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Library: Policy

317:35-19-5. Application for nursing facility care; forms

Revised 6-26-00

(a) Application procedures for nursing facility care. An application for Nursing Facility (NF) level of care consists of the Medical Assistance Application form. The form is signed by the client, parent, spouse, guardian or someone else acting on the client's behalf.

  • (1) All conditions of eligibility must be verified and documented in the case record. When current information already available in the local office establishes eligibility, such information may be used by recording source and date of information.
  • (2) At the request of an individual in an NF or the community spouse, if application for Medicaid is not being made, an assessment of the resources available to each spouse is made by use of DHS form MA-11 (new form number 08MA011E), Assessment of Assets. Documentation of resources must be provided by the individual and/or spouse. This assessment reflects all countable resources of the couple (owned individually or as a couple) and establishes the spousal share to be protected when subsequent determination of Medicaid eligibility is made. A copy of Form MA-11 (new form number 08MA11E) is provided to each spouse for planning in regard to future eligibility. A copy is retained in the county office in case of subsequent application.
  • (3) If assessment by Form MA-11 (new form number 08MA011E) was not done at the time of entry into the nursing home, assessment by use of Form MA-11 (new form number 08MA011E) must be done at the time of application for Medicaid. The spousal share of resources is determined for the month of entry into the nursing home. If the individual applies for Medicaid at the time of entry into the nursing home, Form MA-11 (new form number 08MA011E) is not appropriate. However, the spousal share must be determined using the resource information provided on the Medicaid application form and computed using Form MA-12 (new form number 08MA012E), Title XIX Worksheet.

(b) Date of application. When application is made in the county office, the date of application is the date the applicant or someone acting on his/her behalf signs the application form. When the application is initiated outside the county office, the date of application is the date the application is stamped into the county office. When a request for Medicaid services is first made by an oral request and the application form is signed later, the date of the oral request is entered in "red" above the date the form is signed. The date of the oral request is the date of application. An exception is when DHS has contracts with certain providers to take applications and obtain documentation. After the documentation is obtained, the application and documentation are forwarded to the DHS county office of the client's county of residence for Medicaid eligibility determination. Under this circumstance, the application date is the date the client signed the application form for the provider.

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