Hawaii Medicaid (Med-QUEST) Long-Term Care Application Packet

HAWAII MEDICAID (MED-QUEST) LONG-TERM CARE APPLICATION PACKET

TABLE OF CONTENTS

1. Cover Memorandum to Med-QUEST
2. Applicant and Household Information
3. Program Selected and Level of Care
4. Income Schedule
5. Resource (Asset) Schedule
6. 60-Month Look-Back and Transfer Disclosure
7. Spousal Impoverishment Worksheet (Married Applicants)
8. Primary Residence and Home Equity
9. Spend-Down Plan
10. Authorization for Release of Records
11. Applicant Certification
12. Hawaii Practice Notes
13. Sources and References

1. COVER MEMORANDUM TO MED-QUEST

TO: Hawaii Department of Human Services — Med-QUEST Division
Eligibility Branch — [Oahu / Hawaii Island / Maui / Kauai / Molokai] Section

FROM: [________________________________] (Applicant or Authorized Representative)

RE: Application for Hawaii Medicaid Long-Term Care Benefits — Med-QUEST

APPLICANT: [________________________________]

DATE OF BIRTH: [__/__/____]

SOCIAL SECURITY NUMBER: [____-__-____]

MEDICARE/MEDICAID ID (if any): [________________________________]

DATE OF SUBMISSION: [__/__/____]

This packet contains the application materials for Med-QUEST long-term care coverage. The applicant is a Hawaii resident, U.S. citizen or qualified non-citizen, and meets the categorical and financial eligibility criteria of HAR Title 17, Chapter 1700.1, as supplemented herein.

2. APPLICANT AND HOUSEHOLD INFORMATION

2.1. Full legal name: [________________________________]

2.2. Mailing address (Hawaii): [________________________________]

2.3. Physical address / facility: [________________________________]

2.4. County of residence: ☐ Honolulu ☐ Hawaii ☐ Maui ☐ Kauai ☐ Kalawao

2.5. Marital status: ☐ Single ☐ Married ☐ Widowed ☐ Divorced ☐ Separated

2.6. Spouse name (if applicable): [________________________________]

2.7. Spouse residence: ☐ Same household ☐ Community (non-applicant) ☐ Same facility

2.8. Citizenship status: ☐ U.S. citizen ☐ Qualified non-citizen — provide alien registration: [________________________________]

2.9. Hawaii residency since: [__/__/____]

2.10. Authorized representative (if any):

• Name: [________________________________]
• Capacity: ☐ Agent under DPOA ☐ Court-appointed guardian/conservator ☐ Authorized representative form DHS-1147 ☐ Family member with applicant's written consent
• Address & phone: [________________________________]

3. PROGRAM SELECTED AND LEVEL OF CARE

3.1. The applicant seeks coverage under (check all that apply):

• ☐ Institutional / Nursing Facility Medicaid (skilled nursing facility or ICF)
• ☐ QUEST Integration HCBS Services (home- and community-based long-term services and supports)
• ☐ Aged, Blind, or Disabled (ABD) Medicaid (community Medicaid for individuals 65+ or with disability)

3.2. Level-of-care determination: Hawaii uses the long-term services and supports (LTSS) screening tool. Applicant has been (or will be) screened by:

• Provider/agency: [________________________________]
• Date of screening: [__/__/____]
• Determination: ☐ Nursing facility level of care ☐ At-risk for nursing facility ☐ Pending

3.3. Health plan preference (post-eligibility QI enrollment):

• ☐ AlohaCare ☐ HMSA ☐ Kaiser Permanente ☐ 'Ohana Health Plan ☐ UnitedHealthcare Community Plan

4. INCOME SCHEDULE

4.10. Personal Needs Allowance (PNA) for nursing-facility residents (2026): $75.00/month retained by resident.

4.11. Medicare premiums to be deducted from patient share: $[__________]/month.

4.12. Health-insurance premiums to be deducted from patient share: $[__________]/month.

5. RESOURCE (ASSET) SCHEDULE

5.15. The applicant ☐ does ☐ does not currently exceed the applicable resource limit by $[__________].

6. 60-MONTH LOOK-BACK AND TRANSFER DISCLOSURE

6.1. Look-back start date: [__/__/____] (60 months before application).

6.2. Did the applicant or applicant's spouse transfer assets for less than fair market value during the look-back? ☐ Yes ☐ No

