Kansas Medicaid (KanCare) Long-Term Care Application Packet — Frail Elderly Waiver

KANSAS MEDICAID (KANCARE) LONG-TERM CARE APPLICATION PACKET — FRAIL ELDERLY WAIVER

TABLE OF CONTENTS

1. Application Cover Sheet
2. Applicant and Household Information
3. Coverage Group and Program Requested
4. Functional Eligibility — Nursing-Facility Level of Care
5. Income Eligibility Worksheet
6. Resource (Asset) Eligibility Worksheet
7. Spousal Impoverishment / Community Spouse Calculations
8. Primary Residence Treatment
9. Five-Year Look-Back and Transfer Disclosure
10. Spend-Down / Medically Needy Pathway
11. Required Verifications and Documents
12. Authorized Representative Designation
13. Estate Recovery Disclosure
14. Applicant Certification and Signature
15. Kansas Practice Notes
16. Sources and References

1. APPLICATION COVER SHEET

STATE OF KANSAS — KANCARE / KDHE CLEARINGHOUSE

FROM: [________________________________] (Applicant / Authorized Representative)

RE: Application for Kansas Medical Assistance — Long-Term Care / HCBS Frail Elderly Waiver

APPLICANT: [________________________________]

SOCIAL SECURITY NUMBER: [________________________________]

DATE OF BIRTH: [__/__/____]

DATE OF APPLICATION: [__/__/____]

REQUESTED EFFECTIVE DATE: [__/__/____]

MAILING ADDRESS: [________________________________]

TELEPHONE: [________________________________]

2. APPLICANT AND HOUSEHOLD INFORMATION

2.1. Applicant Full Legal Name: [________________________________]

2.2. Maiden / Other Names Used: [________________________________]

2.3. Marital Status: ☐ Single ☐ Married ☐ Widowed ☐ Divorced ☐ Separated

2.4. Spouse Full Legal Name (if any): [________________________________]

2.5. Spouse Date of Birth / SSN: [__/__/____] / [________________________________]

2.6. Current Living Arrangement:

• ☐ Own home (community)
• ☐ Family member's home
• ☐ Assisted living / Home Plus / Residential health care facility
• ☐ Skilled nursing facility (SNF) — Facility Name: [________________________________]
• ☐ Hospital (pending discharge)
• ☐ Other: [________________________________]

2.7. U.S. Citizenship / Qualified Non-Citizen Status: ☐ Citizen ☐ Qualified non-citizen — Documentation type: [________________________________]

2.8. Kansas Residency Established On: [__/__/____]

2.9. Medicare Status: ☐ Part A ☐ Part B ☐ Part D ☐ MSP (QMB / SLMB / QI) Medicare Number: [________________________________]

3. COVERAGE GROUP AND PROGRAM REQUESTED

The Applicant requests determination of eligibility under the following coverage group(s) (check all that apply):

• ☐ Nursing Facility (Institutional) Medicaid — long-term institutional care under 42 C.F.R. § 435.236.
• ☐ HCBS Frail Elderly (FE) Waiver — 1915(c) waiver administered by KDADS for persons age 65+ who meet nursing-facility level of care but elect community-based services.
• ☐ Working Healthy / Working Disabled — for working applicants with disabilities (where applicable).
• ☐ Medically Needy (Spend-Down) — for applicants with income above the categorical limit.
• ☐ Medicare Savings Program (QMB / SLMB / QI) — premium / cost-sharing assistance.
• ☐ PACE — Program of All-Inclusive Care for the Elderly (where available).

4. FUNCTIONAL ELIGIBILITY — NURSING-FACILITY LEVEL OF CARE

4.1. The Applicant has been or will be assessed by an Aging and Disability Resource Center (ADRC) using the uniform functional assessment.

