Arkansas Medicaid Application Packet — Long-Term Services & Supports

ARKANSAS MEDICAID APPLICATION PACKET — LONG-TERM SERVICES & SUPPORTS

TABLE OF CONTENTS

1. Application Cover Sheet
2. Applicant Identification
3. Program Selection
4. Eligibility Snapshot — 2025/2026 Figures
5. Income Disclosure
6. Asset Disclosure
7. Primary Residence and Home Equity
8. Five-Year Look-Back / Transfer Disclosure
9. Spousal Impoverishment Protections
10. Spend-Down Plan
11. Authorized Representative / Power of Attorney
12. Medicaid Estate Recovery Acknowledgment
13. Applicant Certification and Signature
14. Document Checklist
15. Sources and References

1. APPLICATION COVER SHEET

2. APPLICANT IDENTIFICATION

2.1. Full legal name: [________________________________]

2.2. Other names used (maiden, prior married, alias): [________________________________]

2.3. Marital status: ☐ Single ☐ Married ☐ Widowed ☐ Divorced ☐ Legally Separated

2.4. Spouse name (if married): [________________________________]

2.5. Spouse SSN: [________________________________]

2.6. Spouse residence: ☐ Same household ☐ Community (separate residence) ☐ Same long-term-care facility ☐ Other [________________________________]

2.7. Citizenship / lawful presence: ☐ U.S. citizen ☐ Qualified non-citizen (attach documentation per 8 U.S.C. § 1641)

2.8. Arkansas residency since: [__/__/____]

3. PROGRAM SELECTION

Indicate every Medicaid LTSS program for which the applicant seeks coverage:

• ☐ Nursing Facility (NF / Institutional) Medicaid — for individuals admitted to a Medicaid-certified nursing facility.
• ☐ ARChoices in Homecare (1915(c) HCBS waiver) — home- and community-based services for individuals 21+ with NFLOC.
• ☐ Living Choices Assisted Living (1915(c) HCBS waiver) — assisted-living services for individuals 65+ (or 21+ with physical disability) with NFLOC.
• ☐ Program of All-Inclusive Care for the Elderly (PACE) — integrated care for individuals 55+ in a PACE service area.
• ☐ PASSE (Provider-led Arkansas Shared Savings Entity) — for individuals with certain behavioral-health or developmental-disability needs.
• ☐ QMB / SLMB / QI Medicare Savings Program (in addition to or in lieu of LTSS).

4. ELIGIBILITY SNAPSHOT — 2025/2026 FIGURES

The following figures are the most recent published values as of the date of last update; verify the current DHS/DCO Quick Reference chart before filing.

5. INCOME DISCLOSURE

List all gross monthly income from any source for applicant and spouse:

5.1. Are any income sources received irregularly or seasonally? ☐ Yes ☐ No If yes: [________________________________]

5.2. Does the applicant own an annuity? ☐ Yes ☐ No If yes, attach contract; the annuity must be irrevocable, non-assignable, actuarially sound, and name the State of Arkansas DHS as primary remainder beneficiary (up to Medicaid expenditures) per 42 U.S.C. § 1396p(c)(1)(F).

6. ASSET DISCLOSURE

List every asset (countable and exempt) held by applicant or spouse, individually or jointly, on the first moment of the month of application:

7. PRIMARY RESIDENCE AND HOME EQUITY

7.1. Address of homestead: [________________________________]

7.2. Owner(s) of record: [________________________________]

7.3. Tenancy: ☐ Sole owner ☐ Joint tenants with right of survivorship ☐ Tenants in common ☐ Life estate ☐ Trust

7.4. Fair market value: $[________]

7.5. Encumbrances (mortgage, equity line, lien): $[________]

7.6. Net equity: $[________]

7.7. Equity cap satisfied? Net equity ≤ $730,000 (2025): ☐ Yes ☐ No ☐ Cap waived because community spouse / child under 21 / blind or disabled child resides in home

7.8. Intent to return. If applicant is residing in a long-term-care facility, applicant declares: "I intend to return to the homestead identified above whenever medically able. I have not abandoned the homestead and continue to claim it as my principal place of residence." Applicant initials: [______]

8. FIVE-YEAR LOOK-BACK / TRANSFER DISCLOSURE

Disclose every transfer of an asset for less than fair market value made by applicant or spouse during the 60 months immediately preceding this application:

8.1. ☐ No transfers were made during the look-back period.

