Medicaid Application Checklist

Medicaid Application Checklist

Purpose

This comprehensive checklist guides applicants through the Medicaid long-term care application process, ensuring all required documents are gathered and requirements are met.

Application Timeline

2026 Eligibility Requirements

Asset Limits (Most States)

Income Limits

States with Different Limits:

• New York: $33,038
• California: $130,000
• Illinois: $17,500
• Connecticut: $1,600
• Mississippi: $4,000

Section 1: Identity and Citizenship Documents

Primary Identification (Required)

☐ Government-issued photo ID (driver's license or state ID)
☐ U.S. Passport (current or expired)
☐ Social Security card (original or copy)

Citizenship/Immigration Status

☐ Birth certificate
☐ U.S. Passport
☐ Certificate of Naturalization
☐ Certificate of Citizenship
☐ Permanent Resident Card (Green Card)
☐ Immigration documentation (if applicable)

Residency Verification

☐ Utility bills showing current address
☐ Lease agreement or mortgage statement
☐ Bank statements with address
☐ State residency documentation

Section 2: Financial Documents - Bank Accounts

Current Bank Statements (All Accounts)

Checking Accounts:

Savings Accounts:

Look-Back Period Documentation (60 Months)

☐ Monthly or quarterly statements for past 60 months
☐ All accounts identified (checking, savings, money market)
☐ Closed account statements and closure documentation
☐ Joint account statements (all joint holders identified)
☐ Documentation for any large withdrawals or transfers

Statement Collection Tracking:

Section 3: Investment and Retirement Accounts

Investment Accounts

☐ Stocks and bonds statements
☐ Mutual fund statements
☐ Brokerage account statements
☐ Certificate of Deposit (CD) documentation

Retirement Accounts

☐ Required Minimum Distribution (RMD) documentation (if applicable)
☐ Pension benefit statements
☐ 401(k) statements (past 60 months)
☐ IRA statements (past 60 months)

Section 4: Income Documentation

Regular Income Sources

Required Income Verification Documents

☐ Social Security award letter (most recent)
☐ SSI award letter (if applicable)
☐ Pension statements
☐ Annuity contracts and statements
☐ Pay stubs (most recent 30-60 days)
☐ Previous year's tax return
☐ W-2 forms
☐ 1099 forms (all types)
☐ Child support documentation
☐ Alimony/spousal support documentation
☐ Unemployment compensation statements
☐ Worker's compensation awards

Section 5: Real Property and Home

Primary Residence

☐ Property deed
☐ Current mortgage statement
☐ Property tax bills
☐ Homeowner's insurance declaration
☐ Current appraisal or tax assessment value

Primary Residence Information:

☐ Applicant resides in home
☐ Intent to return home filed (if in facility)
☐ Spouse resides in home
☐ Dependent child under 21 resides in home
☐ Blind or disabled child resides in home

Other Real Property

Property Transfers (Past 60 Months)

☐ No property transfers in past 60 months

If transfers occurred:

☐ Sale agreement/closing documents
☐ Documentation of fair market value at time of sale

Section 6: Vehicle and Personal Property

Vehicles

☐ Vehicle titles
☐ Registration documents
☐ Loan documents (if financed)

Personal Property of Value

☐ Jewelry appraisals
☐ Art/collectibles appraisals
☐ Other valuable items documentation

Vehicles/Property Sold (Past 60 Months)

☐ Bills of sale obtained
☐ Documentation of fair market value

Section 7: Insurance Policies

Life Insurance

☐ Life insurance policy documents
☐ Current statements showing cash surrender value
☐ Beneficiary designation forms

Note: Term life insurance has no cash value and is generally exempt. Whole life policies with cash value may be countable.

