c8. SONY A PIERCE, STAFF MANAGER, ELIGIBILITY BUREAU

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1 e- DErARTMENT Susana Martinez, Governor Sidonie Squier, Secretary Julie B. Weinberg, Director DEPARTMENTAL MEMORANDUM MAD-MR: DATE: TO: FROM: THROUGH: BY: SUBJECT: t 0{ ISD AND MAD STAFF JULIE B. WEINBERG, DIRECTOR. MEDICAL ASSISTANCE DIVISION I~. TED ROTH, DIRECTOR, INCOME SUPPORT DIVISION ~ ROY BURT, CHIEF, ELIGIBILITY BUREAU c8. SONY A PIERCE, STAFF MANAGER, ELIGIBILITY BUREAU ESTATE RECOVERY FORMS GENERAL INFORMATION The Human Services Department has contracted with Health Management Systems (HMS) to conduct its Estate Recovery Program. The following forms will be sent out by HMS upon the death of the recipient that has received Long Term Care Medicaid benefits, who meets the Basis for defining the eligible group in Estate Recovery Policy found at NMAC, B. The forms include: The Estate Recovery Brochure (MAD 237), Asset Identification Questionnaire Form (MAD 238), the New Mexico Estate Recovery Notice of Recovery (MAD 239), the New Mexico Estate Recovery Exception Approved (MAD 242), the New Mexico Estate Recovery Request for Update (MAD 243), the New Mexico Estate Recovery Satisfaction of Claim (MAD 244), the New Mexico Estate Recovery Request for Additional Information (MAD 245), the New Mexico Estate Recovery Exception Denied (MAD 246) and the Receipt of Claims Against the Estate (MAD 247) in English and Spanish regarding Estate Recovery. FILING INSTRUCTIONS Please make the following replacements or additions in the Medical Assistance Forms Manual. New MAD 237 Form: Estate Recovery Brochure in English dated May 01, Delete MAD 237 Form: Estate Recovery Brochure in English dated November 0 1, 20 I O. New MAD 237 SP Form: Estate Recovery Brochure ~ Spanish dated May 01, Delete MAD 237 SP Form: Estate Recovery Brochure in Spanish dated November 01,2010. New MAD 238 Form: Estate Recovery Asset Identification Questionnaire Form in English dated May 01, Delete MAD 238 Form: Estate Recovery Asset Identification Form in English dated November 01, New MAD 238 SP Form: Estate Recovery Asset Identification Questionnaire Form in Spanish dated May 01, Delete MAD 238 SP Form: Estate Recovery Asset Identification Questionnaire Form in Spanish dated November 01, MEDICAL AsSISTANCE DIVISION 1 PO BOX SANTA FE, NM PHONE: (50S) FAX: (50S)

2 New MAD 239 Form: Estate Recovery Notice of Recovery in English dated May 01, Delete MAD 239 Form: Estate Recovery Application for Hardship Waiver Form dated November 01,2010. New MAD 239 SP Form: Estate Recovery Notice of Recovery in Spanish dated May 01,2013. Delete MAD 239 SP Form: Estate Recovery Application for Hardship Waiver Form in Spanish dated November 01,2010. New MAD 242 Form: Estate Recovery Exception Approved dated May 01, 2013 New MAD 242 SP Form: Estate Recovery Exception Approved in Spanish dated May 01, 2013 New MAD 243 Form: Estate Recovery Request for Update dated May 01,2013. New MAD 243 SP Form: Estate Recovery Request for Update in Spanish dated May 01, 2013 New MAD 244 Form: Estate Recovery Satisfaction of Claim dated May 01,2013. New MAD 244 SP Form: Estate Recovery Satisfaction of Claim in Spanish dated May 01, New MAD 245 Form: Estate Recovery Request for Additional Information dated May 01, New MAD 245 SP Form: Estate Recovery Request for Additional Information in Spanish dated May 01, New MAD 246 Form: Estate Recovery Exception Denied dated May 01, New MAD 246 SP Form: Estate Recovery Exception Denied in Spanish dated May 01, New MAD 247 Form: Receipt of Claims Against the Estate dated May 01, New MAD 247 SP Form: Receipt of Claims Against the Estate in Spanish dated May 01, Please address questions concerning this material to Sonya Pierce at or at

