The LTC resource review, using Form 3654, applies only to nursing home (NH) and SLF customers and to medical customers applying for or receiving DoA Home and Community Based Services (HCBS) waiver services. Have the customer or authorized representative complete Form 3654 to identify all current and transferred resources of the customer, including those held jointly with the community spouse or another person.
The term "community spouse" means the spouse of an SLF resident, NH resident, or medical customer applying for or receiving DoA HCBS waiver services. A spouse who lives in an SLF or NH is not considered a community spouse. However, the community spouse may be applying for or receiving DoA HCBS waiver services, as long as they do not also receive regular or spenddown medical assistance (excludes QMB only, SLIB only, and QI-1 only benefits). For persons applying for or receiving DoA HCBS waiver services, the community spouse may be living with or apart from the LTC customer.
When a person enters an NH or SLF or applies for or begins receiving DoA HCBS waiver services, determine the resources held solely by either the LTC spouse, the community spouse, or jointly by both. Consider this combined total available to the LTC spouse. From this amount, the Community Spouse Resource Allowance (CSRA) may be deducted and transferred to the community spouse, as provided in PM 07-02-22. The remaining amount is the total amount of resources considered available to the LTC spouse.
When counting the resources of the community spouse, count the same types of resources and allow the same disregards as if the spouse was an applicant.
Complete HFS 3654 when a person enters an NH or SLF, or when notified that one spouse has applied for or is receiving DoA HCBS waiver services, and any other time when requested by either spouse or by a representative acting on behalf of either spouse.
LTC applicants who do not return the completed and signed Form 3654 are ineligible for LTC benefits due to non-cooperation but may be approved for community medical coverage, if eligible.
Community Case entering Long Term Care (NH, SLF or DoA HCBS Waiver)
When an active customer on a community case enters LTC, Form 3654 is required. Send the customer Forms 1721 and 3654. Allow 10 days to return Form 3654. If the form is not returned by the due date, do not approve LTC coverage and continue community medical coverage only.
Form 3654 is not required at redetermination, but the form should be completed when a customer's financial circumstances change, when a customer is discharged from a facility and readmitted more than a year later, or when a customer marries or divorces while outside LTC (even if for less than a year).