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Get Asset Transfer Undue Hardship Claim Form

ASSET TRANSFER UNDUE HARDSHIP CLAIM FORM Return To Agency Address Case Name Case Worker Name Worker Telephone The opportunity to claim an Undue Hardship must be offered when the imposition of a penalty period for the uncompensated transfer of assets affects Medicaid payment for long-term care services including nursing facility PACE hospice or community-based care CBC. An undue hardship may be granted when documentation is provided that shows the assets transferred cannot be recovered and the immediate adverse impact of the denial or cancellation of Medicaid coverage would result in the individual being removed discharged from the nursing facility PACE hospice or CBC or becoming unable to receive life-sustaining medical care food clothing or shelter. The request for an Undue Hardship and all documentation must be submitted to the eligibility worker at the local department of social services. The Department of Medical Assistance Services will review the documentation provided with the undue hardship request to determine if an undue hardship may be granted and send written notification to your eligibility worker. Your eligibility worker will notify you in writing of the decision that is made. I want to claim an Undue Hardship* I affirm that the information provided about my claim for an Undue Hardship is true and correct to the best of my knowledge and belief* Signature of Applicant/Recipient or Authorized Representative Date In order to evaluate your Undue Hardship written evidence of the following information must be provided the reason s for the transfer all attempts made to recover the asset or receive full compensation including legal actions and the results of the attempts notice of discharge from the facility PACE hospice or CBC services due to denial or cancellation of Medicaid payment for these services physician s statement that inability to receive long-term care services would result in the applicant/recipient s inability to obtain life-sustaining medical care documentation that individual would not be able to obtain food clothing or shelter list of all assets owned and verification of their value at the time of the transfer if the individual claims he did not transfer resources to become Medicaid eligible and documents such as deeds or wills if ownership of real property is an issue. Section 20-88. 02 of the Virginia Code allows the Department of Medical Assistance Services DMAS to seek recovery from the transferee or recipient of the transfer when a Medicaid enrollee transfers assets with an uncompensated value of 25 000 or more within 30 months of receiving or becoming eligible for Medicaid long-term care services. The DMAS Recipient Audit Unit will notify the Medicaid recipient of the results of the evaluation for recovery. An undue hardship may be granted when documentation is provided that shows the assets transferred cannot be recovered and the immediate adverse impact of the denial or cancellation of Medicaid coverage would result in the individual being removed discharged from the nursing facility PACE hospice or CBC or becoming unable to receive life-sustaining medical care food clothing or shelter. The request for an Undue Hardship and all documentation must be submitted to the eligibility worker at the local department of social services.

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