6.3. If yes, list each transfer:

6.4. Statutory exemptions claimed (if any):

• ☐ Transfer to spouse or for sole benefit of spouse (42 U.S.C. § 1396p(c)(2)(B))
• ☐ Transfer to disabled child or trust for disabled child under age 65
• ☐ Transfer of homestead to caregiver child residing 2+ years
• ☐ Transfer of homestead to sibling with equity interest residing 1+ year
• ☐ Transfer to special-needs trust (d)(4)(A) or pooled trust (d)(4)(C)
• ☐ Transfer made exclusively for purposes other than to qualify for Medicaid (rebuttal)

6.5. Estimated penalty period (if no exemption applies): $[__________] uncompensated ÷ $[__________] (Hawaii penalty divisor in effect) = [____] months of ineligibility, beginning the later of the transfer date or the date the applicant is otherwise eligible and would receive LTC services but for the transfer.

7. SPOUSAL IMPOVERISHMENT WORKSHEET (MARRIED APPLICANTS)

7.1. Snapshot date (date of first continuous institutionalization or HCBS application): [__/__/____]

7.2. Total countable resources of both spouses on snapshot date: $[__________]

7.3. Community Spouse Resource Allowance (CSRA) — 2026:

• Maximum: $162,660 (federal cap)
• Spousal share = ½ of snapshot resources, subject to maximum: $[__________]

7.4. Monthly Maintenance Needs Allowance (MMNA) — 2026:

• Standard MMNA (Hawaii): $4,066.50/month maximum
• Community spouse's gross monthly income: $[__________]
• Shelter expenses (rent/mortgage + utilities + property tax/HOA): $[__________]
• Excess shelter allowance calculation: [__________]
• Final MMNA: $[__________]

7.5. Patient share (institutional spouse contribution to facility): Total income $[______] – PNA $75 – Medicare/health premiums $[______] – MMNA shifted to community spouse $[______] = Patient share $[______].

8. PRIMARY RESIDENCE AND HOME EQUITY

8.1. Address of primary residence: [________________________________]

8.2. Title holders: [________________________________]

8.3. Estimated FMV (2026 county assessor or appraisal): $[__________]

8.4. Outstanding mortgage / liens: $[__________]

8.5. Equity (FMV minus liens): $[__________]

8.6. Hawaii / federal home equity limit (2026): $1,130,000.

8.7. Is equity below the cap? ☐ Yes ☐ No.

8.8. Intent to return home (single applicant in nursing facility): ☐ Yes — homestead remains exempt while intent persists ☐ No

8.9. Spouse, minor child, or disabled child resides in home? ☐ Yes — categorical exemption ☐ No

8.10. Anticipated estate recovery exposure (HRS § 346-29.5): Hawaii recovers from the probate estate of a deceased Medicaid recipient who received LTC services and was age 55 or older. Surviving-spouse, minor-child, and disabled-child deferrals apply. Discuss with counsel before any post-eligibility homestead transfer.

9. SPEND-DOWN PLAN

9.1. Excess countable resources to be spent down: $[__________]

9.2. Planned expenditures (none of the following constitute uncompensated transfers):

• ☐ Pay down mortgage or liens on exempt homestead — $[______]
• ☐ Home repairs, accessibility modifications, appliances — $[______]
• ☐ Replace/repair primary vehicle (one excluded) — $[______]
• ☐ Pre-paid irrevocable funeral / burial contract — $[______]
• ☐ Pay legitimate debts owed by applicant — $[______]
• ☐ Purchase clothing, durable medical equipment — $[______]
• ☐ Pay attorney's fees and care-coordination fees — $[______]
• ☐ Purchase DRA-compliant single-premium immediate annuity (community spouse only) — $[______]
• ☐ Other (specify): [____________________] — $[______]

9.3. Anticipated date of full eligibility after spend-down: [__/__/____]

10. AUTHORIZATION FOR RELEASE OF RECORDS

I, [APPLICANT NAME], authorize the State of Hawaii Department of Human Services, Med-QUEST Division, to obtain, verify, and exchange any record reasonably necessary to determine my eligibility for Medicaid, including but not limited to: financial records held by banks, credit unions, brokerages, and insurers (including via the Asset Verification System); records held by the Social Security Administration, Internal Revenue Service, and Hawaii Department of Labor and Industrial Relations; medical records held by any treating provider or facility; and records held by the Department of Veterans Affairs. This authorization remains effective for the duration of the application process and any continuing eligibility review.

