Connecticut Medicaid (HUSKY C) Long-Term Care Application Packet

CONNECTICUT MEDICAID (HUSKY C) — LONG-TERM CARE APPLICATION PACKET

TABLE OF CONTENTS

1. Cover Letter to DSS
2. Applicant Identification and Household
3. Program and Coverage Selected
4. Connecticut 209(b) Eligibility Notice
5. Income Disclosure and Spend-Down
6. Asset Disclosure
7. Treatment of the Primary Residence
8. 60-Month Look-Back / Transfer Disclosure
9. Spousal Impoverishment / CSPA Worksheet
10. Connecticut Partnership for Long-Term Care Disclosure
11. Authorizations, Releases, and Power of Attorney
12. Attestation and Signature
13. Document Checklist
14. Practice Notes
15. Sources and References

1. COVER LETTER TO DSS

Date: [__/__/____]

State of Connecticut, Department of Social Services
ConneCT Application Processing
[DSS Regional Office Address]

Re: Application for HUSKY C Long-Term Care Medicaid
Applicant: [APPLICANT FULL LEGAL NAME]
Date of Birth: [__/__/____]
Last 4 of SSN: [____]
Facility / Setting: [NURSING FACILITY / HCBS WAIVER / COMMUNITY]

Dear DSS Eligibility Worker:

Enclosed please find the W-1LTC Long-Term Care Application and supporting documentation for the above-referenced applicant. The applicant requests coverage effective [__/__/____] under HUSKY C (Medicaid for the Aged, Blind, and Disabled), with long-term care services. All asset, income, and transfer disclosures required by the Uniform Policy Manual are included.

Please direct correspondence to the undersigned authorized representative.

Respectfully,

[________________________________]

[REPRESENTATIVE NAME — ATTORNEY / POA / FAMILY MEMBER]

[ADDRESS] — [PHONE] — [EMAIL]

2. APPLICANT IDENTIFICATION AND HOUSEHOLD

Community Spouse (if applicable):

3. PROGRAM AND COVERAGE SELECTED

☐ HUSKY C — Institutional Long-Term Care (Skilled Nursing Facility)

☐ HUSKY C — Home and Community-Based Services (HCBS) Waiver

• ☐ CT Home Care Program for Elders (CHCPE)
• ☐ Personal Care Assistance (PCA) Waiver
• ☐ Acquired Brain Injury (ABI) Waiver
• ☐ Other: [__________]

☐ HUSKY C — Medically Needy (Spend-Down) Coverage Group

Date services needed / began: [__/__/____]

Facility (if applicable): [FACILITY NAME, ADDRESS, PROVIDER #]

4. CONNECTICUT 209(b) ELIGIBILITY NOTICE

The applicant acknowledges that Connecticut has elected the Section 209(b) option and applies eligibility criteria that may be more restrictive than federal SSI. The applicant has reviewed (or had reviewed by counsel) the Uniform Policy Manual provisions governing aged/blind/disabled Medicaid and certifies that the financial information provided herein conforms to those rules.

Applicant Initials: [____]

5. INCOME DISCLOSURE AND SPEND-DOWN

5.1 Monthly Gross Income (Applicant). List every source.

5.2 Verification of 2026 Income Limits. The applicant has verified the current ABD / institutional / HCBS income standards published by DSS for the application date and certifies the figures above are accurate.

5.3 Patient Liability / Applied Income (Institutional). For institutional applicants, monthly income is applied to the cost of care less:

• Personal Needs Allowance (PNA) — $[________] per month;
• Health insurance premiums (Medicare Parts B/D, Medigap) — $[________];
• Minimum Monthly Maintenance Needs Allowance (MMMNA) for community spouse — $[________] (verify current floor/ceiling);
• Court-ordered support — $[________].

5.4 Spend-Down Election (Medically Needy). ☐ Applicant elects medically-needy coverage and will demonstrate spend-down by submitting incurred medical expenses each six-month budget period. Anticipated spend-down amount: $[________].

