Georgia Medicaid Application Packet (Long-Term Care / Nursing Home & Elderly and Disabled Waiver)

GEORGIA MEDICAID APPLICATION PACKET — LONG-TERM CARE (NURSING HOME / EDWP)

TABLE OF CONTENTS

1. Cover Letter to DFCS
2. Applicant and Household Information
3. Class of Assistance Election
4. Income Schedule
5. Resource (Asset) Schedule
6. Primary Residence and Real Property
7. Transfer / Look-Back Disclosure
8. Qualified Income Trust Certification
9. Community Spouse Allowance Worksheet
10. Authorized Representative Designation
11. Documents Checklist
12. Verification and Signature
13. Georgia Practice Notes
14. Sources and References

1. COVER LETTER TO DFCS

[LAW FIRM / SENDER NAME]

[STREET ADDRESS]

[CITY, STATE ZIP]

Date: [__/__/____]

Georgia Department of Human Services

Division of Family and Children Services — [COUNTY] County Office

[DFCS COUNTY OFFICE STREET ADDRESS]

[CITY, GA ZIP]

Re: Application for Long-Term Care Medicaid

Applicant: [APPLICANT FULL LEGAL NAME]

Date of Birth: [__/__/____]

SSN (last four): [____]

Class of Assistance Requested: ☐ Nursing Home (NH) ☐ CCSP / EDWP ☐ SOURCE

Dear DFCS Caseworker:

Enclosed please find the long-term care Medicaid application for the above-named applicant, together with all supporting documentation required by the DCH ABD Medicaid Manual. Please direct all correspondence to the undersigned authorized representative. The applicant requests retroactive coverage for the three (3) months preceding the date of this application pursuant to 42 C.F.R. § 435.915.

Respectfully,

[________________________________]

[AUTHORIZED REPRESENTATIVE / ATTORNEY NAME]

Telephone: [NUMBER] | Email: [EMAIL]

2. APPLICANT AND HOUSEHOLD INFORMATION

Spouse (if any):

3. CLASS OF ASSISTANCE ELECTION

The applicant elects the following Class of Assistance (check one):

☐ Nursing Home (NH) Medicaid — Institutional placement in a Medicaid-certified nursing facility. Income cap 300% of SSI FBR; QIT permitted.

☐ Community Care Services Program (CCSP) — 1915(c) HCBS Elderly and Disabled Waiver, case-managed. Income cap 300% of SSI FBR; QIT permitted; CSRA / MMMNA available.

☐ SOURCE (Service Options Using Resources in a Community Environment) — 1915(c) HCBS Elderly and Disabled Waiver tied to a primary care medical home. SSI / SSI-equivalent income limit; QIT NOT permitted; no community-spouse allowance.

☐ ICWP (Independent Care Waiver Program) — for adults 21–64 with severe physical disability or TBI.

Facility / Provider Information:

4. INCOME SCHEDULE

Income-cap analysis:

• 2025/2026 income cap (300% SSI FBR — verify current figure): $[________]/mo
• Applicant's gross monthly income: $[________]/mo
• ☐ Applicant is UNDER the cap (no QIT required)
• ☐ Applicant is OVER the cap (QIT required — see Section 8)

5. RESOURCE (ASSET) SCHEDULE

Resource limit (single applicant): $2,000. Resource limit (both spouses applying): $3,000. Community Spouse Resource Allowance (CSRA — 2025 federal ceiling, verify current): $[________].

6. PRIMARY RESIDENCE AND REAL PROPERTY

The applicant's primary residence:

Homestead exclusion analysis:

☐ Applicant intends to return home (signed Intent to Return statement attached); homestead is excluded under DCH ABD Manual § 2331.

☐ Community spouse, minor child, or disabled child resides in the home; homestead is excluded.

☐ None of the above; homestead may be a countable resource subject to equity cap and lien.

7. TRANSFER / LOOK-BACK DISCLOSURE

The applicant discloses ALL transfers of assets for less than fair market value made within sixty (60) months immediately preceding the date of this application or institutionalization, whichever is later (42 U.S.C. § 1396p(c)).

