Structure
The Nevada Medicaid Redetermination form is an essential document for individuals and families seeking to maintain their Medicaid benefits. This form is used to assess eligibility and gather important information about changes in income, resources, and living situations since the last review. It requires clients to provide details about any additional medical or dental insurance they may have, as well as to report any injuries or accidents that occurred in the past year. Clients must also list all sources of income and resources, including bank accounts, stocks, and life insurance, ensuring they attach verification for these items. The form emphasizes the importance of reporting any changes, such as income fluctuations or new medical expenses, which could impact eligibility. Furthermore, it includes a section for clients to name an authorized representative if they wish to have someone assist them with their case. Understanding the rights and responsibilities outlined in the form is crucial, as failure to complete and return it could jeopardize benefits. By signing the declaration, clients confirm that the information provided is accurate and complete, underscoring the importance of honesty in the application process.
Nevada Medicaid Redetermination Sample
STATE OF NEVADA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
DIVISION OF WELFARE AND SUPPORTIVE SERVICES
MAABD ONLY REDETERMINATION |
|
RD DATE |
|
||
|
|
|
|||
|
|
|
|
||
CLIENT’S NAME |
TELEPHONE |
CASE NO. |
|
||
|
|
|
|
|
|
CLIENT’S ADDRESS |
CITY |
STATE |
ZIP CODE |
|
|
|
|
|
|
|
|
MAILING ADDRESS |
|
|
|
|
|
|
|
|
|
||
Other than MEDICARE/MEDICAID, do you have any other medical/dental insurance? |
|
YES |
NO |
||
If YES, please attach a copy of both sides of your insurance card when you return this form. |
|||||
|
|
||||
|
|
|
|||
Have you been injured or involved in an accident in the past twelve (12) months? |
YES |
NO |
|||
|
|
|
|||
Have you had any changes in your income, resources, living situation, or medical |
|
|
|||
expenses since our last contact? |
|
|
YES |
NO |
|
If YES, please explain the change(s): |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
BANK
RESO
RESOURCES
TRAN
LIFE
PROP
List all resources and income for you and/or your spouse: (attach verification)
|
|
|
|
TOTAL |
|
LOCATION/HOW MANY? |
|
|
|
|
|
|
|
|
|
Patient Trust Fund Account |
$ |
|
|
|
|||
|
|
|
|
|
|
|
|
Money on hand (cash) |
$ |
|
|
|
|||
|
|
|
|
|
|
|
|
Savings account |
$ |
|
|
|
|||
|
|
|
|
|
|
|
|
Checking account |
$ |
|
|
|
|||
|
|
|
|
|
|
|
|
Stocks/Bonds |
$ |
|
|
|
|||
|
|
|
|
|
|
|
|
Life insurance (burial, life) |
$ |
|
|
|
|||
|
|
|
|
|
|
|
|
Burial funds |
$ |
|
|
|
|||
|
|
|
|
|
|
|
|
Other (list type of resource): |
$ |
|
|
|
|||
|
|
|
|
|
|
|
|
Have you transferred or given away any resources? |
|
|
|
YES |
NO |
||
Have you purchased any annuities? |
|
|
|
YES |
NO |
||
If YES, give type |
|
|
And amount: $ |
|
|
||
Transferred to/Purchased: |
|
|
Date transferred/Purchased: |
|
|||
Be aware that by virtue of the provision of medical assistance for institutional care, annuities purchased on or after February 8, 2006 must name the State of Nevada as the remainder beneficiary.
JINC
INCOME
OINC
UNIN
Social Security benefits
Supplemental Security Income (SSI)
Retirement/pension
Veterans benefits
Spouse’s income (list type of income):
Other (wages, gifts, etc.) (list type of income):
AMOUNT
$
$
$
$
$
$
(Side 1) 2930 - EM (11/07)
RENT
INCOME
SPOUSAL LIVING EXPENSES
UTIL
Shelter expenses (rent, mortgage, taxes, insurance, utilities)
List type of expense(s):
AMOUNT
$
$
$
AREP
MEDICAL EXPENSES
MEDX
Insurance premiums (list type of insurance): |
TOTAL AMOUNT/VALUE |
PAYMENT FREQUENCY |
|
|
|
|
$ |
|
|
|
|
Client medical bills (not payable by Medicaid): |
$ |
|
|
|
|
|
|
|
|
$ |
|
|
|
|
|
$ |
|
|
|
|
If you have had other changes not described above, please describe them in the area below. If you (or your spouse) are receiving any additional income or resources not listed on this form, please list them below and attach verification. If you want to name an authorized representative (A/R), or you want to name a different person as your A/R, please check this box 
. Your case manager will send you a document to record your request. It must be completed and returned before your representative will be acknowledged on your case.
RIGHTS, RESPONSIBILITIES AND PENALTIES
At the time of your application, you signed a copy of your rights and responsibilities. These requirements continue to apply. You may contact your local office for a copy of these provisions.
Federal regulations now require Social Security Numbers (SSNs) for all individuals receiving or seeking to receive assistance for themselves. If you or an individual in your household is applying for assistance and do not wish to provide or apply for an SSN, only this person’s request for assistance will be denied. Undocumented or ineligible
DECLARATION AND SIGNATURE(S)
I/We have read (or had explained to me/us) and understand the information on both sides of this eligibility review form. I/We declare under the penalty of perjury, information I/we gave in this review is true, correct and complete to the best of my/our knowledge.
NOTE: Failure to return this form will affect your eligibility for benefits.
SIGNATURE OF CLIENT
TELEPHONE NUMBER
DATE
SIGNATURE OF AUTHORIZED REPRESENTATIVE
TELEPHONE NUMBER
DATE
CASE MANAGER SIGNATURE
DATE
(Side 2) 2930 - EM (11/07)
File Attributes
| Fact Name | Description |
|---|---|
| Purpose of the Form | The Nevada Medicaid Redetermination form is used to assess ongoing eligibility for Medicaid benefits. Clients must complete this form periodically to ensure they continue to qualify for assistance. |
| Required Information | Clients must provide detailed information about their income, resources, living situation, and any changes since the last review. This includes financial accounts, insurance details, and medical expenses. |
| Submission Guidelines | Clients are required to return the completed form along with any necessary documentation, such as proof of income or insurance cards. Failing to submit the form can affect eligibility for benefits. |
| Rights and Responsibilities | By signing the form, clients acknowledge their rights and responsibilities regarding Medicaid benefits. This includes understanding that providing false information can result in penalties. |
| Social Security Numbers | Federal regulations mandate that all individuals seeking assistance provide their Social Security Numbers (SSNs). This information is crucial for verifying income and resources. |
| Governing Laws | The Nevada Medicaid program operates under state law, specifically NRS 422. This law outlines the eligibility criteria and requirements for receiving Medicaid benefits in Nevada. |
Fill out Common Forms
Department of Employment Training and Rehabilitation - The provided envelope facilitates the secure and direct return of the form and payment to the Contributions Section, ensuring prompt processing.
For those seeking to establish their LLC in Illinois, understanding the legal framework is vital, including the necessary components such as the Illinois Operating Agreement essentials.
Nevada Modified Business Tax Form - Acts as an official record of tax compliance, serving as a valuable document during audits or reviews.