3 INFORMATION: More information about Estate Recovery can be found on the internet or at a public library. The federal Medicaid Estate Recovery Law can be found at 42 U.S.C. 1396p (b)(4)(a). Information on the state laws can be found in the New Mexico Statutes: the Medicaid Estate Recovery Law can be found in Chapter 27, Article 2A; and the Uniform Probate Code can be found in Chapter 45. TERMS: Medicaid Claim is a legal notice that the estate of the Medicaid recipient owes a debt to the government for the amount of money that was spent on behalf of the recipient for long-term medical care. Decedent means the person that died. Estate means the property that is left after someone dies. An estate can include homes, land, money, bank accounts, stocks, dividends, mineral rights, trusts, interests in a law suit, vehicles, boats, household items and any other belongings or property owned by the decedent. Estate Recovery is the process used to repay the government the cost of the long-term medical care from the Medicaid recipient s estate. Heirs are the living family members (husband/wife, children, parents, brother(s)/sister(s) and/or grandparents) that are placed in line by law to receive the decedent s property if there is no legal will. Personal Representative is the person that takes the legal action(s) required to hand out the property of the estate. Probate is the court process used to decide what will happen to the property of an estate. MEDICAL CLAIMS: Upon the death of the Medicaid client, the recipient s personal representative or heir may contact the HSD Estate Recovery Program to find out how much in Medicaid claims had been paid out on behalf of the client. When making this request, the representative will need to provide the following information for the recipient: Name Social Security Number Date of birth Date of death The claim information will then be sent to the personal representative or attorney who is handling the affairs of the deceased. The HSD Estate Recovery Program cannot provide legal advice so you should contact a lawyer if you have any special concerns or questions about Estate Recovery laws. For more information, contact: Mail: HMS NM ESTATES PO BOX IRVING, TX Phone: Fax: ESTATE RECOVERY PROGRAM Federal law requires that the cost of long-term medical care be repaid from the estates of certain Medicaid recipients. This law is carried out in New Mexico through the Estate Recovery Program. MAD 237 Revised 06/01/13

4 ESTATE RECOVERY: If you are fifty-five (55) years of age or older when you receive Medicaid services for long-term care, your estate (the property that is left after your death) will be used to pay the State of New Mexico back any money that was spent on your care. These costs can include: nursing home care, in home or community-based services, hospital expenses and prescription drugs. The Human Services Department (HSD) has contracted with Health Management Systems (HMS) to conduct its Estate Recovery Program Operations. WHY: Federal law requires the State of New Mexico to seek repayment from certain Medicaid recipients because the state receives money from the federal government to help fund its Medicaid program. Since New Mexico also uses state tax dollars for the Medicaid program, state laws must be followed as well. These laws include the Medicaid Estate Recovery Act and the Uniform Probate Code. WHEN: Estate Recovery only happens after a Medicaid recipient dies. It s set up this way so that people can get the proper medical care they need without having to take out a loan or sell their belongings to pay for their medical services. Estate Recovery will not apply if the Medicaid client has a surviving spouse, a child that is blind or permanently disabled, or a surviving child that is under twenty-one (21) years old. The New Mexico Human Services Department (HSD) may also reduce or waive the Medicaid claim if a Qualified Hardship is identified. Some examples of Qualified Hardships are listed in this brochure. HOW: After the client s death, HSD files a Medicaid claim against the client s estate for the amount of money that was spent on the recipient s long-term medical care. If the Estate has a lot of claims filed against it for other debts, taxes or expenses, a court may help to decide which claims will be paid first. Modest funeral expenses and taxes are examples of claims that are usually paid first in New Mexico. The estate is then responsible to repay the debt owed to HSD. An estate can be used to pay HSD back whether the Medicaid client wrote a will or not and even if the estate does not go through Probate. If there is not enough money in the estate to cover the Medicaid claim, HSD does not waive its right, as permitted by the Uniform Probate Code, to recover the value of non-probate transfers such as properties transferred on death by deed. QUALIFIED HARDSHIPS: Some Estates may qualify for relief from Estate Recovery, but only if HSD decides that one or more of the following hardship conditions are met: an heir would qualify for public benefits to meet food, clothing and shelter needs; an heir would not be able to get off of public assistance if the Estate property is used for repayment; an heir has no source of money other than what the Estate could provide; the home in the Estate is worth 50% or less than the average price of homes in that county. Any relief request must be submitted in writing to HSD by the client s personal representative or heir(s). If HSD denies any part of the request, a Fair Hearing may be requested to review the decision. No relief will be given if the hardship was caused by the recipient s (or their representative s) effort to avoid the legal responsibility to repay Medicaid. MAD 237 Revised 06/01/13