4.2. Date of CARE / functional assessment: [__/__/____]

4.3. Assessment outcome: ☐ Meets NF level of care ☐ Does not meet NF level of care ☐ Pending

4.4. Activities of Daily Living (ADL) deficits:

• ☐ Bathing ☐ Dressing ☐ Toileting ☐ Transferring ☐ Continence ☐ Eating ☐ Mobility

4.5. Cognitive impairment / dementia diagnosis: ☐ Yes ☐ No Diagnosis: [________________________________]

4.6. Primary care physician statement attached: ☐ Yes ☐ No

5. INCOME ELIGIBILITY WORKSHEET

5.1. Applicant Gross Monthly Income:

5.2. Comparison to Applicable Income Standard (2026):

• Special Income Limit (institutional / waiver) — approximately $2,901/month (300% SSI; verify): ☐ Below ☐ Above
• Medically Needy Income Limit (single) — verify against current KFMAM: ☐ Below ☐ Above

5.3. Personal Needs Allowance (institutional): Nursing-facility residents retain $62/month under federal/state policy (verify), plus enough to pay Medicare/health-insurance premiums where applicable.

5.4. Patient Liability / Client Obligation: $[________________________________] per month after deduction of PNA, Medicare premiums, MMNA (if any), and dependent allowances.

6. RESOURCE (ASSET) ELIGIBILITY WORKSHEET

6.1. Countable Resources:

6.2. Excluded / Non-Countable Resources:

• ☐ Primary residence (subject to home-equity cap — see § 8)
• ☐ One vehicle of any value
• ☐ Personal effects / household goods
• ☐ Irrevocable burial trust / pre-need contract (within Kansas limits — verify)
• ☐ Burial space / plot
• ☐ Burial fund up to $1,500 designated
• ☐ Term life insurance (no cash value) and whole-life with face value $1,500 or less
• ☐ Properly drafted and funded sole-benefit special-needs / pooled trust

6.3. Resource Total Compared to Limit: Applicant: ☐ At/below limit ☐ Above limit by $[__________]

7. SPOUSAL IMPOVERISHMENT / COMMUNITY SPOUSE CALCULATIONS

7.1. Community Spouse Name: [________________________________]

7.2. Snapshot Date (date of first continuous period of institutionalization of 30 or more days): [__/__/____]

7.3. Combined Countable Resources at Snapshot: $[__________]

7.4. Community Spouse Resource Allowance (CSRA) — 2026: lesser of (a) one-half of combined resources up to $162,660 maximum, or (b) state-set minimum ($32,532 minimum CSRA — verify against current federal standards).

• Calculated CSRA: $[__________]
• Applicant resource limit: $2,000

7.5. Minimum Monthly Maintenance Needs Allowance (MMMNA) — 2026: $2,643.75 (federal minimum; verify).

7.6. Maximum Monthly Maintenance Needs Allowance (MMNA) — 2026: $4,066.50 (federal maximum; verify).

7.7. Community Spouse's Gross Monthly Income: $[__________]

7.8. Shelter Cost Calculation (rent/mortgage + property tax + insurance + utility allowance):

• Total shelter cost: $[__________]
• Excess shelter allowance: $[__________]

7.9. Community Spouse Income Allowance (transferable from institutionalized spouse): $[__________] per month.

8. PRIMARY RESIDENCE TREATMENT

8.1. Home Equity Interest Cap — 2026: $752,000 (verify against current federal/state policy).

8.2. Applicant Home Equity: $[__________] ☐ Within cap ☐ Exceeds cap

8.3. Home Excluded if any of the following apply:

• ☐ Applicant intends to return home (signed Intent to Return statement attached)
• ☐ Spouse resides in home
• ☐ Child under age 21 resides in home
• ☐ Blind or permanently disabled child of any age resides in home
• ☐ Sibling with equity interest resided in home for at least one year before institutionalization
• ☐ "Caretaker child" exception — adult child resided in home for at least two years before institutionalization and provided care that delayed institutionalization

8.4. Estate Recovery Risk: Even when excluded as a resource, the home is generally subject to Medicaid Estate Recovery under K.S.A. § 39-719a after the recipient's death (subject to surviving-spouse and minor/disabled-child deferrals). See § 13.

