Missouri Medicaid (MO HealthNet) Application Packet — Aged, Blind, and Disabled / HCBS Aged & Disabled Waiver

MISSOURI MEDICAID (MO HEALTHNET) APPLICATION PACKET — AGED, BLIND, AND DISABLED / HCBS AGED & DISABLED WAIVER

TABLE OF CONTENTS

1. Applicant and Representative Identification
2. Program Track Selection
3. Categorical Eligibility — Age, Blindness, Disability
4. Income Determination
5. Resource (Asset) Determination
6. Primary Residence and Home-Equity Treatment
7. 60-Month Look-Back and Transfer of Assets
8. Spousal Impoverishment (Community Spouse) Protections
9. Required Verification Documents
10. Spend-Down Election (Medically Needy)
11. HCBS Aged & Disabled Waiver Specifics
12. Estate Recovery Disclosure
13. Authorized Representative Designation
14. Applicant Certification and Signature
15. Cover Letter to Family Support Division
16. Missouri Practice Notes
17. Sources and References

1. APPLICANT AND REPRESENTATIVE IDENTIFICATION

Authorized Representative (if applicable):

2. PROGRAM TRACK SELECTION

Check ALL programs for which determination is requested:

• ☐ MO HealthNet for the Aged, Blind, and Disabled (MHABD) — Non-Spend-Down
• ☐ MO HealthNet for the Aged, Blind, and Disabled (MHABD) — Spend-Down (Medically Needy)
• ☐ MO HealthNet for Nursing Facility / Vendor Care (Long-Term Care)
• ☐ HCBS Aged & Disabled Waiver (ADW) — community-based services to delay nursing-home placement
• ☐ Qualified Medicare Beneficiary (QMB) / Specified Low-Income Medicare Beneficiary (SLMB) / Qualifying Individual (QI)
• ☐ Ticket to Work Health Assurance (TWHA) — working disabled

3. CATEGORICAL ELIGIBILITY — AGE, BLINDNESS, DISABILITY

The applicant qualifies under the following category (check one or more):

• ☐ Aged — age 65 or older. Date of birth verifies age.
• ☐ Blind — meets SSA definition of statutory blindness (20/200 or worse in better eye with correction, or visual field ≤ 20°).
• ☐ Disabled — meets SSA definition under 42 U.S.C. § 1382c(a)(3): inability to engage in substantial gainful activity by reason of medically determinable impairment expected to last at least 12 months or result in death.

Existing Federal Disability Determination:

• ☐ SSDI awarded — Date of Onset: [__/__/____]
• ☐ SSI awarded — Effective Date: [__/__/____]
• ☐ No federal determination — request Missouri Medical Review Team (MRT) review

4. INCOME DETERMINATION

List ALL gross monthly income for applicant and spouse (if any):

Income-Standard Comparison:

• ABD non-spend-down income limit (single, ≈ 85% FPL — verify current): $[____]
• Medically Needy Income Limit (MNIL), aged/disabled (4/1/26-3/31/27): $1,131 single / $1,533 couple
• MNIL, blind: $1,330 single / $1,804 couple
• HCBS Aged & Disabled Waiver income cap (2026): $1,737 / month (single)
• Long-Term Care vendor income cap (300% of FBR — verify current)

5. RESOURCE (ASSET) DETERMINATION

List ALL countable resources as of the first moment of the application month:

Applicable Resource Limit (verify current):

• ABD / Long-Term Care / HCBS Waiver — Single applicant: $6,068.80 (effective 7/1/2025)
• ABD / Long-Term Care / HCBS Waiver — Both spouses applying: $12,137.55 (effective 7/1/2025)
• Spousal Impoverishment — Community Spouse Resource Allowance (CSRA): minimum / maximum federal figures (verify current at medicaid.gov)

Excluded Resources (not counted — confirm each applies):

• ☐ Primary residence (subject to home-equity cap and intent-to-return rules — see Section 6)
• ☐ One automobile (any value, regardless of use, for primary applicant)
• ☐ Household goods and personal effects
• ☐ Burial spaces and prepaid irrevocable burial contracts
• ☐ Burial fund up to $1,500 per spouse
• ☐ Term life insurance (no cash value)
• ☐ Property essential to self-support
• ☐ Other excluded resource (specify): [____]

6. PRIMARY RESIDENCE AND HOME-EQUITY TREATMENT

Check applicable exemption(s) keeping the home a non-countable resource:

• ☐ Spouse resides in home
• ☐ Child under 21 resides in home
• ☐ Blind or disabled child of any age resides in home
• ☐ Sibling with equity interest who has resided in home ≥ 1 year prior to institutionalization
• ☐ Caregiver child who resided in home and provided care ≥ 2 years preventing institutionalization
• ☐ Applicant has a documented and reasonable intent to return home

7. 60-MONTH LOOK-BACK AND TRANSFER OF ASSETS

The look-back period is 60 months (5 years) immediately preceding the date of long-term care application or first day of institutionalization, whichever is later, per 42 U.S.C. § 1396p(c).

