Idaho Medicaid Application Packet — Aged & Disabled (A&D) Waiver / Long-Term Care

IDAHO MEDICAID APPLICATION PACKET — AGED & DISABLED (A&D) WAIVER AND NURSING-HOME MEDICAID

TABLE OF CONTENTS

1. Cover Letter to DHW Self-Reliance
2. Applicant Information
3. Program Selection and Level of Care
4. Categorical and Financial Eligibility — 2026 Limits
5. Income Schedule and Miller Trust Analysis
6. Resource (Asset) Schedule
7. Verification Checklist
8. Transfer Disclosure and 60-Month Look-Back
9. Spousal Impoverishment Allocation (If Married)
10. Primary Residence and Home-Equity Treatment
11. Estate Recovery Notice and Acknowledgement
12. Authorized Representative Designation
13. Signature, Verification, and Penalties for False Statement
14. Idaho Practice Notes
15. Sources and References

1. COVER LETTER TO DHW SELF-RELIANCE

Idaho Department of Health and Welfare

Division of Self-Reliance — Medicaid Eligibility

P.O. Box 83720, Boise, ID 83720-0026

Date: [__/__/____]

Re: Application for Long-Term Care Medicaid — A&D Waiver / Nursing-Home Coverage

Applicant: [APPLICANT FULL LEGAL NAME]

DOB: [__/__/____] SSN (last 4): [____]

To Whom It May Concern:

Enclosed please find the Application for Assistance and supporting documentation for the above-named applicant seeking long-term care Medicaid under the Aged & Disabled (A&D) Home and Community-Based Services Waiver pursuant to 42 U.S.C. § 1396n(c) and IDAPA 16.03.10, and/or institutional Nursing-Home Medicaid pursuant to 42 U.S.C. § 1396a(a)(10)(A)(ii)(V) and IDAPA 16.03.05.

This packet contains: (i) a fully completed Form HW-0009; (ii) financial verifications listed in the Verification Checklist (Section 7); (iii) a sworn Transfer Disclosure addressing the 60-month look-back (Section 8); and (iv) where required, an executed Qualified Income Trust ("Miller Trust") under 42 U.S.C. § 1396p(d)(4)(B).

Please direct any requests for additional information to the undersigned authorized representative.

Respectfully,

[________________________________]

[AUTHORIZED REPRESENTATIVE NAME]

[FIRM NAME / RELATIONSHIP]

Telephone: [NUMBER] Email: [EMAIL]

2. APPLICANT INFORMATION

Spouse Information (if applicable):

3. PROGRAM SELECTION AND LEVEL OF CARE

3.1. Program Requested (check all that apply):

• ☐ Aged & Disabled (A&D) HCBS Waiver — IDAPA 16.03.10
• ☐ Nursing-Home (Institutional) Medicaid — IDAPA 16.03.05
• ☐ Idaho Medicaid Plus (IMPlus) dual-eligible managed care
• ☐ Personal Care Services (state plan, non-waiver)

3.2. Nursing Facility Level of Care (NFLOC). Applicant requires NFLOC as documented by [PHYSICIAN NAME, NPI] in the attached Form 3528 (Plan of Care) and supported by the Uniform Assessment Instrument administered by DHW Regional Medicaid Services on [__/__/____]. NFLOC is established by deficits in activities of daily living (ADLs), instrumental activities of daily living (IADLs), and/or cognitive/behavioral status per IDAPA 16.03.10.213.

3.3. Plan of Care. The proposed plan of care is annexed as Exhibit A and identifies the qualified A&D Waiver provider(s), service hours, and projected monthly Medicaid cost not to exceed the institutional cost cap.

4. CATEGORICAL AND FINANCIAL ELIGIBILITY — 2026 LIMITS

Idaho is an income-cap state. Spend-down of income to the medically-needy level is not permitted for long-term care. Applicants whose gross monthly income exceeds $3,002 must establish a Qualified Income Trust (Miller Trust) under 42 U.S.C. § 1396p(d)(4)(B). See Section 5.

