Minnesota Medical Assistance (Medicaid) Application Packet — Long-Term Care / Elderly Waiver

MINNESOTA MEDICAL ASSISTANCE APPLICATION PACKET — LONG-TERM CARE & ELDERLY WAIVER

TABLE OF CONTENTS

1. Cover Letter to County Human Services Agency
2. Applicant and Household Identification
3. Program Selection and Level of Care
4. Income Disclosure
5. Asset Inventory and Verification
6. Spousal Impoverishment Protections
7. 60-Month Look-Back and Transfer Disclosure
8. Primary Residence Treatment
9. Spend-Down (Medically Needy) Election
10. Estate Recovery and Lien Acknowledgement
11. Authorizations and Signatures
12. Document Index
13. Minnesota Practice Notes
14. Sources and References

1. COVER LETTER TO COUNTY HUMAN SERVICES AGENCY

[__/__/____]

[COUNTY] County Human Services
Attn: Long-Term Care Eligibility Worker
[________________________________]
[CITY], MN [_______]

Re: Application for Medical Assistance — Long-Term Care
Applicant: [APPLICANT FULL LEGAL NAME]
Date of birth: [__/__/____]
SSN: XXX-XX-[____]
Baseline date requested: [__/__/____]

Dear Eligibility Worker:

Enclosed please find the Application for Health Care Programs (DHS-6696) and supporting documentation for [APPLICANT NAME], submitted under Minn. Stat. §§ 256B.055 and 256B.056. Applicant requests determination for:

☐ MA-LTC (institutional / nursing-facility level of care)
☐ MA — Elderly Waiver (EW) under Minn. Stat. § 256B.0915
☐ MA — Alternative Care (AC)
☐ MA spenddown (medically needy) under Minn. Stat. § 256B.056, subd. 5

Applicant requests a baseline date of [__/__/____] and requests retroactive coverage for the three months preceding application pursuant to 42 C.F.R. § 435.915.

Please direct all eligibility correspondence to the undersigned authorized representative.

Respectfully submitted,

[________________________________]
[ATTORNEY / AUTHORIZED REPRESENTATIVE NAME]
[FIRM]
[ADDRESS]
[PHONE] | [EMAIL]

2. APPLICANT AND HOUSEHOLD IDENTIFICATION

3. PROGRAM SELECTION AND LEVEL OF CARE

Applicant requests eligibility for the following Medical Assistance long-term-services-and-supports (LTSS) programs:

☐ MA-LTC (Institutional). Applicant resides in a nursing facility, ICF/DD, or hospital and meets the nursing-facility level of care under Minn. R. 9505.0335. Anticipated length of stay: ☐ 30+ days ☐ Other [____].

☐ Elderly Waiver (EW) under Minn. Stat. § 256B.0915. Applicant is age 65+, meets nursing-facility level of care, and receives or will receive HCBS in the community.

☐ Alternative Care (AC) under Minn. Stat. § 256B.0913 (for age 65+ not yet financially eligible for MA but at risk of nursing-home placement).

Required level-of-care assessment: ☐ MnCHOICES assessment completed [__/__/____] ☐ Pending — request assessment at filing.

4. INCOME DISCLOSURE

Applicant attests that the following is the complete monthly gross income of the applicant (and, where required, the community spouse) for the month of application:

5. ASSET INVENTORY AND VERIFICATION

Applicant attests under penalty of perjury that the following is a complete inventory of all countable and excluded assets owned in whole or in part by the applicant (and spouse) as of the first moment of the month of application:

5.1 Liquid Assets

5.2 Real Property

5.3 Vehicles, Personal Property, Insurance

5.4 Trusts and Business Interests

☐ Applicant or spouse is grantor, trustee, or beneficiary of trust [________________________________]. A complete copy of the trust instrument and all amendments is attached.

☐ Applicant or spouse holds an interest in [BUSINESS / PARTNERSHIP / LLC]. Schedule K-1 and balance sheet are attached.

5.5 Asset Limits (2026)

6. SPOUSAL IMPOVERISHMENT PROTECTIONS

If applicant is married and has a community spouse, the parties invoke the protections of Minn. Stat. § 256B.059 and 42 U.S.C. § 1396r-5:

☐ Snapshot date: First date of continuous institutionalization of 30 days or more — [__/__/____]. Snapshot countable resources: $[_______].

☐ Community Spouse Resource Allowance (CSRA): Calculated as the greater of one-half of snapshot resources or the federal minimum, capped at $162,660 (2026). CSRA = $[_______].

☐ Minimum Monthly Maintenance Needs Allowance (MMMNA): Community spouse claims monthly income allowance of $[_______]. Documentation of community-spouse shelter expenses attached.

☐ Fair-hearing request to increase CSRA / MMMNA: ☐ Yes — separate request enclosed under Minn. Stat. § 256B.0595, subd. 5; ☐ No.