Health Insurance

☐ Medicare card (front and back copies)
☐ Medicare Supplement (Medigap) policy
☐ Medicare Advantage plan information
☐ Other health insurance cards
☐ Prescription drug plan (Part D) card
☐ Dental insurance information
☐ Vision insurance information

Long-Term Care Insurance

☐ Long-term care insurance policy (if any)
☐ Current premium statements
☐ Benefits summary

Section 8: Legal Documents

Powers of Attorney

☐ Durable Power of Attorney for Finances
☐ Healthcare Power of Attorney/Healthcare Proxy
☐ Letter of incompetency (if POA is springing)

Trust Documents

☐ Revocable living trust documents (if applicable)
☐ Irrevocable trust documents (if applicable)
☐ Trust asset list
☐ Trust beneficiary information
☐ Trust amendments

Court Documents

☐ Guardianship/Conservatorship papers (if applicable)
☐ Divorce decree/judgment of dissolution
☐ Separation agreement
☐ Prenuptial/postnuptial agreement

Estate Planning Documents

☐ Last Will and Testament
☐ Burial/funeral pre-arrangements
☐ Irrevocable Funeral Trust documentation

Section 9: Gift and Transfer Documentation

Gifts Made (Past 60 Months)

☐ Documentation of all gifts made
☐ Explanation for each gift
☐ Evidence of fair market value received (if sold below value)

Warning: Transfer Penalties

Gifts or transfers for less than fair market value during the look-back period may result in a penalty period of Medicaid ineligibility.

Section 10: Medical Documentation

Current Medical Information

☐ Current physician information
☐ List of current medications
☐ List of diagnoses and conditions
☐ Recent medical records (if disability claim)

For Nursing Home Applicants

☐ Nursing home admission records
☐ Current facility account statements
☐ Level of care determination

For Disability-Based Applications

☐ Disability determination letter
☐ Medical records supporting disability
☐ Physician statements

Section 11: Unpaid Medical Bills (For Retroactive Coverage)

☐ Unpaid medical bills (past 3 months)
☐ Hospital bills
☐ Physician bills
☐ Prescription costs
☐ Medical equipment costs
☐ Other healthcare expenses

Section 12: Married Couple Additional Documents

For Community Spouse

☐ Community spouse's income documentation
☐ Community spouse's asset documentation
☐ Spousal impoverishment documentation

Community Spouse Resource Allowance (CSRA)

Spousal Refusal (If Applicable)

☐ Spousal refusal letter (state-specific)
☐ Documentation of spouse's non-cooperation

Section 13: Application Submission Checklist

Before Submitting

☐ All sections above completed
☐ All documents copied (keep originals)
☐ Documents organized by category
☐ Application form completed
☐ Signatures obtained where required
☐ Application reviewed for accuracy

Submission Method

☐ In-person at Medicaid office
☐ By mail
☐ Online (if state allows)
☐ Through authorized representative

Record Keeping

☐ Copy of complete application made
☐ List of all documents submitted
☐ Date of submission recorded: _______________
☐ Confirmation number (if applicable): _______________
☐ Caseworker name and contact: _______________

Section 14: Post-Submission Follow-Up

Timeline Tracking

If Additional Information Requested

☐ Respond within deadline specified
☐ Keep copies of additional documents
☐ Send by certified mail or obtain receipt
☐ Follow up if no response within timeframe

If Application Denied

☐ Review denial letter carefully
☐ Note deadline for appeal (typically 30-90 days)
☐ Request fair hearing if disagreeing with decision
☐ Consult with elder law attorney

Contact Information

State Medicaid Office:

• Agency Name: _________________________________
• Phone: _________________________________
• Address: _________________________________
• Website: _________________________________

Caseworker Assigned:

• Name: _________________________________
• Phone: _________________________________
• Email: _________________________________

Elder Law Attorney:

• Name: _________________________________
• Phone: _________________________________

Important Reminders

1. Burden of Proof: The applicant must prove financial eligibility
2. Completeness: Incomplete applications will be denied
3. Accuracy: False information results in denial and potential penalties
4. Deadlines: Missing deadlines may require starting over
5. State Variations: Requirements vary by state - verify with local office

This checklist is for informational purposes only. Medicaid requirements vary by state. Consult with your state Medicaid office or an elder law attorney for specific guidance.