Alaska Medicaid (DenaliCare) Long-Term Care Application Packet

ALASKA MEDICAID (DENALICARE) LONG-TERM CARE APPLICATION PACKET

TABLE OF CONTENTS

1. Cover Letter to Division of Public Assistance
2. Applicant Information
3. Spouse / Household Information
4. Categorical Eligibility
5. Income Disclosure
6. Asset / Resource Disclosure
7. Primary Residence and Home-Equity Treatment
8. Five-Year Look-Back and Transfer Disclosure
9. Spousal-Impoverishment Allocation (If Applicable)
10. Level-of-Care Determination
11. Authorized Representative Designation
12. Verification Document Checklist
13. Applicant Certification and Signature
14. Alaska Practice Notes
15. Sources and References

1. COVER LETTER TO DIVISION OF PUBLIC ASSISTANCE

Date: [__/__/____]

Alaska Department of Health
Division of Public Assistance — Adult Long-Term Care Unit
[LOCAL DPA OFFICE ADDRESS]

Re: Application for DenaliCare Long-Term Care Medical Assistance
Applicant: [APPLICANT FULL LEGAL NAME]
SSN (last 4): [____] Date of Birth: [__/__/____]

Dear DPA Eligibility Technician:

Enclosed please find the completed GEN 50C / ARIES application packet for long-term care medical assistance under AS 47.07 and 7 AAC 100, together with the verification documents listed in the attached checklist. Applicant requests benefits effective [__/__/____] and elects retroactive coverage for the three calendar months preceding the application month to the extent eligibility can be established under 42 C.F.R. § 435.915.

Please direct all correspondence concerning this application to the Authorized Representative identified in Section 11.

Sincerely,

[________________________________]

[APPLICANT or AUTHORIZED REPRESENTATIVE NAME]

2. APPLICANT INFORMATION

3. SPOUSE / HOUSEHOLD INFORMATION

4. CATEGORICAL ELIGIBILITY

Applicant is a resident of the State of Alaska and qualifies under the following category (check one):

• ☐ Aged 65 or older — AS 47.07.020(a)
• ☐ Blind — AS 47.07.020(a)
• ☐ Disabled (SSI / SSDI determination attached) — AS 47.07.020(a)
• ☐ Medically Needy / Spend-down — verify Alaska implementation
• ☐ Other: [________________________________]

Coverage requested:

• ☐ Institutional Nursing Facility (entitlement)
• ☐ HCBS Waiver — Adults with Physical and Developmental Disabilities (APDD)
• ☐ HCBS Waiver — Alaskans Living Independently (ALI)
• ☐ HCBS Waiver — Older Alaskans
• ☐ Personal Care Services (PCS) Program (State Plan)
• ☐ Other: [________________________________]

5. INCOME DISCLOSURE

6. ASSET / RESOURCE DISCLOSURE

List ALL assets owned by Applicant and (if married) Spouse as of the first moment of the application month and on the snapshot date for spousal cases.

7. PRIMARY RESIDENCE AND HOME-EQUITY TREATMENT

8. FIVE-YEAR LOOK-BACK AND TRANSFER DISCLOSURE

For the 60 calendar months immediately preceding the application date — that is, from [__/__/____] to [__/__/____] — disclose every transfer of an asset by Applicant or Spouse for less than fair market value.

Penalty calculation:

Total uncompensated value $[____] ÷ AK transfer-penalty divisor $[____] /month = [____] months ineligible.

Penalty period begins on the later of (a) the date of transfer or (b) the date Applicant is otherwise eligible for institutional Medicaid and would be receiving services but for the penalty (42 U.S.C. § 1396p(c)(1)(D)).

Exempt / undue-hardship transfers claimed:

• ☐ Transfer to spouse (§ 1396p(c)(2)(B)(i))
• ☐ Transfer to blind or disabled child (§ 1396p(c)(2)(B)(iii))
• ☐ Transfer to caregiver child (2-year rule, § 1396p(c)(2)(A)(iv))
• ☐ Transfer to sibling with equity interest residing 1+ year (§ 1396p(c)(2)(A)(iii))
• ☐ Transfer to (d)(4)(A) or (d)(4)(C) trust for disabled individual under 65
• ☐ Undue-hardship waiver requested
• ☐ None — no transfers occurred during look-back period

9. SPOUSAL-IMPOVERISHMENT ALLOCATION (IF APPLICABLE)

10. LEVEL-OF-CARE DETERMINATION

11. AUTHORIZED REPRESENTATIVE DESIGNATION

I, [APPLICANT NAME], hereby designate the following individual as my Authorized Representative for purposes of this DenaliCare application under 42 C.F.R. § 435.923 and 7 AAC 100.026:

[________________________________]

[APPLICANT SIGNATURE] Date: [__/__/____]

12. VERIFICATION DOCUMENT CHECKLIST

• ☐ State-issued photo identification or U.S. passport
• ☐ Social Security card
• ☐ Birth certificate or naturalization documents
• ☐ Proof of Alaska residency (utility bill, lease, etc.)
• ☐ Marriage certificate / divorce decree / death certificate as applicable
• ☐ Most recent federal income tax return
• ☐ 60 months of bank statements (all accounts, all months)
• ☐ Brokerage / IRA / 401(k) / annuity statements (60 months)
• ☐ Life insurance policies (face and cash value)
• ☐ Deed and tax-assessor record for primary residence and any other real property
• ☐ Copies of any trust instruments (revocable and irrevocable)
• ☐ Copies of any annuity contracts (with disclosure of state remainder beneficiary clause)
• ☐ Closing statements for any real-property sale within look-back
• ☐ Documentation of all transfers/gifts > $500 within look-back
• ☐ Caregiver-child documentation (if caregiver-child exemption claimed)
• ☐ Power of Attorney / Guardianship Letters
• ☐ DD-214 (if veteran)
• ☐ Tribal enrollment documentation (if applicable)
• ☐ Medical records establishing level of care
• ☐ Funeral / burial pre-need contract