9. FIVE-YEAR LOOK-BACK AND TRANSFER DISCLOSURE

9.1. Look-Back Period: 60 months (5 years) immediately preceding the application date for both Nursing Facility Medicaid and HCBS Waiver Medicaid, per 42 U.S.C. § 1396p(c).

9.2. Look-Back Begin Date: [__/__/____]

9.3. Transfers / Gifts / Sales for Less Than Fair Market Value (Applicant or Spouse) During Look-Back:

9.4. Total Uncompensated Transfers: $[__________]

9.5. Kansas Statewide Transfer Penalty Divisor — 2026: approximately $287.14 per day (verify against the current Kansas Family Medical Assistance Manual; the divisor is updated periodically and represents the average daily private-pay nursing-facility cost).

9.6. Calculated Penalty Period: [Total uncompensated transfers] ÷ [daily divisor] = [______] days of ineligibility.

9.7. Penalty Period Begin Date: the later of (a) the date of transfer or (b) the date the applicant is otherwise eligible for and receiving institutional services and would be receiving Medicaid but for the penalty.

9.8. Exemptions / Allowable Transfers (apply where applicable):

• ☐ To spouse (or for sole benefit of spouse)
• ☐ To blind or permanently disabled child (or sole-benefit trust for same)
• ☐ Home transfer to: spouse / child under 21 / blind or disabled child / sibling-with-equity / caretaker child
• ☐ Transfer for fair market value
• ☐ Transfer with intent unrelated to qualifying for Medicaid (rebuttal evidence required)
• ☐ Undue hardship waiver requested (attach waiver request and supporting evidence)

10. SPEND-DOWN / MEDICALLY NEEDY PATHWAY

10.1. Kansas operates a medically-needy program for certain non-institutional coverage groups. Applicants whose income exceeds the categorical limit may "spend down" excess income on incurred medical expenses to reach the Medically Needy Income Limit (MNIL) for the relevant base period (Kansas historically uses a six-month base period; verify current KFMAM).

10.2. Spend-Down Base Period: [_____] months (verify current KFMAM)

10.3. Excess Income (gross income minus MNIL): $[__________] per month

10.4. Total Spend-Down Obligation per Base Period: $[__________]

10.5. Allowable Incurred Medical Expenses to Apply Toward Spend-Down:

• Medicare premiums and cost-sharing
• Health insurance premiums
• Co-payments and deductibles
• Prescription drugs
• Medically necessary services and supplies
• Past unpaid medical bills (subject to KFMAM rules)

10.6. Asset Conversion (Permitted Spend-Down on Excess Resources):

• ☐ Pay down legitimate debt
• ☐ Pre-pay funeral/burial via irrevocable burial contract (within state limits)
• ☐ Home repairs / accessibility modifications
• ☐ Replace older vehicle with one suitable for transportation needs
• ☐ Purchase exempt personal effects
• ☐ Medicaid-compliant annuity (community spouse) — strict requirements; consult counsel

11. REQUIRED VERIFICATIONS AND DOCUMENTS

Attach legible copies of all applicable items:

• ☐ Photo ID / driver's license
• ☐ Social Security card (applicant and spouse)
• ☐ Birth certificate or proof of age
• ☐ Proof of U.S. citizenship or qualified-non-citizen status
• ☐ Marriage certificate (if married)
• ☐ Death certificate (if widowed)
• ☐ Divorce decree (if divorced)
• ☐ Medicare card (Parts A/B/D)
• ☐ Health and long-term care insurance policies and premium statements
• ☐ Sixty (60) months of bank statements (all accounts, all owners with applicant)
• ☐ Brokerage / retirement account statements (60 months)
• ☐ Life insurance policies (face and cash value statements)
• ☐ Annuity contracts and statements
• ☐ Real estate deeds, current tax assessments, and mortgage statements
• ☐ Vehicle titles
• ☐ Burial contracts / pre-need agreements
• ☐ Trust instruments (any trust to which applicant or spouse is settlor or beneficiary)
• ☐ Income verification (Social Security award letter, pension statements, paystubs, tax returns)
• ☐ Federal tax returns (most recent 2 years)
• ☐ Documentation of all transfers within the 60-month look-back
• ☐ Power of attorney / guardianship / conservatorship documents
• ☐ Physician's level-of-care certification / CARE assessment
• ☐ Facility admission documents (if institutional)

12. AUTHORIZED REPRESENTATIVE DESIGNATION

Pursuant to 42 C.F.R. § 435.923, Applicant designates the following individual as Authorized Representative for the purpose of filing this application, receiving notices, and acting on behalf of Applicant in connection with this Medicaid case:

Name: [________________________________]

Relationship: [________________________________]

Address: [________________________________]

Telephone / Email: [________________________________]

Authority granted (check all that apply):

• ☐ Submit application and verifications
• ☐ Receive notices and decisions
• ☐ Request fair hearing
• ☐ Communicate with KDHE Clearinghouse, MCOs, KDADS, and DCF
• ☐ All purposes related to this Medicaid case

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

Authorized Representative signature: [________________________________] Date: [__/__/____]

13. ESTATE RECOVERY DISCLOSURE

13.1. Pursuant to 42 U.S.C. § 1396p(b) and K.S.A. § 39-719a, the State of Kansas is required to seek recovery from the estate of a deceased Medicaid recipient who was age 55 or older when the recipient received medical assistance, for the cost of all such assistance — including nursing-facility services, home- and community-based services, and related hospital and prescription-drug services.

13.2. Recovery is generally deferred during the lifetime of (a) a surviving spouse, (b) a child under age 21, or (c) a blind or permanently disabled child of any age.

13.3. Hardship waivers may be available under K.A.R. and KFMAM standards.

13.4. Acknowledgment: Applicant acknowledges receipt and understanding of this Estate Recovery Disclosure.

Applicant initials: [______] Date: [__/__/____]

14. APPLICANT CERTIFICATION AND SIGNATURE

I, the undersigned, declare under penalty of perjury under the laws of the State of Kansas and the United States that:

a. The information provided in this application and all attachments is true, correct, and complete to the best of my knowledge and belief;

b. I understand that providing false information may result in denial of benefits, recovery of benefits paid, civil penalties, and criminal prosecution under K.S.A. § 39-720 and 42 U.S.C. § 1320a-7b;

c. I authorize KDHE, KDADS, DCF, the KanCare MCOs, and their agents to verify the information in this application with banks, employers, the Social Security Administration, the IRS, the Kansas Department of Revenue, the Kansas Department of Labor, insurance companies, and other appropriate sources, including via the federal Asset Verification System (AVS);

d. I assign to the State of Kansas any rights to medical support and to payments for medical care from any third party to the extent such payments are made for services covered by Medicaid;

e. I will report any change in income, resources, household composition, residence, or other circumstances within ten (10) days of the change.

Applicant signature: [________________________________]

Print name: [________________________________]

Date: [__/__/____]

Spouse signature (if applicable): [________________________________]

Date: [__/__/____]

Witness / Notary (if required): [________________________________]

Date: [__/__/____]

