The Nevada Medicaid Redetermination form is an essential document designed by the State of Nevada Department of Health and Human Services, Division of Welfare and Supportive Services, specifically for individuals receiving medical assistance through MAABD. This form plays a pivotal role in ensuring the continuity of Medicaid benefits by requesting updated information on a range of areas including personal details, insurance coverage (beyond Medicare/Medicaid), and significant life events such as injuries or accidents within the past year. It comprehensively inquires about changes in income, resources, living situations, or medical expenses, and requires detailed disclosures of financial resources and income, including but not limited to bank accounts, cash, life insurance, and any annuities purchased. The form also delves into living expenses, medical expenses not covered by Medicaid, and the declaration of any newly acquired income or resources. Essential for maintaining transparency and updated records, this form highlights the necessity for clients to report any transfers or gifts of resources, the acquisition of annuities after a specific date, and stresses the importance of naming the State of Nevada as the remainder beneficiary in such transactions. It serves multiple purposes: verifying family income and resources, ensuring compliance with federal regulations, and preventing duplication of benefits through inter-agency cooperation. Additionally, it outlines the rights, responsibilities, and potential penalties involved, including the mandate for Social Security Numbers for anyone seeking assistance, underscoring the thoroughness and accountability expected in the continuation of Medicaid assistance. Failure to return this document duly filled can significantly impact an individual's eligibility for benefits, marking it as crucial for beneficiaries aiming to extend their Medicaid coverage.
| Question | Answer |
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| Form Name | Nevada Medicaid Redetermination Form |
| Form Length | 2 pages |
| Fillable? | Yes |
| Fillable fields | 72 |
| Avg. time to fill out | 14 min 58 sec |
| Other names | medicaid redetermination nevada, nevada medicaid redetermination oline, nevada medicaid renewal, nrd1 cl medicaid form |
STATE OF NEVADA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
DIVISION OF WELFARE AND SUPPORTIVE SERVICES
MAABD ONLY REDETERMINATION |
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CLIENT’S NAME |
TELEPHONE |
CASE NO. |
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CLIENT’S ADDRESS |
CITY |
STATE |
ZIP CODE |
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MAILING ADDRESS |
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Other than MEDICARE/MEDICAID, do you have any other medical/dental insurance? |
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YES |
NO |
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If YES, please attach a copy of both sides of your insurance card when you return this form. |
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Have you been injured or involved in an accident in the past twelve (12) months? |
YES |
NO |
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Have you had any changes in your income, resources, living situation, or medical |
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expenses since our last contact? |
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YES |
NO |
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If YES, please explain the change(s): |
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BANK
RESO
RESOURCES
TRAN
LIFE
PROP
List all resources and income for you and/or your spouse: (attach verification)
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TOTAL |
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LOCATION/HOW MANY? |
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Patient Trust Fund Account |
$ |
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Money on hand (cash) |
$ |
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Savings account |
$ |
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Checking account |
$ |
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Stocks/Bonds |
$ |
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Life insurance (burial, life) |
$ |
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Burial funds |
$ |
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Other (list type of resource): |
$ |
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Have you transferred or given away any resources? |
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YES |
NO |
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Have you purchased any annuities? |
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YES |
NO |
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If YES, give type |
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And amount: $ |
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Transferred to/Purchased: |
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Date transferred/Purchased: |
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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 |
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$ |
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Client medical bills (not payable by Medicaid): |
$ |
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$ |
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$ |
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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)