Penalty period calculation (informational; final determination by DFCS):

• Total uncompensated value transferred: $[________]
• Georgia regional penalty divisor (verify current DCH figure; approximately $7,500/mo): $[________]
• Estimated penalty months: [____] months
• Earliest start date of penalty period (otherwise eligible date): [__/__/____]

Exceptions claimed (check all that apply):

☐ Transfer to spouse — 42 U.S.C. § 1396p(c)(2)(B)(i)

☐ Transfer to or for the sole benefit of a blind / disabled child — § 1396p(c)(2)(B)(iii)

☐ Transfer to a sole-benefit trust for a disabled individual under 65 — § 1396p(c)(2)(B)(iv)

☐ Caregiver child exception (home transfer; child resided in home and provided care for 2+ years) — § 1396p(c)(2)(A)(iv)

☐ Sibling exception (sibling with equity interest residing in home for 1+ year) — § 1396p(c)(2)(A)(iii)

☐ Transfer made exclusively for a purpose other than to qualify for Medicaid (rebuttal under § 1396p(c)(2)(C))

8. QUALIFIED INCOME TRUST CERTIFICATION

(Complete only if applicant's gross income exceeds the income cap and applicant elects NH or CCSP.)

The undersigned certifies that a Qualified Income Trust ("QIT" or "Miller Trust") has been established meeting the requirements of 42 U.S.C. § 1396p(d)(4)(B):

The trust is irrevocable and provides that, upon the death of the beneficiary, the State of Georgia receives all amounts remaining up to the total medical assistance paid on the beneficiary's behalf.

Attachments: ☐ Executed trust instrument ☐ EIN confirmation ☐ Bank account opening confirmation ☐ First-month deposit verification

9. COMMUNITY SPOUSE ALLOWANCE WORKSHEET

(Complete only where applicant has a community spouse and is applying for NH or CCSP. SOURCE does not permit spousal impoverishment protections.)

Community Spouse Resource Allowance (CSRA):

• One-half of countable couple's resources at "snapshot" date: $[________]
• 2025/2026 federal CSRA floor (verify): $[________]
• 2025/2026 federal CSRA ceiling (verify): $[________]
• CSRA awarded: $[________]

Minimum Monthly Maintenance Needs Allowance (MMMNA):

• Community spouse gross monthly income: $[________]
• 2025/2026 MMMNA floor (verify): $[________]
• Excess shelter allowance: $[________]
• MMMNA awarded: $[________]
• Spousal income diversion from institutionalized spouse: $[________]

☐ Community spouse requests fair hearing for higher CSRA / MMMNA based on need.

10. AUTHORIZED REPRESENTATIVE DESIGNATION

I, [APPLICANT NAME], hereby designate [REPRESENTATIVE NAME] as my authorized representative pursuant to 42 C.F.R. § 435.923 and DCH ABD Manual § 2052 to act on my behalf in all matters relating to this application, including the receipt of notices, requests for additional information, fair-hearing requests, and renewals.

[________________________________]

[APPLICANT NAME] (or legal surrogate / agent under POA)

Date: [__/__/____]

Representative contact: [NAME, ADDRESS, PHONE, EMAIL]

Relationship: ☐ Attorney ☐ Family ☐ Power of Attorney ☐ Guardian / Conservator ☐ Other: [__________]

11. DOCUMENTS CHECKLIST

The following documents accompany this application:

☐ Completed Form 700 / 297 (DFCS Medicaid application) or online Gateway submission confirmation

☐ Form DMA-285 (Third-Party Liability Health Insurance Questionnaire), if applicable

☐ Photo identification (driver's license / state ID)

☐ Social Security card

☐ Medicare card / MBI

☐ Birth certificate or other proof of U.S. citizenship

☐ Marriage certificate / divorce decree / death certificate of prior spouse

☐ Proof of residence (utility bill, lease, deed)

☐ Income verification (SSA award, pension statement, pay stubs, VA award)

☐ Bank statements — all accounts, most recent 60 months (look-back period)

☐ Brokerage / IRA / retirement statements — most recent 60 months

☐ Life insurance policies and current carrier statements

☐ Real property deeds, current tax assessments, mortgage statements

☐ Vehicle titles

☐ Burial / funeral contracts

☐ Trust instruments (revocable, irrevocable, and Miller Trust if applicable)

☐ Long-term care insurance policy and benefit statement, if any

☐ Health insurance cards (Medigap, Medicare Advantage, employer-sponsored)

☐ Power of attorney / guardianship / conservatorship orders

☐ Level of care determination (DMA-6 / DON-R) for waiver applicants

☐ Intent to Return Home statement (if homestead retained)

☐ Authorized Representative designation (Section 10 above)

12. VERIFICATION AND SIGNATURE

I declare under penalty of perjury under the laws of the State of Georgia that the foregoing is true and correct to the best of my knowledge and belief. I understand that a false or fraudulent statement may result in denial of benefits, recoupment, civil penalties, and criminal prosecution under O.C.G.A. § 49-4-15 and 18 U.S.C. § 1001.

