SR 11-43 Dated 11/11

STATE OF NEW HAMPSHIRE

INTER-DEPARTMENT COMMUNICATION

SUMMARY

This SR releases revised DFA Form 770, Reimbursement Agreement and Acknowledgement, and its associated instructions.

DESCRIPTION OF REVISIONS MADE TO DFA FORM 770

DFA Form 770 is used by the Family Services Specialists (FSS) to inform Old Age Assistance (OAA), Aid to the Needy Blind (ANB), Medicaid for Employed Adults with Disabilities (MEAD), Breast and Cervical Cancer Program (BCCP), and Aid to the Permanently and Totally Disabled (APTD) applicants and their spouses of:

§   the State’s right to recover the cost of financial or medical assistance provided; and

§   the requirement that financial assistance applicants acknowledge the right of recovery as a condition of eligibility.

DFA Form 770 was revised as follows:

§   The "I understand" statement associated with receipt of financial assistance on page 1 of the form was expanded to include additional state laws as follows [bold text represents the inserted text]:

I understand that N.H. State Laws, RSA 167:13, RSA 167:14, RSA 167:14-a, and RSA 167:28, require reimbursement to the State and County from me or my spouse for the financial assistance provided, as a condition of eligibility for the APTD, ANB, and OAA Programs.

§   DFA Form 770 will no longer be printed as a 2-page, 3-part, no-carbon-required (NCR) form. Previously, each page of this form was a 3-part NCR form. Due to scanning access in all DFA District Offices and the Estate Recoveries Unit, NCRs are no longer required. Instead, when using the new version of the form, Family Services Specialists (FSS) will scan both sides of the form once it is completed, and then provide the original to the applicant for the applicant’s records. Because BCCP workers do not have access to scanning and electronic case files, BCCP workers must make copies of page 2 for their records, as well as for the client if the client requests a copy, and must then send the original of page 2 to the Estate Recoveries Unit (ERU), per current procedures.

§   The "I understand" statement associated with receipt of medical assistance on page 2 of the form was expanded to include BCCP applicants as follows [bold text represents the inserted text]:

I understand that under Federal and State law, I may be required to reimburse the government for the cost of Medicaid payments made on my behalf under OAA, ANB, MEAD, BCCP, or APTD while I am age 55 or older, and that the State may file a lien against my real property and/or file a claim against my estate to recover Medicaid costs.

The instructions for DFA Form 770 and the Bosnian and Spanish translations of DFA Form 770 were updated to incorporate the statements above.

The standing stock of current and older versions of DFA Form 770 must be used until the stock has been depleted, at which point:

§   the DHHS Warehouse may be contacted in the usual manner, via the Quarterly Forms Order (QFO), for additional supplies of the English version; or

§   the Supervisor of the DFA Policy Development Unit may be contacted for copies of the Bosnian and Spanish versions of this form. The Spanish and Bosnian versions of this form will be retranslated in the very near future and released under separate cover.

The new version of DFA Form 770 will be printed once the current supply of the form has been exhausted.

POLICY MANUAL REVISIONS

Revised Adult Assistance Manual Topics

Section 317.01  Reimbursement - Financial Assistance

Section 317.03  Reimbursement - Medical Assistance for Non-Institutionalized Individuals

Section 317.04  Reimbursement - Medical Assistance Provided to Permanent Residents of Medical Institutions

IMPLEMENTATION

District Offices are to continue to use the old versions of DFA Form 770 until their supply is exhausted. The new version of DFA Form 770 will be printed when the current supply is depleted.

CLIENT NOTIFICATION

No client notification is planned or needed.

TRAINING

No special 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 revised manual topics released by this SR have been posted to the On-line manuals.

DISTRIBUTION

This SR will be distributed according to the electronic distribution list for Division of Family Assistance policy releases. This SR, and revised On-Line Manuals, 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 December 5, 2011. Additionally, this SR, and printed pages with posting instructions, will be distributed under separate cover to all internal hard copy holders of the Adult Assistance and Forms Manuals.

DFA/JBV:s