Indiana Medicaid Application Packet — Long-Term Care / Aged & Disabled Waiver

INDIANA MEDICAID APPLICATION PACKET — LONG-TERM CARE / AGED & DISABLED WAIVER

TABLE OF CONTENTS

1. Applicant Information
2. Program Selection and Level of Care
3. Household and Spousal Information
4. Income Disclosure
5. Resource (Asset) Disclosure
6. Primary Residence and Home Equity
7. 60-Month Look-Back / Transfer Disclosure
8. Spend-Down Plan
9. Qualified Income Trust (Miller Trust)
10. Indiana Long-Term Care Insurance Program (Partnership)
11. Authorized Representative and HIPAA Authorization
12. Estate Recovery Acknowledgment
13. Applicant Signature and Verification
14. Attorney Cover Letter
15. Document Checklist
16. Indiana Practice Notes
17. Sources and References

1. APPLICANT INFORMATION

2. PROGRAM SELECTION AND LEVEL OF CARE

The Applicant requests determination of eligibility for the following Indiana Medicaid program(s):

• ☐ Nursing Facility (Institutional) Medicaid — care in a licensed Indiana nursing facility
• ☐ Aged & Disabled (A&D) Home and Community-Based Services Waiver — services in the home or community in lieu of nursing-facility care
• ☐ Traditional Medicaid for Aged, Blind, Disabled (M.A.B.D.) — community-based, non-waiver
• ☐ PACE (Program of All-Inclusive Care for the Elderly) — where available
• ☐ Hoosier Care Connect — managed care for ABD population
• ☐ Other: [________________________________]

Level-of-care determination:

• Has a Pre-Admission Screening / Resident Review (PASRR) been completed? ☐ Yes ☐ No
• Date of nursing-facility admission (if applicable): [__/__/____]
• Facility name and address: [________________________________]
• Has an Area Agency on Aging (AAA) options counseling assessment been performed for waiver applicants? ☐ Yes ☐ No

3. HOUSEHOLD AND SPOUSAL INFORMATION

For spousal-impoverishment cases (institutionalized spouse / community spouse):

• Snapshot date of resources (first day of first continuous period of institutionalization of 30+ days): [__/__/____]
• Total countable resources on snapshot date: $[________________________________]
• Community Spouse Resource Allowance (CSRA) requested: $[________________________________]

4. INCOME DISCLOSURE

List ALL gross monthly income received by the Applicant (and the spouse, if separate accounting is needed). Attach award letters, pay stubs, and most recent tax return.

2026 Indiana Medicaid Income Reference (verify before filing):

• Special-income limit for Nursing Facility / A&D Waiver (single): $2,982/month (300% of SSI Federal Benefit Rate)
• If gross monthly income exceeds the special-income limit, the Applicant MUST establish a Qualified Income Trust (QIT / Miller Trust) before approval.
• Community-spouse income is generally not deemed to the institutionalized spouse after the post-eligibility computation.

5. RESOURCE (ASSET) DISCLOSURE

List ALL countable and non-countable resources owned by the Applicant and spouse (jointly or severally) as of the application month, with most recent statements attached.

5.1 Countable Resources

5.2 Non-Countable / Exempt Resources

2026 Indiana Resource Reference (verify before filing):

• Single applicant resource limit: $2,000
• Married, both applying (institutionalized): $3,000 combined
• Married, one applying: $2,000 applicant + CSRA up to $162,660 community spouse
• Home-equity cap: $752,000 (no cap if spouse, minor child, or permanently disabled child resides in the home)

6. PRIMARY RESIDENCE AND HOME EQUITY

7. 60-MONTH LOOK-BACK / TRANSFER DISCLOSURE

Pursuant to 42 U.S.C. § 1396p(c) and Ind. Code § 12-15-7, all transfers of assets for less than fair market value within the 60 months preceding the first month of Medicaid application are subject to review and may produce a transfer penalty (period of ineligibility for Medicaid-paid long-term care services).

Look-back window: From [__/__/____] (month of application) back 60 months to [__/__/____].

List ALL transfers, gifts, sales below market, additions/removals of joint owners, trust funding, annuity purchases, and large unexplained withdrawals during the look-back window:

Penalty calculation:

• Total uncompensated transfers: $[________________________________]
• Indiana transfer-penalty divisor in effect on application date: $[________________________________] (verify with FSSA — divisor approximates statewide average monthly private-pay nursing facility cost; updates each July 1)
• Calculated penalty period (months / partial months): [________________________________]
• Penalty start date (first day applicant is otherwise eligible and receiving institutional services): [__/__/____]

Asserted exceptions (check all that apply and attach proof):

