Health First Colorado (Medicaid) Long-Term Care Application Packet

HEALTH FIRST COLORADO (MEDICAID) LONG-TERM CARE APPLICATION PACKET

TABLE OF CONTENTS

1. Cover Letter / Authorized Representative Designation
2. Applicant Identification
3. Program Selection — Long-Term Services and Supports
4. Financial Eligibility — Income
5. Financial Eligibility — Assets / Resources
6. Spousal Impoverishment / Community Spouse Protections
7. Primary Residence and Home Equity
8. Transfer / Look-Back Disclosure
9. Functional Eligibility — ULTC 100.2 Assessment
10. Spend-Down / Income Trust (Miller Trust)
11. Document Checklist
12. Verifications, Releases, and Signature
13. Colorado Practice Notes
14. Sources and References

1. COVER LETTER / AUTHORIZED REPRESENTATIVE DESIGNATION

Date: [__/__/____]

To: [NAME OF COUNTY] County Department of Human Services

Long-Term Care Eligibility Unit

[COUNTY ADDRESS]

Re: Application for Long-Term Care Medical Assistance — [APPLICANT FULL LEGAL NAME]

Date of Birth: [__/__/____] | SSN (last 4): XXX-XX-[____]

Please find enclosed the application of [APPLICANT NAME] for Health First Colorado Long-Term Care benefits, including Home and Community-Based Services (HCBS) and/or Nursing Facility Medicaid, together with all supporting documentation listed in Section 11.

The undersigned is the applicant's designated Authorized Representative pursuant to 10 C.C.R. 2505-10 § 8.100 and is empowered to act on behalf of the applicant in all matters relating to this application, including receipt of notices, attendance at interviews, and submission of additional documentation.

Signature of Authorized Representative: [________________________________]

2. APPLICANT IDENTIFICATION

Spouse (if any):

3. PROGRAM SELECTION — LONG-TERM SERVICES AND SUPPORTS

The applicant requests eligibility for the following Health First Colorado Long-Term Services and Supports ("LTSS") category (check all that apply):

• ☐ Nursing Facility (NF) Medicaid — institutional placement in a Medicaid-certified skilled nursing or intermediate care facility.
• ☐ HCBS Elderly, Blind, and Disabled (EBD) Waiver — community-based services for adults age 18+ who require nursing-facility-level care.
• ☐ HCBS Community Mental Health Supports (CMHS) Waiver.
• ☐ HCBS Brain Injury (BI) Waiver.
• ☐ HCBS Spinal Cord Injury (SCI) Waiver.
• ☐ HCBS Children with Life-Limiting Illness (CLLI) Waiver.
• ☐ HCBS Children's Home and Community-Based Services (CHCBS) Waiver.
• ☐ Program of All-Inclusive Care for the Elderly (PACE).
• ☐ Community First Choice (CFC) State Plan benefit (effective July 1, 2025 — personal care, homemaker, PERS, home-delivered meals, health maintenance activities).

4. FINANCIAL ELIGIBILITY — INCOME

4.1. Income Limit (2026). For LTC Medicaid (Nursing Facility and HCBS Waivers), the applicant's gross monthly income limit is generally $2,982 per month (300% of the SSI Federal Benefit Rate, effective January 1, 2026). The non-applicant spouse's income is not counted toward the applicant's limit. Verify current figure with HCPF before filing.

4.2. Sources of Applicant Income (monthly gross):

4.3. If applicant income exceeds $2,982/month, applicant must establish a Qualified Income Trust ("Income Trust" or "Miller Trust") under 42 U.S.C. § 1396p(d)(4)(B) and 10 C.C.R. 2505-10 § 8.100.7. See Section 10.

5. FINANCIAL ELIGIBILITY — ASSETS / RESOURCES

5.1. Asset Limit (2026). The countable resource limit for an unmarried LTC applicant is $2,000. For a married couple where both spouses are applying, the limit is $3,000.