7. 60-MONTH LOOK-BACK AND TRANSFER DISCLOSURE

Pursuant to Minn. Stat. § 256B.0595 and 42 U.S.C. § 1396p(c), applicant discloses every transfer of assets by applicant or spouse during the 60 months preceding the baseline date of [__/__/____].

7.1 Transfer Schedule

7.2 Excluded / Permitted Transfers Asserted

Applicant asserts that the following transfers are excluded under Minn. Stat. § 256B.0595, subd. 3 or 4, and should not generate a penalty period:

☐ Transfer to spouse or for sole benefit of spouse (subd. 3(a))
☐ Transfer to a child who is blind or permanently disabled (subd. 3(b))
☐ Transfer to a "caretaker child" who resided in the home and provided care for at least two years immediately before institutionalization (subd. 4)
☐ Transfer to a "sibling-equity" sibling under federal rule
☐ Transfer to a special-needs trust under 42 U.S.C. § 1396p(d)(4)(A) or pooled trust under (d)(4)(C)
☐ Transfer made exclusively for a purpose other than to qualify for MA — supporting evidence attached

7.3 Transfer Penalty Calculation (if applicable)

Total uncompensated value: $[_______]
SAPSNF divisor in effect for eligibility month: $11,653 (Jul 1 2025 – Jun 30 2026) / $11,869 (Jul 1 2026 – Jun 30 2027) — circle applicable
Penalty period (months) = uncompensated value ÷ SAPSNF = [______] months and [____] days
Penalty start date (first day applicant is otherwise eligible and receiving LTSS): [__/__/____]

8. PRIMARY RESIDENCE TREATMENT

Applicant's homestead address: [________________________________]

☐ Homestead is occupied by applicant's spouse — excluded under Minn. Stat. § 256B.056, subd. 2 / 42 U.S.C. § 1396p(f)(1).
☐ Homestead is occupied by a child under 21, blind, or permanently disabled — excluded.
☐ Homestead is occupied by a sibling with equity interest who has resided there for at least one year before institutionalization — excluded.
☐ Applicant intends to return home — Statement of Intent to Return attached.
☐ Equity exceeds $752,000 federal cap — homestead is a countable resource per Minn. Stat. § 256B.056, subd. 3a.

A Medical Assistance lien may be filed against the homestead under Minn. Stat. § 514.981 once applicant is determined permanently institutionalized.

9. SPEND-DOWN (MEDICALLY NEEDY) ELECTION

Minnesota administers a medically needy MA program under Minn. Stat. § 256B.056, subd. 5. Applicants whose income exceeds the applicable categorical income standard may qualify by incurring medical expenses sufficient to reduce countable income below the medically needy income standard (MNIS).

☐ Applicant elects six-month spenddown beginning [__/__/____].
Excess monthly income: $[_______] × 6 = total spenddown obligation $[_______].
☐ Applicant elects monthly spenddown.
Bills used to satisfy spenddown:
[________________________________]

10. ESTATE RECOVERY AND LIEN ACKNOWLEDGEMENT

Applicant acknowledges that under Minn. Stat. § 256B.15 and 42 U.S.C. § 1396p(b):

1. The State of Minnesota and the county human services agency may assert a claim against applicant's "estate" for the total amount of MA paid for long-term services and supports received by applicant on or after age 55 (and for any age for AC and GAMC).
2. "Estate" for MA-recovery purposes is expanded beyond probate property and includes joint-tenancy interests, life estates, payable-on-death accounts, and certain trust interests in which applicant had legal title or beneficial interest at death (Minn. Stat. § 256B.15, subd. 1a–1k).
3. A claim against the estate of applicant's surviving spouse may be asserted for MA paid on applicant's behalf (Minn. Stat. § 256B.15, subd. 1a(b)).
4. A Medical Assistance lien may be filed against applicant's real property under Minn. Stat. § 514.981 if applicant is determined to be permanently residing in a medical institution.
5. Hardship waivers may be requested under Minn. Stat. § 256B.15, subd. 5, by an heir who would be deprived of necessary support.

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

11. AUTHORIZATIONS AND SIGNATURES

11.1 Verification Under Penalty of Perjury

I, [APPLICANT NAME], declare under penalty of perjury under the laws of the State of Minnesota that the information in this application packet is true and correct to the best of my knowledge.

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

[________________________________] Date: [__/__/____]
Authorized representative / attorney-in-fact

11.2 Authorization to Release Information / Asset Verification (DHS-3543)

Applicant authorizes the county and DHS to obtain financial records covering the 60 months preceding the application date from any depository, broker, insurer, employer, or government agency necessary to determine MA-LTC eligibility.

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

11.3 Designation of Authorized Representative (DHS-5841)

[________________________________] is designated as authorized representative to receive notices, file appeals, and act on applicant's behalf.