Disclose ALL transfers of assets for less than fair market value during the look-back period:

Transfer-Penalty Divisor (Missouri 2026): $7,909 per month (verify current).

Penalty Calculation Worksheet:

• Aggregate uncompensated value transferred during look-back: $[________]
• Divide by $7,909 → [____] months of penalty period
• Penalty period begins on the date the applicant is otherwise eligible AND would be receiving institutional-level care but for the transfer.

Permitted (non-penalized) transfers — check any that apply:

• ☐ Transfer to spouse (or for sole benefit of spouse)
• ☐ Transfer to blind or disabled child
• ☐ Transfer to a (d)(4)(A) special needs trust for disabled person under age 65
• ☐ Transfer to a (d)(4)(C) pooled trust
• ☐ Transfer of home to caregiver child (≥ 2 years of qualifying care)
• ☐ Transfer of home to sibling with equity interest (≥ 1 year residence)
• ☐ Transfer for purpose other than to qualify for Medicaid (rebuttable presumption — burden on applicant)
• ☐ Undue hardship — application attached

8. SPOUSAL IMPOVERISHMENT (COMMUNITY SPOUSE) PROTECTIONS

Complete only if applicant is married and one spouse is institutionalized or in HCBS waiver:

9. REQUIRED VERIFICATION DOCUMENTS

Attach the following (check each as included):

• ☐ Photo ID (driver license / state ID / passport)
• ☐ Social Security card (applicant and spouse)
• ☐ Medicare card / MBI letter
• ☐ Birth certificate or proof of age
• ☐ Proof of citizenship / lawful presence
• ☐ Marriage certificate (if applicable)
• ☐ Divorce decree / death certificate of prior spouse (if applicable)
• ☐ Health-insurance cards (Medicare supplement, Part D, employer plan)
• ☐ Last 60 months of bank statements (all accounts) — Section 1396p(c) look-back
• ☐ Most recent statements for IRAs / 401(k) / brokerage / annuities
• ☐ Life-insurance policy face sheets and current cash-surrender values
• ☐ Deeds for all real property; current tax assessment or appraisal
• ☐ Vehicle titles
• ☐ Prepaid burial / funeral contracts
• ☐ Trust instruments (with all amendments)
• ☐ Powers of attorney / guardianship / conservatorship orders
• ☐ Last 3 months of pay stubs / pension statements
• ☐ Award letters: Social Security, SSI, VA, pensions, annuities
• ☐ Last 2 years of federal income tax returns
• ☐ Documentation of any transfers in look-back period (deeds, gift letters, account closures)
• ☐ Nursing-facility admission contract / level-of-care assessment (DA-124 family)
• ☐ Physician certification of medical necessity / level of care (for LTC and ADW)

10. SPEND-DOWN ELECTION (MEDICALLY NEEDY)

Complete only if applicant elects the medically-needy spend-down track:

Spend-down satisfaction method (check one):

• ☐ "Pay-In" Spend-Down — applicant remits the spend-down amount monthly to MO HealthNet to obtain coverage for that month.
• ☐ Incurred Medical Expense Spend-Down — applicant submits proof of incurred (paid or unpaid) covered medical expenses equal to or exceeding the spend-down amount each month.

11. HCBS AGED & DISABLED WAIVER SPECIFICS

Complete only if applying for ADW services in lieu of nursing-facility placement:

12. ESTATE RECOVERY DISCLOSURE

I acknowledge that under RSMo § 208.215 and 42 U.S.C. § 1396p(b), MO HealthNet may seek recovery from my probate estate for the cost of medical assistance correctly paid on my behalf, subject to statutory deferrals while a surviving spouse, minor child, or blind/disabled child of any age remains, and subject to undue-hardship waivers.

Applicant Initials: [____] Date: [__/__/____]

13. AUTHORIZED REPRESENTATIVE DESIGNATION

I, [________________________________], designate [________________________________] as my authorized representative to act on my behalf with respect to this application, including the right to receive all notices, attend interviews, submit verifications, request fair hearings, and otherwise pursue the application to conclusion.

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

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

14. APPLICANT CERTIFICATION AND SIGNATURE

I declare under penalty of perjury under the laws of the State of Missouri that the information provided in this application is true, correct, and complete to the best of my knowledge. I understand that knowingly making a false statement to obtain MO HealthNet benefits is a crime under RSMo § 570.090 (forgery) and § 578.305 (Medicaid fraud), and that benefits obtained by fraud may be recouped with interest, civil penalties, and criminal prosecution.

I authorize the Family Support Division, the MO HealthNet Division, and the Division of Senior and Disability Services to verify all information provided herein with financial institutions, employers, the Social Security Administration, the Internal Revenue Service, and any other source necessary to determine eligibility.

Applicant (or Representative) Signature: [________________________________]

Print Name: [________________________________]

Date: [__/__/____]

15. COVER LETTER TO FAMILY SUPPORT DIVISION

[DATE]

Family Support Division
Missouri Department of Social Services
[LOCAL FSD OFFICE ADDRESS]

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

Dear FSD Eligibility Specialist:

Enclosed please find the MO HealthNet application packet for the above-referenced applicant, together with all required verification documents listed in Section 9. The applicant seeks coverage under [MHABD / MHABD Spend-Down / Long-Term Care Vendor / HCBS Aged & Disabled Waiver] effective [__/__/____].

