ISABELLA SPRINGER

MA-LTC Basics Rev. 05/01/2017 - Health Care Training 1

Case Summary:

Isabella (age 4) has been disabled since birth. Isabella’s parents are requesting MA payment of LTC services for services received through the Developmental Disability (DD) Waiver program. Isabella lives with her parents, Alicia and Erik Springer, and her older brother, Gavin.

Isabella’s case manager, Margaret Mead, has submitted a DHS-5181 indicating Isabella had a full team DD screening on LM/25/YY. Isabella requires the following services that are only provided through the DD waiver program:

• Assistive technology.• Case management services.• Extended personal care assistance services.• Home modification.• Specialist services.• Transportation services.

Isabella has other health care coverage through her father’s employer. Her father completed a DHS-1922B. She has submitted proof of medical expenses from last month.

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1

See Required Proofs on Page A If you need more space, write the question number and the answer on a separate piece of paper.

*DHS-3531-ENG*DHS-3531-ENG 1-15

Minnesota Health Care Programs

Application for Payment of Long-Term Care Services

Office Use OnlyDATE RECEIVED CASE NUMBER WORKER NUMBER

� Answer all questions the best you can. � Return the form right away. �We will contact you for any additional information we need.

1. Person living in or planning to live in a long-term care facility or planning to get services tohelp the person live at home

FIRST NAME MI LAST NAME

DATE OF BIRTH SEX

M FMARITAL STATUS SOCIAL SECURITY NUMBER

No Yes No Yes

Are you pregnant?N/A No Yes

IF YES, DUE DATE Have you had a Long-Term Care Consultation?No Yes Don’t know

What language do you speak most of the time? Do you need an interpreter?No Yes No Yes

No Yes

IF YES, DATE ENTERED THE HOSPITAL IF YES, DATE LEFT THE HOSPITAL

OPTIONAL INFORMATION

RACE Asian Black/African American American Indian/Native Alaskan

Pacific Islander or Native Hawaiian White

American Indians: Certain assets owned by an American Indian do not count.

HISPANIC OR LATINO?

No Yes

2. Address and phone numberSTREET ADDRESS WHERE YOU ARE CURRENTLY LIVING CITY STATE ZIP CODE COUNTY

MAILING ADDRESS (if different) CITY STATE ZIP CODE COUNTY

PHONE NUMBER

No Yes No YesIF YES, FILL IN THE

FOLLOWING ➔

WHICH STATE?

No YesIF YES, FILL IN THE

FOLLOWING ➔

LONG-TERM CARE FACILITY NAME DATE MOVED INTO THIS FACILITY

STREET ADDRESS BEFORE MOVING TO THIS FACILITY CITY STATE ZIP CODE COUNTY

Do you plan to return to your home? No Yes

Are you a veteran or the spouse of a veteran?

Are you blind or do you have a physical or mental health condition that limits your ability to work or perform daily activities?

Are you getting services from the Center for Victims of Torture?

Were you in the hospital before moving to a facility or getting services in your home?

Do you plan to make Minnesota your home?

Do you currently have medical benefits from another state?

Are you living in a long-term care facility?

2

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. Are you a U.S. citizen or U.S. national? Yes No – fill in below

IMMIGRATION STATUS DATE ENTERED THE U.S. Do you have a sponsor?Yes No

4. Do you want someone to act on your behalf as an authorized representative?An authorized representative is a person authorized to act on your behalf as an applicant or enrollee in any of thehealth care programs. In most cases, authorized representatives have the same responsibilities and rights as applicants orenrollees. An authorized representative will receive forms, notices, and premium notices on your behalf.

An authorized representative must: � Be at least 18 years old. � Know your circumstances in order to provide necessary information.

