Bhsf Form 2-L (Nf) - Medicaid Renewal Form For Nursing Home/group Home Care Page 5
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9YOUR RIGHTS AND RESPONSIBILITIES
WHAT MEDICAID HAS THE RIGHT TO EXPECT OF YOU (the person getting Medicaid)
REPORTING THE TRUTH: You state that the information you give on this renewal form is true and correct. You
understand if you purposely give information that is not true or if you purposely do not tell information that you are
supposed to, you may get health benefits that you should not get. If that happens, you can by law be punished for fraud.
Also, you may have to pay money back to Medicaid for the bills it paid by mistake.
VERIFICATION OF INFORMATION: You understand that the information you give will be checked. You agree to
help with this and let Medicaid get information it needs from government agencies, employers, medical providers, etc.
SOCIAL SECURITY NUMBERS: You understand Social Security numbers will only be used to get information from
other government agencies to make a decision about your eligibility for Medicaid.
PAYMENT OF MEDICAL CARE BY A THIRD PARTY: You understand by accepting Medicaid, the Department
has the right to money you get from other sources like insurance payments or lawsuit settlements for services that Medicaid
has paid for you.
REPORTING CHANGES: You agree to tell Medicaid within 10 days of these changes: 1) if you move out of state;
2) changes in mailing or home address; 3) if anyone moves in or out of your home; 4) changes in health insurance and
premiums; 5) changes in income; and 6) changes in things you own.
CHILD SUPPORT ENFORCEMENT: You understand that Medicaid will only send information to Child Support
Enforcement for medical support if you ask them to.
ANNUITIES: You agree that by accepting Medicaid, the State of Louisiana will be named as the remainder beneficiary at
your death for the total amount of medical assistance paid on your behalf for all annuities purchased on or after Feb. 8,
2006, unless you have a spouse, minor child, or a child with a disability. In these cases, the State must be named as
beneficiary after these individuals. You agree to tell Medicaid about any annuity you and your spouse own or co-own
regardless if the annuity is irrevocable (cannot be changed) or Medicaid counts it. You understand that you must tell
Medicaid about changes made to any annuity which may affect the amount paid, frequency of payments, when payments
begin, and additions to the principal.
WHAT YOU (the person getting Medicaid) HAVE THE RIGHT TO EXPECT FROM MEDICAID
RIGHT TO A FAIR HEARING: You understand that you can ask for a Fair Hearing if you think any decision made on
your case is unfair, incorrect, or made too late.
NO DISCRIMINATION: You understand Medicaid cannot treat you differently because of race, color, sex, age,
disability, religion, nationality, or political belief. If you think it has, you can call the U.S. DHHS Regional Office for Civil
Rights in Dallas, TX at 1-800-368-1019 or write to Louisiana’s Department of Health & Hospitals, Human Resources at P.
O. Box 4818 Baton Rouge, LA 70821-4818.
OTHER SERVICES: You understand Medicaid will send you information about WIC, KIDMED, and other Medicaid
services.
ESTATE RECOVERY: You understand that Estate Recovery rules require the Department to recover the cost of certain
Medicaid payments from your estate. These costs include the total amount of payments for facility services, hospital care,
payments to HCBS or PACE providers, and prescription drugs received at age 55 or older. The estate is the property
owned at the time of death. The Department will not make a claim against the estate while you or your legal spouse is still
living or if you have a dependent child who is under age 21, blind, or disabled. Collection may not be made if it is not cost
effective for the Department to do so, or if your heirs apply for a hardship waiver after your death. A hardship may exist if
the estate property is the only source of income for the heirs, if that income is limited, or other convincing situations.
SIGN BELOW
Sign Here:
Date
If signed with an “X”, two witnesses must sign.
Date
Date
Date
If Medicaid filled out this form, they will sign here.
See next page for a list of documents you may need to send us.
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Parent category: Medical