5. INCOME SCHEDULE AND MILLER TRUST ANALYSIS

5.1. Monthly Gross Income — Applicant:

5.2. Miller Trust Required? ☐ Yes ☐ No

If gross income exceeds $3,002 / month, a Miller Trust is required. Idaho Miller Trust requirements:

• The trust must be irrevocable.
• The trust must contain only the applicant's income (and any income earned thereon).
• Idaho Department of Health and Welfare must be named the residual beneficiary up to the total amount of medical assistance paid on the applicant's behalf.
• The trustee may not be the applicant or the applicant's spouse.
• Disbursements are limited to: (i) the personal-needs allowance ($40); (ii) MMMNA paid to a community spouse; (iii) health-insurance premiums (Medicare Parts B/D, Medigap); and (iv) the patient liability paid to the facility or A&D Waiver provider.

5.3. Trust Funding. Date executed: [__/__/____]. Funded with: [INCOME SOURCES DEPOSITED]. Trustee: [NAME]. Tax ID (EIN): [__-_______]. Executed Trust Agreement annexed as Exhibit B.

6. RESOURCE (ASSET) SCHEDULE

6.1. Countable Resources (as of application date):

6.2. Excluded (Non-Countable) Resources (identify and document):

• ☐ Primary residence (subject to home-equity limit; see Section 10)
• ☐ One motor vehicle of any value (used for transportation of applicant or household member)
• ☐ Household goods and personal effects
• ☐ Burial space / plot for applicant and immediate family
• ☐ Irrevocable burial trust or burial fund up to Idaho exclusion (verify current cap)
• ☐ Term life insurance (no cash value)
• ☐ Property essential to self-support
• ☐ Non-applicant spouse's IRA / 401(k) in payout status (verify case-by-case)

7. VERIFICATION CHECKLIST

Attach the following — DHW will not adjudicate without them:

• ☐ Photo ID (driver's license / state ID / passport)
• ☐ Social Security card or letter
• ☐ Medicare card (front and back)
• ☐ Proof of US citizenship or qualified-alien status (birth certificate, passport, USCIS)
• ☐ Proof of Idaho residency (utility bill, lease, mortgage statement)
• ☐ Marriage certificate / divorce decree / death certificate of prior spouse
• ☐ Sixty (60) months of bank statements for every account titled to applicant or spouse
• ☐ Most recent statements for every brokerage, IRA, 401(k), annuity, and life-insurance policy
• ☐ Deeds for all real property owned in last 60 months
• ☐ Vehicle titles
• ☐ Five years of federal tax returns (1040 + schedules)
• ☐ Pension award letters / SSA-1099 / VA award letter
• ☐ Long-term care insurance policy (if any)
• ☐ Burial-contract / pre-need agreement
• ☐ Health-insurance card(s) and premium documentation
• ☐ Executed Power of Attorney / Guardianship / Conservatorship order (if applicable)
• ☐ Executed Miller Trust agreement, if used (Exhibit B)
• ☐ Plan of Care (Form 3528) and physician certification (Exhibit A)

8. TRANSFER DISCLOSURE AND 60-MONTH LOOK-BACK

8.1. Look-Back Period. Pursuant to 42 U.S.C. § 1396p(c) and IDAPA 16.03.05, all uncompensated transfers by the applicant or spouse during the sixty (60) months immediately preceding the application date must be disclosed. Applicant declares under penalty of perjury that the transfers below are complete and accurate.

8.2. Transfer Schedule:

8.3. Penalty Computation. Total uncompensated transfers ÷ Idaho transfer-penalty divisor = months of ineligibility. The penalty period begins the later of (i) the date of transfer or (ii) the date the applicant is otherwise eligible for Medicaid and would, but for the penalty, be receiving covered long-term care.