No Yes – fill in below

FIRST NAME MI LAST NAME PHONE NUMBER

STREET ADDRESS CITY STATE ZIP CODE

Does this person have Power of Attorney? No Yes

5. Do you or your spouse have cash, a savings or checking account, money market accountor certificates of deposit?

No Yes – fill in below

Owner(s) name Type Name of bank

6. Do you or your spouse own or have an interest in an annuity? No Yes – fill in below

OWNER(S) NAME YOUR INTEREST

Owner Annuitant Beneficiary

7. Do you or your spouse have life insurance, a burial contract or money set aside for burialexpenses? No Yes – fill in below

Owner(s) name Name of insurance company, funeral home or other company that holds the contract or money

3

See Required Proofs on Page A If you need more space, write the question number and the answer on a separate piece of paper.

8. Do you or your spouse own or co-own stocks, bonds, retirement accounts, trusts, contractsfor deed or any other assets? No Yes – fill in below

Owner(s) name Type of asset Name of company or bank

9. Do you or your spouse have a vehicle?Include cars, trucks, snowmobiles, four-wheelers, motorcycles, boats and motors, trailers, campers and motor homes.

No Yes – fill in below

Owner(s) name Type of vehicle Year/Make/Model

10. Do you or your spouse own or co-own a home, life estate, cabin, land, time share, rentalproperty or any other real estate? No Yes – fill in below

Owner(s) name Address Type Who lives here?

11. Did you or your spouse create a trust in the last 60 months? No Yes – fill in below

NAME(S) OF WHO CREATED THE TRUST DATE CREATED

12. Did you or your spouse buy an annuity, life estate in another person’s home, apromissory note, loan or mortgage in the last 60 months? No Yes – fill in below

WHAT WAS BOUGHT? DATE BOUGHT

13. Did you or your spouse not accept items or income you could have taken, such as aninheritance or a pension, in the last 60 months? No Yes – fill in below

Item(s) you did not take Value of the item or income Date happened

$

$

4

See Required Proofs on Page A If you need more space, write the question number and the answer on a separate piece of paper.

14. Did you or your spouse sell, trade or give away items or income in the last 60 months?No Yes – fill in below

Owner(s) name Item or income ValueSold, traded or given away? To whom? Date

Amount you were paid

$ $

$ $

$ $

$ $

$ $

15. Have you worked in the last 30 days or do you expect to work next month?Include temporary and seasonal work.

No Yes – fill in below

EMPLOYER NAME START DATE

How often are you paid? Is this job seasonal?No Yes

Has this job ended?No Yes

IF YES, END DATE

16. Were you self-employed this month or do you expect to be self-employed next month?No Yes – fill in below

BUSINESS NAME START DATE Do you plan to continue the business?No Yes

IF NO, END DATE

17. Did you get money this month or do you expect to get money next month from sourcesother 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

No Yes – fill in below

Type of income Start date How often received? Has this income ended?

No Yes IF YES, END DATE

No Yes IF YES, END DATE

No Yes IF YES, END DATE

No Yes IF YES, END DATE

WORKER NOTES

5

See Required Proofs on Page A If you need more space, write the question number and the answer on a separate piece of paper.

18. Expenses

Not Applicable No Yes

IF YES, TYPE OF EXPENSE(S) MONTHLY AMOUNT

$

Do you have a legal guardian or conservator?No Yes

IF YES, NAME FEE PAID

$

No Yes

IF YES, AMOUNT PER MONTH

$

No Yes

IF YES, AMOUNT PER MONTH

$

No Yes

IF YES, LIST MONTHS

19. Do you have medical expenses?Include health insurance premiums, pharmacy copays, doctor office copays and all unpaid medical bills.

No Yes – fill in below

LIST EACH MEDICAL EXPENSE

________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________

20. Are you getting medical care for an accident or injury that happened in the last sixyears? No Yes – fill in below

TYPE OF ACCIDENT OR INJURY DATE HAPPENED Is there a lawsuit?No Yes

21. Did you buy, exchange, or add a rider to a long-term care insurance policy on or afterJuly 1, 2006? No Yes – fill in below

Is this policy paying benefits now?No Yes

If no, did this policy ever pay benefits?No Yes

IF YES, DATE BENEFITS STOPPED

POLICYHOLDER’S NAME INSURANCE COMPANY NAME

WORKER NOTES

If you are blind or have a disability, do you have work expenses?