8.2. Penalty calculation (if transfers disclosed): Total uncompensated value $[________] ÷ $5,098 transfer-penalty divisor (verify current divisor) = [____] months of ineligibility, beginning the later of (a) date of transfer or (b) date applicant is otherwise eligible and receiving institutional-level services.

8.3. Exempt transfers asserted (42 U.S.C. § 1396p(c)(2)):

• ☐ Transfer to spouse;
• ☐ Transfer to blind or disabled child;
• ☐ Transfer to child under 21;
• ☐ Caregiver-child exception (child resided in home and provided care preventing institutionalization for at least two years immediately preceding application);
• ☐ Sibling-equity exception (sibling with equity interest who resided in home for at least one year);
• ☐ Transfer to special-needs trust (under-65 disabled beneficiary, 42 U.S.C. § 1396p(d)(4)(A));
• ☐ Transfer to pooled trust (42 U.S.C. § 1396p(d)(4)(C));
• ☐ Undue-hardship waiver requested.

9. SPOUSAL IMPOVERISHMENT PROTECTIONS

Complete this section only if the applicant is married and one spouse remains in the community.

9.1. Snapshot date (first day of first continuous period of institutionalization of 30 days or more): [__/__/____]

9.2. Total countable resources on snapshot date: $[________]

9.3. Computed CSRA: ½ of snapshot resources, not less than the federal minimum and not more than $157,920 (2025) = $[________]

9.4. Community spouse income on application: $[________] / month

9.5. MMMNA applicable: $2,643.75 (7/1/2025 – 6/30/2026)

9.6. Excess shelter allowance claimed: ☐ Yes ☐ No Documented shelter expenses exceeding 30% of MMMNA: $[________]

9.7. Income allocation from institutionalized spouse to community spouse: $[________] / month (post-eligibility income calculation per 42 U.S.C. § 1396r-5)

9.8. Fair-hearing election: ☐ Community spouse requests fair hearing to increase CSRA based on inadequate income generation.

10. SPEND-DOWN PLAN

If countable assets exceed the applicable limit, the applicant proposes to spend down through legally permissible expenditures (no gifts):

• ☐ Pay outstanding medical bills, attorney fees, funeral/burial expenses;
• ☐ Purchase exempt items (irrevocable burial contract, prepaid funeral plan, modest household replacements, accessibility modifications to homestead);
• ☐ Repair / maintain homestead;
• ☐ Pay off mortgage, taxes, or insurance on exempt homestead;
• ☐ Purchase a single non-luxury vehicle (if no exempt vehicle exists);
• ☐ Establish a Medicaid-compliant annuity (community spouse or sole-benefit annuity for disabled child);
• ☐ Establish a (d)(4)(A) or (d)(4)(C) special-needs trust (applicant under 65 only for (d)(4)(A));
• ☐ Other lawful spend-down: [________________________________]

10.1. Projected date assets will be at or below limit: [__/__/____]

10.2. Application timing. Applicant requests that DCO process this application after spend-down completion / requests interim review. ☐ Yes ☐ No.

11. AUTHORIZED REPRESENTATIVE / POWER OF ATTORNEY

11.1. Authorized representative name: [________________________________]

11.2. Relationship to applicant: [________________________________]

11.3. Authority basis: ☐ Durable Power of Attorney (attach) ☐ Court-appointed guardian (attach Letters) ☐ DHS Form ARO-001 designation ☐ Trustee of revocable trust ☐ Other: [________________________________]

11.4. Mailing address for all correspondence: [________________________________]

11.5. Telephone: [________________________________]

11.6. Email: [________________________________]

12. MEDICAID ESTATE RECOVERY ACKNOWLEDGMENT

Pursuant to 42 U.S.C. § 1396p(b) and Ark. Code Ann. § 20-77-307, Arkansas DHS is required to seek recovery from the estate of a deceased Medicaid recipient (age 55 or older at the time benefits were received, or any age if institutionalized) for the value of LTSS Medicaid benefits paid. Recovery is deferred while a surviving spouse is living, while a child under 21 is living, or while a blind or disabled child is living. Hardship waivers are available.