5 INFORMACIÓN: Más información sobre Recuperación del Estado se puede encontrar en la Internet o en la biblioteca pública. La ley federal de Medicaid para Recuperación de Estado se puede encontrar en 42 U.S.C. 1396p (b)(4)(a). Información sobre la leyes del Estado se puede encontrar en los Estatutos de Nuevo México: la ley de Medicaid para Recuperación de Estado se puede encontrar en el capítulo 27, artículo 2A; y Validación Legal del Código de Uniforme se puede encontrar en el capítulo 45. TÉRMINOS: Reclamación de Medicaid es la notificación legal de que el Estado del recipiente de Medicaid tiene una deuda al gobierno por la cantidad de dinero que se gastó en nombre del recipiente por cuidado médico a largo plazo. Fallecido es la persona que ha muerto. Estado corresponde a la propiedad dejada después que alguien muere. Un Estado puede incluir casas, terrenos, dinero, cuentas de banco, acciones, dividendos, derechos de minas, fideicomisos, intereses en un juicio, vehículos, barcos, artefactos para el hogar, y cualquier otra pertenencia o propiedad del fallecido. Recuperación del Estado es el proceso utilizado para reembolsar al gobierno del Estado del recipiente de Medicaid por el costo de cuidados médicos a largo plazo. Herederos son los miembros sobrevivientes de la familia del fallecido (esposo/a, hijos/as, padres, hermanos/as y/o abuelos) que se consideran en línea por la ley para recibir la propiedad del fallecido si no hay testamento legal. Representante Personal es la persona que toma acción(es) legales requeridas para entregar la propiedad del Estado. Legalización de un Testamento es el proceso que la corte utiliza para decidir qué sucederá con la propiedad de un Estado. DEMANDAS MÉDICAS: Sobre la muerte del cliente de Medicaid, el representante personal o el heredero se puede contactar con el Programa de Recuperación del Estado de HSD para descubrir cuanto son las demandas de Medicaid que se han pagado a nombre del cliente. Al hacer esta petición, el representante necesitara proveer la información siguiente para el recipiente: Nombre Número de Seguro Social Fecha de nacimiento Fecha de fallecimiento La información de la demanda entonces será envíada al representante personal o el abogado que está manejando los asuntos del fallecido. El Programa del la Recuperación del Estado de HSD no puede proveer aconsejo legal, así que usted debe contactar con un abogado si usted tiene cualquiera preocupaciones especiales o preguntas sobre leyes de la Recuperación del Estado. Para más información, contacte: Por Correo: HMS NM ESTATES PO BOX IRVING, TX Por Teléfono: Por Fax: Nuevo México Departamento de Servicios Humanos Programa de La Recuperación del Estado La ley federal requiere que el costo de asistencia médica de largo plazo este compensado de los estados de ciertos recipientes de Medicaid. Esta ley se realiza en Nuevo México a través del Programa de La Recuperación del Estado. MADSP 237 Revised 06/01/13

6 RECUPERACIÓN DEL ESTADO: Si Ud. tiene cincuenta y cinco (55) años de edad o más cuando Ud. recibe servicios de Medicaid para cuidados médicos a largo plazo, su Estado (los bienes que Ud. haya dejado después de su muerte) será utilizado para reembolsar al estado de Nuevo México el dinero que ha gastado en su cuidado médico. Estos costos pueden incluir: cuidado en un hogar de ancianos, servicio en su hogar o servicios de la comunidad, costos de hospital y drogas de prescripción. El Departamento de Servicios Humanos (HSD) tiene un contrato con Health Systems Management (HMS) para llevar a cabo sus operaciones del Programa de Recuperación del Estado. POR QUÉ? La ley federal requiere el estado de Nueve México que persiga el reembolso de ciertos recipientes de Medicaid porque el estado recibe dinero del gobierno federal para ayudar a financiar su programa de Medicaid. Nuevo México también utiliza dinero por impuestos para el programa de Medicaid, y las leyes del estado deben ser cumplidas también. Estas leyes incluyen el Acto de Medicaid para Recuperación de Estado y Validación Legal del Código de Uniforme (Uniform Probate Code). CUÁNDO? La Recuperación de Estado sucede solamente después que el recipiente de Medicaid haya fallecido. Esta fijado de esta manera para que la gente pueda recibir los cuidados médicos que necesiten sin tener que pedir un préstamo o vender sus propiedades para pagar sus servicios médicos. La Recuperación de Estado no se aplica si el cliente de Medicaid tiene sobreviviente un esposo/a, un hijo/a que es ciego(a) o permanentemente incapacitado, o menor de 21 años. El Departamento de Servicios Humanos (siglas en inglés HSD) también puede reducir o renunciar la reclamación de Medicaid si se identifica una dificultad calificada. Algunos ejemplos de dificultades calificadas se enumeran en este folleto. COMO? Después que el recipiente haya fallecido, HSD presenta un reclamo de Medicaid en contra al Estado por la cantidad de dinero que se pago por el recipiente en cuidado médico a largo plazo. Si el Estado tiene muchas reclamaciones para otras deudas, impuestos o gastos, la corte puede ayudar a decidir cuáles reclamaciones se pagarían primero. Gastos modestos de funerales e impuestos son ejemplos de reclamaciones que se pagarían generalmente primero en Nuevo México. Entonces el Estado está responsable de reembolsar la cantidad debido a HSD. Un Estado se puede usar para reembolsar a HSD, aunque el recipiente de Medicaid haya o no haya dejado un testamento de última voluntad y aunque el Estado no vaya a legalización de testamento. Si no hay suficiente dinero en el Estado para cubrir las reclamación de Medicaid, HSD no renuncia el derecho, como lo permite Validación Legal del Código Uniforme, de recuperar el valor de transferencias que son incluidos en el legalización de testamento (tales como transferencia de propiedades después de muerte del difunto por medio de una escritura pública). DIFICULTADES CALIFICADA: Algunos Estados pueden calificar por alivio de Recuper ación del Estado, pero solamente HSD puede decidir que una o más de las siguientes condiciones de dificultad se cumplen: Un/a heredero/a califica para beneficios públicos para sus necesidades de alimentos, ropa y lugar para vivir; Un/a heredero/a no puede dejar asistencia pública si la propiedad del Estado es utilizada para el reembolso; Un/a heredero/a no tiene ninguna otra fuente de dinero, excepto el que es proporcionado por el Estado; La casa en el Estado vale 50% o menos que el precio promedio de las casas en ese condado. Cualquier petición de alivio debe ser sometida por escritura a HSD por el Representante Personal o los herederos del cliente. Si HSD niega cualquier parte de la petición, una Audiencia Justa puede ser solicitada para revisar la decisión No se dará ningún alivio si la dificultad fue causada por el recipiente (o su representante) en un esfuerzo de evitar la responsabilidad legal de devolver el dinero a Medicaid. MAD SP 237 Revised 06/01/13