Do you have court-ordered child or medical support payments taken from your income?

Do you have court-ordered spousal maintenance payments taken from your income?

Do you want help paying for medical bills from the past three months?

6

See Required Proofs on Page A If you need more space, write the question number and the answer on a separate piece of paper.

22. Do you have Medicare, health insurance or long-term care insurance now or have youhad coverage in the last 4 months? No Yes – fill in below

COVERAGE TYPES

Medicare Medicare supplemental policy Medical Hospital only HMO Prescription drugDental Vision Long-term care Other – List type:

POLICYHOLDER’S NAME INSURANCE COMPANY NAME START DATE END DATE

POLICY NUMBER LIST EVERYONE WHO IS COVERED BY THIS POLICY MONTHLY PREMIUM

$

Is this health insurance through an employer or union? No Yes

23. Do you have a spouse? No Yes – fill in below

NAME OF SPOUSE

No Yes

IF YES, IN WHAT STATE OR COUNTY?

No Yes

IF YES, TYPE(S) OF INCOME YOUR SPOUSE GETS

No Yes

No Yes No YesIF YES,

FILL IN BELOW

DATE OF BIRTH SOCIAL SECURITY NUMBER Is your spouse a U.S. citizen or U.S. national?No Yes

24. Do you want to give part of your income to any of the following family members? � A child under 21 � A child 21 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 formsNo Yes – fill in below

Name Relationship Date of birth Type(s) of incomeLiving with your

spouse?Do they want

to apply?

N/ANo Yes

NoYes

N/ANo Yes

NoYes

WORKER NOTES

Has a state or county ever reviewed all assets owned by you and your spouse (asset assessment)?

Do you want to give part of your income to your spouse?

Does your spouse pay housing costs?

Does your spouse live in a long-term care facility or get help from a waiver program?

Does your spouse want to apply for health care coverage?

7

Signature Page (Effective Date: June 1, 2013)

Read the following information and sign.

Authorization to Share Information for Fraud Investigation and AuditsI agree that third parties may share information about me with persons investigating fraud and completing federal or state audits. This may include, but is not limited to:

■■ Employers and schools,■■ Landlords and utility companies,■■ Financial and insurance agencies, and■■ Other government offices.

If I am enrolled in MinnesotaCare, the Minnesota Department of Revenue may share copies of my income tax returns with investigators.

I understand this consent is good for six months after my benefits stop.

Authorization for Release (Sharing) of My Medical Information I give my consent to the following agencies or individuals to share between them medical information about me only for the limited purposes indicated:

■■ Health providers including school districts, health plans, insurance agencies, Minnesota Health Care Programs, county advocates, my county or state case workers, and their contractors and subcontractors:

■■ To determine who should pay for my health care, and■■ To provide, manage, and coordinate health care services.

■■ All other agencies or persons as listed on the Notice of Privacy Practices.

This consent applies to medical information about my minor children I applied for on this application. I understand the school district needs a separate consent to share information about my children with private insurance plans. I can stop this consent at any time by asking in writing for it to end. The written notice to stop this consent will not affect information the agency has already given to others. This consent is good while I am enrolled in Minnesota Health Care Programs, up to one year, or longer if the law permits. However, it does not end after one year for records given to consulting providers, records given for payment of my bills, fraud investigations, or quality of care review and studies. An agency or person who gets my information through this consent could give the information to others.

If I do not sign or I end this consent, I cannot enroll or stay enrolled in Minnesota Health Care Programs.

Medical Assignment of BenefitsI give my rights to all medical payments for me and anyone else I apply for to the State of Minnesota. This includes medical payments from all other persons or companies. For MA for Long-Term Care, this includes my right to support from my spouse under Minnesota Statutes, section 256B.14, subdivision 3. This begins as soon as health care coverage starts.

I agree to help the state to get paid back for medical expenses that should have been paid by others. I may not have to help the state if I have a good reason for not doing so and the state approves the reason.

