The Nevada Medicaid Redetermination form is a crucial document that helps the state assess an individual's ongoing eligibility for Medicaid benefits. This form collects important information about your income, resources, and any changes in your living situation or medical expenses since your last application. Completing this form accurately is essential to ensure you maintain your benefits, so be sure to fill it out by clicking the button below.
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?
Have you had any changes in your income, resources, living situation, or medical
expenses since our last contact?
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?
Have you purchased any annuities?
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
SPOUSAL LIVING EXPENSES
UTIL
Shelter expenses (rent, mortgage, taxes, insurance, utilities)
List type of expense(s):
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 non-qualified citizens and other non-applicants or ineligible persons are not required to provide or apply for an SSN. SSNs are used to verify your family’s income and resources and to conduct computer matching with other agencies such as the Social Security Administration, Employment Security Division, Child Support Enforcement Programs and the Internal Revenue Service. It is also used to gather workforce information, investigations, recover overpaid benefits and to ensure duplicate benefits are not received.
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
CASE MANAGER SIGNATURE
(Side 2) 2930 - EM (11/07)
After you complete the Nevada Medicaid Redetermination form, submit it to your case manager. This step is crucial for maintaining your eligibility for Medicaid benefits. Ensure you provide all necessary information and documentation. Here are the steps to fill out the form:
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What is the Nevada Medicaid Redetermination form?
The Nevada Medicaid Redetermination form is a document that individuals must complete to confirm their eligibility for Medicaid benefits. It collects information about changes in income, resources, and living situations since the last review. This process ensures that individuals continue to meet the requirements for receiving assistance.
Who needs to fill out this form?
Anyone currently receiving Medicaid benefits in Nevada must complete the Redetermination form. This includes individuals who may have had changes in their circumstances, such as income or living arrangements, since their last application or review.
What information do I need to provide?
You will need to provide details about your current income, resources, and any medical expenses. This includes information about bank accounts, insurance, and any additional income sources. If there have been changes in your situation, you must explain those as well.
What happens if I don’t return the form?
If you fail to return the Redetermination form, it may impact your eligibility for Medicaid benefits. It is crucial to submit the form by the deadline to avoid any interruption in your coverage.
Do I need to include documentation with the form?
Yes, if you have other medical or dental insurance, you should attach a copy of both sides of your insurance card. Additionally, any other income or resources not listed on the form must be verified with appropriate documentation.
Can I have someone else help me with this form?
Yes, you can designate an authorized representative to assist you with the Redetermination process. You will need to check the appropriate box on the form, and your case manager will provide you with a document to complete this request.
What if my situation has changed since my last review?
If there have been changes in your income, resources, or living situation, you must report those changes on the form. Be specific about the nature of the changes, as this information is essential for your eligibility assessment.
Is there a deadline for submitting the form?
Yes, there is typically a deadline for submitting the Redetermination form. It is important to check with your local office for the specific date to ensure that you meet the requirements and maintain your benefits.
What should I do if I have questions about the form?
If you have questions or need assistance while completing the form, you can contact your local Medicaid office. They can provide guidance and help clarify any uncertainties you may have about the process.
What are the consequences of providing false information?
Providing false information on the Redetermination form can lead to serious consequences, including penalties or loss of benefits. It is essential to ensure that all information is accurate and truthful to the best of your knowledge.
Incomplete Information: One common mistake is leaving sections of the form blank. This can include not providing all necessary details about income, resources, or medical expenses. Every section is important for determining eligibility, so it’s crucial to fill out the entire form thoroughly.
Failure to Attach Documentation: People often forget to include required documents, such as copies of insurance cards or proof of income. Without these attachments, the application may be delayed or denied. Always double-check that you have included all necessary paperwork before submitting.
Not Reporting Changes: Some individuals neglect to report changes in their circumstances, such as a new job, increased income, or changes in living situations. These updates are essential for accurate assessment and must be disclosed to avoid issues with eligibility.
Ignoring Signature Requirements: Another frequent oversight is not signing the form. It’s vital to ensure that all required signatures are present, including those of any authorized representatives. A missing signature can result in the form being considered invalid, leading to delays in processing.
The Nevada Medicaid Redetermination form is essential for individuals seeking to maintain their Medicaid benefits. Alongside this form, several other documents may be required to support the application process. Below is a list of these documents, along with a brief description of each.
Gathering these documents can streamline the redetermination process and help ensure that all necessary information is provided. Each piece of documentation plays a vital role in verifying eligibility and maintaining access to Medicaid benefits.
Medicaid Application Form: This document serves as the initial request for Medicaid benefits. Similar to the Redetermination form, it collects personal information, income details, and any changes in circumstances since the last application.
Medicare Enrollment Form: Like the Redetermination form, this document requires information about medical insurance coverage and any changes in health status. Both forms aim to ensure that the applicant's current situation is accurately reflected.
Food Assistance Application: This application also requires detailed information about income and resources. It parallels the Redetermination form in its purpose of assessing eligibility based on current financial circumstances.
Supplemental Security Income (SSI) Application: This form gathers information about income and living arrangements, similar to the Redetermination form. Both documents aim to verify eligibility for assistance based on updated personal data.
Long-Term Care Application: This application is used for individuals seeking long-term care benefits. It requires similar financial disclosures and personal information, ensuring that the applicant's needs are accurately assessed.
Health Insurance Marketplace Application: This document collects information about income and household size. Like the Redetermination form, it helps determine eligibility for health coverage based on current circumstances.
Veterans Benefits Application: This form requires detailed financial and personal information to assess eligibility for benefits. It shares similarities with the Redetermination form in its focus on verifying current resources and income.