Case name:
Date assessment requested:
Resource Assessment / Date assessment completed:
Name of person getting care: / Date of birth: / Social Security number:
Spouse’s name: / Date of birth: / Social Security number:
Home address:
Type of care (nursing facility care, in-home care, adult foster care, etc.):
Name and address of place of care: / Date care started:
month / day / year
Enter the date the person getting carestarted getting care in their home, in thecommunity or in a nursing facility. If there was a break in care that lasted
30 days or more, enter the date carebegan again after the break.
1. / Complete all items below. Enter amounts owned by you, your spouse or both of you.
(If none, write “none.”)
On the date care started / Now
Amount orvalue: / Who does itbelong to? / Location andaccountnumber: / Amount orvalue: / Who doesit belong to? / Location andaccountnumber:
Time certificate
of deposit: / $ / $
PI funds: / $ / $
Money in safe deposit box: / $ / $
Bonds: / $ / $
Stocks: / $ / $
Trust fund: / $ / $
Money held for
you by others: / $ / $
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1. / Complete all items below. Enter amounts owned by you, your spouse or both of you.(Continued)(If none, write “none”)
On the date care started / Now
Amount or value: / Who does itbelong to? / Location andaccount number: / Amount orvalue: / Who doesit belong to? / Location andaccount number:
Sales contract: / $ / $
Estate fund: / $ / $
Annuity: / $ / $
Cash on hand: / $ / $
Checking account: / $ / $
Savings account: / $ / $
Securities: / $ / $
Retirement fund: / $ / $
Other: / $ / $
Agency use only
#1 countable resources: / $ / $
2. / Complete all items below. Enter amounts owned by you, your spouse or both of you.
(If none, write “none”).
On the date care started / Now
Make, model andyear: / Approximate value: / Amount owed: / Make, model and year: / Approximate value: / Amount owed:
Automobiles: / $ / $ / $ / $
Motorcycle: / $ / $ / $ / $
Boat: / $ / $ / $ / $
Business equipment: / $ / $ / $ / $
Camper: / $ / $ / $ / $
Crops: / $ / $ / $ / $
Farm equipment: / $ / $ / $ / $
Livestock: / $ / $ / $ / $
Page 1 of 11 SDS 3401 (01/18)
2. / Complete all items below. Enter amounts owned by you, your spouse or both of you.(Continued)(If none, write “none”).
On the date care started / Now
Make, model and year: / Approximate value: / Amount owed: / Make, model and year: / Approximate value: / Amount owed:
Mining equipment: / $ / $ / $ / $
Motor home: / $ / $ / $ / $
Snowmobile: / $ / $ / $ / $
Timber: / $ / $ / $ / $
Tools of trade: / $ / $ / $ / $
Trailer: / $ / $ / $ / $
Other property: / $ / $ / $ / $
Agency use only
#2 countable resources: / $ / $
3. / Do you or your spouse, own or are you buying: a house, mobile home, houseboat,other land or buildings? On the date care started? Yes No Now? Yes No
If yes completethe following: / On the date care started / Now
Property: / Property:
Address:
Do you or your spouse live there? Yes No
If not, how do you use
the property?
(rent, lease, vacant, for sale)
Type of property:
Owner (name on title):
Fair market value: / $ / $ / $ / $
Amount owed: / $ / $ / $ / $
Agency use only
#3 countable resources: / $ / $
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4. / Do you or your spouse have burial or life insurance?On the date care started? Yes NoNow? Yes No
If yes complete the following: / On the date care started / Now
Type of insurance:
Name of insured:
Name of insurance company:
Policy number:
Face value: / $ / $ / $ / $
Cash value: / $ / $ / $ / $
Agency use only
#4 countable resources: / $ / $
5. / Do you or your spouse have prepaid funeral plan?
On the date care started? / Yes / No / Now? / Yes / No
Do you or your spouse have money left with others for funeral expenses?
On the date care started? / Yes / No / Now? / Yes / No
If yes complete the following: / On the date care started / Now
Person covered:
Who holds plan or money?
