Section He-W 895.05 - Request for Undue Hardship(a) A request for an undue hardship waiver shall be in writing and include the following information: (1) The deceased Medicaid recipient's name;(2) The deceased Medicaid recipient's last street address;(3) The applicant's name;(4) The applicant's relationship to the deceased Medicaid recipient; and(5) The reason(s) for the undue hardship waiver request as described in He-W 895.04.(b) Relevant documentation shall be attached to support the undue hardship waiver request including, but not limited to, the following: (3) IRS forms, including business, personal or farm deduction forms;(4) Proof of residency such as a copy of the heir's driver's license or W-2;(5) Canceled checks relating to the income producing property or business;(6) City or town tax assessor bills;(7) A copy of the deceased Medicaid recipients' death certificate;(8) Estate paperwork filed with probate court;(9) An affidavit from the applicant describing the kind and quality of care provided the deceased Medicaid recipient including dates the care was provided, if applicable; and(10) Affidavits from at least 2 medical professionals who cared for the deceased Medicaid recipient prior to admission to the medical institution stating that the applicant provided the kind and quality of care necessary to maintain the Medicaid recipient at home rather than in a medical institution for at least 2 years immediately before the Medicaid recipient's admission to the medical institution.N.H. Admin. Code § He-W 895.05
Adopted by Volume XXXVI Number 36, Filed September 8, 2016, Proposed by #11170, Effective 8/26/2016, Expires 8/26/2026.