Iowa Medicaid Long-Term Care Application Packet

IOWA MEDICAID LONG-TERM CARE APPLICATION PACKET

TABLE OF CONTENTS

1. Cover Letter to Iowa Medicaid Enterprise
2. Applicant and Spouse Information
3. Program Selection
4. Income Schedule
5. Resource (Asset) Schedule
6. Homestead and Real Property Disclosure
7. Five-Year Look-Back Disclosure
8. Spousal Impoverishment Calculation
9. Medical Assistance Income Trust (Miller Trust)
10. Authorized Representative and HIPAA Release
11. Required Documentation Checklist
12. Applicant Verification and Signature
13. Iowa Practice Notes
14. Sources and References

1. COVER LETTER TO IOWA MEDICAID ENTERPRISE

To: Iowa Department of Health and Human Services

Iowa Medicaid Enterprise — Member Services

P.O. Box 36510, Des Moines, IA 50315

Phone: 1-855-889-7985

From: [________________________________] (Applicant or Authorized Representative)

Date: [__/__/____]

Re: Application for Medical Assistance — Long-Term Care

Applicant: [APPLICANT FULL LEGAL NAME]

Date of Birth: [__/__/____]

Social Security No.: [____]-[____]-[________]

State ID / IA HHS Case No. (if known): [________________________________]

Dear Iowa Medicaid Enterprise:

Please find enclosed an application for Iowa Medicaid long-term care benefits on behalf of the above-named Applicant under Iowa Code Chapter 249A and Iowa Admin. Code r. 441—75 and 441—83. The Applicant requests determination of eligibility for the program(s) selected in Section 3 below, retroactive to [__/__/____] under Iowa Admin. Code r. 441—76.5 (three-month retroactive coverage). All financial schedules, the five-year look-back disclosure, and supporting documentation are attached.

Please direct all correspondence to the undersigned Authorized Representative.

Respectfully,

[________________________________]

[REPRESENTATIVE NAME / TITLE]

2. APPLICANT AND SPOUSE INFORMATION

3. PROGRAM SELECTION

The Applicant requests determination of eligibility under the following Iowa Medicaid long-term care category (check all that apply):

• ☐ Nursing Facility (Institutional) Medicaid — Iowa Admin. Code r. 441—75 and 441—81
• ☐ HCBS Elderly Waiver (EW) — age 65+, nursing-facility level of care, Iowa Admin. Code r. 441—83.22
• ☐ HCBS Health and Disability Waiver — under age 65, Iowa Admin. Code r. 441—83.1
• ☐ HCBS Brain Injury Waiver — Iowa Admin. Code r. 441—83.81
• ☐ HCBS AIDS/HIV Waiver — Iowa Admin. Code r. 441—83.41
• ☐ PACE (Program of All-Inclusive Care for the Elderly) — where available
• ☐ Medically Needy / Spend-Down Coverage — Iowa Admin. Code r. 441—75.1(35) (non-LTC categorical, $483/mo MNIL)

4. INCOME SCHEDULE

List ALL gross monthly income received by the Applicant and Community Spouse from any source.

Income-cap analysis (LTC Special Income Limit, 300% SSI/FBR):

For 2025/2026 the Iowa LTC income cap is approximately $2,901–$2,982/month for a single applicant (verify current figure with IA HHS). If Applicant gross income exceeds the cap, a Medical Assistance Income Trust (MAIT) under Iowa Code § 249A.53 is required — see Section 9.

• ☐ Applicant income is below cap — no MAIT required.
• ☐ Applicant income exceeds cap — MAIT executed and funded; copy attached.

5. RESOURCE (ASSET) SCHEDULE

Iowa countable-resource limit (2025/2026, verify current): $2,000 for a single applicant; Community Spouse Resource Allowance (CSRA) up to approximately $162,660 in 2026 (50% of combined resources, subject to federal floor and ceiling — verify).

(A = Applicant, S = Spouse, J = Joint)

6. HOMESTEAD AND REAL PROPERTY DISCLOSURE

7. FIVE-YEAR LOOK-BACK DISCLOSURE

Iowa enforces a 60-month look-back from the date of application. Disclose ALL gifts, transfers for less than fair market value, and uncompensated transfers by the Applicant or Spouse during the look-back period.

Total uncompensated transfers: $[________]

Iowa transfer penalty divisor (verify with IA HHS for year of application): approximately $7,200/month for 2026 — equal to Iowa's average monthly private-pay nursing-facility cost.

