California Medi-Cal Long-Term Care Application Packet

Retroactive coverage — application-date check. Under 42 U.S.C. § 1396a(a)(34), the federal baseline for applications made before January 1, 2027 reaches covered care furnished in or after the third month before the application month, if the individual was or would have been eligible when the care was furnished. Pub. L. 119-21, § 71112(a), (d) changes that baseline for applications made on or after January 1, 2027: one preceding month for the § 1396a(a)(10)(A)(i)(VIII) expansion group and two preceding months for other eligible individuals. Identify the actual eligibility group, application month, covered services, and any applicable approved waiver before completing any retroactive request below. These are calendar-month rules, not a rolling 90-day period; this workbook does not establish eligibility for a particular month.

CALIFORNIA MEDI-CAL LONG-TERM CARE APPLICATION PACKET

CRITICAL 2026 CALIFORNIA-SPECIFIC NOTICE

Asset limit reinstated effective January 1, 2026. From January 1, 2024 through December 31, 2025, California eliminated the asset test for non-MAGI Medi-Cal. Citing budget constraints, AB 102 (2025 budget trailer) reinstated the asset limit on January 1, 2026 at the pre-2022 level: $130,000 for an individual, plus $65,000 for each additional household member (up to 10).

Long-term care look-back is being phased in. California's look-back period is 30 months (NOT the federal 60-month standard) under § 1924 grandfather authority. DHCS All-County Welfare Directors Letter (ACWDL) 25-18 confirms transfers made between January 1, 2024 and December 31, 2025 are excluded from the look-back under any circumstance. The look-back grows by one month per month beginning February 2026 and reaches the full 30-month scope in July 2028.

2026 transfer penalty divisor (Average Private Pay Rate / APPR): $14,440 per month (DHCS LTC Bulletin, 2026). Only uncompensated transfers exceeding the APPR for the month of transfer trigger a period of ineligibility for nursing facility (NF) services.

PART I — APPLICANT INFORMATION

Authorized Representative (if any)

PART II — PROGRAM SELECTION

☐ Medi-Cal Long-Term Care (Nursing Facility) — applicant resides or will reside in a Skilled Nursing Facility (SNF) or Intermediate Care Facility (ICF).
☐ Aged & Disabled Federal Poverty Level (A&D FPL) — community-based; income ≤ 138% FPL ($1,801/individual; $2,433/couple in 2026).
☐ Aged, Blind, Disabled — Medically Needy (Share of Cost) — community-based with countable income above A&D FPL; subject to Maintenance Need Allowance ($600 individual / $934 couple in 2026).
☐ 250% Working Disabled Program (WDP).
☐ Home and Community-Based Services (HCBS) Waiver / Assisted Living Waiver — spousal impoverishment rules apply.
☐ Medicare Savings Program (QMB / SLMB / QI).

PART III — ELIGIBILITY DETERMINATION

A. Categorical Eligibility

B. Income (2026 figures)

C. Assets (post-1/1/2026 reinstatement — applies to ALL non-MAGI applicants)

Asset limit for 2026: $130,000 individual; +$65,000 per additional household member (up to 10).

D. Spousal Impoverishment (Married LTC Applicants)

PART IV — TRANSFER OF ASSETS / LOOK-BACK ANALYSIS

A. Look-Back Window (Phase-In Schedule)

Per ACWDL 25-18, the LTC look-back grows one month per month beginning February 2026:

Transfers between 1/1/2024 and 12/31/2025 are EXCLUDED from the look-back regardless of application date.

B. Disclosure of Transfers in Look-Back Window

C. Penalty Calculation

Penalty period (months) = (Uncompensated transfer amount) ÷ (APPR for month of transfer)

• 2026 APPR: $14,440/month
• Penalty begins: First day of month of transfer (California's pre-DRA rule, retained under § 1924 grandfather).
• Only transfers greater than the APPR threshold trigger a penalty.

D. Permitted (Non-Penalized) Transfers

☐ Transfer to spouse or for sole benefit of spouse
☐ Transfer to disabled child of any age (or trust for such child)
☐ Transfer to child under 21
☐ Transfer of home to caregiver child residing 2+ years prior to institutionalization
☐ Transfer of home to sibling with equity interest residing 1+ year prior
☐ Transfer to disability trust under 42 U.S.C. § 1396p(c)(2)(B)(iv)
☐ Return of asset (transfer cured)
☐ Transfer for fair market value
☐ Transfer made between 1/1/2024 and 12/31/2025 (per ACWDL 25-18)

PART V — PRIMARY RESIDENCE TREATMENT

The applicant's principal place of residence is exempt while:

☐ Occupied by the applicant, OR
☐ Occupied by spouse, minor child, blind / disabled child, or dependent relative, OR
☐ Subject to a signed Statement of Intent to Return Home (no equity cap under California rules — California has not adopted the federal home equity limit).