7 !!! 'iii )5- H U MA N iii SERVICES DErARTMENT MEDICAL ASSISTANCE DIVISION ESTATE RECOVERY ASSET IDENTIFICATION Federal law requires that the cost of long-term medical care be repaid from the estates of certain Medicaid recipients. This law is carried out through the New Mexico Estate Recovery Program. As a result, the estate of any New Mexico Medicaid recipient over age 55, who received long-term care, home and community based services through the Medicaid program is subject to recovery. Instructions: Provide all requested information and sign at the end of this form. Provide a copy of the deceased member's death certificate. (No exceptions; a copy must accompany this questionnaire.) Provide copies of all additional documentation identified. Provide an address where information may be sent regarding this form. Asset Identification form and documents can be either mailed to: Or Faxed to: ( ) Or NM Estates Program P.O. Box Irving, TX If you have any questions about how to complete this form, please call toll-free (855) Person Completing this form: Name: Address: Telephone: Please Check all that apply: "- - 0 Personal Representative 0 Attorney for Estate 0 Other: c> J 0 [' r~' ~]" Has there been (or do you anticipate) any lawsuits filed on behalf of the estate? DYes DNo If YES provide: Case or File number: Date Filed: County Court: ~' ''IT'....,..' ~ ~ ~ ~ Has a petition for probate of the estate been filed? DYes DNo If YES provide: Case or File number: Date Filed: MAD 238 Issued 05/01/13

8 County Probate Court: If NO, do you anticipate a petition for probate being filed? DYes DNo I Decedents Information: Name: Marital Status: D Married D Divorced D Never Married If married is the decedents spouse deceased? DYes DNo If NO, provide his/her information below and provide proof of marriage. Spouse Name: Decedents Asset Information: List all assets of the applicant/recipient and how the ownership ofthe asset is titled. Some examples of assets are: house{s) and land, vehicle{s), bank account{s), and other investments l PROPERlY TYPE ADDRESS CITY/STATE ESTIMATED VALUE VEHICLES CITY/STATE VIN/PLATE NUMBER ESTIMATED VALUE ACCOUNT TYPE BANK NAME ACCOUNT NUMBER CURRENT BALANCE OTHER (DESCRIBE) LOCATION '~ "TT. ESTIMATED VALUE l. 2. For any additional Assets please use a separate piece of paper. I certify that the information I have provided is true and complete to the best of my knowledge. Signature of Authorized Representative: Date: MAD 238 Issued 05/01/13