Estimated penalty period (uncompensated transfer total ÷ divisor) = [____] months of ineligibility, beginning the date the Applicant is otherwise eligible and receiving institutional care.

Exceptions claimed (check all that apply, attach proof):

• ☐ Transfer to spouse — 42 U.S.C. § 1396p(c)(2)(B)(i)
• ☐ Transfer to a blind or disabled child — § 1396p(c)(2)(B)(iii)
• ☐ Transfer to a sole-benefit trust for a disabled person under 65 — § 1396p(c)(2)(B)(iv)
• ☐ Caregiver-child exception (homestead transferred to adult child who provided 2+ years of care) — § 1396p(c)(2)(A)(iv)
• ☐ Sibling-equity exception (homestead) — § 1396p(c)(2)(A)(iii)
• ☐ Transfer made exclusively for purpose other than to qualify for Medicaid (rebuttal of presumption)
• ☐ Hardship waiver requested under Iowa Admin. Code r. 441—75.23(8)

8. SPOUSAL IMPOVERISHMENT CALCULATION

(Complete only if Applicant is married and Spouse is non-institutionalized "community spouse.")

9. MEDICAL ASSISTANCE INCOME TRUST (MILLER TRUST)

Required only if Applicant's gross monthly income exceeds the LTC Special Income Limit (~$2,901–$2,982/month for 2025/2026, verify).

The trust complies with 42 U.S.C. § 1396p(d)(4)(B) and Iowa Code § 249A.53. Authorized monthly distributions, in priority order:

1. Up to $10.00 for trust administration
2. Personal Needs Allowance ($50/month for nursing-facility residents)
3. MMMNA paid to community spouse (if any)
4. Health insurance premiums and unmet medical needs
5. Patient-paid amount (Medicaid client participation) to facility / waiver provider, up to Medicaid rate

10. AUTHORIZED REPRESENTATIVE AND HIPAA RELEASE

The Applicant authorizes the Iowa Department of Health and Human Services to release protected health information and financial-eligibility information to the Authorized Representative consistent with 45 C.F.R. § 164.508 and Iowa Code Chapter 22 confidentiality protections.

[________________________________]

[APPLICANT / GUARDIAN SIGNATURE] Date: [__/__/____]

11. REQUIRED DOCUMENTATION CHECKLIST

• ☐ Iowa HHS Form 470-2549 (Health Services Application) or 470-0462
• ☐ Photo identification (driver's license or state ID)
• ☐ Social Security card(s)
• ☐ Proof of U.S. citizenship or qualified-alien status
• ☐ Iowa residency proof (utility bill, lease, mortgage statement)
• ☐ Medicare card and Medicare Summary Notices (last 12 months)
• ☐ Health-insurance cards (all policies)
• ☐ 60 months of statements for ALL bank, brokerage, IRA, and credit-union accounts
• ☐ Most recent statements for life-insurance policies (face value and cash value)
• ☐ Vehicle titles and registrations
• ☐ Deed(s) for all real property
• ☐ Most recent property tax assessment (homestead and other parcels)
• ☐ Mortgage statement(s)
• ☐ Burial / funeral contract(s)
• ☐ Trust instruments (revocable, irrevocable, MAIT)
• ☐ Promissory notes, annuity contracts, structured settlements
• ☐ 60 months of gift-tax returns (Form 709) and large-check explanations
• ☐ Income verification (Social Security award letter, pension statement, W-2/1099, last federal return)
• ☐ Marriage certificate / death certificate / divorce decree
• ☐ Power of Attorney instrument and any guardianship/conservatorship orders
• ☐ Long-term care insurance policy (if any) with benefit summary
• ☐ Veterans benefit letter (if any)
• ☐ Verification of nursing-facility / waiver-provider admission
• ☐ Level-of-care determination (InterRAI / IA HHS assessment)

12. APPLICANT VERIFICATION AND SIGNATURE

Under penalty of perjury under Iowa Code § 249A.6 and § 714.16 (false claims), I declare that the foregoing is true and correct to the best of my knowledge. I understand that knowingly providing false information to obtain Medical Assistance is a fraudulent practice and may result in criminal prosecution, civil penalties, recoupment, and disqualification from Medicaid. I acknowledge that the State of Iowa may assert estate-recovery rights under Iowa Code § 249A.53(2) and § 249A.5 against my probate and non-probate assets following my death (and the death of my surviving spouse, if any).