Statement of Intent to Return Home

I, [________________________________], declare under penalty of perjury under the laws of the State of California that I intend to return to my principal residence located at [________________________________] if and when my medical condition permits.

Applicant signature: [________________________________] Date: [__/__/____]

PART VI — CALIFORNIA PARTNERSHIP FOR LONG-TERM CARE (CPLTC)

If the applicant holds (or held) a Partnership-certified LTC insurance policy:

PART VII — REQUIRED ATTACHMENTS CHECKLIST

☐ Completed MC 210 (Statement of Facts for Medi-Cal) — primary application
☐ MC 210 PS (Property Supplement) — required for non-MAGI
☐ MC 210 S-C (Supplement to Statement of Facts; Sneede class members)
☐ MC 219 (Important Information for Persons Requesting Medi-Cal)
☐ MC 239 LTC notice (LTC applicants)
☐ Birth certificate / proof of age
☐ Social Security card
☐ Proof of California residence (utility bill, lease, ID)
☐ Proof of citizenship / immigration status
☐ Medicare card (front and back)
☐ Verification of all income (last 3 months pay stubs / award letters / 1099s)
☐ Bank statements (last 3 months — all accounts)
☐ Brokerage / retirement account statements
☐ Life insurance policies (face + cash value declarations)
☐ Deed(s) and most recent property tax bill
☐ Vehicle registration(s)
☐ Burial plot / prepaid burial contracts
☐ Health insurance cards / policies
☐ Marriage certificate / divorce decree / death certificate of spouse
☐ POA / conservatorship documents
☐ For LTC: facility admission agreement and physician's certification of need
☐ CPLTC policy and benefit ledger (if applicable)
☐ Documentation of all transfers in applicable look-back window
☐ Statement of Intent to Return Home (if home is unoccupied)

PART VIII — FILING INSTRUCTIONS

Processing standard: 45 days for non-disability cases; 90 days for disability determinations (W&I § 14154; 22 C.C.R. § 50177). Retroactive coverage available for the applicable prior months prior to application month.

PART IX — APPLICANT DECLARATION

I declare under penalty of perjury under the laws of the State of California that the information provided in this application and supporting documents is true, correct, and complete to the best of my knowledge. I understand that knowingly providing false information may result in denial of benefits, recovery of paid benefits, and criminal prosecution under W&I Code § 14107.

SOURCES AND REFERENCES

• DHCS — Medi-Cal Asset Limits FAQ: https://www.dhcs.ca.gov/Medi-Cal/Pages/Help/asset-limits-faqs.aspx
• DHCS — Asset Limit Reinstatement Fact Sheet: https://www.dhcs.ca.gov/Budget/Documents/DHCS-TBL-Asset-Limit-Fact-Sheet.pdf
• DHCS — California Partnership for Long-Term Care: https://www.dhcs.ca.gov/services/ltc/Pages/CPLTC.aspx
• DHCS — Long-Term Care Program: https://www.dhcs.ca.gov/services/ltc/Pages/default.aspx
• CANHR — 2026 Asset Limit Reinstatement FAQ: https://canhr.org/2026-asset-limit-reinstatement-frequently-asked-questions/
• CANHR — Overview of Medi-Cal for Long Term Care: https://canhr.org/overview-of-medi-cal-for-long-term-care/
• Justice in Aging — Reinstatement of the Medi-Cal Asset Limit: https://justiceinaging.org/reinstatement-of-medi-cal-asset-limit-faq/
• California Health Advocates — Medi-Cal Asset Limits Reinstated: https://cahealthadvocates.org/medi-cal-asset-limits-for-older-adults-reinstated-as-of-january-1-2026-see-resources-to-help/
• California Welfare and Institutions Code (Medi-Cal Act): https://leginfo.legislature.ca.gov/faces/codes_displayexpandedbranch.xhtml?tocCode=WIC
• Covered California: https://www.coveredca.com
• BenefitsCal: https://benefitscal.com

This template was prepared for informational use by California elder law practitioners. It is not a substitute for individualized legal advice. Verify all dollar thresholds and statutory citations against current DHCS guidance before filing — the 2024-2025 asset elimination, 2026 reinstatement, and 30-month look-back phase-in have created a fluid eligibility environment.