Total uncompensated transfers: [$________]

Current Idaho transfer-penalty divisor (verified date [__/__/____]): [$________]

Computed months of ineligibility: [____]

8.4. Exempt Transfers (no penalty if proven):

• ☐ Transfer to spouse, or to another for the sole benefit of the spouse
• ☐ Transfer to a child who is blind or permanently and totally disabled (any age)
• ☐ Transfer to a "caregiver child" who resided in the home and provided care for ≥2 years prior to institutionalization, delaying placement
• ☐ Transfer to a "sibling with equity interest" who resided in the home for ≥1 year prior to institutionalization
• ☐ Transfer to or in trust for a disabled individual under age 65 (42 U.S.C. § 1396p(c)(2)(B)(iv))
• ☐ Transfer for fair market value (full consideration)
• ☐ Transfer for purpose other than to qualify for Medicaid (rebuttable; documentation required)

9. SPOUSAL IMPOVERISHMENT ALLOCATION (IF MARRIED)

9.1. Snapshot Date. The "snapshot" of countable couple resources is taken as of the first continuous 30-day period of institutionalization or A&D Waiver enrollment. Snapshot date: [__/__/____].

9.2. Spousal Resource Calculation:

• Total countable couple resources at snapshot: [$________]
• 50% of total: [$________]
• CSRA (lesser of 50% or $162,660; floor $32,532): [$________]
• Resources allocated to applicant (must be reduced to $2,000 to qualify): [$________]

9.3. Spousal Income Allocation (MMMNA):

• Community spouse's gross monthly income: [$________]
• MMMNA shortfall (deficit between income and $2,643.75 baseline, increasable to $4,066.50 with excess-shelter): [$________]
• Monthly transfer from applicant to community spouse: [$________]

10. PRIMARY RESIDENCE AND HOME-EQUITY TREATMENT

10.1. The applicant's primary residence located at [STREET ADDRESS], [COUNTY], Idaho, is excluded from countable resources during institutionalization or A&D Waiver enrollment if the applicant or spouse demonstrates an intent to return home or the home is occupied by:

• ☐ A community spouse;
• ☐ A child under age 21, or a blind/disabled child of any age;
• ☐ A sibling with equity interest who has lived there ≥1 year; or
• ☐ A caregiver child who lived there ≥2 years and provided care delaying placement.

10.2. Home-Equity Cap. If the applicant has no spouse, minor child, or disabled child living in the home, equity in excess of $752,000 (2026) disqualifies the applicant from long-term care Medicaid until equity is reduced (e.g., reverse mortgage, home-equity loan, sale).

Current assessed value: [$________] Mortgage / liens: [$________] Net equity: [$________]

10.3. TEFRA Lien / Estate Recovery. Idaho may file a TEFRA lien against the home of a permanently-institutionalized applicant under 42 U.S.C. § 1396p(a) and Idaho Code § 56-218. Estate recovery against the deceased recipient's probate estate (and certain non-probate assets) is mandated by Idaho Code § 56-218 and § 56-209h.

11. ESTATE RECOVERY NOTICE AND ACKNOWLEDGEMENT

I, [APPLICANT NAME], acknowledge that under Idaho Code § 56-218 and 42 U.S.C. § 1396p(b), the State of Idaho is required to seek recovery from my estate, after my death (and the death of any surviving spouse), for all medical assistance correctly paid on my behalf for long-term care services received at age 55 or older. I understand that:

• Recovery may reach the home and other assets passing through probate, and certain non-probate transfers permitted by Idaho law.
• Recovery is deferred while a surviving spouse is living, while a child under 21 survives, or while a blind or disabled child of any age survives.
• I may apply for an undue-hardship waiver under IDAPA 16.03.05.

Acknowledged: [________________________________] Date: [__/__/____]

12. AUTHORIZED REPRESENTATIVE DESIGNATION

I, [APPLICANT NAME], designate [REPRESENTATIVE NAME], [RELATIONSHIP / CAPACITY (attorney-in-fact / guardian / family member / attorney)], as my authorized representative for purposes of this Medicaid application pursuant to 42 C.F.R. § 435.923. The representative is authorized to receive notices, submit information, request hearings, and act on my behalf in all matters relating to this application until revoked in writing.

