can the results of the asset assessment change? Results can change if other assets are discovered or you get other assets that were not included in the assessment or if the value of an asset changes before you apply for MA LTC. You must tell us about all assets you and your spouse own or co-own. A worker will determine whether an asset counts. Keep this page. B