5.2. Countable vs. Exempt Resources.

5.3. Asset Schedule. List EVERY resource owned by applicant (and spouse, if married) as of the application date.

TOTAL COUNTABLE RESOURCES: $[____________]

6. SPOUSAL IMPOVERISHMENT / COMMUNITY SPOUSE PROTECTIONS

Applicable only if applicant is married and the non-applicant ("community") spouse resides in the community.

6.1. Community Spouse Resource Allowance (CSRA). Effective for cases with a "snapshot date" between January 1, 2026 and December 31, 2026, the maximum CSRA is $157,920 and the minimum is $31,584. Verify current figure with HCPF.

6.2. Minimum Monthly Maintenance Needs Allowance (MMMNA). Effective July 1, 2025 – June 30, 2026, the MMMNA is $2,643.75 per month. The Colorado shelter standard is $793.13 per month; excess shelter costs above this amount may increase the community spouse's income allowance up to the federal maximum (verify current cap with HCPF). Verify current figures with HCPF.

6.3. Snapshot. The first continuous period of institutionalization of 30+ days fixes the "snapshot" date used to value countable resources for CSRA computation.

7. PRIMARY RESIDENCE AND HOME EQUITY

7.1. Home Equity Cap (2026). Where no spouse, minor child, or blind/disabled child of any age resides in the home, the applicant's equity interest in the principal residence cannot exceed $1,130,000 (federal cap, 2026). Verify current figure with HCPF.

7.2. Status of Applicant's Residence:

• ☐ Applicant's spouse resides in the home (residence exempt regardless of equity).
• ☐ Applicant's child under age 21, or any blind/disabled child, resides in the home (residence exempt).
• ☐ Applicant intends to return home (intent-to-return statement attached); equity cap applies.
• ☐ Applicant does not intend to return home; residence is countable subject to sale/spend-down.

7.3. Home Information.

7.4. Estate Recovery Notice. Applicant acknowledges that, pursuant to 42 U.S.C. § 1396p(b) and C.R.S. § 25.5-4-302, the State of Colorado may seek recovery from the applicant's estate for Medicaid benefits paid on the applicant's behalf after age 55, including LTC services. Hardship waivers are available under 10 C.C.R. 2505-10 § 8.063.

Applicant Initials: [____]

8. TRANSFER / LOOK-BACK DISCLOSURE

8.1. Look-Back Period. Colorado applies a 60-month (5-year) look-back from the application/filing date for all asset transfers under 42 U.S.C. § 1396p(c)(1) and 10 C.C.R. 2505-10 § 8.485.

8.2. Penalty Divisor. The Colorado statewide average private-pay nursing facility rate ("penalty divisor") is updated annually by HCPF. Verify the current monthly and daily divisors with HCPF before computing any penalty period. The penalty divisor for 2025 was approximately $9,500/month; recent prior years were lower (e.g., $9,186/month). Penalty months equal uncompensated transfer ÷ current divisor; the penalty period begins on the date the applicant would otherwise be eligible AND is receiving institutional or HCBS services AND has applied (whichever is later).

8.3. Disclosure of Transfers in the Past 60 Months. List EVERY asset transfer (gift, sale below market, addition/removal of joint owner, trust funding, etc.) by applicant or spouse:

8.4. Exempt Transfers (assert if applicable):

• ☐ Transfer to spouse, or to another for the sole benefit of the spouse.
• ☐ Transfer to a blind or permanently disabled child of the applicant.
• ☐ Transfer to a trust for the sole benefit of a disabled individual under age 65.
• ☐ Transfer of home to a "caregiver child" (resided with parent 2+ years and provided care delaying institutionalization).
• ☐ Transfer of home to a sibling with an equity interest who resided in the home for 1+ year.
• ☐ Transfer was made exclusively for a purpose other than to qualify for Medicaid (rebuttal evidence attached).

