Kentucky Medicaid Application Packet — Long-Term Care / HCBS Waiver

KENTUCKY MEDICAID APPLICATION PACKET — LONG-TERM CARE / HCBS WAIVER

TABLE OF CONTENTS

1. Cover Letter / Submission Memorandum
2. Applicant and Household Information
3. Program Selected
4. Eligibility Snapshot — 2025/2026 Figures
5. Income Worksheet
6. Resource (Asset) Worksheet
7. Primary Residence and Home Equity
8. 60-Month Look-Back and Transfer Disclosure
9. Spousal Impoverishment / CSRA Computation
10. Medically Needy / Spend-Down Election
11. Patient Liability and Personal Needs Allowance
12. Documents Index (Verification Checklist)
13. Authorized Representative Designation
14. Applicant Certification and Signature
15. Kentucky Practice Notes
16. Sources and References

1. COVER LETTER / SUBMISSION MEMORANDUM

Date: [__/__/____]

Department for Community Based Services (DCBS)
Family Support Office — [COUNTY] County
[DCBS OFFICE STREET ADDRESS]
[CITY, KY ZIP]

Re: Medicaid Application — [APPLICANT FULL LEGAL NAME]
SSN (last 4): xxx-xx-[####]
Date of birth: [__/__/____]
Program requested: ☐ Nursing Facility (Institutional Medicaid) ☐ HCB Waiver (Aged & Disabled) ☐ Medically Needy / Spend-Down ☐ QMB / SLMB

To the Caseworker:

Enclosed please find the completed Medicaid application (DCBS Form [FORM NUMBER, e.g., DCBS-1A]) together with all required verifications listed in Section 12 of this packet for the above-named applicant. Please direct all correspondence to the Authorized Representative identified in Section 13.

Respectfully,

[________________________________]

[ATTORNEY OR REPRESENTATIVE NAME]

2. APPLICANT AND HOUSEHOLD INFORMATION

3. PROGRAM SELECTED

The applicant is applying for the following Kentucky Medicaid coverage group (check one primary):

• ☐ Institutional / Nursing Facility Medicaid (long-term care in a Medicaid-certified nursing facility).
• ☐ HCB Waiver — Aged and Disabled (home and community-based services in lieu of institutional care; administered by DAIL).
• ☐ Model Waiver II / Acquired Brain Injury / Supports for Community Living (specify): [________________________________].
• ☐ Medically Needy / Spend-Down (KY is a medically needy state for the aged, blind, and disabled — see Section 10).
• ☐ Medicare Savings Program (QMB / SLMB / QI).

4. ELIGIBILITY SNAPSHOT — 2025/2026 FIGURES

The following are commonly cited Kentucky figures for the aged, blind, and disabled categories. VERIFY all figures against the current DCBS Operation Manual and CMS Spousal Impoverishment Standards before filing.

5. INCOME WORKSHEET

List ALL gross monthly income for the applicant (and spouse, if married):

Direct-deposit institution(s) and account number(s) for verification:

• [BANK / ACCOUNT NUMBER]
• [BANK / ACCOUNT NUMBER]

6. RESOURCE (ASSET) WORKSHEET

List ALL resources owned individually, jointly, or held in trust as of the first moment of the application month:

A. Countable Resources

B. Non-Countable / Exempt Resources

• ☐ Primary residence (subject to home-equity cap, see Section 7)
• ☐ One automobile (no value limit if used for transportation)
• ☐ Household goods and personal effects
• ☐ Burial space and irrevocable burial reserve / pre-need contract
• ☐ Burial fund up to $1,500 (designated)
• ☐ Term life insurance (no cash value)
• ☐ Life insurance with face value $1,500 or less
• ☐ Income-producing property essential to self-support
• ☐ Special Needs Trust (d4A / d4C) — attach trust instrument

7. PRIMARY RESIDENCE AND HOME EQUITY

• Property address: [________________________________]
• Owner(s) of record: [________________________________]
• Date of purchase: [__/__/____]
• Current fair market value (PVA assessment or appraisal): $[______]
• Outstanding mortgage / lien balance: $[______]
• Net equity: $[______]
• Home equity exceeds the federal cap ($752,000 for 2026, verify)? ☐ Yes ☐ No

Intent to Return Home

The applicant ☐ does ☐ does not intend to return to the residence. (For institutional applicants, "intent to return home" is sufficient under 42 U.S.C. § 1396p(f)(1)(A)(i) to keep the home non-countable, even if return is medically improbable.)