• ☐ Transfer to spouse (or to another for sole benefit of spouse)
• ☐ Transfer to a child under age 21 or who is blind or permanently disabled
• ☐ Transfer to a trust solely for the benefit of a disabled individual under 65 (42 U.S.C. § 1396p(d)(4)(A) or (C))
• ☐ Caregiver child exception — homestead transferred to child who resided in the home and provided care permitting applicant to remain at home at least 2 years prior to institutionalization
• ☐ Sibling exception — homestead transferred to sibling with equity interest who resided there at least 1 year prior to institutionalization
• ☐ Transfer made exclusively for purpose other than to qualify for Medicaid (rebuttable)
• ☐ Hardship waiver requested under 42 U.S.C. § 1396p(c)(2)(D)

8. SPEND-DOWN PLAN

If countable resources currently exceed the resource limit, the Applicant intends to "spend down" excess assets through the following permissible expenditures (all must be at fair market value, for the applicant's benefit, and well documented):

9. QUALIFIED INCOME TRUST (MILLER TRUST)

Required only if Applicant's gross monthly income exceeds the special-income limit ($2,982/month for 2026; verify current figure).

10. INDIANA LONG-TERM CARE INSURANCE PROGRAM (PARTNERSHIP)

The Indiana Long-Term Care Insurance Program (ILTCIP), authorized at Ind. Code § 12-15-39.5 and administered jointly by FSSA and the Indiana Department of Insurance, allows holders of qualifying Partnership policies to disregard assets when applying for Indiana Medicaid:

• Dollar-for-Dollar Asset Disregard: Every dollar of qualified benefits paid by an ILTCIP policy adds a dollar to the resource limit.
• Total Asset Policy: Policies meeting Indiana's higher daily-benefit and inflation-protection thresholds disregard ALL of the policyholder's assets for Medicaid eligibility (Indiana is one of the few states offering total-asset protection).

Attach a Verification of Benefits letter from the carrier confirming Partnership status and benefits paid.

11. AUTHORIZED REPRESENTATIVE AND HIPAA AUTHORIZATION

Applicant designates the following individual as Authorized Representative for Medicaid application, hearings, redetermination, and communications with FSSA / DFR:

The Applicant authorizes FSSA, DFR, OMPP, AAA, the nursing facility, banks, brokerages, employers, the Social Security Administration, the Veterans Administration, the IRS, and the Indiana Department of Revenue to release any records necessary to determine eligibility. This authorization conforms with HIPAA (45 C.F.R. § 164.508) and Indiana confidentiality law and shall remain in effect for [____] months from the date signed unless revoked in writing.

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

12. ESTATE RECOVERY ACKNOWLEDGMENT

Applicant acknowledges that under 42 U.S.C. § 1396p(b) and Ind. Code § 12-15-9, the State of Indiana is required to seek recovery from the estate of a deceased Medicaid recipient (age 55 or older, or permanently institutionalized) for medical assistance paid, including nursing-facility services, home and community-based services, and related hospital and prescription-drug services.

Recovery is deferred during the lifetime of:

• A surviving spouse;
• A child under age 21; or
• A child who is blind or permanently and totally disabled.

Hardship waivers may be available in narrow circumstances.

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

13. APPLICANT SIGNATURE AND VERIFICATION

I, [APPLICANT NAME], under penalty of perjury under the laws of the State of Indiana, declare that I have reviewed this Medicaid Application Packet and the attached documents and that the information provided is true, complete, and correct to the best of my knowledge. I understand that providing false or misleading information may result in denial of benefits, civil penalties, and criminal prosecution under Ind. Code § 35-43-5 and 42 U.S.C. § 1320a-7b.

Applicant (or Authorized Representative) signature: [________________________________]

Print name: [________________________________]

Capacity: ☐ Self ☐ Attorney-in-Fact (POA) ☐ Guardian ☐ Authorized Representative

Date: [__/__/____]

STATE OF INDIANA

COUNTY OF [________________________________]

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

[________________________________]

Notary Public

(My Commission Expires: [_______________])

14. ATTORNEY COVER LETTER

Date: [__/__/____]

Indiana Family and Social Services Administration

Division of Family Resources — [COUNTY] Office

[ADDRESS]

Re: Medicaid Application — [APPLICANT NAME], DOB [__/__/____], SSN xxx-xx-[____]

Dear Eligibility Caseworker:

Enclosed please find the long-term care Medicaid application packet for the above-referenced Applicant, together with the documents itemized in the attached Document Checklist. We respectfully request expedited review pursuant to 405 IAC 2 and the Indiana Medicaid Eligibility Policy Manual.

Please direct all correspondence and requests for additional verification to the undersigned Authorized Representative.

