Form Mc 176 Pi - Period Of Ineligibility For Nursing Facility Level-Of-Care Work Sheet Page 2

Download a blank fillable Form Mc 176 Pi - Period Of Ineligibility For Nursing Facility Level-Of-Care Work Sheet in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form Mc 176 Pi - Period Of Ineligibility For Nursing Facility Level-Of-Care Work Sheet with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

PERIOD OF INELIGIBILITY FOR NURSING FACILITY LEVEL-OF-CARE.

1. Uncompensated value of transferred property that would have resulted in excess

property (line E.5.)........................................................................................................

___________

2. APPR............................................................................................................................

___________

3. Number of months in the period (line 1 divided by line 2, round down to nearest whole

number)........................................................................................................................

___________

If less than one, STOP. No period of ineligibility exists.

4. Applicants: Number of months including month of transfer and up to and excluding

month of application and retroactive month (line D.2.) ................................................

Beneficiaries: Number of months including month of transfer up to and excluding

current month

___________

5. Months of ineligibility remaining (line 3 minus line 4) ..................................................

___________

6. If the number of months remaining in line 5 is greater than zero, the PERIOD OF

INELIGIBILITY WILL EXPIRE ON __________________

(Begin with the month of application, retroactive month, or current month if the

person is a beneficiary.)

G. BENEFICIARIES ONLY: DID THE PERSON RECEIVE MEDI-CAL FOR NURSING FACILITY

LEVEL -OF-CARE IN A MONTH THROUGHOUT WHICH A PERIOD OF INELIGIBILITY SHOULD HAVE

EXISTED? ................................................................................................................................................... ❒ YES

❒ NO

If YES, there is an overpayment for nursing facility level-of-care only. A referral is required.

NOTE: Prior to sending a Notice of Action imposing a period of ineligibility for nursing facility level-of-care:

Evaluate for undue hardship.

●

If undue hardship DOES NOT exist, forward case information to DHCS Medi-Cal Eligibility Division Property

●

Analyst for review.

Page 2 of 2

MC 176 PI (05/07)