MaineCare (Medicaid) Long-Term Care Application Packet

MAINECARE LONG-TERM CARE APPLICATION PACKET — STATE OF MAINE

TABLE OF CONTENTS

1. Applicant Information
2. Program Selection and Level of Care
3. Financial Eligibility — Income
4. Financial Eligibility — Assets
5. Spousal Impoverishment Protections
6. Primary Residence Treatment
7. 60-Month Look-Back and Transfer Penalty
8. Medically Needy / Spend-Down Pathway
9. Required Documentation Checklist
10. Authorized Representative and HIPAA Release
11. Applicant Certification
12. Sources and References

1. APPLICANT INFORMATION

2. PROGRAM SELECTION AND LEVEL OF CACE

Select the MaineCare long-term care program for which the applicant is applying:

☐ Section 67 — Nursing Facility Services (institutional MaineCare). Requires a medical eligibility determination ("Medical Eligibility Determination" or MED form, completed by Goold Health Systems or successor assessor) finding the applicant meets nursing facility level of care.

☐ Section 19 — Home and Community Benefits for the Elderly and Adults with Disabilities Waiver (HCBS waiver). Requires (a) age 18+ or elderly status, (b) nursing facility level of care, and (c) services delivered in the community in lieu of institutionalization. The waiver is subject to a slot/funding cap and may have a wait list; request confirmation of slot availability.

☐ Section 21 / Section 29 — applicable to adults with intellectual or developmental disabilities (different financial rules; consult counsel).

☐ Section 97 — PNMI / Residential Care Facility services.

Level of Care Determination:

• MED-form completed by: [________________________________]
• Date of LOC determination: [__/__/____]
• Determination outcome: ☐ Meets NF LOC ☐ Does not meet NF LOC ☐ Pending

3. FINANCIAL ELIGIBILITY — INCOME

Applicable income standard (2026, verify on date of application):

Applicant gross monthly income:

Patient Pay / Cost of Care Calculation (Section 67, NF residents):

4. FINANCIAL ELIGIBILITY — ASSETS

Asset limits (verify on date of application):

Countable Assets Inventory:

Excluded / Non-Countable Assets:

☐ Primary residence (subject to equity cap and intent-to-return rules — see §6)
☐ One automobile (any value, if used for transportation of applicant or spouse)
☐ Household goods and personal effects
☐ Term life insurance with no cash value
☐ Cash value life insurance with face value of $1,500 or less
☐ Irrevocable burial contract / burial fund up to $1,500 (per state policy — VERIFY)
☐ Burial space and related items
☐ Personal-needs account up to allowable balance
☐ Income-producing property essential to self-support (if applicable)
☐ Retirement account in payout status (verify treatment under current OFI policy)

5. SPOUSAL IMPOVERISHMENT PROTECTIONS

Applicable when one spouse is institutionalized or on the Section 19 HCBS waiver and the other ("community spouse") remains in the community.

Resource Assessment (snapshot):

Income Allowance to Community Spouse:

A fair-hearing request or court order may increase CSRA or MMNA where the standard amounts are insufficient (42 U.S.C. § 1396r-5(e)).

6. PRIMARY RESIDENCE TREATMENT

The applicant's primary residence is generally a non-countable asset for eligibility purposes, subject to:

1. Home equity cap. If the applicant has no spouse, dependent child under 21, or blind/disabled child residing in the home, equity above the federal cap (approximately $1,097,000-$1,130,000 in 2026 — VERIFY) renders the home countable. 42 U.S.C. § 1396p(f).
2. Intent to return. For an institutionalized single applicant, the home remains exempt only while the applicant has a documented intent to return.
3. Spouse or qualifying dependent in residence. Home is fully exempt while a community spouse or qualifying dependent resides there, regardless of equity.
4. Estate recovery. Even where exempt during life, the home is subject to MaineCare estate recovery under 22 M.R.S. § 14 and 42 U.S.C. § 1396p(b) following the death of the recipient (and any surviving spouse, qualifying child, etc.). A TEFRA / pre-death lien is generally not imposed in Maine but verify current OFI policy.

7. 60-MONTH LOOK-BACK AND TRANSFER PENALTY

Maine enforces the federal 60-month look-back for transfers for less than fair market value (42 U.S.C. § 1396p(c); 10-144 C.M.R. ch. 332). The look-back date is the later of (a) the date of application or (b) the date the applicant entered a nursing facility or began HCBS waiver services.

Look-back window: [__/__/____] through [__/__/____]

Transfer Disclosure:

Penalty Period Calculation (Section 67 / Section 19):

Exempt Transfers (federal):

☐ Transfer to spouse, or to another for the sole benefit of the spouse
☐ Transfer to a child under 21, or to a blind or permanently disabled child of any age (or trust solely for such child)
☐ Transfer of home to a sibling with equity interest who resided in home for ≥ 1 year before institutionalization
☐ Transfer of home to a "caretaker child" who resided in home for ≥ 2 years immediately before institutionalization and provided care that delayed institutionalization
☐ Transfer to a (d)(4)(A) special-needs trust or (d)(4)(C) pooled trust
☐ Transfer demonstrably made exclusively for a purpose other than to qualify for MaineCare (rebuttal evidence)

Undue Hardship Waiver: A penalty may be waived where its imposition would deprive the applicant of medical care endangering health or life, or food, clothing, shelter, or other necessities. Submit a written hardship request with supporting documentation.