6. ASSET DISCLOSURE

6.1 Countable Assets — Applicant.

6.2 Connecticut Asset Limit (HUSKY C — verify at filing):

• Single applicant: $1,600 (countable);
• Married couple, both applying: $3,200 ($1,600 each);
• Married couple, one applying: $1,600 applicant + Community Spouse Protected Amount (see Section 9).

6.3 Excluded / Non-Countable Assets.

• ☐ Primary residence (subject to home-equity cap and intent-to-return rules — see Section 7);
• ☐ One automobile of any value;
• ☐ Household goods and personal effects;
• ☐ Irrevocable burial trust / pre-paid funeral contract — $[________];
• ☐ Term life insurance (no cash value);
• ☐ Whole-life insurance with face value ≤ $1,500 (verify current threshold);
• ☐ Medicaid-compliant annuity — issuer [__________];
• ☐ Connecticut Partnership LTC asset disregard — disregarded amount $[________].

7. TREATMENT OF THE PRIMARY RESIDENCE

7.1 Homestead Address: [________________________________]

7.2 Equity Interest: $[________] (verify current home-equity ceiling — federal cap adjusted annually; CT applies the federal upper limit).

7.3 Intent-to-Return Statement (Institutional Applicant):

I, [APPLICANT NAME], declare that I intend to return to the residence located at [ADDRESS] if and when my medical condition permits. I therefore claim the home as an exempt resource for purposes of HUSKY C eligibility.

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

7.4 Family Member Resident Exemptions:

• ☐ Spouse resides in home;
• ☐ Child under 21, blind, or disabled resides in home;
• ☐ "Caretaker child" who resided with applicant for two (2) years immediately preceding institutionalization and provided care that delayed institutionalization;
• ☐ Sibling with equity interest who resided in the home one (1) year preceding institutionalization.

7.5 Estate Recovery Disclosure. Applicant acknowledges that under Conn. Gen. Stat. § 17b-95 and § 17b-261n, the State of Connecticut may seek recovery against the applicant's estate (including the homestead, subject to statutory exemptions) for Medicaid benefits paid on or after age 55.

8. 60-MONTH LOOK-BACK / TRANSFER DISCLOSURE

8.1 Look-Back Period. Per 42 U.S.C. § 1396p(c) and Conn. Gen. Stat. § 17b-261a, all uncompensated transfers within sixty (60) months prior to the application date (the "Baseline Date") are reviewed.

Baseline Date: [__/__/____] (date of application or institutionalization, whichever is later)

Look-Back Begins: [__/__/____] (60 months prior)

8.2 Transfer Schedule. List EVERY transfer of cash, real estate, or other property during the look-back period for less than fair market value.

8.3 Penalty Calculation.

Total Uncompensated Transfers: $[________]

CT Monthly Penalty Divisor (verify current figure with DSS at filing): $[________]

Penalty Period (months): [____]

Penalty Begin Date: the later of (i) the date the applicant is otherwise eligible (resource-eligible and institutionalized) or (ii) [__/__/____].

8.4 Permitted Transfers (Exemptions).

• ☐ Transfer to spouse;
• ☐ Transfer to blind or disabled child of any age;
• ☐ Transfer to disabled individual under age 65 in qualifying trust;
• ☐ Transfer of homestead to: spouse / minor or disabled child / sibling with equity interest residing 1 year / caretaker child residing 2 years;
• ☐ Transfer for purpose other than to qualify for Medicaid (rebuttable);
• ☐ Return of transferred asset (cures penalty).

8.5 Hardship Waiver. ☐ Applicant requests an undue-hardship waiver under 42 U.S.C. § 1396p(c)(2)(D); facts supporting hardship are attached.