9 !!t e ( le- HUMAN iff SERVICES DEPARTMENT MEDICAL ASSISTANCE DIVISION RECUPERACI6N DE PATRIMONIO IDENTIFICACI6N DE ACTIVOS La ley federal requiere que el costa de la atenci6n medica a largo plazo se pagarfa con los bienes de alguno de los beneficiarios de Medicaid. Esta ley se lieva a cabo a traves del Programa de Recuperaci6n de New Mexico. Como resultado, el estado de cualquier New Mexico Medicaid receptor mayor de 55 anos, quien recibi6 la atenci6n a largo plazo, el hogar y los servicios basados en la comunidad a traves del programa Medicaid esta sujeta a la recuperaci6n. Instrucciones: Proporcionar toda la informaci6n solicitada y firmar al final de este formulario. Proporcionar una copia del certificado de defunci6n del miembro fallecido. (Sin excepciones, una copia debe acompanar a este cuestionario.) Proporcione copias de toda la documentaci6n adicional identificada. Proporcionar una direccion donde se puede enviar informacion acerca de este formula rio. Esta forma y los documentos pueden ser enviados por correo a cualquiera de las tres: o por fax al: ( ) o por correo electronico a: NM Estates Program P.O. Box Irving, TX Si usted tiene alguna pregunta sobre como completar este formulario, por favor liame al (855) Persona que Completa este Formulario: Nombre: Direccion: Telefono: ~ -~- Por favor, marque todas las que o Representante Personal o Abogado de Bienes correspondan: u.,", o Otro: ~.~ cf'" " lha habido (0 anticipa usted) las demandas presentadas en nombre de los bienes? OSi ONo En caso afirmativo proporcionar: Corte del Condado: Caso 0 numero de archivos: Fecha de Radicacion: '" r " ~ lha presentado una solicitud de legalizacion de la propiedad? OSiONo MAD 238 SP Issued 05/01/13

10 ~. En caso afirmativo proporcionar: Caso 0 numero de archivos: Fecha de Radicaci6n: Corte del Condado de Sucesiones: En caso negativo, lse anticipa una presentaci6n de petici6n de legalizaci6n? DSi DNo Informacion del Difunto: Nombre: Estado Civil: D Casado D Divorciado D Nunca se ha casado lsi esta casado es el c6nyuge del difunto fallecido? DSi DNo En caso negativo, proporcione su informacion abajo y proporcione la prueba del matrimonio. Nombre del c6nyuge: ~ Difunto Informaci6n doe Activos: lista todos los activos del solicitante/beneficiario y como la propiedad del activo se titula. Algunos ejemplos de activos son: casa(s) y de la tierra, vehiculo(s), cuenta bancaria(s), y otras inversiones TIPO DE PROPIEDAD DIRECCI6N CIUDAD/ESTADO VALOR ESTIMADO VEHfcULOS CIUDAD/ESTADO VIN/MATRfCULA VALOR ESTIMADO TIPO DE CUENTA NOMBRE DEL BANCO NUMERO DE CUENTA BALANCE ACTUAL OTRO (DESCRIBIR).1 UBICACI6N.; ~!' "!., VALOR ESTIMADO Para cualquier Activos adicionales por favor use una hoja de papel Certifico que la informaci6n que he proporcionado es verdadera y completa a mi mejor entender. Firma del Representante Autorizado: Fecha: MAD 238 SP Issued 05/01/13

11 !l! -:r ):lt H U MA N 111 SERVICES D l r " II.. I M N T MEDICAL ASSISTANCE DIVISION hms 'OR OFJIICIAL USE ONLY CASE NAME «Recipient First Name Last Name» MEDICAID 10 NUMBER «MA NUM» ESTATE CASE 10 NUMBER «CaseID» NOTICE SENT «Notice Sent Date (Date input box) >> «Contact First Name Last Name» «Org Name» «Contact Address 1» «Contact Address2» «Contact City, State ZIP» «DATE» NEW MEXICO ESTATE RECOVERY NOTICE OF RECOVERY RE: Estate of «Recipient First Name Last Name» Medicaid ID#: «MID» Date of Death: «DOD» Dear «Contact First Name Last Name»: This letter is to notify you that Health Management Systems (HMS), on behalf of the New Mexico Human Services Department (HSD) intends to seek recovery from the estate of «Recipient First Name Last Name»for the amount of medical assistance paid on behalf of «Recipient First Name Last Name». HSD is the State Agency authorized to provide Medicaid services. HSD contracts with HMS to conduct its Estate Recovery Program. The claim against the estate is «Total Lien» for the period «Service From Date» through «Service To Date». The Social Security Act (42 V.S.c. 1396p) and State law NMSA 27-2A-I et seq., require HSD to recover Medicaid expenditures paid by HSD for clients who were 55 years and older and are now deceased. The HSD claim against the estate includes payments for: Nursing Facility services, Home and Community Based services, and Related hospital and prescription drug services We have enclosed a copy of the HSD Long Term Care Payment History for the client listing the expenditures subject to recovery. * «CONTEXT_CD» * *«CASE_ID»* *«DOcTypecode»* «Project Address» I «Project City, State ZIP» I tel «Project Phone» I fax «Project Fax» I toll free «Toll Free» I

