How to Fill Out and Submit the Connecticut PCA Waiver Form (W-982)

The Connecticut PCA Waiver form W-982 is the Department of Social Services referral form you submit to be screened for the Personal Care Attendant Waiver, a Medicaid program that pays for in-home personal care for adults with severe disabilities.¹ Download it from the DSS website or MyPlaceCT, complete the four sections and the signature block, and mail or fax it to DSS headquarters in Hartford.² Submitting the form puts you in line for a waiting list, not into the program directly.

Before You Start

The PCA Waiver is for adults ages 18 through 64 with chronic, severe, and permanent disabilities who need hands-on help with daily activities and would otherwise need nursing-facility care.³⁴ Three thresholds matter before you spend time on the form.

You need to qualify for Medicaid financially. Countable assets cannot exceed $1,600 for a single person. You do not have to be enrolled in Medicaid the day you send in the W-982, but you must have applied for and qualified for Medicaid by the time your name comes up on the waiting list.⁵

You also need to be able to direct your own care. The PCA program is consumer-directed, which means you hire, train, supervise, and if necessary fire your own attendant. If you cannot do that yourself, a court-appointed conservator can act in that role.³

Two boundaries to know. If you work and your income is too high for standard Medicaid, Connecticut’s Med-Connect program allows working adults with disabilities up to $75,000 in annual income and $10,000 in assets, which can be the route into Medicaid eligibility.⁵ And the PCA Waiver stops at age 65; at that point participants transition to a different program.

Getting the Form

You can download the W-982 from the DSS website or MyPlaceCT. A Spanish version, the W-982S, is posted in the same places.² You can also start by phone at 860-424-4904, where a nurse or social worker will take your information and do a preliminary eligibility screen before pointing you to the form.

If you are deaf or hard of hearing, DSS has a TDD/TTY line at 1-800-842-4524. If you are blind or visually impaired, call 1-860-424-5040 for help.¹

Filling Out Each Section

The form has four sections and a signature block. DSS tells applicants to complete every field, because missing information causes processing delays.¹ Before you sit down with it, pull together your Social Security number, current income figures, and your primary medical diagnosis.

Section A: Personal Information

Full legal name, date of birth, Social Security number, gender, marital status, home address, and phone number. If you already have a Medicaid number, write it in so DSS can link the referral to your existing file. If your Medicaid application is still pending, leave that field blank. Check the box for your current living situation (alone, with family, group home, or assisted living).

Section B: Financial Assessment

Enter your total monthly income and total assets. These figures let DSS run a preliminary check against Medicaid limits. If you are married, the form includes a spousal assessment notice. When one spouse needs nursing-home-level care, including care at home through a waiver, the couple can protect some combined assets for the spouse remaining at home. Check “Yes” to request a spousal assessment if this applies, and DSS will calculate how much your spouse can keep.

Section C: Functional Assessment

This section carries the most weight in the referral decision. You rate how much help you need with eight daily activities on a four-point scale: 0 for no help, 1 for supervision or reminders, 2 for hands-on help, and 3 for total dependence. The eight activities are bathing, dressing, eating, toileting, transferring in and out of bed or chairs, walking, taking medications, and continence.

Rate honestly. Underreporting your needs can cost you a place on the waiting list. If a task is harder some days than others, rate it on your worse days, not your best. Below the ratings, circle your living arrangement, say whether a family member or neighbor currently helps you, check any behavioral concerns that apply (such as wandering, self-injury, or verbal aggression), and write in your primary medical diagnosis.

Section D: Point of Contact

This section is optional. If you want DSS to reach a family member, friend, or advocate about your application rather than contacting you directly, list that person’s name, phone number, and relationship. Leave it blank if you prefer DSS to come straight to you.

Signature Block

Sign and date the form at the bottom. If you sign with an “X” instead of a written signature, a witness must sign on the same line.¹ If someone else fills out the form on your behalf, they must write their name, relationship to you, and phone number. If that person holds power of attorney, conservatorship, or guardianship, they should circle the appropriate role on the form.

Facility Staff Section

If you are currently in a hospital or nursing home, a staff member there must complete the “Facility Staff Only” section at the end of the form. That section is not required if a health screen is already attached to your application.

Where to Submit the Form

Mail the completed W-982 to:

Department of Social Services
Home and Community Based Services, 9th Floor
55 Farmington Avenue
Hartford, CT 06105-3725¹

You can also fax it to 860-424-4963. If you fax, check that the ink is dark enough to come through clearly and keep your confirmation receipt. Either way, make a copy of the completed form for your own records before you send it.

What Happens After You Submit

The PCA Waiver has a capped number of slots, so your referral does not put you straight into the program. DSS fills openings in the order referrals are received, provided the applicant meets every eligibility requirement.² After processing, your name goes on a waiting list.

When a slot opens, a care manager will visit your home. During that visit, the care manager runs a full assessment of your home and community-based service needs, explains how the program works, and brings any additional forms. The two of you decide together which services you need. Once eligibility is confirmed, you have 90 days to select your providers.

Use the wait to lock in your Medicaid. If your Medicaid application was pending when you sent in the W-982, follow up until it is approved. Federal rules give state Medicaid agencies 45 days to process a standard application and 90 days for a disability-based one.⁶ If Medicaid is not in place by the time your name comes up, services cannot start.

If You Are Denied

If DSS denies your referral, reduces your services, or terminates your enrollment, you will get a written Notice of Action. You can request a fair hearing to challenge the decision, generally within 60 days of the date on that notice.⁷

The simplest route is the Hearing Request Form attached to the Notice of Action. If you no longer have it, a signed letter to the DSS Hearing Office works too, as long as it says which decision you disagree with and includes your name, address, and identification number. For Medicaid, your benefits can continue while the hearing is pending if you file the request before the date of the proposed action. You do not need a lawyer, though you may name someone to represent you.

1
Department of Social Services. Personal Care Attendant (PCA) Request for Referral
2
MyPlaceCT. Personal Care Attendant (PCA) Waiver
3
Department of Social Services. Disability Services – What Next
4
Department of Social Services. Overview of Connecticut Medicaid Waiver Programs
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Department of Social Services. The Personal Care Attendant Program
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Connecticut General Assembly. Medicaid – Eligibility, Administration, and Provider Participation
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Department of Social Services. Requesting a Hearing