Lawful Resident Exceptions (Home Remains Non-Countable Regardless of Equity)

• ☐ Spouse lawfully resides in the home.
• ☐ Child under age 21 lawfully resides in the home.
• ☐ Blind or disabled child of any age lawfully resides in the home.

Estate Recovery Notice

The applicant has received and reviewed the Kentucky Estate Recovery notice required by KRS § 205.622 / 907 KAR 1:585. Estate recovery may seek reimbursement against the probate estate of a deceased Medicaid recipient age 55+ for long-term-care services received.

8. 60-MONTH LOOK-BACK AND TRANSFER DISCLOSURE

The applicant has reviewed every transfer of assets (cash, real property, securities, beneficial interests) made during the 60 months immediately preceding the application date ([__/__/____]). All transfers for less than fair market value (FMV) are disclosed below.

Penalty Period Computation (illustrative)

Total uncompensated transfers: $[______]
Current Kentucky daily divisor: $305.28 (verify)
Penalty period (in days): [______]
Penalty period (months/days): [______]
Penalty start date: the first day the applicant is otherwise eligible AND receiving institutional or HCB Waiver services.

Statutory Exceptions Asserted (check all that apply)

• ☐ 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 (d)(4)(A) Special Needs Trust for individual under 65 with disability.
• ☐ Transfer to (d)(4)(C) Pooled Trust.
• ☐ Caregiver-child exception (home transferred to adult child who resided in the home for 2+ years and provided care delaying institutionalization, § 1396p(c)(2)(A)(iv)).
• ☐ Sibling-equity-interest exception (§ 1396p(c)(2)(A)(iii)).
• ☐ Transfer made exclusively for purpose other than to qualify for Medicaid (rebuttable; affidavit attached).
• ☐ Hardship waiver requested per 42 U.S.C. § 1396p(c)(2)(D) (statement of hardship attached).

9. SPOUSAL IMPOVERISHMENT / CSRA COMPUTATION

(Complete only if applicant is married and one spouse remains in the community.)

A. Resource Assessment Snapshot Date

The "snapshot" date is the first day of the first continuous period of institutionalization (or HCB Waiver enrollment) of 30 days or more.

• Snapshot date: [__/__/____]
• Total combined countable resources on snapshot date: $[______]

B. CSRA Calculation

• Half of combined countable resources: $[______]
• Federal minimum CSRA (2026, verify): $32,532
• Federal maximum CSRA (2026, verify): $162,660
• Community Spouse Resource Allowance: $[______] (the greater of half-of-resources, capped at the federal maximum, but not less than the federal minimum)
• Applicant's individual resource allowance: $2,000
• Resources that must be spent down or properly converted before approval: $[______]

C. MMMNA / Income Allocation

• Community spouse's gross monthly income: $[______]
• MMMNA shortfall: $[______]
• Monthly income transferred from institutionalized spouse to community spouse under § 1396r-5(d): $[______]

10. MEDICALLY NEEDY / SPEND-DOWN ELECTION

Kentucky operates a Medically Needy program for the aged, blind, and disabled. Applicants whose income exceeds the categorically needy limit but who incur medical expenses sufficient to reduce income to the Medically Needy Income Limit (MNIL) may qualify on a quarterly basis.