Address of holder:
Amount of plan or money: / $ / $
Agency use only
#5 countable resources: / $ / $
6. / Within the last 60 months, have you or your spouse sold, traded or given away any personal property (cars or cash) or real property (land or buildings)? Yes No
If yes, describe the situation:
This form is not an application for Medicaid. You may apply for Medicaid at any time. Where would you like your copy of this form sent?
Name: / Phone number:
Mailing address:
Signature of person requesting assessment / Date
Signature of agency eligibility worker / Date
Agency calculation
Step 1 / Determine total countable resources
Add together the countable resources from each question on this form.
Question
number / On the date care started / Now
1. / $ / $
2. / $ / $
3. / $ / $
4. / $ / $
5. / $ / $
Total: / $ / Box A / $ / Box B
Step 2 / Determine the community spouse’s share of resources.
Enter one-half of total countable resources on the date care started
(from Step 1, Box A)...... ...... / $
Step 3 / Determine the community spouse’s resource allowance.
Check the largest amount:
Spouse’s share of countable resources (from Step 2)
(Effective January 1, 2018 limited to $123,600.) ...... / $
State community spouse resource allowance (Effective January 1, 2018 the minimum community spouse resource allowance.)...... / $ / $24,720.00
Court ordered community spouse resource allowance...... / $
Spouse’s resource allowance based on the amount necessary to generate income (the amount required to purchase a single premium immediate annuity: OAR 461-160-0580[2][c][D]and [2][f][D])...... . . . . . / $
Step 4 / Determine client’s resources.
Enter total countable resources now / $
(from Step 1, Box B) ......
Subtract spousal allowance / $
(Largest amount from Step 3.)......
Resources available to client...... / $
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Step 5 / Compare resources available to client to OSIP resource standard.Resources available to client (from Step 4)...... / $
OSIP resource standard for one person ...... / $ / 2000.00
Decision
Please review the information below regarding your resource assessment.
Resources are less or equal to the Medicaid standard
Resources are over the Medicaid standard
Oregon Administrative Rule - OAR 461-160-0580
Countable resources at time of application...... / $
Resources allowed for applicant ...... / $ / 2000.00
Resources allowed for your spouse...... / $
Amount of excess resources...... . / $
You may spend some of your resources on the cost of care and reapply at a later date. As of today, if you spent the amount of excess resources above, your resources would meet the Medicaid limit.
To be eligible, your resources cannot exceed: / $ / .
(total resources allowed for applicant and spouse above)
If you get more resources, this calculation will change. Please contact your worker.
The money you spend must be spent on items worth fair market value.
Otherwise, there could be a disqualification from Medicaid.
If you disagree with this action, you have the right to a hearing.
Read your hearing rights below.Please call if you have a question.
YourHearingRights
Whatyoucandowhenyoudonotagreewiththisdecision:
•Youhavetherighttochallengethisdecisionbyrequestingahearing.HearingsareheldbytheOfficeofAdministrativeHearings,whichisindependentfromtheDepartmentofHumanServices(DHS)orOregonHealthAuthority(OHA).
Ifyouwantahearing,youmustrequestitontime.
•Youcanalsotalkwithamanager.Youcancallalocalofficephonenumberlistedat(part1below)doesnotchangeevenifyouareincontactwithamanageroraretryingtoreachone.Ifyoustillneedfurtherassistance,youmaycontacttheGovernor’sAdvocacyOfficeat1-800-442-5238.
Part1—Askforahearing.
WhatmustIdotogetahearing?Forfoodbenefitsandmedicaleligibility,youcanaskforahearingonformMSC0443,byphone,inwriting,orbyaskingaDHSemployeeinperson.Forotherbenefits,youmustfilloutanAdministrativeHearingRequestform(MSC0443)andreturnittoaDHSorOHAoffice.YoucangetthisformataDHSorOHAofficeoronthewebat
Youmayrequestahearingatanytimeifyoudisagreewiththecurrentamountofyourfoodbenefits.Youhave90daystorequestahearingforfoodbenefits,medicaleligibility,andforTANFreductionsfornotcooperatingwithyourcaseplan.Inothersituations,DHSmustreceiveyourrequestwithin45daysfromthedateonthenotice.
