EMILY S. A - Minnesotapathlore.dhs.mn.gov/courseware/HealthCare/HCP881_MA-LTC...Abbott Northwestern Hospital - $1316 for 2017 Medicare Part B Premium - $109 1/1/17 Medicare Blue RX

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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Page 1 of 7

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


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?


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?


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


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.


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


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


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.


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


29. Are you getting medical care for an accident or injury that happened in the last six years?


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?


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



















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



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

http://www.peoplecreditunion.net/


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


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.


Liberty Life Insurance Company

3800 Alamo Way

Austin, TX 58698

LM/ 01/ YY


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


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 ______________________


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 ______________________


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




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


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.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.

http://www.abbottnorthwestern.com/ahs/anw.nsf/

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


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


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


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

Documents

EMILY S. A - Minnesotapathlore.dhs.mn.gov/courseware/HealthCare/HCP881_MA-LTC...Abbott Northwestern Hospital - $1316 for 2017 Medicare Part B Premium - $109 1/1/17 Medicare Blue RX