• ☐ Applicant elects Medically Needy / spend-down review.
• Spend-down period: 3 months (quarterly).
• MNIL applied (single): approx. $217 / month (verify current figure).
• Excess income to be spent down per quarter: $[______]
• Allowable medical expenses identified (bills, premiums, prescriptions, medical transportation): $[______]

11. PATIENT LIABILITY AND PERSONAL NEEDS ALLOWANCE

For an institutionalized applicant, monthly patient liability is computed as:

12. DOCUMENTS INDEX (VERIFICATION CHECKLIST)

The following documents are enclosed (☐) or are to follow within the DCBS deadline (X):

• ☐ Photo ID for applicant and spouse
• ☐ Social Security cards (or SSA verification)
• ☐ Birth certificate / proof of age
• ☐ Proof of U.S. citizenship or qualified non-citizen status
• ☐ Marriage certificate (if married); divorce decree(s) (if applicable)
• ☐ Death certificate of prior spouse (if widowed)
• ☐ Medicare card and supplemental insurance cards
• ☐ Five (5) years of bank statements for ALL accounts (checking, savings, CDs, brokerage)
• ☐ Five (5) years of brokerage / IRA / 401(k) statements
• ☐ Recent statement for every life-insurance policy with cash value
• ☐ Deed(s) and most recent PVA assessment for all real estate
• ☐ Mortgage / HELOC statement(s)
• ☐ Title and registration for each vehicle
• ☐ Pre-need burial contract / cemetery deed
• ☐ Trust instruments (revocable and irrevocable) — full text
• ☐ Annuity contracts and payout schedules
• ☐ Tax returns for the most recent two years (federal and KY)
• ☐ Pension and Social Security award letters
• ☐ DD-214 (if veteran); VA award letter
• ☐ Long-term-care insurance policy and benefits paid
• ☐ MAP-350 / MAP-351 level-of-care assessment (if facility/HCBW)
• ☐ Power of Attorney / Guardianship order designating Authorized Representative
• ☐ Documentation supporting every transfer disclosed in Section 8

13. AUTHORIZED REPRESENTATIVE DESIGNATION

Pursuant to 907 KAR 1:011 and 42 C.F.R. § 435.923, the applicant designates the following individual as Authorized Representative for all matters relating to this Medicaid application, including receipt of correspondence, attendance at interviews, and submission of verifications.

• Name: [________________________________]
• Relationship to applicant: [________________________________]
• Address: [________________________________]
• Telephone: [________________________________]
• Email: [________________________________]
• Authority basis: ☐ Durable Power of Attorney ☐ Guardian / Conservator (KRS Ch. 387) ☐ Written designation by competent applicant

14. APPLICANT CERTIFICATION AND SIGNATURE

I, the undersigned, certify under penalty of perjury that the information contained in this application packet is true, correct, and complete to the best of my knowledge. I understand that knowingly providing false information may result in denial of benefits, recoupment, civil penalties, and criminal prosecution under KRS § 205.8453 and 18 U.S.C. § 1001. I authorize DMS, DCBS, and DAIL to verify all information with financial institutions, employers, the Social Security Administration, and other agencies as needed.

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

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

Notary (optional but recommended for transfer affidavits):

Sworn to and subscribed before me this [____] day of [_______________], 20[____].

[________________________________]
Notary Public — Commonwealth of Kentucky
My Commission Expires: [__/__/____]