Applicant initials acknowledging notice of estate recovery: [______]

13. APPLICANT CERTIFICATION AND SIGNATURE

I certify under penalty of perjury under the laws of the State of Arkansas and the United States that all information provided in this application and its attachments is true, complete, and correct to the best of my knowledge. I understand that knowingly making a false statement to obtain Medicaid benefits is a felony under Ark. Code Ann. § 5-55-103 and federal law (42 U.S.C. § 1320a-7b). I authorize DHS to verify the information disclosed by contacting financial institutions, employers, the Social Security Administration, the IRS, the Asset Verification System (AVS), and any other source necessary to determine eligibility.

[________________________________]

[APPLICANT NAME] — Applicant

Date: [__/__/____]

[________________________________]

[REPRESENTATIVE NAME] — Authorized Representative (if applicable)

Date: [__/__/____]

14. DOCUMENT CHECKLIST

• ☐ Photo identification (driver license / state ID / passport)
• ☐ Social Security card
• ☐ Medicare card (front and back)
• ☐ Birth certificate or other proof of age
• ☐ Marriage certificate / divorce decree / death certificate of prior spouse
• ☐ Proof of Arkansas residency (utility bill, lease)
• ☐ Five years of bank statements (all accounts, all months)
• ☐ Most recent statements for every brokerage, IRA, 401(k), pension
• ☐ Life-insurance policies with current cash-surrender-value statements
• ☐ Deed and most recent property-tax statement for every parcel of real estate
• ☐ Vehicle titles
• ☐ Burial-contract / prepaid funeral documentation
• ☐ Long-term-care insurance policy (if any)
• ☐ Trust instruments (revocable and irrevocable)
• ☐ Annuity contracts
• ☐ Power of Attorney / guardianship Letters
• ☐ Income verification (Social Security award letter, pension statements, recent pay stubs)
• ☐ Documentation of every disclosed transfer (deeds, gift letters, canceled checks)
• ☐ ARIA Level-of-Care assessment (for ARChoices / Living Choices)
• ☐ DMS-703 Physician Determination of Need (NF Medicaid)
• ☐ Pre-Admission Screening and Resident Review (PASRR), if applicable

15. SOURCES AND REFERENCES

• 42 U.S.C. § 1396a et seq. — https://www.law.cornell.edu/uscode/text/42/1396a
• 42 U.S.C. § 1396p (transfers, liens, recoveries, home equity) — https://www.law.cornell.edu/uscode/text/42/1396p
• 42 U.S.C. § 1396r-5 (spousal impoverishment) — https://www.law.cornell.edu/uscode/text/42/1396r-5
• Arkansas DHS — Division of County Operations / Medical Services — https://humanservices.arkansas.gov/divisions-shared-services/county-operations/
• Arkansas DHS Quick Reference Medicaid Chart — https://humanservices.arkansas.gov/wp-content/uploads/Quick-Reference-Medicaid-Chart-1.24.pdf
• Access Arkansas (online application portal) — https://access.arkansas.gov/
• ARChoices in Homecare Waiver — https://humanservices.arkansas.gov/divisions-shared-services/aging-adult-behavioral-health-services/services-for-adults/archoices-in-homecare/
• Living Choices Assisted Living Waiver — https://humanservices.arkansas.gov/divisions-shared-services/aging-adult-behavioral-health-services/services-for-adults/living-choices-assisted-living/
• Arkansas Code Title 20, Chapter 77 (Medical Assistance) — https://advance.lexis.com/container?config=00JAA1NTk5MzkzZS04YWE1LTQ4MGEtOWEzZC1mZWNiNmFkNDRkM2MKAFBvZENhdGFsb2fxgkYZSWRwQGz3Bri7eMiV
• Elrod Firm — Arkansas penalty divisor update — https://elrodfirm.com/blog/medicaid-increases-penalty-divisor-5098/
• CMS Spousal Impoverishment Standards — https://www.medicaid.gov/medicaid/eligibility-policy/medicaid-eligibility-aged-blind-disabled-individuals/spousal-impoverishment/

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. Medicaid figures change frequently; verify all current limits with DHS/DCO and consult a licensed Arkansas elder-law attorney before submission.