9. SPOUSAL IMPOVERISHMENT / CSPA WORKSHEET

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

9.2 Total Combined Countable Assets on Snapshot Date: $[________]

9.3 Community Spouse Protected Amount (CSPA).

• 50% of combined assets: $[________]
• Federal floor (verify current year): $[________]
• Federal ceiling (verify current year): $[________]
• CSPA awarded: $[________] (the greater of 50% capped at federal ceiling, or the federal floor)

9.4 Minimum Monthly Maintenance Needs Allowance (MMMNA). Spousal income allowance from institutionalized spouse to community spouse:

• MMMNA floor (verify): $[________]
• MMMNA ceiling (verify): $[________]
• Excess shelter allowance: $[________]
• MMMNA awarded: $[________]

9.5 Fair Hearing Right. The community spouse may request a fair hearing under 42 U.S.C. § 1396r-5(e) and DSS Uniform Policy Manual to seek an increased CSPA or MMMNA based on exceptional circumstances or insufficient income.

10. CONNECTICUT PARTNERSHIP FOR LONG-TERM CARE DISCLOSURE

☐ Applicant DOES hold a Connecticut Partnership-approved long-term care insurance policy.

If yes:

The applicant claims a dollar-for-dollar Medicaid asset disregard under Conn. Gen. Stat. § 17b-252 et seq. equal to the cumulative benefits paid by the Partnership policy. Connecticut Partnership policies also confer reciprocal estate-recovery protection on the disregarded assets.

☐ Applicant does NOT hold a Partnership policy.

11. AUTHORIZATIONS, RELEASES, AND POWER OF ATTORNEY

11.1 Authorized Representative. I designate [NAME] ("Representative") to file this application, communicate with DSS, receive notices, and act on my behalf in all matters relating to HUSKY C eligibility. Representative's contact: [ADDRESS / PHONE / EMAIL].

11.2 Financial Information Release. I authorize all banks, brokerages, insurers, employers, the Social Security Administration, the IRS, the VA, and any third party holding records to release financial information to DSS as needed to determine eligibility.

11.3 Medical Information Release (HIPAA). I authorize all health-care providers to release medical records, treatment plans, and level-of-care assessments to DSS and any contracted assessor.

Applicant Signature: [________________________________]

Date: [__/__/____]

Witness: [________________________________]

12. ATTESTATION AND SIGNATURE

I declare under penalty of perjury under the laws of the State of Connecticut and the United States that the foregoing application and all attachments are 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 overpayments, and criminal prosecution under federal and Connecticut law (including Conn. Gen. Stat. § 53a-122 — larceny by defrauding a public community).

Applicant: [________________________________]

Print Name: [APPLICANT NAME]

Date: [__/__/____]

If signed by Authorized Representative / Conservator / Agent under POA:

Representative: [________________________________]

Print Name & Capacity: [__________]

Date: [__/__/____]

13. DOCUMENT CHECKLIST

Attach copies (do not send originals):

• ☐ Photo ID and Social Security card
• ☐ Birth certificate / proof of citizenship or qualified-non-citizen status
• ☐ Medicare card and any other health-insurance cards
• ☐ Marriage certificate / divorce decree / death certificate of spouse
• ☐ Five (5) years of statements for every account listed in Section 6
• ☐ Tax returns (5 years)
• ☐ Deeds, mortgages, and assessor cards for all real property
• ☐ Vehicle titles and registrations
• ☐ Life insurance policies (face page + cash-value statement)
• ☐ Annuity contracts and most recent statements
• ☐ Pre-paid burial / funeral contract
• ☐ Trust instruments (revocable and irrevocable)
• ☐ Power of Attorney / Conservatorship decree
• ☐ Income verification (Social Security award, pension, VA letters)
• ☐ Medical / level-of-care assessment supporting nursing-facility level of need
• ☐ Connecticut Partnership LTC policy and benefits-paid statement (if any)
• ☐ Documentation supporting any transfer exemption claimed in Section 8