Date: [__/__/____]

[________________________________]

[APPLICANT NAME]

[________________________________]

[AUTHORIZED REPRESENTATIVE NAME, IF ANY]

STATE OF IOWA

COUNTY OF [________________________________]

Subscribed and sworn to before me this [____] day of [_______________], 20[____].

[________________________________]

Notary Public — State of Iowa

(Commission expires: [_______________])

13. IOWA PRACTICE NOTES

• Annual figure verification. The 300% SSI income cap, MNIL, MMMNA, CSRA, home-equity cap, and penalty divisor are revised annually. Always confirm current values with Iowa HHS or Iowa Medicaid Eligibility Manual before filing.
• Look-back trap. Iowa's 60-month look-back starts on the application date. Filing one day "early" can needlessly drag a transfer back into the window. Coordinate the application date with any planning steps (annuity, pooled-trust funding, caregiver agreement).
• Penalty divisor mechanics. Penalties run from the date the Applicant is otherwise eligible AND receiving institutional or waiver services — not from the date of the gift. Plan funding to ensure the Applicant has resources to private-pay through the penalty.
• Medically Needy program. Iowa's Medically Needy program ($483/mo MNIL, two-month spend-down) covers categorically-related individuals (aged, blind, disabled) for non-LTC services. It does not cover nursing-facility care; institutional applicants must qualify under the LTC income cap or via a MAIT.
• MAIT funding. Pour ALL countable income types (Social Security, pension, etc.) into the MAIT each month to avoid eligibility lapses. Underfunding even one stream can blow the cap and trigger a denial.
• Estate recovery. Iowa pursues estate recovery aggressively under Iowa Code § 249A.53(2). Expanded recovery extends to non-probate assets (joint tenancies, life estates, transfer-on-death). Plan accordingly.
• Spousal refusal / "just-say-no." Iowa permits spousal refusal in narrow circumstances under federal law, but the State retains a right of recovery against the refusing spouse. Use cautiously and only with written legal advice.
• Caregiver agreements. Properly documented, written, fair-market-value caregiver agreements signed before services are rendered are not transfers. Retroactive agreements are presumptively invalid.
• Annuities. Post-DRA Medicaid-compliant annuities must be irrevocable, non-assignable, actuarially sound, name the State of Iowa as primary remainder beneficiary up to total Medicaid paid, and pay equally over the annuitant's life expectancy.
• Hearings. Adverse eligibility decisions are appealable within 30 days under Iowa Admin. Code r. 441—7 to an Administrative Law Judge, with judicial review in Iowa District Court under Iowa Code Chapter 17A.

14. SOURCES AND REFERENCES

• Iowa Department of Health and Human Services — Long-Term Care: https://hhs.iowa.gov/medicaid/services-care/long-term-care
• Iowa HHS — Medical Assistance Income Trust (Miller Trust): https://hhs.iowa.gov/medicaid/services-care/long-term-care/medical-assistance-income-trust-long-term-care
• Iowa HHS — HCBS Elderly Waiver: https://hhs.iowa.gov/medicaid/services-care/long-term-care/elderly-waiver
• Iowa Code Chapter 249A — Medical Assistance: https://www.legis.iowa.gov/docs/code/249A.pdf
• Iowa Code § 249A.53 — Medical Assistance Income Trust and Estate Recovery
• Iowa Admin. Code r. 441—75 (Eligibility) and r. 441—83 (HCBS Waivers): https://www.legis.iowa.gov/law/administrativeRules
• 42 U.S.C. § 1396p — Transfers, liens, estate recovery, and qualifying trusts
• 42 U.S.C. § 1396r-5 — Spousal impoverishment
• CMS State Medicaid Manual — Long-Term Care
• Iowa Legal Aid — Gifts and Qualifying for Medicaid for Nursing Home Care: https://www.iowalegalaid.org/resource/gifts-and-qualifying-for-medicaid-for-nursing
• Iowa Legal Aid — Elderly Waiver Program: https://iowalegalaid.org/resource/elderly-waiver-program-keeps-people-out-of-nursing-homes/

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. Medicaid eligibility figures change yearly; verify all amounts (income cap, MNIL, MMMNA, CSRA, home-equity cap, penalty divisor) with Iowa HHS for the year of application. An Iowa-licensed elder-law attorney must review and customize this packet before submission.