415.31 Required Documentation for an Undue Hardship Waiver Application (MAM)

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Applicants and recipients who have applied for a hardship waiver are notified of the documentation required to verify the hardship and the timeframes for providing the documentation on the application for the hardship waiver.

Applicants and recipients must provide the following verifications when applying for a hardship waiver to waive serving a penalty period for transferring assets for less than fair market value:

•       Lack of Mental Capacity

-    a signed written statement from a licensed physician stating that the applicant or recipient was mentally incapacitated at the time of the transfer; or

-    an order of findings from a probate court concerning the applicant's or recipient's competency.

•       Health or Life Endangerment

-    a signed statement from the nursing facility that indicates that the applicant or recipient is currently residing in the nursing facility and does not demonstrate the ability to pay for services; and

-    a signed statement from a licensed physician or licensed nurse practitioner that indicates that he or she is the applicant's or recipient's primary care professional and that a penalty period would deprive the individual of medical care such that the individual's health or life would be endangered. Applicants and recipients of HCBC/CFI services must additionally have the medical professional document that the individual does not demonstrate the ability to pay for services.

•       Deprival of the Necessities of Life

-    a signed statement by the applicant, recipient, or authorized representative documenting that a penalty period would deprive the individual of food, clothing, shelter, heat, hot water, electricity, gas service, cooking fuel, or transportation to medical appointments;

-    a signed statement from every individual who directly received any asset transferred by the applicant or recipient of NF or HCBS/CFI services subject to a penalty period, documenting that the individual who received the transferred asset is unable or unwilling to provide the applicant or recipient of NF or HCBS/CFI services with food, clothing, shelter, heat, hot water, electricity, gas service, cooking fuel, or transportation to medical appointments; and

-    individuals claiming to be deprived of heat, hot water, electricity, gas service, cooking fuel, or transportation to medical appointments must additionally provide documentation that the penalty period would result in a:

o   discontinuation of the utility; or

o   lack of transportation to obtain Medicaid-covered services from Medicaid-enrolled providers.

Applicants and recipients must provide the following verifications when applying for a hardship waiver to waive the denial or termination of NF/HCBS/CFI services due to having an equity interest in a home that exceeds $713,000:

•       Health or Life Endangerment

-    a signed statement from the nursing facility that indicates that the applicant or recipient is a current resident of the nursing facility and does not demonstrate the ability to pay for services; and

-    a signed statement from a licensed physician or licensed nurse practitioner that indicates that he or she is the applicant's or recipient's primary care professional and the denial or termination of services would deprive the individual of medical care such that the individual's health or life would be endangered. Applicants and recipients of HCBS/CFI services must additionally have the medical professional document that the individual does not demonstrate the ability to pay for services.

•       Deprival of the Necessities of Life

-    a signed statement by the applicant, recipient, or authorized representative documenting that denial or termination of services would deprive the individual of food, clothing, shelter, heat, hot water, electricity, gas service, cooking fuel, or transportation to medical appointments;

-    documentation that verifies that the denial or termination of services would deprive the individual of food, clothing, shelter, heat, hot water, electricity, gas service, cooking fuel, or transportation to medical appointments; and

-    individuals claiming to be deprived of heat, hot water, electricity, gas service, cooking fuel, or transportation to medical appointments must additionally provide documentation that the denial or termination of services would result in a:

o   discontinuation of the utility; or

o   lack of transportation to obtain Medicaid-covered services from Medicaid-enrolled providers.

References: He-W 820; He-W 821; RSA 167:4; RSA 167:13-16; 42 USC 1396p; 42 CFR 411.302