13. APPLICANT CERTIFICATION AND SIGNATURE

I, [APPLICANT NAME] (or, where signed below, the Authorized Representative on Applicant's behalf), declare under penalty of perjury under the laws of the State of Alaska and the United States that:

1. The information provided in this application and all attachments is true, correct, and complete to the best of my knowledge.
2. I understand that knowingly making a false statement in connection with a Medicaid application is a crime under AS 47.05.210, 18 U.S.C. § 1001, and 42 U.S.C. § 1320a-7b, punishable by fine, imprisonment, or both, and may result in denial of benefits and program disqualification.
3. I authorize the Alaska Department of Health to verify all information provided, including obtaining records from financial institutions, the IRS, the Social Security Administration, the Alaska Permanent Fund Division, employers, insurers, and any other relevant source.
4. I acknowledge that the State of Alaska is entitled, under AS 47.07.045 and 42 U.S.C. § 1396p(b), to seek estate recovery for medical assistance correctly paid on my behalf.
5. I will report any change in income, assets, household composition, or living arrangement to DPA within ten (10) days.

Signed at [CITY, ALASKA] this [____] day of [_______________], 20[____].

[________________________________]

[APPLICANT or AUTHORIZED REPRESENTATIVE]

Subscribed and sworn before me this [____] day of [_______________], 20[____].

[________________________________]

Notary Public for the State of Alaska — My Commission Expires: [_______________]

14. ALASKA PRACTICE NOTES

• Program name and administration. Alaska's Medicaid program is branded "DenaliCare" and is administered by the Alaska Department of Health, Division of Public Assistance (DPA). Long-term care eligibility is centralized in the DPA Adult LTC unit; functional / level-of-care determinations are conducted under the Senior and Disabilities Services framework.
• Income cap state. Alaska is an income-cap state for institutional and HCBS Waiver Medicaid. The 2026 cap is $2,982/month (300% of SSI FBR). Applicants over the cap must use a Qualified Income Trust (Miller Trust) under 42 U.S.C. § 1396p(d)(4)(B). Confirm Alaska's current QIT administration before drafting.
• Asset limit. $2,000 for an individual; $3,000 combined where both spouses apply. Spousal-impoverishment rules raise the practical limit substantially for the community spouse (CSRA).
• Transfer-penalty divisor. Alaska's penalty divisor is the highest in the United States, reflecting Alaska's nursing-home cost structure. DPA training materials reference a divisor of approximately $25,000/month. ALWAYS confirm the current divisor with DPA before computing penalty periods or drafting planning documents.
• Look-back. 60 months for both nursing-facility and HCBS Waiver applications.
• Permanent Fund Dividend. The PFD is generally counted as unearned income in the month received and as a resource thereafter; the federal "garnishment" rule does not exempt the PFD from Medicaid resource counting. Plan accordingly.
• Native applicants. Certain Alaska Native trust-land allotments, ANCSA distributions, and Indian Health Service-related resources may receive special treatment. See 25 U.S.C. § 1407 and DPA manual guidance.
• Estate recovery. Alaska pursues estate recovery under AS 47.07.045 against the probate estate of recipients age 55 or older who received long-term care services. Pre-mortem deeds, lady-bird deeds, and irrevocable trusts may reduce probate exposure but require attorney review.
• Fair hearings. Adverse eligibility decisions may be appealed under 7 AAC 49; a fair hearing must be requested within 30 days of the notice of action.

15. SOURCES AND REFERENCES

• Alaska Department of Health — DenaliCare / Medicaid: https://health.alaska.gov/
• Division of Public Assistance — Adult LTC: http://dpaweb.hss.state.ak.us/
• DPA Adult Public Assistance Manual § 554 (Transfer of Assets): http://dpaweb.hss.state.ak.us/manuals/adltc/554/554_transfer_of_assets.htm
• 2025 Alaska Medicaid Recipient Handbook: https://health.alaska.gov/media/ux4ds44w/2025-medicaid-recipient-handbook.pdf
• AS 47.07 (Alaska Medical Assistance): https://www.akleg.gov/basis/statutes.asp#47.07
• 7 AAC 100 (Medicaid eligibility regulations)
• 42 U.S.C. § 1396p (federal Medicaid transfer / estate recovery / spousal rules)
• 42 U.S.C. § 1396r-5 (spousal impoverishment)
• 42 C.F.R. §§ 435.601–.965 (federal eligibility regulations)
• Office of the Long Term Care Ombudsman of Alaska: https://akoltco.org/
• Alaska Native Justice Center / Alaska Legal Services Corp. — Medicaid help: https://www.alsc-law.org/

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. Medicaid figures, divisors, and rules change without notice. An Alaska-licensed elder law attorney must review and customize this packet before submission. Verify all citations and dollar amounts against the current DPA manual and Alaska Statutes before relying.