15. KENTUCKY PRACTICE NOTES

• Filing channels. Applications may be filed online at kynect.ky.gov, by telephone (1-855-459-6328), in person at any DCBS Family Support office, by mail, or by fax. Long-term-care applications are processed by the local DCBS office in the applicant's county of residence (or the county in which the facility is located, depending on case assignment).
• Decision timeline. DCBS must act on applications within 45 days for non-disability cases and within 90 days when disability determination is required (42 C.F.R. § 435.912; 907 KAR 1:011).
• Retroactive coverage. Medicaid coverage may begin up to 3 months prior to the month of application if the applicant met all eligibility criteria during those months and incurred covered expenses (42 C.F.R. § 435.915).
• HCB Waiver level of care. The applicant must be assessed as needing a nursing-facility level of care via the MAP-351 (initial) and MAP-350 (recertification) instruments. DAIL contracts with regional Area Agencies on Aging and Independent Living (AAAILs) for case management.
• Estate recovery. Kentucky pursues estate recovery only against the probate estate (limited recovery state) for recipients age 55+ who received nursing-facility, ICF/IID, HCBW, or related drug and hospital services. Hardship waiver provisions apply. KRS § 205.622; 907 KAR 1:585.
• Fair hearings. A denial, termination, or reduction triggers the right to a Medicaid fair hearing under 907 KAR 1:560 and 42 C.F.R. Part 431, Subpart E. Request must be filed within 30 days of the adverse action notice. Aid pending hearing is available if requested within 10 days for terminations of existing benefits.
• Annuities, promissory notes, and life estates. Each is heavily regulated under DRA 2005 and 42 U.S.C. § 1396p(c)(1)(F)–(J). A KY-licensed elder-law attorney should structure any such instrument to avoid characterization as a transfer for less than FMV.
• Caregiver-child agreements. Personal-services contracts compensating an adult child for caregiving must be in writing, prospectively executed, supported by FMV hourly rates, contemporaneously documented, and reported as taxable income to be respected by DMS.
• Spousal refusal / "just say no." Kentucky generally does not honor pure spousal refusal, but spousal-impoverishment protections under § 1396r-5 apply automatically. Counsel should preserve the community spouse's CSRA and consider a fair-hearing CSRA increase under § 1396r-5(e)(2)(C) when income alone is insufficient to meet the MMMNA.

16. SOURCES AND REFERENCES

• 42 U.S.C. § 1396 et seq. (Medicaid) — https://uscode.house.gov/
• 42 U.S.C. § 1396p (Transfers, liens, recovery) — https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1396p
• 42 U.S.C. § 1396r-5 (Spousal impoverishment) — https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1396r-5
• KRS Chapter 205 (Public Assistance and Medical Assistance) — https://apps.legislature.ky.gov/law/statutes/chapter.aspx?id=37852
• KRS § 205.622 (Estate recovery) — https://apps.legislature.ky.gov/law/statutes/statute.aspx?id=8095
• 907 KAR 1:011 (Application, intake, interview) — https://apps.legislature.ky.gov/law/kar/titles/907/001/011/
• 907 KAR 1:640 (ABD eligibility) — https://apps.legislature.ky.gov/law/kar/titles/907/
• 907 KAR 1:645 (ABD resources) — https://apps.legislature.ky.gov/law/kar/titles/907/
• 907 KAR 1:650 (ABD income / spend-down) — https://apps.legislature.ky.gov/law/kar/titles/907/
• 907 KAR 1:655 (Transfer of resources) — https://apps.legislature.ky.gov/law/kar/titles/907/
• 907 KAR 1:835 (HCB Waiver services) — https://apps.legislature.ky.gov/law/kar/titles/907/
• Kentucky Cabinet for Health and Family Services, Department for Medicaid Services — https://www.chfs.ky.gov/agencies/dms/
• DCBS Family Support / kynect — https://kynect.ky.gov/
• Kentucky Department for Aging and Independent Living (HCB Waiver) — https://www.chfs.ky.gov/agencies/dail/
• CMS Spousal Impoverishment Standards — https://www.medicaid.gov/medicaid/eligibility/spousal-impoverishment/index.html
• CMS State Medicaid Manual — https://www.cms.gov/regulations-and-guidance/guidance/manuals

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. Medicaid figures and policies change annually. A Kentucky-licensed elder-law attorney must verify all citations, regulations, and dollar amounts against current DMS / DCBS / DAIL policy and CMS guidance before any submission, transfer, or planning step. Improper transfers can produce months or years of disqualification.