SR 11-06 Dated 03/11

STATE OF NEW HAMPSHIRE

INTER-DEPARTMENT COMMUNICATION

SUMMARY

This SR releases new DFA Form 774, LTC Asset Verification Letter, and its associated instructions.

POLICY

New DFA Form 774, LTC Asset Verification Letter, was created to assist applicants of nursing facility (NF) or home and community-based care (HCBC) services, including Choices for Independence (CFI) services, meet asset verification eligibility requirements. District Office (DO) staff had indicated that many NF and HCBC applicants had complained that when attempting to meet NF and HCBC asset verification eligibility requirements, financial institutions were charging a fee for retrieval and printing of the applicant’s asset information, and this fee was often a hardship for the applicant. Sometimes this fee was waived if the financial institution was made aware that the applicant’s request was due to application for NF or HCBC services, collectively called long-term care (LTC) services for the remainder of this SR. New DFA Form 774 was created in response to these complaints to help LTC applicants obtain their asset history from their financial institutions free of fees. DFA Form 774, which must be printed on DO letterhead, authorizes the release of the individual’s most recent 60-month asset history for use by DFA and requests that the financial institution waive any fees related to providing this asset history that would otherwise be incurred by the individual.

This new form does not guarantee that the LTC applicant will be able to collect this information free of fees because the Department has no authority to prevent financial institutions from charging fees for any service provided. However, a version of the letter has been piloted in the Concord District Office with some success at eliminating the fees charged to our LTC applicants when attempting to collect these documents.

Additionally, this new form is used solely by the LTC applicant only if the applicant would like to use it. DO staff are not required to provide this new form to every LTC applicant, nor will every LTC applicant necessarily need this new form. If an applicant for LTC requests help in obtaining the verification needed to meet LTC eligibility requirements, staff may assist the applicant by providing this form.

Regardless of whether this form successfully helps the LTC applicant retrieve the required asset verification, or regardless of whether this form successfully assists in eliminating or reducing any fees charged by the financial institution, documentation of asset history is still a requirement of the LTC financial eligibility process and applicants must provide this verification to DFA within 10 days from the date of application. Failure to provide the asset verification by the due date may result in denial of services.

DESCRIPTION OF NEW DFA FORM 774

New DFA Form 774, LTC Asset Verification Letter, is a 1-page, single-sided, electronic Word document that DO staff can print on DO letterhead when requested by the LTC applicant. The letter explains the reason for the asset history request and includes the:

·   date and Family Services Specialist’s name;

·   LTC applicant’s name;

·   information being requested;

·   date of application;

·   verification due date;

·   request that the financial institution waive any fees; and

·   applicant’s signed and dated authorization to release the asset history for use by DFA.

Because DFA Form 774 is used solely by the LTC applicant and only if the applicant would like to use it, it is not retained in the case record. Instructions for this new form were created accordingly.

IMPLEMENTATION

New DFA Form 774 is effective upon this SR’s release and can be used immediately upon electronic receipt.

CLIENT NOTIFICATION

No special client notification is planned.

TRAINING

No training is planned or needed.

FORMS MANUAL POSTING INSTRUCTIONS

DISPOSITION

This SR may be destroyed or deleted after its contents have been noted and the SR has been posted to the On-line manual.

DISTRIBUTION

This SR will be distributed according to the electronic distribution list for Division of Family Assistance policy releases. This SR will be available for agency staff in the On-Line Manual Library, and for public access on the Internet at www.dhhs.nh.gov/DFA/publications.htm, effective May 2, 2011. Additionally, this SR will be distributed under separate cover to all internal hard copy holders of the Forms Manual.

DFA/KD:s