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Date: 08/24/2017
To: Alternative Care (AC) and Elderly Waiver (EW) Program Managers
Case Managers/Certified Assessors
Long Term Care Consultation Administrative Contacts
Social Service Staff and Supervisors
Tribal Administrators
From: DHS
Aging and Adult Services Division waiver policy staff
RE: Updated
DHS forms
Updates have been made to the following forms:
- Form DHS-2630
Alternative Care Program Eligibility Worksheet for Unmarried individuals
- Form DHS-2630A
Alternative Care Program Eligibility worksheet for a Married Person who
has a Community Spouse
- Form DHS-5186
Alternative Care Program Estate Recovery Information
- Form DHS-4639
Alternative Care Program Monthly Fee and Payment Information
- Form DHS-3956
Elderly Waiver Conversion Rate Request
Please discontinue using the older
versions of the worksheets and begin using the new versions for all new
applicants and reassessments as of 7-1-17.
DHS forms 2630 and 2630A have been updated to reflect changes to the
Statewide Average Monthly Payment Rate for Skilled Nursing Facility (SAPSNF),
Monthly Spousal Income Allocation, AC Minimum Income Limits and the Adjusted
Income Limits used to determine the amount of AC fees. The Disclosure and
Agreement/Requirements of Program Participation section has been revised to
remove the check boxes where the participant stated yes or no. These check
boxes are not necessary since the participant agrees to the requirements of the
AC program and acknowledges that they have received the required documentation
concerning their notice of privacy practice and estate recovery information
when they sign the form.
DHS form 4639 has been updated to reflect current fee and payment
information with current phone and fax numbers. Attached to the form is a
current example of the invoice that the participant receives. At this time the
participant does not receive an AC fee statement and this has been removed from
the form.
DHS form 5186 has been updated to reflect the changes in estate
recovery legislation.
DHS form 3956 has been update to reflect the change in the Maintenance
Needs Allowance (MNA).
All forms can be found using eDocs:
https://mn.gov/dhs/general-public/publications-forms-resources/edocs/
Please submit any
questions through Disability &
Aging PolicyQuest
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