9. FUNCTIONAL ELIGIBILITY — ULTC 100.2 ASSESSMENT

9.1. A Case Management Agency ("CMA") must complete the Uniform Long-Term Care 100.2 Assessment ("ULTC 100.2") to determine that the applicant meets nursing-facility level of care.

9.2. CMA Information.

9.3. Diagnoses, ADLs, and IADLs. Attach physician statement or PASRR (preadmission screening / resident review) and ULTC 100.2 result.

10. SPEND-DOWN / INCOME TRUST (MILLER TRUST)

10.1. Spend-Down. Applicants whose countable resources exceed the $2,000 / $3,000 limit must reduce ("spend down") to that level through permissible expenditures (medical bills, home/auto repairs, prepaid funeral, payment of debt, etc.). Document each expenditure.

10.2. Income Trust ("Miller Trust") under 42 U.S.C. § 1396p(d)(4)(B). Applicants whose gross monthly income exceeds the income cap must irrevocably assign excess income to a qualifying Income Trust naming HCPF as residual beneficiary. The trust must be:

• Irrevocable;
• Funded with applicant's own income (Social Security, pension, etc.);
• Administered by a fiduciary trustee;
• Filed with HCPF and the county; and
• Designed so the State of Colorado receives all funds remaining at the applicant's death up to the total Medicaid benefits paid.

11. DOCUMENT CHECKLIST

Submit copies (HCPF and counties typically retain copies; bring originals only if requested):

• ☐ Photo identification (driver's license / state ID / passport).
• ☐ Social Security card.
• ☐ Medicare card.
• ☐ Birth certificate or other proof of citizenship/lawful status.
• ☐ Marriage certificate / divorce decree / death certificate of prior spouse (as applicable).
• ☐ Proof of residence (utility bill, lease, deed).
• ☐ Bank statements (checking, savings, CD, money market) — most recent 60 months.
• ☐ Brokerage / IRA / 401(k) / annuity statements — most recent 60 months.
• ☐ Life insurance policies (face/cash value statements).
• ☐ Pre-paid funeral / burial trust contract.
• ☐ Vehicle title(s) and registration.
• ☐ Deed(s) and most recent property tax statement for ALL real property.
• ☐ Mortgage / home equity loan statements.
• ☐ Federal and state tax returns (last 3 years).
• ☐ Pay stubs / SSA award letter / pension award letter / VA award letter.
• ☐ Trust documents (revocable, irrevocable, special needs, income trust).
• ☐ Power of Attorney / Guardianship Letters / Conservatorship Letters.
• ☐ Closing statements and HUD-1s for any real-estate transactions in last 60 months.
• ☐ Gift letters / promissory notes / loan documents from last 60 months.
• ☐ ULTC 100.2 functional assessment.
• ☐ PASRR Level I / Level II (for nursing facility admission).
• ☐ Physician's medical certification / face-to-face encounter documentation.

12. VERIFICATIONS, RELEASES, AND SIGNATURE

12.1. Right to Apply / Non-Discrimination. The applicant has the right to apply for Health First Colorado without regard to race, color, national origin, sex, age, religion, disability, or political belief. 42 C.F.R. § 435.906; Title VI; ADA.

12.2. Penalty for False Statements. I declare under penalty of perjury under the laws of the State of Colorado and the United States that the foregoing information is true, correct, and complete to the best of my knowledge. I understand that intentional misrepresentation may result in denial of benefits, recoupment, civil penalties, and criminal prosecution under C.R.S. § 18-8-503 and 42 U.S.C. § 1320a-7b.

12.3. Authorization to Release Information. I authorize HCPF, the county department, and their contractors to obtain financial, medical, and other records necessary to determine eligibility, including records from financial institutions under the Asset Verification System (AVS) pursuant to 42 U.S.C. § 1396w.