If I have Medicare Part B, Medicare can pay my health providers for the care I get while I am on a Minnesota Health Care Program.

Over

8

By signing below:■■ I agree that I have read and understand the Notice of Privacy Practices and the list of my responsibilities in that Notice.■■ I agree that I have read and understand the Rights and Responsibilities section including Following the rules, Changes and Liens and Estate Claims.

■■ I agree and understand that my information will be released to the parties listed in the Notice of Privacy Practices in order to verify eligibility for Minnesota Health Care Programs.

■■ I agree and understand that my information will be shared for fraud investigations and audits as stated in the Authorization to Share Information for Fraud Investigations and Audits section.

■■ I agree to assign my medical benefits as stated in the Medical Assignment of Benefits.■■ I agree to the release of my Minnesota Health Care Programs health records to the parties listed in the Authorization for Release (Sharing) of My Medical Information section.

■■ I declare that, under penalty of perjury, all parts of this form and any updates to information I give during the year are true and correct statements, to the best of my knowledge. I understand what happens to people convicted of perjury (not telling the truth). They may be sentenced to prison for up to five years, a fine up to $10,000, or both.

You must sign this application even if you are authorizing someone to act on your behalf.

If an applicant is unable to sign, provide copies of legal documents of guardianship, conservatorship or power of attorney.

YOUR SIGNATURE DATE

SIGNATURE OF AUTHORIZED REPRESENTATIVE PHONE NUMBER DATE

Did you remember to: Sign and date this form?

Attach the proofs you have? See page A for required proofs.

Mail or take this form to your county agency. Do this right away even if you do not have all your proofs ready. See pages B and C at the back of this form for the address.

Alicia Springer

*DHS-5181-ENG*DHS-5181-ENG 10-14

Page 1 of 4

Lead Agency Assessor/Case Manager/Worker LTC Communication Form

Part 1: Sections A & B completed by the lead agency assessor. Sections A & C completed by lead agency assessor or case manager.

DATE

SECTION A – Contact InformationTO

, WorkerCOUNTY/TRIBAL AGENCY

ADDRESS

CITY STATE ZIP CODE

FAX NUMBER PHONE NUMBER

FROM

, Lead Agency Assessor/Case ManagerLEAD AGENCY

ADDRESS

CITY STATE ZIP CODE

FAX NUMBER PHONE NUMBER

CLIENT NAME DATE OF BIRTH PMI NUMBER CASE NUMBER

SECTION B – Status

The client is currently requesting services/enrolled in the following waiver program:

AC BI CAC CADI DD EW

CHOOSE ONE:

Diversion Conversion

OR Essential Community Supports

Individual has NO level of care, MA application required (DHS-3876). Please forward determination in Section F when completed.

LTCF RESIDENT ADMISSION DATE

NAME OF FACILITY ADDRESS

INITIAL REQUESTS (check all that apply)

Waivers: Assessment on determines client:

Needs waiver services and meets LOC requirement. Anticipated effective date no sooner than:

Estimated monthly waiver costs $

Does not meet waiver services level-of-care (LOC) requirement.

Ongoing case manager assigned:

LTCF: Assessment on determines client:

Meets MA-LOC requirement.

Ongoing case manager assigned:

Ongoing case manager not available.

Does not meet LOC requirement.

DATE

DATE

NAME

DATE

NAME

Margaret Mead

Ramsey County Public Health

160 E Kellogg Blvd

St Paul MN 55101

651-123-1200 651-123-4577

Isabella C Springer 12/01/CY-4

LM / 25 / CY

Ima Superworker

Ramsey County

160 E Kellogg Blvd

St Paul MN 55101

651-123-4500

LM/25/CY

LM/25/CY

Rev. 05/01/2017 - Health Care Training

Page 2 of 4 DHS-5181-ENG 12-14

SECTION B – Status

Medical Assistance Requests/Applications

Client applied for MA

Client is an MA enrollee – Assessor provided DHS-3543 on

Completed DHS-3543 or DHS-3531 attached

Completed DHS-3543 or DHS-3531 faxed to county on:

Please send DHS-3543 to client (MA enrollee)

Please send DHS-3531 to client (Not MA enrollee)

Please send DHS-3340 to client – Asset Assessment needed

Changes completed by the Assessor

Client no longer meets LOC – Effective date should be no sooner than:

(Date must be at least 30 days after assessor sends notification to the person that he/she no longer meets the LOC)

Waiver program change from to effective

SECTION C – Changes

CHANGES (check all that apply)

Exited waiver program

Client’s choice

Client deceased

Client moved to long-term care facility on

Waiver program change from to effective

Client disenrolled from health plan

New address

Other:

SECTION D – Comments

DATE

DATE

ADDRESS

DATE

DATE

EFFECTIVE DATE

DATE OF DEATH

DATE FACILITY NAME

EFFECTIVE DATE

ADDRESS DATE ADDRESS CHANGED

Rev. 05/01/2017 - Health Care Training

Page 3 of 4 DHS-5181-ENG 12-14

Part 2: To be completed by the workerDATE

SECTION E – Contact InformationTO

, Lead Agency Assessor/Case ManagerLEAD AGENCY

ADDRESS

CITY STATE ZIP CODE

FAX NUMBER PHONE NUMBER

FROM

, WorkerCOUNTY/TRIBAL AGENCY

ADDRESS

CITY STATE ZIP CODE

FAX NUMBER PHONE NUMBER

CLIENT NAME DATE OF BIRTH PMI NUMBER CASE NUMBER

SECTION F – Medical Assistance (MA) Status for LTC Services

Applied for MA-LTC

DHS-3531 sent to client on:

DHS-3543 sent to client on:

DHS-3543/DHS-3531 has been returned; eligibility determination pending

DHS-3543/DHS-3531 has not been returned

Determination

MA opened

Basic MA Medical Spenddown $

MA for LTC services open effective

LTC spenddown/waiver obligation for initial month:

MA denied

MA payment of LTC services denied

Client is ineligible for MA payment of LTC services until:

Basic MA continues until:

Results from the Asset Assessment have been sent to client

DATE APPLIED

DATE

DATE

EFFECTIVE DATE

DATE

EFFECTIVE DATE

EFFECTIVE DATE

DATE

DATE

Isabella C Springer 12/01/CY-4

Rev. 05/01/2017 - Health Care Training

Page 4 of 4 DHS-5181-ENG 12-14

SECTION F – Medical Assistance (MA) Status for LTC Services

CHANGES

MA terminated (Basic MA and MA payment of LTC services)

MA spenddown $

MA payment of LTC services terminated , Basic MA remains open.

Client is ineligible for MA payment of LTC services until:

Client deceased

Client moved to long-term care facility on

New address

Other:

SECTION G – Comments

EFFECTIVE DATE

EFFECTIVE DATE

DATE

DATE OF DEATH

DATE FACILITY NAME

ADDRESS DATE ADDRESS CHANGED

Rev. 05/01/2017 - Health Care Training

12/01/CY-4

St. Paul, MN USA

0000865478

17 Nov CY-2

17 Nov CY+15

Springer

Springer

Isabella

F

Isabella

Rev. 09/15/09 – Health Care Training

This page intentionally left blank.

Last Month 28, YY

Office of Public Inquiries Windsor Park Building 6401 Security Blvd. Baltimore, MD 21235

SSN: 470 - ___ - ___55

Dear Isabella C. Springer:

Your application for Social Security benefits has been denied due to excess deemed income.

If you have questions regarding this decision please contact the Social Security Administration at 1-800-GET-HELP.

Sincerely, A. Federal Pencil-Pusher

Rev. 10/15/09 - Health Care Training

This page intentionally left blank.

Page 1 of 3

Date:

To:

Minnesota Health Care Programs

Health Insurance Information Form (HIIF)

Case number:

Case name:

Worker name:

Worker phone number:

Fax number:

Agency name:

Agency address:

We need you to fill out this form. We need information about health insurance coverage. It must include information about you and any of your family members. Information is needed for current coverage and any past coverage. If you do not give us this information, you may not qualify for our health care programs. Your signature on the application form allows us to collect payment from any insurance company while you are enrolled in a Minnesota Health Care Program.

