Medicaid Long-Term Care Application Checklist

Purpose and Overview

This checklist guides the preparation and submission of a Medicaid long-term care application. Medicaid eligibility requirements differ by state and program type (nursing home, home and community-based services waivers, etc.). Current federal rules require a 60-month (5-year) lookback period for asset transfers.

Key 2025 Federal Limits (verify current state-specific amounts):
- Individual Asset Limit (most states): $2,000
- Community Spouse Resource Allowance (CSRA): Up to $157,920
- Monthly Income Limit (300% of SSI/FBR): Approximately $2,901/month
- Community Spouse Monthly Maintenance Needs Allowance (MMMNA): Up to $3,948/month

Section 1: Pre-Application Planning

1.1 Initial Assessment

• ☐ Determine applicant's current level of care needs (nursing facility vs. HCBS waiver)
• ☐ Identify appropriate Medicaid program (Institutional, HCBS Waiver, Community Medicaid)
• ☐ Confirm applicant meets age/disability requirements (65+ or disabled)
• ☐ Verify U.S. citizenship or qualified immigration status
• ☐ Confirm state residency requirements

1.2 Lookback Period Analysis

• ☐ Calculate 60-month lookback period start date: _______________
• ☐ Obtain 60 months of bank statements for all accounts
• ☐ Obtain 60 months of brokerage/investment statements
• ☐ Review all asset transfers during lookback period
• ☐ Document any gifts made during lookback period
• ☐ Identify potentially disqualifying transfers
• ☐ Calculate potential penalty period for any violations
• ☐ Note: Penalty divisor varies by state (average monthly cost of nursing home care)

1.3 Spousal Considerations (if married)

• ☐ Determine Community Spouse Resource Allowance (CSRA) for your state
• ☐ Calculate snapshot date for resource assessment
• ☐ Identify spousal impoverishment protections
• ☐ Consider spousal refusal option (state-specific)
• ☐ Plan for income allocation to community spouse

Section 2: Personal Information Documents

2.1 Identity and Citizenship

• ☐ Government-issued photo ID (driver's license, state ID, passport)
• ☐ Social Security card or SSA-1099
• ☐ Birth certificate or other proof of age
• ☐ Proof of U.S. citizenship or qualified alien status
• ☐ Immigration documentation (if applicable)
• ☐ Marriage certificate (if applicable)
• ☐ Divorce decree (if applicable)
• ☐ Death certificate of spouse (if applicable)

2.2 Residency Documentation

• ☐ Current lease or mortgage statement
• ☐ Utility bills in applicant's name
• ☐ Driver's license with current address
• ☐ Voter registration card
• ☐ State income tax returns

Section 3: Income Documentation

3.1 Regular Income Sources

• ☐ Social Security benefit statement (SSA-1099)
• ☐ Pension statements (all sources)
• ☐ Annuity statements
• ☐ IRA/401(k) required minimum distribution statements
• ☐ Employment income (if any)
• ☐ Self-employment income documentation
• ☐ Rental income documentation
• ☐ Interest and dividend income (1099-INT, 1099-DIV)
• ☐ Royalty income

3.2 Other Income

• ☐ VA benefits statement
• ☐ Workers' compensation payments
• ☐ Disability income
• ☐ Alimony/spousal support
• ☐ Trust income distributions
• ☐ Life estate income
• ☐ Any other regular payments

3.3 Income Calculations

• ☐ Total gross monthly income: $_______________
• ☐ Compare to state income limit
• ☐ If over limit, consider Qualified Income Trust (Miller Trust)

Section 4: Asset Documentation

4.1 Bank Accounts

For each account, provide 60 months of statements:
- ☐ Checking accounts (all institutions)
- ☐ Savings accounts (all institutions)
- ☐ Money market accounts
- ☐ Certificate of Deposit (CD) statements
- ☐ Credit union accounts
- ☐ PayPal, Venmo, or other digital payment accounts

4.2 Investment Accounts

• ☐ Brokerage account statements (60 months)
• ☐ Stock certificates
• ☐ Bond certificates
• ☐ Mutual fund statements
• ☐ IRA statements (all types)
• ☐ 401(k)/403(b) statements
• ☐ Annuity contracts and statements
• ☐ Note: IRAs in payout status may be non-countable in some states

4.3 Real Property

• ☐ Deed to primary residence
• ☐ Property tax statements
• ☐ Current market value appraisal or tax assessment
• ☐ Mortgage statements
• ☐ Home equity line of credit statements
• ☐ Deeds to other real property
• ☐ Rental property documentation
• ☐ Life estate deeds
• ☐ Note: Primary residence generally exempt if equity below state limit ($713,000-$1,071,000 in 2025)

4.4 Vehicles

• ☐ Vehicle titles
• ☐ Current registration
• ☐ Fair market value documentation
• ☐ Loan/lien information
• ☐ Note: One vehicle generally exempt