[________________________________]

[APPLICANT NAME] — or legal surrogate

Date: [__/__/____]

Sworn to and subscribed before me this [____] day of [_______________], 20[____].

[________________________________]

Notary Public — State of Georgia

(My Commission Expires: [_______________])

13. GEORGIA PRACTICE NOTES

• Income-cap state. Georgia is one of approximately a dozen "income-cap" states. Where gross monthly income exceeds 300% of the SSI Federal Benefit Rate, the applicant cannot become eligible by spending down income; a Qualified Income Trust under 42 U.S.C. § 1396p(d)(4)(B) is mandatory for NH and CCSP. Verify the current cap each calendar year — for 2025 the cap was $2,901/mo and trends with the FBR for 2026.
• CCSP vs. SOURCE. Both operate under the EDWP 1915(c) waiver, but eligibility methodologies differ. CCSP uses NH-equivalent rules (300% cap, QIT permitted, spousal impoverishment protections). SOURCE uses the lower SSI-equivalent income standard and does NOT permit a QIT or community spouse allowance. Choice of program materially affects eligibility planning.
• Look-back period. Sixty (60) months for all uncompensated transfers, measured from the later of the application date or institutionalization. Annuity, promissory note, life-estate deed, and trust transactions during the look-back must be disclosed and may trigger penalty under § 1396p(c).
• Penalty divisor. Georgia uses a regional / statewide penalty divisor based on average private-pay nursing facility cost. As of 2026 the divisor is approximately $7,500/month (verify with current DCH ABD Manual). The penalty period does not begin until the applicant is otherwise eligible and institutionalized.
• Homestead. The home is excluded if (a) the applicant signs an Intent to Return Home statement, (b) a community spouse, minor child, blind/disabled child, or qualified caregiver child or sibling resides there, or (c) the applicant is on a CCSP / SOURCE waiver and lives in the home. Equity above the federal home-equity cap (verify current 42 U.S.C. § 1396p(f) figure) is countable absent a community spouse / minor child / disabled child.
• Estate recovery. O.C.G.A. § 49-4-147.1 authorizes Georgia to recover from the probate estate of a deceased Medicaid recipient who received LTC services after age 55, subject to federal hardship exceptions and survivor protections. Georgia recovers from probate-only assets; non-probate transfers (joint accounts, life-estate remainders, pay-on-death designations, trust property) generally fall outside recovery — confirm against current policy.
• Retroactive coverage. 42 C.F.R. § 435.915 permits up to three (3) months of retroactive coverage prior to the application month if the applicant met all eligibility criteria during those months. Always request retroactive coverage in the cover letter.
• Application channels. Apply through Georgia Gateway (gateway.ga.gov) online; in person at the county DFCS office; by mail or fax; or by phone at 1-877-423-4746. Nursing facility business offices commonly assist; counsel should still review.
• Fair hearing rights. A denial, reduction, or termination triggers the right to a fair hearing under 42 C.F.R. § 431.220 and DCH policy. Hearing must be requested within thirty (30) days of the notice; aid-paid-pending available if requested within ten (10) days.

14. SOURCES AND REFERENCES

• Georgia Department of Community Health — Medicaid: https://medicaid.georgia.gov
• DCH ABD Medicaid Manual: https://medicaid.georgia.gov/manuals
• Georgia DHS Division of Family and Children Services — Medicaid: https://dfcs.georgia.gov/services/medicaid
• DFCS PAMMS Medicaid Manual (2050–2700): https://pamms.dhs.ga.gov/dfcs/medicaid/
• Georgia DHS Division of Aging Services — EDWP / CCSP: https://aging.georgia.gov
• Georgia Gateway (online application portal): https://gateway.ga.gov
• 42 U.S.C. § 1396p (transfers, look-back, QIT, estate recovery): 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
• O.C.G.A. § 49-4-140 et seq. (Georgia Medical Assistance Act): https://law.justia.com/codes/georgia/title-49/chapter-4/
• O.C.G.A. § 49-4-147.1 (Estate recovery)
• 42 C.F.R. Part 435 (Eligibility): https://www.ecfr.gov/current/title-42/part-435
• Georgia Long Term Care Ombudsman Program: https://www.georgiaombudsman.org

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. Medicaid figures (income cap, penalty divisor, CSRA, MMMNA, home equity cap) update annually and counsel must verify current DCH ABD Manual and DFCS PAMMS values before use. An attorney licensed in Georgia must review and customize this packet before submission.