14. PRACTICE NOTES

• 209(b) state. CT does not auto-enroll SSI recipients into Medicaid. ABD applicants must apply through DSS and meet the state's resource and income standards.
• Asset cap. $1,600 countable for a single ABD/LTC applicant — among the lowest in the country.
• Penalty divisor. CT publishes a monthly transfer-penalty divisor that is updated annually. ALWAYS verify the current divisor with DSS Bulletin or the UPM before computing penalty months. Reported divisors have varied year to year; the figure controlling the application is the divisor in effect on the Baseline Date.
• Look-back. 60 months for both nursing-facility and HCBS waiver applications.
• Spend-down. Applicants over the income limit may qualify under the medically-needy pathway by incurring medical expenses each six-month budget period.
• Homestead. Exempt while occupied or while applicant signs an intent-to-return statement, subject to the federal home-equity cap. Federal cap is adjusted annually; verify at filing.
• Estate recovery. Conn. Gen. Stat. § 17b-95 and § 17b-261n authorize recovery against the probate estate of any recipient who received Medicaid at age 55+. CT pursues recovery aggressively against the homestead unless a statutory exception applies.
• Partnership policies. Pre-certified CT Partnership LTC policies provide dollar-for-dollar Medicaid asset disregard AND estate-recovery protection on the disregarded amount — a meaningful planning advantage.
• Annuities. Spousal annuities must satisfy the DRA-2005 requirements (irrevocable, non-assignable, actuarially sound, equal monthly payments, State of CT named as remainder beneficiary in the appropriate position).
• Fair hearing. Adverse eligibility decisions may be appealed to the DSS Office of Legal Counsel, Regulations and Administrative Hearings within sixty (60) days of notice.
• Appeals to Superior Court. Final agency decisions may be appealed under the Uniform Administrative Procedure Act, Conn. Gen. Stat. § 4-183, within forty-five (45) days.

15. SOURCES AND REFERENCES

• Connecticut Department of Social Services (DSS) — https://portal.ct.gov/dss
• HUSKY Health Program — https://portal.ct.gov/husky
• DSS Uniform Policy Manual (UPM) — https://portal.ct.gov/dss/health-and-home-care/medicaid
• ConneCT Online Application — https://connect.ct.gov
• Connecticut General Statutes Chapter 319v (Medical Assistance) — https://www.cga.ct.gov/current/pub/chap_319v.htm
• Conn. Gen. Stat. § 17b-261 (Medicaid eligibility) — https://www.cga.ct.gov/current/pub/chap_319v.htm#sec_17b-261
• Conn. Gen. Stat. § 17b-261a (Asset transfers; penalty) — https://www.cga.ct.gov/current/pub/chap_319v.htm#sec_17b-261a
• Conn. Gen. Stat. § 17b-95 (Estate claims) — https://www.cga.ct.gov/current/pub/chap_319r.htm
• Conn. Gen. Stat. § 17b-252 et seq. (CT Partnership for LTC) — https://www.cga.ct.gov/current/pub/chap_319v.htm
• Connecticut Partnership for Long-Term Care — https://portal.ct.gov/OPM/PDPD-HHS-Long-Term-Care/LTC-Home/Partnership-LTC-Home-Page--USE-TO-UPDATE
• 42 U.S.C. § 1396a(f) (Section 209(b)) — https://www.govinfo.gov/
• 42 U.S.C. § 1396p (Liens, transfers, recovery) — https://www.govinfo.gov/
• CMS State Medicaid Manual — https://www.cms.gov/regulations-and-guidance/guidance/manuals
• Medicaid Planning Assistance — Connecticut — https://www.medicaidplanningassistance.org/medicaid-eligibility-connecticut/

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. An attorney licensed in Connecticut must review and customize this document before submission. Medicaid eligibility figures, penalty divisors, federal floors and ceilings, and home-equity caps change annually; verify all authorities and current numerical thresholds with DSS before filing.