We will share this information with: � Minnesota Health Care Program Staff � Medical providers � Human Services Benefit Recovery Section � Your spouse or children who live in your household � The insurance company � Parents who do not live with a child

If there are any changes in health insurance coverage, provide the information to your worker within 10 days. If you have questions, contact your worker at the above phone number.

1. Do you, your spouse or your children have health insurance, long term care insurance, orprescription drug coverage now? No – go to question 2 Yes – fill in below

POLICYHOLDER’S NAME DATE OF BIRTH POLICY TYPE

Individual Employer/Group

POLICY NUMBER

INSURANCE COMPANY NAME PHONE NUMBER POLICY BEGIN DATE POLICY END DATE

CLAIMS ADDRESS CITY STATE ZIP

LIST FAMILY MEMBERS COVERED What is the total monthly premium amount that you pay? $

DEDUCTIBLES (NOT CO-PAY)

$ _________________________ per person in network $ _________________________ per family in network

$ _________________________ per person out of network $ _________________________ per family out of network

OFFICE CO-PAY

$

PRESCRIPTION CO-PAY

$

EMPLOYER/GROUP NAME

Not employer insurance

EMPLOYER/GROUP NUMBER

EMPLOYER/GROUP ADDRESS CITY STATE ZIP

*DHS-1922B-ENG*DHS-1922B-ENG 10-12

Page 2 of 3 DHS-1922B-ENG 10-12

COVERAGE TYPES (check each box that applies)

01 Basic Hospital

02 Medical - Surgical

03 Medicare Supplemental Policy

04 Prescription Drugs with Deductible

05 Prescription Drugs with Co-pay of $_____

06 HMO (Health Maintenance Organization)

07 HMO (Medicare)

08 PPO (Preferred provider Organization)

09 TRICARE / CHAMPUS

10 Comprehensive Dental

11 Preventive Dental only

12 Vision Care / Eyeglasses

13 Nursing Home Care

14 Hospital / Surgical only

15 Cancer only

16 Accident only

17 Indemnity Coverage

20 OTC (Over the Counter) Drugs

21 VA (Veteran’s Administration)

24 PPO Dental

Employer Insurance InformationEMPLOYEE EMPLOYER/UNION PAYS

$ Monthly Twice a month

Weekly Every 2 weeks

AMOUNT YOU PAY

$ Monthly Twice a month

Weekly Every 2 weeks

SPOUSE/DEPENDENT (do not include employee amount)

EMPLOYER/UNION PAYS

$ Monthly Twice a month

Weekly Every 2 weeks

AMOUNT YOU PAY

$ Monthly Twice a month

Weekly Every 2 weeks

2. Answer the questions below regarding past insurance coverage.

1. Did you, your spouse or your children have health insurance coverage in the past fourmonths?

No Yes

2. Did you, your spouse, or children have health insurance coverage in the past 18 months? No Yes

3. Did you or your spouse turn down health insurance offered by your employer? No Yes

4. Did you have insurance through your current employer and it ended? No Yes – fill in below

DATE INSURANCE ENDED REASON INSURANCE ENDED

5. Did your employer or your spouse’s employer offer health insurance in the past 18 months,but doesn’t offer it now?

No Yes – fill in below

DATE THE EMPLOYER STOPPED OFFERING INSURANCE AS A BENEFIT FOR EMPLOYEES

3. Do you, your spouse or your children have Medicare coverage? No Yes – fill in below

PERSON COVERED MEDICARE ID NUMBER START DATE OF PART A START DATE OF PART B

PERSON COVERED MEDICARE ID NUMBER START DATE OF PART A START DATE OF PART B

You may be asked to submit a copy of both sides of your insurance card.