Respectfully submitted,

[________________________________]

[ATTORNEY NAME], Indiana Bar No. [####]

[LAW FIRM]

[ADDRESS / TELEPHONE / EMAIL]

15. DOCUMENT CHECKLIST

• ☐ Indiana Application for Health Coverage (FSSA Form / online portal printout)
• ☐ Photo identification (driver's license / state ID)
• ☐ Social Security card and Medicare card
• ☐ Birth certificate / proof of citizenship
• ☐ Marriage certificate; divorce decree or death certificate of prior spouse (if applicable)
• ☐ Proof of Indiana residency (utility bill, lease, deed)
• ☐ All bank, brokerage, IRA, and retirement statements covering the 60-month look-back period
• ☐ Most recent property tax bills and homestead valuation
• ☐ Vehicle registrations and titles
• ☐ Life insurance policies with cash surrender value statements
• ☐ Burial / funeral contracts
• ☐ Pension award letters; Social Security / SSI / VA award letters
• ☐ Most recent federal and Indiana income tax returns (3 years)
• ☐ Health insurance and ILTCIP / long-term care insurance policies and claim summaries
• ☐ Power of Attorney or guardianship order
• ☐ Trust instruments (revocable, irrevocable, special-needs, QIT)
• ☐ Deeds and closing documents for any real property transfers within 60 months
• ☐ Gift letters or affidavits supporting transfer exceptions
• ☐ Annuity contracts (with state-remainder-beneficiary language)
• ☐ Promissory notes and loan documents
• ☐ Nursing facility admission paperwork and PASRR
• ☐ Verification of QIT account establishment and funding
• ☐ HIPAA authorization signed and dated

16. INDIANA PRACTICE NOTES

• Administering agency. Indiana Medicaid is administered by FSSA. Applications are processed by the Division of Family Resources (DFR); policy is set by the Office of Medicaid Policy and Planning (OMPP). Apply at fssabenefits.in.gov, by phone at 1-800-403-0864, or in person at the local DFR office.
• Eligibility update cycle. Income figures (special-income limit, MMMNA, etc.) update on March 1 each year following federal cost-of-living adjustments. The transfer-penalty divisor updates on July 1 reflecting changes in statewide average private-pay nursing-facility cost.
• 2026 reference figures (verify before filing).
• Single-applicant income limit (NF / A&D Waiver): $2,982/month
• Single-applicant resource limit: $2,000
• Community Spouse Resource Allowance: minimum $32,532, maximum $162,660
• MMMNA (7/1/25 – 6/30/26): $2,644
• Home-equity cap: $752,000
• 60-month look-back. Applies uniformly to outright transfers and transfers into trust. Joint-account additions and life-estate / TOD-deed creations may trigger transfer review depending on facts; Indiana has historically applied SI 01140 SSI principles for joint accounts.
• Primary residence. Exempt during applicant's continued residence or signed Intent to Return; remains exempt while a community spouse, minor child, or permanently/totally disabled child resides there. Subject to estate recovery on death absent statutory deferral.
• Aged & Disabled (A&D) Waiver. Provides home- and community-based services as an alternative to institutional care. Requires nursing-facility level of care; AAA performs the assessment. Slot availability and waiting lists vary by region.
• Hoosier Care Connect. Managed-care delivery system for ABD non-LTSS members; enrollment in a managed-care entity (MCE) follows eligibility determination.
• Estate recovery. Indiana pursues recovery against probate estates of recipients age 55+ for all long-term care services and related costs. Estate-planning techniques (life-estate deeds, TOD deeds, irrevocable trusts properly seasoned outside the look-back, properly structured tenancy by the entireties) may legitimately reduce probate-estate exposure but each carries risk of being treated as an uncompensated transfer if executed within the look-back period.
• Hearings and appeals. Adverse eligibility determinations are appealable via written request for fair hearing within 33 days of the notice of action under 405 IAC 1.1. Continued benefits during appeal require timely filing within 10 days of notice.
• Partnership policy disregard. ILTCIP "Total Asset" policies provide unique full-asset protection and warrant verification with the carrier early in the application process.

17. SOURCES AND REFERENCES

• Indiana FSSA Medicaid Portal — https://www.in.gov/medicaid/
• FSSA Medicaid Eligibility Policy Manual — https://www.in.gov/fssa/ompp/forms-documents-and-tools2/medicaid-eligibility-policy-manual/
• Indiana Benefits Portal — https://fssabenefits.in.gov
• Indiana Long-Term Care Insurance Program (ILTCIP) — https://www.in.gov/iltcp/
• Ind. Code Title 12 (Human Services) — http://iga.in.gov/legislative/laws/
• 405 IAC 2 (Medicaid Administrative Rules)
• 42 U.S.C. § 1396 et seq.; 42 U.S.C. § 1396p (transfers, liens, recovery); 42 U.S.C. § 1396r-5 (spousal impoverishment)
• POMS SI 01730 (Special-Income-Level Trusts / Miller Trusts)
• Indiana Area Agencies on Aging — https://www.in.gov/fssa/da/area-agencies-on-aging/
• Indiana Long-Term Care Ombudsman — 1-800-622-4484; https://www.in.gov/ombudsman/long-term-care-ombudsman/

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. Medicaid is a complex, frequently changing benefit program; eligibility figures, divisors, and policies update at least annually. An attorney licensed in Indiana with elder law experience must review and customize this packet for the specific Applicant's situation before filing. Verify all dollar figures, statutory citations, and program features against current FSSA / OMPP guidance.