12 Exceptions HSD may defer, waive, or reduce its claim against the estate if one of the following exceptions below exists: Estate Claim Statutory Exemption Undue Hardship Waiver Partial Recovery If you believe that one of these exceptions may apply, please refer to the Application for that Exception included with this notice. You are additionally directed to inform the heirs that they may also apply for a. Exception. The Application will provide further information on how to request a deferral, waiver, or reduction of the estate claim and the supporting documentation that must be provided. The Application must be received in our office within 30 days from the date of this notice. Administrative Hearing Rigbts Rigbt to a bearing: The human services department (HSD) must grant an opportunity for an administrative hearing. A. When a recipient requests an administrative hearing because he believes that HSD has taken an action erroneously. B. When services of a medicaid recipient are terminated, modified, reduced, suspended, or denied. Time limits: A medicaid recipient has 90 days from the date of notice of action to request a fair hearing. To be considered timely, the request must be received by the HSD hearings bureau, the local ISD office, or MAD no later than the close of business on the 90th day. In order to receive continuation of benefits while the hearing process goes forward, the request must be received by HSD (including the HSD hearings bureau, the local ISD office, or the medical assistance division) no later than the close of business on the 13th day. Hearings are conducted and a written decision is issued by the medical assistance division director or designee to the recipient within 90 days from the date that HSD receives the hearing request. Contact: Human Services Department, Hearings Bureau P.O. Box 2348 Santa Fe, NM Acknowledgement Please acknowledge receipt of this letter within 30 days of the date of this notice by completing the enclosed receipt form and returning it to us in the enclosed business reply envelope. If you have any questions please do not hesitate to call me at the toll free number listed below. Sincerely, «Electronic Signature» «Caseworker» HMS Caseworker MAD 239 Issued 05/13 <Project Address» I «Project City. State ZIP» I tel «Project Phone» I fax «Project Fax» I toll free «Toll Free» I

13 Enclosures: Receipt form HSD Long Term Care Payment History Applications for Estate Claim Statutory Exemption, Undue Hardship Waiver, or Partial Reduction Copy of the Court Claim Against the Estate (if filed) MAD 239 Issued 05/13 <Project Address» I «Project City, State ZIP» I tel «Project Phone» I fax «Project Fax» I toll free «Toll Free» I

14 I. Application For Statutory Exemption Recovery from the a recipient's estate will be made only after the death of the recipient's surviving spouse, if any, and only at a time that the recipient does not have surviving child(ren) who are less than 21 years of age or blind or who meet the social security administration's definition of disability. HSD will defer its claim against the estate when the HSD client is survived by a surviving spouse, a surviving child under age 21, or a surviving child of any age who is blind or disabled and receives SS! or SSA disability benefits. Ifthe HSD client is survived by any of these individuals, check the appropriate boxes below and attach supporting documentation. I am attaching documentation which verifies that the HSD client is survived by one of the following individuals (please check all that apply): o o o Spouse; Child under the age of21; or ~ --L. ~ "" L. ~ Child of any age who is blind or disabled and receives Social Security Administration (SSA) disability benefits or Supplemental Security Income (SSI) disability benefits. o o o AFFIRMATION I have attached, or have already provided to HMS a copy of the marriage license and a copy of the HSD client's death certificate. I have attached, or have already provided to HMS a birth certificate or other legal document that verifies the child's age and tlie child's relationship to the HSD client. I have attached, or have already provided to HMS a birth certificate or other legal document that verifies the child's relationship to the HSD client, and a copy of the child's SSA/SSI disability benefit award letter from the Social Security Administration which verifies the child receives SSA or SSI disability benefits. By signing below I certify that the information I have provided for an Estate Claim Statutory Exemption is true and correct. Signature of Authorized Representative / / (Date) Telephone Number Address (Street, City, State, Zip Code) MAD 239 Issued 05/13 <Project Address» I «Project City. State ZIP» I tel «Project Phone» I fax «Project Fax» I toll free «Toll Free» I

15 - II. Application for Undue Hardship HSD or its designee may waive recovery because recovery would work an undue hardship on the heirs: The following are deemed to be causes for hardship: 1. Without the receipt of the proceeds of the estate, the heir(s) would become eligible for a needsbased assistance program (such as Medicaid or temporary assistance to needy families (TANF» DYES D NO Without the receipt of the proceeds of the estate, the heir(s) would be put at risk of serious deprivation. 3. Heir(s) would be able to discontinue reliance on a needs-based assistance program (such as Medicaid or temporary assistance to needy families (TANF) if he/she received the inheritance from the estate. 4. The assets subject to recovery are the sole income source for the heir(s). 5. The homestead is worth 50 percent or less than the average (median) price of a home in the county where the home is located based on census data compared to the property tax value of the home. DYES DNO DYES DNO DYES DNO DYES DNO If you answered YES to any of these questions, you must provide all of the documents listed below to verify your responses. D I have enclosed a copy of the County Assessor's Statement or an official document from the New Mexico State Department of Revenue that verifies the HSD client's real property is residential property. - D I have enclosed a copy of my most recent Federal income tax return and verification of all gross income received by my household You may qualify for an Undue Hardship based on your responses to QJlestions 6 through 9 below. 6. Do you currently reside at the HSD client's residence? DYES DNO 7. Did you reside at the HSD client's residence at the time of the client's death? 8. Is the HSD client's residence also your primary residence for the 12 months immediately preceding the HSD client's death? 9. Do you own a residence?. ".., DYES DNO DYES DNO DYES DNO If you answered YES to Questions 6 through 8, and NO to Question 9, you must provide all ofthe documentation listed below to verify your responses D D D I have attached verification which establishes that I resided continuously at the residential property for the 12 month period immediately preceding the HSD client's death I have attached verification which establishes that I resided at the residential property at the time of the HSD client's death, and I have attached verification which establishes that I currently reside at the residential property. Acceptable verification includes utility or other statements, pay stubs, vehicle registration, etc. MAD 239 Issued 05/13 <Project Address» I «Project City, State ZIP» I tel «Project Phone» I fax «Project Fax» I toll free «Toll Free» I

