Free Declaration Regarding Transfer of Resources - LTC Medicaid Waiver or COP - Wisconsin


File Size: 28.4 kB
Pages: 2
Date: June 10, 2009
File Format: PDF
State: Wisconsin
Category: Health Care
Author: DHS
Word Count: 853 Words, 5,383 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://dhs.wisconsin.gov/forms1/f2/f20919D.pdf

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DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F-20919D (02/2009)

STATE OF WISCONSIN Wis. Stat. 46.27(6u)(d);49.453 and 49.47 42 CFR 441

DECLARATION REGARDING TRANSFER OF RESOURCES
LONG-TERM CARE MEDICAID WAIVER PROGRAM AND / OR COMMUNITY OPTIONS PROGRAM
Completion of this form is mandatory per Wis. Stat. 46.27(6u)(d); 49.453 and 49.47; and the Federal Deficit Reduction Act of 2005. Prohibited divestments are a bar to the Community Options Program and to the Medicaid Home and Community Based Waiver eligibility; therefore, applicants/ participants must complete this form so the caseworker can ascertain whether or not they are eligible.

Care Manager / Support and Service Coordinator:
Complete this form at application or at review and send it to your Income Maintenance Worker for an evaluation of a possible divestment when a Community Options Program and / or Group A (SSI, SSI-E, Katie Beckett) Medicaid Waiver participant / applicant answers "Yes" to one or more of the questions below. NOTE: Beginning on February 1, 2012, you should ask all of the following questions referencing back to January 1, 2009. Starting January 1, 2009, the number of months in the look-back period will increase by one additional month until the look-back period reaches 60 months--January 2014. Refer to the chart at the end of this form to insert the correct look-back period.

Name - Applicant / Participant: Participant's Medicaid Number: Yes No 1. Have you or your spouse sold, traded, transferred or given away property, land, stocks, bonds, cash, vehicles, or anything of value in the past 36 months? (Note that beginning February 1, 2012, the number of months in the look-back period will increase each month by one additional month, until the look-back period reaches 60 months in January 2014. Beginning February 2012, refer to the look-back period chart at the end of this form to insert the correct look-back period.) If yes, specify the date of the purchase, the value of the life interest, and the seller's relationship to the applicant/participant.
Date of Transfer 1. 2. 3. 4. 5. Approximate Value Name of Person to Whom Property was Transferred & Relationship to Applicant / Participant

Item(s) Transferred

Yes

No 2. Have you or your spouse purchased a life interest in another individual's home? If yes, specify the date of the purchase, the value of the life interest, and the seller's relationship to the applicant/participant.
Date of Life Interest Purchase 1. 2. Approximate Value Name of Person from Whom Life Interest was Purchased & Relationship to Applicant / Participant

Yes

No 3. Have you or your spouse purchased a promissory note(s), a loan(s), or a mortgage(s)? If yes, specify the date of the purchase, the value of the note(s), loan(s), or mortgage(s), and the seller's relationship to the applicant/participant.
Date of Purchase 1. 2. 3. Approximate Value Name of Person from Whom Note, Loan or Mortgage was Purchased & Relationship to Applicant / Participant

F-20919D, Declaration Regarding Transfer of Resources

Page 2

Yes

No 4. Have you or your spouse purchased an annuity? If yes, specify the date of the purchase, the value of the annuity and the seller's relationship to the applicant/participant.
Date of Purchase 1. 2. 3. Approximate Value Name of Person from Whom the Annuity was Purchased & Relationship to Applicant / Participant

Yes

No 5. If you or your spouse own any annuities that were purchased prior to January 1, 2009, have any of the following transactions occurred after January 1, 2009, to that annuity? · Additions of principal · Elective withdrawals · Requests to change the distribution of the annuity · Elections to annuitize the contract · A change in ownership If yes, specify the date, transaction, amount(s), and the seller's relationship to the applicant/participant.
Date of Transaction 1. 2. 3. Type of Transaction Value of the Transaction

Yes

No 6. Have you or your spouse created a trust or added funds to a trust within the last five years? If yes, specify the date, transaction, amount(s), and the seller's relationship to the applicant/participant.
Date of Transaction 1. 2. 3. Type of Trust Established (if funds were added to trust, so indicate) Approximate Value

Because the 60-month look-back period for transfers not involving trusts is applied only to transfers that occurred on or after January 1, 2009, the look-back period for these transfers will remain 36 months until January 1, 2012. After January 1, 2012, the look-back period will increase by one additional month between February 2012 and December 2013, as illustrated below: · Years 2009, 2010, 2011 - Look-Back Period (LBP) in Months for Divestments Other than Trusts--36 months Years 2012 and 2013 ­ Look-Back Period (LBP) in Months for Divestments Other than Trusts 2012 2013 LBP Month LBP Month LBP Month 36 July 42 January 48 July 37 August 43 February 49 August 38 September 44 March 50 September 39 October 45 April 51 October 40 November 46 May 52 November 41 December 47 June 53 December

Month January February March April May June

LBP 54 55 56 57 58 59

Then, beginning January 1, 2014, the look-back period for ALL divestments will be 60 months from the date the individual has applied for HCBW or MLTC.

SIGNATURE - Participant NOTE: If more space is needed, use additional forms (F-20919D).

Date Signed