Appendix G: Partial Approval of Undue Hardship Waiver Notice

PARTIAL APPROVAL OF UNDUE HARDSHIP WAIVER REQUEST NOTICE TEXT-LTC ASSET TRANSFERS  

 

Until automated notices are available the following text and citations should be printed on the manual notice sent to the individual in the LTC facility as well as all involved parties, informing them that the undue hardship waiver was partially granted:   

 

You previously received a notice stating you would not qualify for payment of

Long Term Care (LTC) facility services for a certain time period because you gave

away or transferred assets for less than fair market value (FMV). You requested

an undue hardship waiver. Payment of LTC facility services has been approved for

part of this time period. Because you gave away or transferred a total of

$_____ in assets for less than FMV you are not eligible for payment towards

the cost of LTC facility services beginning on _____ and ending on

_____. During this time, you will need to pay the LTC facility for the services

that you are given. You are eligible for all other Medical Assistance benefits. You

may qualify for payment of LTC facility services after this period.

 

Citations: 42 U.S.C. § 1396p(c),

 55 Pa. Code 178.104b, 181.452 and 181.453

 

PARTIAL APPROVAL OF UNDUE HARDSHIP WAIVER REQUEST NOTICE TEXT-HCBS ASSET TRANSFERS

 

Until automated notices are available the following text and citations should be printed on the manual notice sent to the individual requesting payment of HCBS as well as all involved parties, informing them that the undue hardship waiver was partially granted:  

 

You previously received a notice stating you would not qualify for payment of

Home and Community Based Services (HCBS) for a certain time period because

you gave away or transferred assets for less than fair market value (FMV). You

requested an undue hardship waiver. Payment of HCBS has been approved for

part of this time period. Because you gave away or transferred a total of

$_____ in assets for less than FMV you are not eligible for payment towards

the cost of HCBS beginning on _____ and ending on _____. During this

time, you will need to pay the HCBS provider for the services that you are

given. You are eligible for all other Medical Assistance benefits. You may qualify

for payment of HCBS after this period.

 

Note:  If the individual is receiving services in OLTL waivers, the following text must be included:

 

 

 In the event that you desire more or different services than are available under the Office of Long Term Living (OLTL) Waiver to which  you have been assigned, including any OLTL Waiver for which there is a waiting list, you or your representative can request to be transferred to another Waiver by contracting your Service Coordinator and request such a transfer.      

 

For additional information regarding OLTL Waivers, please contact the OLTL Participant Hotline at 1-800-757-5042. 

 

Citations:  42 U.S.C. § 1396p(c),

 55 Pa. Code 178.104b

 

Updated May 2, 2016  Issued March 12, 2012