12. DOCUMENT INDEX

☐ DHS-6696 — Combined Application for Health Care Programs
☐ DHS-3543 — Authorization for Release of Information
☐ DHS-5841 — Authorized Representative designation
☐ Birth certificate / proof of age
☐ Proof of citizenship / immigration status
☐ Marriage certificate (if married); divorce decree (if applicable)
☐ Social Security and Medicare cards
☐ All bank statements — 60 months
☐ Brokerage / IRA / 401(k) statements — 60 months
☐ Tax returns — 5 years
☐ Deeds, mortgages, property tax statements
☐ Vehicle titles
☐ Life-insurance policies and cash-value statements
☐ Annuity contracts
☐ Trust instruments and amendments
☐ Power of attorney / health-care directive
☐ Pre-need / burial contracts
☐ MnCHOICES assessment (or request)

13. MINNESOTA PRACTICE NOTES

1. County administration. Minnesota MA eligibility is administered at the county level. File with the human-services agency in the county of residence; institutionalized applicants may file in the county of physical residence (county where the facility is located) per Minn. Stat. § 256G.02.

2. MnCHOICES assessment. EW and MA-LTC require a current MnCHOICES level-of-care assessment under Minn. Stat. § 256B.0911. Request the assessment immediately — backlogs of 30–60 days are common.

3. Annuities. Annuity rules are strict. To be a non-countable asset/non-transfer, an annuity must be irrevocable, non-assignable, actuarially sound, name the State of Minnesota as primary remainder beneficiary up to total MA paid, and pay equal payments without a balloon. See 42 U.S.C. § 1396p(c)(1)(F)–(G).

4. Half-a-loaf and gift-and-loan strategies. Permitted but require careful execution and a promissory note compliant with 42 U.S.C. § 1396p(c)(1)(I) (actuarially sound, no balloon, non-cancellable on death, non-negotiable). Do NOT attempt without elder-law counsel — drafting errors disqualify the entire structure.

5. Spousal refusal. Minnesota does not bar a community spouse from refusing to make resources available, but DHS will pursue support contributions under Minn. Stat. § 256B.14, subd. 2. Document refusal carefully.

6. Appeals. Adverse eligibility decisions may be appealed under Minn. Stat. § 256.045 within 30 days of the notice of action. Submit appeal in writing to the Appeals Office.

7. Estate-recovery planning. Because Minnesota's "estate" definition is expanded, joint-tenancy and TOD planning that avoids probate does NOT automatically avoid MA recovery. Coordinate Minn. Stat. § 256B.15 planning before the recipient turns 55.

8. Annual updates. Eligibility figures change. Confirm current SAPSNF, asset limits, CSRA, MMMNA, and EW income limits at hcopub.dhs.state.mn.us/epm/appendix_f.htm before every filing.

14. SOURCES AND REFERENCES

• Minn. Stat. § 256B.055 — https://www.revisor.mn.gov/statutes/cite/256B.055
• Minn. Stat. § 256B.056 — https://www.revisor.mn.gov/statutes/cite/256B.056
• Minn. Stat. § 256B.0595 (transfer of assets / look-back) — https://www.revisor.mn.gov/statutes/cite/256B.0595
• Minn. Stat. § 256B.059 (spousal impoverishment) — https://www.revisor.mn.gov/statutes/cite/256B.059
• Minn. Stat. § 256B.0915 (Elderly Waiver) — https://www.revisor.mn.gov/statutes/cite/256B.0915
• Minn. Stat. § 256B.15 (estate recovery) — https://www.revisor.mn.gov/statutes/cite/256B.15
• Minn. Stat. § 514.981 (MA lien) — https://www.revisor.mn.gov/statutes/cite/514.981
• DHS Health Care Programs Eligibility Policy Manual — https://hcopub.dhs.state.mn.us/epm/
• EPM Appendix F (Standards & Guidelines, including SAPSNF $11,653 / $11,869) — https://hcopub.dhs.state.mn.us/epm/appendix_f.htm
• EPM § 2.4.1.3.1 (Look-back period and transfer date) — https://hcopub.dhs.state.mn.us/epm/2_4_1_3_1.htm
• EPM § 2.4.1.3.2 (MA-LTC transfer penalty) — https://hcopub.dhs.state.mn.us/epm/2_4_1_3_2.htm
• DHS Income & Asset Limits — https://mn.gov/dhs/people-we-serve/adults/health-care/health-care-programs/programs-and-services/income-asset-limits.jsp
• DHS-6696 Combined Application — https://edocs.dhs.state.mn.us/lfserver/Public/DHS-6696-ENG
• 42 U.S.C. § 1396p — https://www.law.cornell.edu/uscode/text/42/1396p
• 42 U.S.C. § 1396r-5 — https://www.law.cornell.edu/uscode/text/42/1396r-5