[________________________________]

[APPLICANT SIGNATURE]

Date: [__/__/____]

11. APPLICANT CERTIFICATION

I certify under penalty of perjury under the laws of the State of Hawaii that the information provided in this application packet is true, correct, and complete to the best of my knowledge. I understand that intentionally providing false information to obtain Medicaid benefits is a crime under HRS Chapter 346 and applicable federal law (42 U.S.C. § 1320a-7b), and that I am required to report any change in income, resources, residence, or household composition within ten (10) days.

[________________________________]

[APPLICANT NAME]

Date: [__/__/____]

If signed by authorized representative:

[________________________________]

[REPRESENTATIVE NAME], [CAPACITY]

Date: [__/__/____]

12. HAWAII PRACTICE NOTES

• Med-QUEST structure. Med-QUEST is the Medicaid program administered by the Hawaii DHS. QUEST Integration (QI) is the managed-care delivery system for most Medicaid beneficiaries (including the aged, blind, and disabled population formerly served by QUEST Expanded Access (QExA)). Eligibility is determined by Med-QUEST; managed care is provided by contracted health plans.
• 2026 figures (effective Feb. 1, 2026 – Jan. 31, 2027). Resource limits: single $2,000; married both applying $3,000. HCBS income limit: $1,530/month. Personal needs allowance: $75/month. CSRA: up to $162,660. MMNA: up to $4,066.50/month. Home-equity cap: $1,130,000. Confirm all figures with Med-QUEST before filing.
• Look-back. 60 months for all uncompensated transfers (HAR § 17-1722.3, 42 U.S.C. § 1396p(c)).
• Penalty divisor. Hawaii does not publish a single statewide divisor in the regulations; DHS applies the average private-pay nursing-facility rate in effect at the time of application. Hawaii has among the highest nursing-home costs in the nation, which produces relatively short penalty periods per dollar transferred.
• Estate recovery. HRS § 346-29.5 authorizes recovery from the probate estate of a deceased recipient (age 55+) who received LTC services. Hardship waivers are available.
• Filing channels. Online: https://medical.mybenefits.hawaii.gov. Phone: Med-QUEST Customer Service Center 1-800-316-8005 (toll-free). In person: Med-QUEST eligibility offices on each island.
• Appeals. A denial or adverse-action notice may be appealed to the DHS Administrative Appeals Office within 90 days (HRS § 346-12; HAR § 17-1703). Continued benefits pending appeal are available if requested within 10 days of the notice.
• Trust planning. Self-settled special-needs trusts (42 U.S.C. § 1396p(d)(4)(A)), pooled trusts ((d)(4)(C)), and Miller / qualified-income trusts ((d)(4)(B)) can be used in Hawaii where statutorily authorized; consult Hawaii counsel for current administrative practice.
• Annuities. Single-premium immediate annuities for the community spouse must comply with the Deficit Reduction Act of 2005: irrevocable, non-assignable, actuarially sound, equal payments, and naming the State of Hawaii as remainder beneficiary up to benefits paid.

13. SOURCES AND REFERENCES

• Hawaii Med-QUEST Division — https://medquest.hawaii.gov
• Hawaii DHS Med-QUEST Customer Service: 1-800-316-8005
• Online application portal — https://medical.mybenefits.hawaii.gov
• Hawaii Revised Statutes Chapter 346 — https://www.capitol.hawaii.gov/hrscurrent/Vol07_Ch0346-0398/HRS0346/
• HRS § 346-29.5 (estate recovery) — https://www.capitol.hawaii.gov/
• Hawaii Administrative Rules Title 17, Chapter 1700.1 — https://humanservices.hawaii.gov/
• 42 U.S.C. § 1396p (look-back, transfer of assets, 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
• Medicaid Planning Assistance — Hawaii 2026 figures — https://www.medicaidplanningassistance.org/medicaid-eligibility-hawaii/
• QUEST Integration program description — https://medquest.hawaii.gov/en/members-applicants.html
• Hawaii Long-Term Care Ombudsman (resident-rights resource) — https://www.hi-ltc-ombudsman.org

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. Medicaid eligibility figures change annually (Hawaii adjusts each February); confirm all current limits with Med-QUEST before submission. A Hawaii-licensed elder law attorney must review any application that involves transfers, trusts, annuities, or homestead planning before filing.