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

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

13. SIGNATURE, VERIFICATION, AND PENALTIES FOR FALSE STATEMENT

I declare under penalty of perjury under the laws of the State of Idaho that the foregoing application, schedules, and disclosures are true, correct, and complete to the best of my knowledge. I understand that Idaho Code § 56-227A and 18 U.S.C. § 1001 impose civil and criminal penalties for false statements made to obtain Medicaid benefits, including restitution, fines, and imprisonment.

Applicant (or Representative): [________________________________]

Printed Name: [________________________________]

Date: [__/__/____]

Spouse Signature (if married, for spousal verifications): [________________________________]

Date: [__/__/____]

14. IDAHO PRACTICE NOTES

• Income-cap state. Idaho does not allow medically-needy spend-down of income for long-term care. A Miller Trust is the standard workaround when gross income exceeds $3,002.
• Functional eligibility is separate. Financial eligibility through Self-Reliance and NFLOC determination through Regional Medicaid Services proceed in parallel; both must be approved.
• Annuity rules. Idaho recognizes Medicaid-compliant annuities only if irrevocable, non-assignable, actuarially sound, equal monthly payments, and naming Idaho DHW as the primary remainder beneficiary up to medical assistance paid (or secondary if a community spouse / minor / disabled child survives). Non-compliant annuities are treated as transfers.
• Promissory notes / loans. Must satisfy the DRA-2005 safe harbor (actuarially sound term, equal payments, no balloon, non-cancellable).
• Caregiver-child transfers. Document care before the look-back-period statements with physician letters and a written caregiver-services agreement; oral arrangements rarely survive DHW scrutiny.
• Hearing rights. Adverse action triggers a right to a Fair Hearing under IDAPA 16.05.03 within 30 days of the notice of decision; aid-paid-pending is available if requested before the effective date.
• Estate recovery. Idaho aggressively pursues recovery through TEFRA liens and probate. Counsel should evaluate whether titling, life-estate deeds, or "ladybird" alternatives (limited in Idaho) are available before institutionalization.
• Five-year planning horizon. Practitioners should plan around the 60-month look-back; transfers more than 60 months prior to application are not penalized.
• idalink.idaho.gov. Online portal for application, renewal, document upload, and status tracking. Paper Form HW-0009 remains accepted.

15. SOURCES AND REFERENCES

• Idaho Department of Health and Welfare — Medicaid for Elderly or Adults with Disabilities — https://healthandwelfare.idaho.gov/services-programs/medicaid-health/about-medicaid-elderly-or-adults-disabilities
• DHW — Medicaid Program Income Limits — https://healthandwelfare.idaho.gov/medicaid-program-income-limits
• IDAPA 16.03.05 (Eligibility for Medicaid for Families and Children, Aged, Blind and Disabled) — https://adminrules.idaho.gov/
• IDAPA 16.03.10 (Medicaid Enhanced Plan Benefits — A&D Waiver)
• Idaho Code Title 56, Chapter 2 (Public Assistance Law) — https://legislature.idaho.gov/statutesrules/idstat/title56/t56ch2/
• Idaho Code § 56-218 (Estate Recovery) — https://legislature.idaho.gov/statutesrules/idstat/title56/t56ch2/sect56-218/
• 42 U.S.C. § 1396p (Liens, Adjustments and Recoveries; Transfers of Assets)
• 42 U.S.C. § 1396r-5 (Spousal Impoverishment Protections)
• CMS — State Medicaid Manual — https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Paper-Based-Manuals-Items/CMS021927
• Medicaid Planning Assistance — Idaho A&D Waiver — https://www.medicaidplanningassistance.org/idaho-aged-and-disabled-waiver/
• idalink Customer Portal — https://idalink.idaho.gov/

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. Idaho Medicaid figures change at least annually; verify all dollar thresholds and the transfer-penalty divisor with DHW before filing. Engage an Idaho-licensed elder law attorney before relying on this packet.