NAME OF PERSON WHO COMPLETED THIS FORM PHONE NUMBER WHERE WE CAN REACH YOU

SIGNATURE DATE

Case number:

Rev. 03/28/17 - Health Care Training

*DHS-2841-ENG*DHS-2841-ENG 6-15

Page 1 of 2

Minnesota Health Care Programs

Cost Effective Insurance Information – Employer or Insurance CompanyCLIENT NAME (LAST, FIRST, MI) CLIENT CASE NUMBER DATE

I give permission to my employer/union (or former employer), or insurance company named below to release the requested information to the agency(s) listed on this form. This information is used to figure my eligibility for medical assistance. This authorization will end one year from the date I sign it.SIGNATURE OF CLIENT OR AUTHORIZED REPRESENTATIVE DATE SIGNED

EMPLOYER NAME EMPLOYER CONTACT PERSON

EMPLOYER ADDRESS CITY STATE ZIP CODE

Fax or mail completed form to the financial worker. If you have any questions, contact the worker.AGENCY NAME WORKER NAME PHONE NUMBER (include area code) FAX NUMBER (include area code)

AGENCY ADDRESS (if unable to fax) CITY STATE ZIP CODE

EMPLOYER: Complete a form for each employer option. For non-group coverage, client or insurance company must complete.

Is insurance available?

No Yes

Is this insurance currently in effect?

No Yes Single Family

Insurance InformationINSURANCE COMPANY NAME POLICY BEGIN DATE NEXT OPEN ENROLLMENT DATE

INSURANCE COMPANY ADDRESS CITY STATE ZIP CODE

POLICY HOLDER (INSURED PERSON) NAME (LAST, FIRST, MI) EMPLOYED Yes No MEDICAL LEAVE Yes No

TERMINATED Yes No RETIRED Yes No

EXPECTED DATE OF RETURN TO WORK

Policy InformationCheck the box(es) that relate to the health insurance policy coverage.

Medical Dental Vision LTC Limited Benefits COBRA

POLICY NUMBER/ID GROUP NUMBER RX CO-PAY

$

LIFETIME MAXIMUM

$

PBM

Covered persons (names)

Premium Amounts (Paid by Employee/Individual)SINGLE PREMIUM (per pay period)

$

FAMILY PREMIUM (per pay period)

$

EMPLOYER PAY SCHEDULE

Weekly Biweekly Semimonthly Monthly

Page 2 of 2 DHS-2841-ENG 6-15

Dental/Vision InformationIs Dental Insurance available?

No Yes

Is this insurance currently in effect?

No Yes Single Family

Premium Amounts (Paid by Employee/Individual)SINGLE PREMIUM (per pay period)

$

FAMILY PREMIUM (per pay period)

$

EMPLOYER PAY SCHEDULE

Weekly Biweekly Semimonthly Monthly

Is Vision Insurance available?

No Yes

Is this insurance currently in effect?

No Yes Single Family

Premium Amounts (Paid by Employee/Individual)SINGLE PREMIUM (per pay period)

$

FAMILY PREMIUM (per pay period)

$

EMPLOYER PAY SCHEDULE

Weekly Biweekly Semimonthly Monthly

COMPLETED BY (print) SIGNATURE DATE

PHONE NUMBER (include area code) FAX NUMBER (include area code)

This information is available in accessible formats for individuals with disabilities by contacting your county worker. For other information on disability rights and protections to access human services programs, contact the agency’s ADA coordinator.

AD

A5 (12-12)

Attention. If you need free help interpreting this document, ask your worker or call the number below for your language.

مالحظة: إذا أردت مساعدة مجانية لترجمة هذه الوثيقة، اطلب ذلك من مشرفك أو اتصل على الرقم 1-800-358-0377.

kMNt’sMKal’ . ebIG~k¨tUvkarCMnYyk~¬gkarbkE¨bäksarenHeday²tKit«f sUmsYrG~kkan’sMNuMerOg rbs’G~k ÉehATUrs&BÍmklex

1-888-468-3787 .

