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State of Connecticut
Department of Social Services
W-1487 (Rev. 1/12)
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- The State of Connecticut wants to give you an opportunity to stay home instead of
going to a nursing home. That is the purpose of a home care program called the Connecticut
Home Care Program for Elders. You can find out whether you may qualify for any of
the services from this program by completing this Request Form.
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- We want to make sure that all Elderly persons 65 years and over are informed about
the program. We are asking that you complete, sign and return this form whether
or not you qualify for services. Please refer to the back of this form for specific
information regarding the income and asset level to determine if you may qualify
for home care services.
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- You will be expected to apply for Medicaid if you meet the financial criteria. If
you do not meet the financial criteria for Medicaid, you may still be eligible for
State Funded Home Care Services. Refer to the back of the form.
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- If your income is below the program limit, but your counted assets currently exceed
the applicable asset limit, you still may qualify to be screened for Home Care Program
services when you reduce your assets to the limit. You are not required to spend
your excess assets on health care. You may spend them on any goods or services for
yourself or your spouse. However, you must receive fair market value in exchange
for your excess assets and keep all of your receipts. When you have reduced your
assets to the limit, you can submit another form like this one, which can be obtained
by calling the toll-free number below.
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- Notice to Married Couples – Under state and federal law, a married couple is allowed
to protect assets for the person who is living in the community while his or her
spouse is institutionalized or living at home and needing the kind of care that
would otherwise be provided in a long term care institution. To obtain additional
information or to request an Assessment of Spousal Assets, if you have not had one
done already, and you are applying for home care, please call toll-free 1-800-445-5394
or 1-860-424-4904. If applying for home care services, please check appropriate
box on the back of this form.
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- Be advised that you are expected to provide any change of income, assets or living
arrangements within 10 days of the change.
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- Be advised that the Department may pursue legally liable relative contributions
from spouses or recipients receiving services under the Connecticut Home Care Program
for Elders.
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- Be advised that the State has the right to recover monies from the sale of real
estate and from the estates of individuals who received services under the Connecticut
Home Care Program for Elders including private insurance premiums paid on behalf
of the individual.
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QUESTIONS – PROBLEMS – CALL OUR TOLL FREE NUMBER
This information is available in alternate formats. Phone (800) 842-1508 or TDD/TTY
(800) 842-4524.
ESTA FORMA ESTA DISPONIBLE EN ESPAÑOL. LLAME AL 1-800-445-5394.
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