4.5 Life Insurance

• ☐ Life insurance policy declarations pages
• ☐ Cash surrender value statements
• ☐ Face value documentation
• ☐ Term vs. whole life determination
• ☐ Note: Cash value over $1,500 is generally countable

4.6 Other Assets

• ☐ Prepaid funeral/burial contracts (irrevocable preferred)
• ☐ Burial plot deeds
• ☐ Promissory notes receivable
• ☐ Business ownership interests
• ☐ Partnership interests
• ☐ Trust documents (grantor and beneficiary)
• ☐ Pending inheritances
• ☐ Personal injury settlements
• ☐ Valuable personal property (jewelry, art, collectibles)

Section 5: Exempt Assets Verification

5.1 Confirm Exempt Status

• ☐ Primary residence (with equity limit verification)
• ☐ One automobile
• ☐ Personal belongings and household goods
• ☐ Prepaid irrevocable funeral contract
• ☐ Burial spaces for applicant and immediate family
• ☐ Life insurance with face value $1,500 or less
• ☐ Term life insurance (no cash value)
• ☐ Property essential for self-support

Section 6: Transfer Review (Lookback Period)

6.1 Document All Transfers

For each transfer during the 60-month lookback period:

6.2 Potentially Exempt Transfers

• ☐ Transfers to spouse
• ☐ Transfers to blind or disabled child
• ☐ Transfers of home to caregiver child (2+ years care in home)
• ☐ Transfers of home to sibling with equity interest (1+ year residence)
• ☐ Transfers for fair market value
• ☐ Transfers that would cause undue hardship (narrow exception)

6.3 Penalty Period Calculation

• ☐ Total value of disqualifying transfers: $_______________
• ☐ State penalty divisor (average monthly nursing home cost): $_______________
• ☐ Calculated penalty period: _______________ months
• ☐ Strategy for addressing penalty period

Section 7: Medical Documentation

7.1 Level of Care Determination

• ☐ Physician's statement of medical necessity
• ☐ Pre-Admission Screening (PAS) assessment
• ☐ Level of Care (LOC) evaluation
• ☐ Nursing facility admission paperwork
• ☐ Hospital discharge summary (if applicable)

7.2 Medical Records

• ☐ List of current medications
• ☐ List of treating physicians
• ☐ Recent medical records supporting level of care
• ☐ Diagnosis documentation
• ☐ Functional assessment (ADL limitations)

Section 8: Legal Documents

8.1 Estate Planning Documents

• ☐ Durable Power of Attorney (financial)
• ☐ Healthcare Power of Attorney/Healthcare Proxy
• ☐ Living Will/Advance Directive
• ☐ Will (current)
• ☐ Trust documents (all trusts, grantor or beneficiary)
• ☐ Medicaid Asset Protection Trust documents (if applicable)

8.2 Other Legal Documents

• ☐ Guardianship/Conservatorship orders (if applicable)
• ☐ Representative Payee documentation
• ☐ Divorce decrees
• ☐ Separation agreements
• ☐ Court orders affecting assets/income

Section 9: Application Submission

9.1 Application Forms

• ☐ State Medicaid application form completed
• ☐ Authorization forms signed
• ☐ Asset verification forms
• ☐ Income verification forms
• ☐ HIPAA authorization

9.2 Submission Checklist

• ☐ All documents copied (retain originals)
• ☐ Documents organized by category
• ☐ Cover letter prepared (recommended)
• ☐ Application dated and signed
• ☐ Submission method selected (mail, online, in-person)
• ☐ Proof of submission obtained
• ☐ Follow-up date calendared (typically 45-90 days for determination)

Section 10: Post-Submission Tasks

10.1 Tracking

• ☐ Application reference number: _______________
• ☐ Submission date: _______________
• ☐ Expected determination date: _______________
• ☐ Caseworker name and contact: _______________

10.2 Response to Information Requests

• ☐ Respond promptly to all requests for additional information
• ☐ Document all communications with Medicaid agency
• ☐ Appeal deadline if denied: _______________ (typically 90 days)

Section 11: State-Specific Considerations

11.1 State Variations to Research

• ☐ Asset limit (some states higher than $2,000, e.g., NY: $31,175)
• ☐ Income cap and Miller Trust requirements
• ☐ Home equity limit
• ☐ Spousal protections
• ☐ Estate recovery policies
• ☐ HCBS waiver availability and waiting lists
• ☐ Transfer penalty divisor
• ☐ Community Medicaid lookback (if applicable)

11.2 Notes

State: _______________

Specific state requirements or variations:

_______________________________________________
_______________________________________________
_______________________________________________

Section 12: Professional Contacts

This checklist is current as of January 2025. Medicaid rules change frequently. Always verify current requirements with your state Medicaid agency and consult with a qualified elder law attorney.