Notetomilitarypersonnel:Activedutyservicemembershavearighttostay(delay)theseproceedingsunderthefederalServicemembersCivilReliefAct(SCRA).Formoreinformation,youmaycontacttheOregonStateBar(1-800-452-8260),theOregonMilitaryDepartment(1-800-452-7500)orthenearestlegalassistanceoffice,legalassistance.law.af.mil.
Whocanhelpwithmyhearing?Forfoodbenefitsandformedicalprograms,anyonemayrepresentyou.Inallotherprograms,youmustrepresentyourselforhavealawyeroralegalassistant(supervisedbyaLegalAidattorney)representyou.YoumaycallthePublicBenefitsHotline(aprogramofLegalAidServicesofOregonandtheOregonLawCenter)at1-800-520-5292foradviceandpossiblerepresentation.
Whataremyotherhearingrights?Atthehearing,youcantellwhyyoudonotagreewiththedecision.Youcanhavepeopletestifyforyou.ThelawsaboutyourhearingrightsandthehearingprocessareatOAR137-003-0501to0700,410-120-1860,410-141-0264,461-025-0300to0375,ORS183.411to183.470andORS411.095.
Whathappensifthereisnohearing?Ifyoudonotaskforahearingontime,orifyouwithdrawthehearingrequestormissyourhearing,youmayloseyourrighttoahearing.ThisnoticewillbethefinalDHSorOHAdecision(calleda“finalorderbydefault”).Youwillnotgetaseparatefinalorderbydefault.Thecasefile,alongwithanymaterialsyousubmittedinthismatter,istherecord.TherecordisusedtosupporttheDHSdecisionupondefault.YoumayappealthefinalorderbydefaultbyfilingapetitionintheOregonCourtofAppeals(ORS183.482).Ifyoudonotaskforahearing,thisappealmustbefiledwithin60daysofthedatethisnoticebecomesafinalorder,bydefault.Ifyouwithdrawahearingrequestormissyourhearing,theappealdeadlineissetoutinthedismissalorder.
Part2—HowcanIkeepgettingbenefitsuntilmyhearing?
•Youcanaskforyourbenefitstostaythesameuntilthehearingdecision(“continuingbenefits”).Forfoodandmedicalbenefits,useformMSC0443,phone,writeoraskaDHSemployeeinperson.Inotherprograms,youmustaskontheAdministrativeHearingRequestform(MSC0443).
•Youmustaskyourbranchforcontinuingbenefitsbyeitherthe“effectivedate”onthenotice,10daysafterthedateofthenotice,or(formedicalonly)10daysafterreceiptofthenotice.Youmustaskbywhicheverdateislater.
•Ifyoukeepgettingbenefitsbutlosethehearing,youmustpaybackthebenefitsyoushouldnothavereceived.
•Ifyoudon’tkeepgettingbenefitsandwinthehearing,DHSorOHAwillgiveyouthebenefitsyoushouldhavereceived.
Part3—CanIhaveanexpeditedhearing?
Youmayhavetherighttoan“expeditedhearing”foranyofthefollowingtypesofbenefitsorsituations:
•Expeditedoremergencyfoodbenefits
•JOBSandPre-TANFpayments
•TemporaryAssistanceforDomesticViolenceSurvivors(TA-DVS)eligibilityandpayments
•Inamedicalcase,youhaveanimmediateneedforhealthservicesandstandardtimelinefortheappealprocesscouldjeopardizeyourlifeorhealthorabilitytoattain,maintain,orregainmaximumfunction
•DHSorOHAdeniedyourrequesttokeepgettingbenefitsuntilyourhearing.
DHSandOHAdonotdiscriminateagainstanyone.ThismeansthatDHS|OHAwillhelpallwhoqualifyandwillnottreatanyonedifferentlybecauseofage,race,color,nationalorigin,gender,religion,politicalbeliefs,disabilityorsexualorientation.YoumayfileacomplaintifyoubelieveDHSorOHAtreatedyoudifferentlyforanyofthesereasons.
MSC0447(01/14)
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