16 Personal Property Estate Assets Only: I., r 1. Does the estate contain only Personal Property assets and no residence? DYES DNO 1""- 2. Does your household's gross annual income, which includes new sources of income, exceed the Federal Annual Income Poverty Guidelines? DYES DNO Do you own a home, land, or other real property?, DYES DNO If you answered YES to Question 1, and NO to Questions 2 and 3, you must provide all of the documentation listed below to support your responses. D I have attached a copy of my most recent Federal income tax return and verification of my household's gross annual income; including new sources of income my household expects to receive. AFFIRMATION 0 I have attached, or have already provided to HMS a copy of the Inventory of the HSD client's estate. I have attached, or already provided to HMS a copy of the HSD client's last will to verify that I am an heir to the D HSD client's estate. The HSD client died intestate (without a Will). I have attached legal documents to verify that I am a descendant to 0 - the HSD client. If I am not a descendant to the HSD client, I have attached an "Affidavit of Heirship" which verifies that I am a legal heir to the HSD client's estate. By signing below, I certify that the information I have provided for an Undue Hardship Waiver of Estate Claim is true and correct. ~ - Signature of Authorized Representative --/---- / (Date) Telephone Number Address (Street, City, State, Zip Code) MAD 239 Issued 05/13 <Project Address» I «Project City. State ZIP» I tel «Project Phone» I fax «Project Fax» I toll free «Toll Free:-> I

17 ~ III. Application for Partial Reduction If you wish to apply for consideration of a Partial Reduction of the Estate Claim, please answer all of the following questions and provide supporting documentation to verify your responses. 1. Will enforcement of the full amount of the HSO claim against the HSD client's estate create a financial hardship to you and your household? DYES DNO If YES, please explain how enforcement of the full amount of the HSO claim will cause you and your household a fmancial hardship, and provide documentation that supports how your household will experience a fmancial hardship if the full amount of the HSO claim is enforced. ':',. " " '"." " p -~. 2. Will enforcement of the HSO claim against the HSO client's estate create a medical hardship to you and your household? DYES DNO If YES, please explain how enforcement of the full amount of the HSO claim will cause you or your household a medical hardship and provide documentation that supports how your household will experience a medical hardship if the full amount of the HSO claim is enforced What is the total number of persons living in your household (include yourselt)? '" ~ 4. Does your household's gross annual income exceed the Federal Income Poverty Guidelines for your household size? DYES DNO S. What is the total fair market value of your household's real and personal property assets, including any " encumbr.ances? $. Attach verification which verifies the fair market value of all sources of real and personal property assets that are owned by you and your household. 6. Are there any other creditors who have a claim against the HSO client's estate? DYES DNO If YES, list the names ofthe creditor(s) and the amount of the creditor's claim. ;: 7. Have any of the creditors that you listed in Question 6 above, foreclosed on the real or personal.- property in the HSO client's estate? DYES DNO 8. Are there any other factors you would like HSO to take into consideration? If so, please provide an explanation of the factors you would like considered and attach supporting documentation. MAD 239 Issued <Project Address» I «Project City, State ZIP» I tel «Project Phone» I fax «Project Fax» I toll free «Toll Free» I

18 AFFIRMATION D I have attached, or have already provided to HMS a copy of the Inventory of the HSD client's estate. D I have attached, or already provided to HMS a copy of the HSD client's last will to verify that I am an heir to the HSD client's estate. The HSD client died intestate (without a Will). I have attached legal documents to verify that I am a descendant to the D HSD client. IfI am not a descendant to the HSD client, I have attached an "Affidavit of Heirship" which verifies that I am a legal heir to the HSD client's estate. By signing below I certify that the information I have provided for a Partial Recovery of the Estate Claim is true and correct. Signature of Authorized Representative / / (Date) Address (Street, City, State, Zip Code) Telephone Number MAD 239 Issued 05/13 <Project Address» I «Project City, State ZIP» I tel «Project Phone» I fax «Project Fax» I toll free «Toll Free» I