12.4. Estate Recovery Acknowledgment. I acknowledge the State's right to estate recovery as described in Section 7.4.

Applicant Signature: [________________________________]

Print Name: [________________________________]

Date: [__/__/____]

Authorized Representative Signature (if applicable): [________________________________]

Print Name and Capacity: [________________________________]

Date: [__/__/____]

13. COLORADO PRACTICE NOTES

• Health First Colorado vs. HCPF. "Health First Colorado" is the brand name for Colorado Medicaid; "HCPF" (Department of Health Care Policy and Financing) is the single state agency. Applications are processed by the applicant's county department of human/social services.
• Colorado PEAK. Applications and renewals can be filed online at https://co.peak.gov. Many supporting documents can be uploaded directly.
• EBD Waiver waitlist. As of 2026, the EBD Waiver has no enrollment cap and no waitlist for adults meeting NF level of care. Capacity limits and waitlists may still apply to certain other waivers; confirm with the CMA.
• Community First Choice (CFC). Effective July 1, 2025, personal care, homemaker services, PERS, home-delivered meals, and health maintenance activities moved out of HCBS waivers into a unified CFC State Plan benefit. Applicants no longer need a separate waiver enrollment for these particular services.
• Retirement accounts. Unlike some states, Colorado generally counts the applicant's IRA/401(k) as a resource even if in payout status. Plan accordingly.
• Annuities. Single-premium immediate annuities (SPIAs) used in Medicaid planning must comply with the Deficit Reduction Act of 2005 (42 U.S.C. § 1396p(c)(1)(F)–(G)): irrevocable, non-assignable, actuarially sound, equal payments, and naming the State of Colorado as primary remainder beneficiary up to total Medicaid paid (or secondary after a community spouse).
• Caregiver child exemption. A common Colorado planning tool: transfer of the home to an adult child who lived with the parent in the home for at least two years immediately before institutionalization and provided care that delayed nursing-facility placement. Document caregiving with contemporaneous records.
• Promissory notes. Permitted when actuarially sound, non-cancelable on death of lender, prohibits acceleration, and provides for equal payments.
• Fair hearings. Denials and adverse actions may be appealed to the Office of Administrative Courts within 60 days of the notice. C.R.S. § 24-4-105; 10 C.C.R. 2505-10 § 8.057. Aid pending hearing may be available if requested timely.
• Three-month retroactive coverage. Eligibility may be established up to three months before the application date if the applicant met all eligibility criteria during that period and incurred covered medical expenses.

14. SOURCES AND REFERENCES

• Colorado Department of Health Care Policy and Financing (HCPF) — https://hcpf.colorado.gov/
• Health First Colorado — https://www.healthfirstcolorado.com/
• Colorado PEAK (online application) — https://co.peak.gov/
• HCPF Long-Term Services and Supports — https://hcpf.colorado.gov/long-term-services-and-supports-programs
• HCPF LTSS Forms (ULTC 100.2, PASRR) — https://hcpf.colorado.gov/long-term-services-and-supports-case-management-tools
• 10 C.C.R. 2505-10 § 8.100 (eligibility) — https://www.sos.state.co.us/CCR/
• 10 C.C.R. 2505-10 § 8.485 (LTC eligibility, transfers, look-back)
• C.R.S. Title 25.5 (Health Care Policy and Financing) — https://leg.colorado.gov/colorado-revised-statutes
• 42 U.S.C. § 1396p (transfers, liens, recoveries) — https://www.govinfo.gov/
• 42 U.S.C. § 1396r-5 (spousal impoverishment)
• CMS State Medicaid Manual; CMS SSI/Spousal Impoverishment Standards (annual CIB) — https://www.medicaid.gov/
• Colorado State Long-Term Care Ombudsman Program — https://www.coombudsman.org/
• National Academy of Elder Law Attorneys (NAELA) Colorado Chapter — https://www.naela.org/

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. Medicaid asset/income limits, the CSRA, MMMNA, home-equity cap, and penalty divisor change annually and are subject to HCPF rulemaking. Verify all figures with HCPF and the applicant's county department of human services. An elder law attorney licensed in Colorado must review and customize this packet before submission.