15. KANSAS PRACTICE NOTES

• Where to file. KanCare applications are processed centrally by the KanCare Clearinghouse (KDHE). Long-term care functional eligibility (level of care for nursing facility or HCBS FE Waiver) is determined separately by an Aging and Disability Resource Center (ADRC) using the CARE / uniform assessment instrument.
• Waiver vs. institutional. The Frail Elderly (FE) Waiver permits otherwise nursing-facility-eligible Kansans age 65+ to receive home- and community-based services in lieu of institutional care. The FE Waiver is NOT an entitlement; slots are capped and a waiting list may apply. The Physical Disability (PD) Waiver and Brain Injury (BI) Waiver serve other populations and have separate criteria.
• Income limits — verify the standard. The 300% SSI special income limit (approximately $2,901/month for an individual in 2026) applies to institutional and waiver applicants. The Medically Needy Income Limit (MNIL) is materially lower and applies to non-institutional spend-down pathways. Mixing the two standards is the most common application error.
• Asset limit. $2,000 individual countable-resource limit for LTC Medicaid in 2026; $3,000 combined where both spouses apply. Community Spouse Resource Allowance up to $162,660 (federal maximum); minimum CSRA approximately $32,532. Verify against current spousal-impoverishment update.
• Look-back and divisor. 60-month look-back. The Kansas transfer penalty divisor for 2026 is approximately $287.14 per day (verify against the current KFMAM at the time of filing). Penalty period begins on the later of (a) date of transfer or (b) the date the applicant would otherwise qualify for and receive Medicaid LTC services.
• Home equity cap. $752,000 in 2026 (verify). Equity above the cap disqualifies the home from exclusion unless a spouse, minor child, or blind/disabled child resides there.
• Estate recovery. Aggressive in Kansas for services received after age 55. Counsel the client and family early; consider lifetime planning options well outside the look-back.
• Annuities and promissory notes. Medicaid-compliant annuities and DRA-compliant promissory notes can be powerful tools for community-spouse planning but must satisfy strict actuarial, irrevocability, and state-as-remainder-beneficiary requirements. Errors are routinely treated as uncompensated transfers.
• Fair hearings. Adverse eligibility determinations are appealable to the Office of Administrative Hearings. Notice of appeal must be filed within the timeframe stated in the denial notice — typically 33 days. Continued benefits pending appeal are available where the request is filed before the effective date of the proposed action.
• Managed care. Once enrolled, the recipient selects (or is auto-assigned to) one of the KanCare MCOs (Aetna Better Health of Kansas, Sunflower Health Plan, or UnitedHealthcare Community Plan). MCO assignment affects provider networks, prior-authorization rules, and care-coordination contacts.

16. SOURCES AND REFERENCES

• KanCare program portal — https://www.kancare.ks.gov/
• KanCare eligibility — https://www.kancare.ks.gov/apply-now/eligibility
• Kansas Department of Health and Environment (KDHE) — https://www.kdhe.ks.gov/
• Kansas Department for Aging and Disability Services (KDADS) — https://www.kdads.ks.gov/
• Kansas Family Medical Assistance Manual (KFMAM) — KDHE policy manual (verify current edition)
• Kansas Statutes Annotated, Chapter 39, Article 7 — Public Assistance — https://ksrevisor.gov/
• K.S.A. § 39-708c, § 39-709, § 39-719a (estate recovery)
• K.A.R. 30-6-1 et seq. (medical assistance regulations)
• 42 U.S.C. § 1396 et seq. (Title XIX Medicaid)
• 42 U.S.C. § 1396p (transfers, look-back, estate recovery)
• 42 U.S.C. § 1396r-5 (spousal impoverishment)
• 42 C.F.R. Part 435 (eligibility regulations)
• Centers for Medicare & Medicaid Services (CMS) — Spousal Impoverishment Standards (federal annual update)
• Kansas HCBS Frail Elderly Waiver — 1915(c) waiver application (CMS approved)
• Kansas Aging and Disability Resource Centers (ADRCs) — https://www.kdads.ks.gov/

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. Medicaid is a complex, rule-driven program; figures and policies change annually and vary by coverage group. A Kansas-licensed elder-law attorney must review and customize this document, and any planning steps, before filing or implementation. All cited figures are subject to change and must be re-verified against the current KFMAM, federal spousal-impoverishment standards, and KanCare guidance at the time of filing.