8. MEDICALLY NEEDY / SPEND-DOWN PATHWAY

Maine operates a Medically Needy program for the aged, blind, and disabled. Applicants whose income exceeds the categorically needy standard but who incur medical expenses sufficient to "spend down" to the Medically Needy Income Level may qualify on a six-month accounting basis.

Medically Needy is most commonly used where a community-based applicant has income above the special income level but substantial recurring medical expenses. Institutional and HCBS waiver applicants typically qualify under the special-income-level pathway with patient-pay liability instead. Confirm pathway with caseworker and counsel.

9. REQUIRED DOCUMENTATION CHECKLIST

☐ Completed MaineCare application (web/paper) submitted via MyMaineConnection or local OFI office
☐ Photo ID for applicant and authorized representative
☐ Social Security card(s) (applicant and spouse)
☐ Birth certificate or proof of age
☐ Proof of Maine residency (lease, utility bill, tax bill)
☐ Proof of U.S. citizenship or qualified immigration status
☐ Marriage certificate (if married, widowed, divorced)
☐ Death certificate of deceased spouse (if applicable)
☐ Divorce decree or separation order (if applicable)
☐ Five (5) years of bank statements for every account ever held during look-back window
☐ Five (5) years of brokerage / IRA / annuity statements
☐ Current Social Security benefit verification letter
☐ Pension/VA award letter
☐ Life-insurance policies (face page and current cash-value statement)
☐ Funeral / burial contract
☐ Deed and most recent tax bill for all real property
☐ Mortgage statements / equity-line statements
☐ Vehicle titles and registrations
☐ Trust instruments and trust accountings (if any)
☐ Power of attorney / guardianship / conservatorship orders
☐ Health-insurance cards (Medicare, Medigap, employer plan)
☐ Resident assessment / MED form (Sections 19, 67)
☐ Facility admission agreement and most recent itemized billing
☐ Documentation of every transfer ≥ $500 in look-back window
☐ Tax returns (last three years)

10. AUTHORIZED REPRESENTATIVE AND HIPAA RELEASE

I, [APPLICANT NAME], authorize the following individual to act as my Authorized Representative for purposes of this MaineCare application and ongoing case management:

I authorize the Maine Department of Health and Human Services, Office for Family Independence, all banks, brokerages, employers, insurance carriers, health-care providers, the Social Security Administration, the Internal Revenue Service, the Veterans Administration, and Goold Health Systems (or successor assessor) to release to the Authorized Representative and to one another all information necessary to process this application.

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

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

11. APPLICANT CERTIFICATION

I declare under penalty of perjury under the laws of the State of Maine and the United States that the foregoing is true and correct to the best of my knowledge and belief. I understand that knowingly providing false or incomplete information may result in denial or termination of MaineCare benefits, recovery of benefits paid, civil penalties, and criminal prosecution under 22 M.R.S. § 15 and 42 U.S.C. § 1320a-7b. I agree to report any change in income, assets, household composition, residence, or facility placement within ten (10) days.

12. SOURCES AND REFERENCES

• Maine DHHS, Office for Family Independence (OFI): https://www.maine.gov/dhhs/ofi
• MyMaineConnection (apply online): https://www.mymaineconnection.gov
• MaineCare Eligibility Manual, 10-144 C.M.R. ch. 332: https://www.maine.gov/sos/cec/rules/10/144/144c332.docx
• MaineCare Benefits Manual, 10-144 C.M.R. ch. 101: https://www1.maine.gov/sos/rulemaking/agency-rules/mainecare-benefits-manual
• Section 19 (HCBS Waiver for Elderly and Adults with Disabilities), Maine DHHS: https://www.maine.gov/dhhs/oms/mainecare-options/older-adults-and-adults-with-disabilities
• Section 67 (Nursing Facility Services): https://www.maine.gov/dhhs/oms/providers/mainecare-policies-rules
• Federal Medicaid statute: 42 U.S.C. § 1396 et seq. (https://www.law.cornell.edu/uscode/text/42/chapter-7/subchapter-XIX)
• 42 U.S.C. § 1396p (transfers, liens, estate recovery): https://www.law.cornell.edu/uscode/text/42/1396p
• Spousal impoverishment standards (annual update): https://www.medicaid.gov/medicaid/eligibility/spousal-impoverishment/index.html
• Legal Services for Maine Elders (LSME): https://mainelse.org
• Maine Long-Term Care Ombudsman Program: https://www.maineombudsman.org
• MaineCare COLA bulletins (rulemaking page): https://www.maine.gov/dhhs/about/rulemaking

END OF MAINECARE LONG-TERM CARE APPLICATION PACKET