19 ill =- )-:' H UMAN ' SERVICES D E P ARTMENT MEDICAL ASSISTANCE DIVI SION hms RECUPERACION DE PATRIMONIO DE NUEVO MEXICO NOTIFICACION DE RECUPERACION «Contact First Name Last Name» «Org Name» «Contact Addressl» «Contact Address2» «Contact City, State ZIP» «DATE» RE: Patrimonio de «Recipient First Name Last Name» N.o de INDV del miembro: «INDV» Fecha de fallecimiento: «DOD» Estimado/a «Contact First Name Last Name»: Esta carta es para notificarle que Health Management Systems (HMS), en nombre del Departamento de Servicios Humanos (HSD) de Nuevo Mexico tiene la intenci6n de recuperar del patrimonio de «Recipient First Name Last Name» los montos por asistencia medica pagados a nombre de «Recipient First Name Last Name». HSD es la Agencia estatal autorizada para proporcionar servicios de Medicaid. HSD contrata a HMS para llevar a cabo su Programa de recuperaci6n de patrimonio. EI reclamo contra el patrimonio es «Total Lien» por el periodo del «Service From Date» hasta el «Service To Date». La Ley de Seguridad Social (42 U.S.C. 1396p) Y la ley estatal NMSA 27-2A-I Y subsiguientes requieren que HSD recupere los gastos de Medicaid que HSD pag6 por los clientes que tenian 55 afios 0 mas y ya fallecieron. EI reclamo de HSD contra el patrimonio incluye los pagos para: Servicios en un centro de enfermeria, Servicios basados en el hogar y la comunidad y Servicios relacionados con los medicamentos con receta medica y servicios de hospital Hemos adjuntado una copia del Historial de pago de atenci6n a largo plazo de HSD para el cliente, que enumera los gastos sujetos a recuperaci6n. MAD 239 SP Issued 5/13 «Project Address» I «Project City, State ZIP» I tel «Project Phone» I fax «Project Fax» I tel gratuita «Toll Free» I

20 Excepciones HSD puede aplazar, eximir 0 reducir su reclamo contra el patrimonio si se presenta una de las excepciones que aparecen a continuaci6n: Exenci6n legal del reclamo del patrimonio Exenci6n por dificultad econ6mica Recuperaci6n parcial Si cree que puede aplicar una de estas excepciones, consulte la Solicitud para esa excepci6n que se incluye con esta notificaci6n. Adicionalmente se Ie indica que debe informar a los herederos que tambien ellos pueden solicitar una Excepci6n. La Solicitud Ie proporcionara informaci6n adicional sobre c6mo solicitar un aplazarniento, exenci6n 0 reducci6n del reclamo del patrimonio y la documentaci6n de apoyo que debe proporcionar. La Solicitud debe recibirse en nuestra oficina en un plazo de 30 dias a partir de la fecha de esta notificaci6n. Derechos de audiencia administrativa Derecho a una audiencia: el Departamento de Servicios Humanos (HSD) debe conceder una oportunidad para una audiencia administrativa segun se describe en esta secci6n y en las siguientes circunstancias. A. Cuando un destinatario solicita una audiencia administrativa porque cree que HSD tom6 una acci6n incorrecta. B. Cuando se terminan, modifican, reducen, suspenden 0 deniegan los servicios de un destinatario de Medicaid. Limites de tiempo: un destinatario de Medicaid tiene 90 dias a partir de la fecha de la notificaci6n de acci6n para solicitar una audiencia justa. Para que se considere oportuna, la oficina de audiencias de HSD, la oficina local de ISD 0 MAD debe recibir la solicitud a mas tardar el dia 90, al finalizar el dia laboral. Para continuar recibiendo los beneficios mientras el proceso de audiencia avanza, HSD (incluye la oficina de audiencias de HSD, la oficina local de ISD 0 la division de asistencia medica) debe recibir la solicitud a mas tardar el dia 13, al finalizar el dia laboral. Se llevan a cabo las audiencias y el director de la divisi6n de asistencia medica 0 la persona designada emite al destinatario una decisi6n por escrito, en un periodo de 90 dias, a partir de la fecha en que HSD recibe la solicitud de la audiencia. Contacto: Human Services Department, Hearings Bureau (Departamento de Servicios Humanos, Oficina de Audiencias) P.O. Box 2348 Santa Fe, NM Reconocimiento Debe acusar recibo de esta carta en un periodo de 30 dias a partir de la fecha de esta notificaci6n al completar el formulario de recibo adjunto y devolvernoslo en el sobre de respuesta comercial adjunto. Si tiene alguna pregunta, no dude en comunicarse conmigo al numero de telefono gratuito que se indica a continuaci6n. Atentamente, MAD 239 SP Issued 5/13 «Project Address» I «Project City, State ZIP» I tel «Project Phone» I fax «Project Fax» I tel gratuita «Toll Free» I

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