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LB1-0001 (3-13)

Page 1 of 2

DHS-2841A-ENG 4-16

Minnesota Health Care Programs

Cost-Effective Insurance CalculationCLIENT NAME - FIRST MI LAST NAME CASE NUMBER DATE

First name Date of BIrth MA-PW

Adult without

children Capitation

Prorated Monthly

Premium

Average

Wraparound Cost

TOTALS A B C

TOTALS (B + C)

Worker StepsUse this form to determine the premium amount considered cost effective. Complete a row of the table above for each MA-eligible person on the case.

• When you enter each client's name and date of birth, the form automaticallypopulates the "Capitation" and "Average Wraparound Cost" fields.

• In the "Prorated Monthly Premium" field, enter the prorated monthly per-person premium amount from the Prorating Premium Amounts (DHS-2841D) form (PDF).

• If the client is pregnant, check the "MA-PW" box only if the insurance policywill cover maternity costs. If you do not check the box, the form will use the basic capitation amount for the client's age.

• If the client is an adult without children and has an eligibility type of AX,check the "Adult without Children" box.

• The form automatically calculates the totals in the last two rows of the table.

If the total capitation amount is more than the sum of the total prorated monthly premium amounts and the total average wraparound costs, the form automatically checks this box:

The policy is cost effective (A > B + C). Approve payment of the prorated premium. You do not need to continue to "Next Steps" below.

If the total capitation amount is less than the sum of the total prorated monthly premium amounts and the total average wraparound costs, the form automatically checks this box:

Continue to "Next Steps" below (A < B + C).

Basic Capitation Amount by Age (Calendar Year 2016)

Age

Basic Capitation

Amount

Average

Wraparound Cost

0 $747.52 $201.59

1 $207.24 $84.68

2-15 $207.54 $117.22

16-20 $207.44 $167.32

21-49 $476.76 $150.43

50-64 $476.20 $312.16

65+ $1,644.62 $1,957.62

MA-PW $1,135.43 $432.92

Adults without Children (Calendar Year 2016)

Age

Basic Capitation

Amount

Average

Wraparound Cost

21-49 $683.04 $283.67

50-64 $681.58 $317.61

Next StepsSend the Cost Effective Insurance Referral – Applicant/Enrollee (DHS-2841B) form (PDF) to the client. Review any copies of explanations of benefits (EOBs) that the client returns.

If benefits paid by the policy exceed the premiums paid by the client by at least a 2:1 ratio, approve the premium for payment.

If benefits paid by the policy do not exceed the premiums paid by the client by at least a 2:1 ratio, do not approve the premium payment. You do not need to send the referral for BRS review.

Isabella C Springer CM/CD/CY

Isabella 12/01/CY-4 $ 207.54 $ 75.00 $ 117.22$ 207.54 $ 75.00 $ 117.22

$ 192.22

X

Page 2 of 2 DHS-2841A-ENG 4-16

Next Steps for Complex CasesIf you cannot determine cost effectiveness because of the case’s complexity, fax the following to the DHS Benefit Recovery Section (BRS) at 651-431-7431 for BRS to determine cost effectiveness: • Cost Effective Insurance Information – Employer or Insurance Company (DHS-2841) form• Cost Effective Insurance Calculation (DHS-2841A) form• Cost Effective Insurance Referral – Applicant/Enrollee (DHS-2841B) form• Summary of benefits for the health insurance policy and any other relevant information• Copies of EOBs

DHS BRS will notify you of its determination by faxing a completed determination using either DHS-7207A or DHS-7207B. You will need to fill in the client’s address and the date of the approval or denial for premium payments. After receiving the determination and filling in the client’s address and the date of approval or denial, notify the client of the determination and the client’s right to appeal it, and document your actions in case notes.

If you have not received a response within 72 hours, call BRS at 651-431-3100, option 3.

Dental or vision coverage • If the client is offered dental, vision, or dental and vision coverage in addition to medical coverage, complete the DHS-2841A

form both with and without these premiums to determine cost effectiveness.• If the client has only dental, vision, or dental and vision coverage, do not approve premiums for payment. If medical coverage

becomes available to the client at any point, consider the dental and vision premiums for reimbursement then.

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