Form 1575
Instructions
Medicaid Estate Recovery Program Worksheet
09-2012
PURPOSE
To document if an applicant or individual has Medicaid Estate Recovery Program (MERP) "grandfathered" status.
PROCEDURE
When to Prepare
Complete this form for Community Based Alternatives (CBA), Consolidated Waiver Program (CWP) and Community Care for Aged and Disabled (CCAD) Community Attendant Services (CAS) new applicants and ongoing individuals when documenting if an applicant or individual has MERP "grandfathered" status. The worksheet provides documentation that presentation of MERP information is not required if the applicant or individual has "grandfathered" status.
Form Retention
The Department of Aging and Disability Services (DADS) case manager retains the original copy in the case record.
DETAILED INSTRUCTIONS
Individual's Name — Enter the name of the applicant or individual.
Program/Service — Check which program/service the applicant is applying for: CBA, CWP or CAS. For ongoing individuals, check the program/service the individual currently receives.
Grandfathered Status — Check Yes if verification supports the applicant or individual has "grandfathered" status. Check No if the verification process indicates the applicant or individual does not have "grandfathered" status. Check Unknown if unable to confirm if the applicant or individual does or does not have MERP "grandfathered" status. The applicant or individual must have applied for one of the following programs/services prior to March 1, 2005:
- CBA
- CWP
- HCBS STAR+PLUS Waiver (SPW)
- CAS
- Nursing Facility (NF) (institutional Medicaid)
- Intermediate Care Facilities for Individuals with an Intellectual Disability or Related Conditions (ICF/IID), including state supported living centers
- Community Living Assistance and Support Services (CLASS)
- Home and Community-based Services (HCS)
- Texas Home Living (TxHmL)
- Deaf Blind with Multiple Disabilities (DBMD)
If Grandfathered Status is Yes, Check Program/Service Applied For — Check the program/service applied for that qualifies the applicant or individual for MERP "grandfathered" status. Check all that apply and are verified.
Date Verified — Enter the date the MERP "grandfathered" status is verified.
Source of Verification — Enter the source of verification used to confirm the applicant or individual is considered to have MERP "grandfathered" status. Sources of verification could include but are not limited to Texas Integrated Eligibility Redesign System (TIERS) and the Service Authorization System (SAS). An applicant's or individual's statement of programs/services applied for or received prior to March 1, 2005 is not acceptable verification.
Verification of the date of application or dates one of the above listed programs/services was received prior to March 1, 2005 must be used to determine if the applicant or individual is "grandfathered" status.
Use the comments section to document additional verification information.
Date of Application — Enter the verified date of application to be used to determine if the applicant or individual has "grandfathered" status.
Dates Program/Service Received — Enter the verified Begin date and End date (if applicable) the program/service was received to be used to determine if the applicant or individual has "grandfathered" status. Verification of program/service Begin dates prior to March 1, 2005 supports application for one of the programs/services prior to March 1, 2005. Document the dates programs/services received for all programs/services verified to support "grandfathered" status.
Example: Verification through TIERS indicates an applicant received Medicaid services in a nursing facility from March 2003 through December 2004, and began receiving CBA services January 2005. Document on the worksheet Type Program (TP) 14/10 services were received March 2003 through December 2004, and TP14/13 began January 1, 2005.
Comments — This space is provided for the case manager to document, if necessary, additional details regarding the applicant or individual and MERP "grandfathered" status.
DADS Case Manager — Enter the case manager's name.
Date — Enter the date the form is completed.