The applicant is represented by the undersigned. Please direct all correspondence, requests for additional information, and notices of action to my office. Please contact me at [TELEPHONE] or [EMAIL] if any item requires clarification before a determination is made.

We respectfully request expedited processing under 13 CSR 40-2.310 to the extent the applicant qualifies (e.g., institutionalized status, hospital discharge planning).

Sincerely,

[________________________________]

[ATTORNEY / REPRESENTATIVE NAME]

Missouri Bar No. [####] (if attorney)

[FIRM / ORGANIZATION]

[ADDRESS]

Telephone: [________________________________]

Email: [________________________________]

Enclosures: Application; verifications per § 9 checklist; authorized-representative designation; medical/level-of-care documentation (if LTC/ADW).

16. MISSOURI PRACTICE NOTES

• Section 209(b) status. Missouri is one of eight states that elected the more-restrictive eligibility option under 42 U.S.C. § 1396a(f). SSI receipt does not confer automatic Medicaid eligibility; FSD makes an independent determination, sometimes applying stricter resource or income criteria. File an MO HealthNet application even if SSI is in pay status.
• Categorical vs. medically needy. Missouri operates BOTH tracks. Applicants whose income exceeds the categorical limit but who can incur sufficient medical expenses each month should consider the medically-needy "spend-down" track to MNIL ($1,131 single / $1,533 couple aged & disabled, 4/1/26-3/31/27).
• Asset limit step-up (7/1/2025). Effective July 1, 2025, Missouri raised the ABD asset limit to $6,068.80 (single) and $12,137.55 (both spouses applying), tied to a federal benchmark. Re-verify before each filing.
• Transfer penalty divisor. As of 2026 the divisor is $7,909/month, representing the average monthly private-pay nursing-home rate. The divisor is updated periodically by DSS; confirm current figure before computing penalties.
• Look-back period. 60 months for both transfers and trust establishments. Documentation of every withdrawal, transfer, or gift over the prior five years is essential.
• Home-equity cap. Federal cap (≈ $730,000 in 2026; states may set up to ≈ $1,097,000) renders the homestead countable above the cap absent a statutory exception (spouse/minor/disabled child in residence).
• HCBS Aged & Disabled Waiver. Capped enrollment, not entitlement. Apply early; document waitlist date. Income cap is the special-income standard ($1,737/mo for 2026), and applicants over the cap can qualify only via Qualified Income Trust where allowed — confirm current MO policy.
• Estate recovery. Missouri pursues estate recovery from the probate estate per RSMo § 208.215, with hardship deferrals. Counsel should advise on TOD deeds, life estates, and joint tenancies that bypass probate (subject to OBRA-93 federal preemption rules and Missouri's recovery scope).
• Fair hearing. A denial, termination, or reduction notice can be appealed under 13 CSR 40-2.160 by requesting a hearing within 90 days. Continuing benefits during appeal is available if requested before the effective date of action.
• Annuities. Post-DRA actuarially-sound, irrevocable, non-assignable annuities naming the State as remainder beneficiary remain a planning tool for crisis cases involving a community spouse — verify current MO policy and DRA compliance before relying on them.

17. SOURCES AND REFERENCES

• Missouri Department of Social Services — myDSS portal: https://mydss.mo.gov/
• DSS Benefit Program Income Limits: https://mydss.mo.gov/benefit-program-income-limits
• DSS Manuals (MO HealthNet eligibility policy): https://dssmanuals.mo.gov/category/mohealthnet-home/
• Missouri Department of Health & Senior Services, Division of Senior & Disability Services: https://health.mo.gov/seniors/
• DSDS HCBS Referral Line: 1-866-835-3505
• MO HealthNet Participant Services: 1-800-392-2161
• MO HealthNet General Application Help: 1-855-373-4636
• Missouri Revisor of Statutes (Chapter 208): https://revisor.mo.gov/main/Home.aspx?chapter=208
• 42 U.S.C. § 1396 et seq. — Title XIX of the Social Security Act
• 42 U.S.C. § 1396a(f) — Section 209(b) more-restrictive option
• 42 U.S.C. § 1396p — Liens; transfer of assets; estate recovery
• 42 U.S.C. § 1396r-5 — Spousal impoverishment
• 42 C.F.R. Part 435 — Eligibility methodologies
• SSA POMS SI 01715.020 (state Medicaid programs for ABD): https://secure.ssa.gov/poms.nsf/lnx/0501715020
• Medicaid.gov eligibility policy: https://www.medicaid.gov/medicaid/eligibility-policy/

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. MO HealthNet eligibility figures, the transfer-penalty divisor, federal home-equity cap, CSRA/MMMNA, and program rules are revised at least annually and must be re-verified before submission. An attorney licensed in Missouri must review and customize this packet before filing.