Referral for an MA Lien or Notice of Potential Claim (DHS-3203)

Follow the instructions for the DHS-3203 to refer an MA member’s interest in real property to the Minnesota Department of Human Services (DHS) for a potential lien to repay Medical Assistance (MA).

Complete the DHS-3203 when (1) an MA member is approved for long-term care (LTC) services or (2) an MA member who received services at 55 years old or older has died. In these circumstances, refer the real property even if it was excluded for MA eligibility purposes.

1. Enter the MA member’s information under Step 1

Enter the following information about the MA member:

· First, middle and last name

· MAXIS case number

· Eight-digit Member ID number (Person Master Index [PMI] number)

· Social Security number

· Date of birth

· Marital status

· MA start date

· Whether the MA member is alive

2. Enter LTC facility and attending physician information under Step 2

If the MA member is still alive, enter the following information:

· Name of the LTC facility

· Date of entry

· Phone number

· Attending physician name, phone number and address

If the MA member is dead, skip to Step 3.

3. Describe the real property you’re referring under Step 3

Check whether the property is classified as homestead property.

a. Homestead property

Select whether the ownership interest is a life estate, joint tenancy, tenancy in common or sole ownership.

Next, describe the property. This should be a brief description of the documents attached in Step 4.  A brief description could include a Parcel ID #, a brief legal description and the address of the property.

b. Non-homestead property

Select whether the ownership interest is a life estate, joint tenancy, tenancy in common or sole ownership.

Next, describe the property. This should be a brief description of the documents attached in Step 4. Examples of descriptions include whether it is a cabin, vacant lot, hunting land, second home or some other form of real property.

c. Both homestead and non-homestead property

When you are referring both homestead and non-homestead property, ensure that your descriptions in the “Describe the property” fields identify which attachments correspond with each property.

4. Attach documentation for the property

Include a copy of at least one of the following documents for each property you are referring to DHS:

· Deed

· Current tax statement

· Parcel number

· Legal description

· Address with the name of county

5. Check whether any of the circumstances listed in Step 5 are true and, if so, submit documentation

Read all of the circumstances listed in Step 5. If one or more circumstances are true, indicate that on the form and send documentation along with the form that substantiates that the circumstances are true.

6. Check whether the MA member designated the real property as a protected asset under Step 6

If the MA member designated the real property you’re referring as a protected asset under long-term care (LTC) Partnership Insurance, then provide the value of the asset protection and describe the property.

7. Enter your contact information under Step 7

Provide your name, your agency name, your email address, phone number and today’s date.

8. Email the completed form or questions about the form to DHS via secure email at DHS.SRUlien@state.mn.us