Mississippi Medicaid Long-Term Care Application Packet

MISSISSIPPI MEDICAID LONG-TERM CARE APPLICATION PACKET

TABLE OF CONTENTS

1. Application Coversheet
2. Applicant and Spouse Identification
3. Program Selected
4. Mississippi Eligibility Snapshot (2025 / 2026)
5. Income Worksheet and Income-Cap Analysis
6. Resource (Asset) Worksheet
7. Primary Residence Treatment
8. Five-Year Look-Back and Transfer Disclosure
9. Spousal Impoverishment Computation
10. Qualified Income Trust (Miller Trust) Election
11. Authorized Representative Designation
12. Document Checklist
13. Applicant Certification and Signature
14. Mississippi Practice Notes
15. Sources and References

1. APPLICATION COVERSHEET

2. APPLICANT AND SPOUSE IDENTIFICATION

Applicant:

• Full Legal Name: [________________________________]
• Date of Birth: [__/__/____]
• Social Security Number: [____]-[__]-[____]
• Mississippi County of Residence: [________________________________]
• Current Living Arrangement: ☐ Own home ☐ Family member's home ☐ Assisted living ☐ Nursing facility ☐ Hospital ☐ Other: [____________]
• Marital Status: ☐ Single ☐ Married ☐ Widowed ☐ Divorced ☐ Separated
• U.S. Citizen / Qualified Non-Citizen: ☐ Yes ☐ No (attach documentation)
• Mississippi Resident ≥ 30 Days: ☐ Yes ☐ No

Community Spouse (if applicable):

• Full Legal Name: [________________________________]
• Date of Birth: [__/__/____]
• Social Security Number: [____]-[__]-[____]
• Address (if different): [________________________________]

3. PROGRAM SELECTED

☐ Institutional / Nursing Facility Medicaid — Miss. Admin. Code Title 23, Part 207. Applicant resides or will reside in a Medicaid-certified nursing facility for ≥ 30 consecutive days.

☐ Elderly and Disabled (E&D) Waiver — Miss. Admin. Code Title 23, Part 208. Home and community-based services for individuals age 21+ who would otherwise require nursing-facility level of care. Score ≥ 50 on InterRAI LTSS assessment required. Slot availability not guaranteed; waiting list possible.

☐ Assisted Living Waiver — limited program; verify slot availability.

☐ Independent Living Waiver — physical disability, ages 16-64.

☐ Traumatic Brain Injury / Spinal Cord Injury Waiver

☐ PACE (Program of All-Inclusive Care for the Elderly) — limited Mississippi service areas.

☐ Home- and Community-Based Services — Other: [________________________________]

4. MISSISSIPPI ELIGIBILITY SNAPSHOT (2025 / 2026)

Mississippi is an INCOME-CAP state. Applicants whose gross monthly income exceeds the income cap are ineligible for LTC Medicaid unless excess income is diverted into a Qualified Income Trust (QIT / Miller Trust / Mississippi Income Trust). There is no medically needy spend-down for the income test.

5. INCOME WORKSHEET AND INCOME-CAP ANALYSIS

Income-Cap Analysis:

• Applicant's gross monthly income: $[__________]
• 2026 Income Cap (300% FBR): $2,982
• Result: ☐ Under cap (no QIT required) ☐ At/over cap → QIT REQUIRED (see Section 10)

6. RESOURCE (ASSET) WORKSHEET

Countable Resources:

Excluded / Non-Countable Resources:

• Primary residence (subject to equity cap and intent-to-return — see Section 7)
• One automobile (any value)
• Personal effects and household goods
• Burial spaces and irrevocable burial plans
• Burial fund up to $1,500 per spouse
• Term life insurance
• Cash-value life insurance with face value ≤ $10,000

7. PRIMARY RESIDENCE TREATMENT

• Address: [________________________________]
• Owner(s): [________________________________]
• Tax-assessed value: $[__________]
• Estimated fair market value: $[__________]
• Outstanding mortgage / liens: $[__________]
• Net equity: $[__________]

Equity-Cap Analysis (single applicant; no spouse, minor, or disabled child residing):

• 2026 Federal home-equity cap: $730,000
• Net equity > cap? ☐ Yes (home BECOMES countable until equity reduced) ☐ No

Intent-to-Return Statement (if applicant institutionalized):

I, [________________________________], state under penalty of perjury that I intend to return to my home located at [________________________________] if my medical condition allows. I have not transferred or abandoned the property.

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

8. FIVE-YEAR LOOK-BACK AND TRANSFER DISCLOSURE

The 60-month look-back begins on the date of application or institutional admission, whichever is later. Disclose ALL transfers of cash, real property, or other assets for less than fair market value during the look-back period.

Penalty Calculation:

• Total uncompensated transfers: $[__________]
• 2026 Penalty Divisor (verify): ~$9,430/mo
• Penalty months: [__________]
• Penalty start date: first day of month in which applicant is otherwise eligible AND institutionalized.

Exempt Transfers (no penalty applies):

• ☐ Transfer to spouse
• ☐ Transfer to blind or disabled child of any age
• ☐ Transfer of home to: caretaker child residing ≥ 2 years immediately preceding institutionalization; sibling with equity interest residing ≥ 1 year; or minor child
• ☐ Transfer to a sole-benefit (d)(4)(A), pooled (d)(4)(C), or qualifying special-needs trust
• ☐ Bona-fide loan with promissory note conforming to 42 U.S.C. § 1396p(c)(1)(I)

9. SPOUSAL IMPOVERISHMENT COMPUTATION

Complete only if applicant is married and spouse will remain in the community.

Resource Assessment (snapshot date = first day of first continuous period of institutionalization ≥ 30 days):

• Snapshot Date: [__/__/____]
• Total countable resources of couple as of snapshot: $[__________]
• One-half of snapshot total: $[__________]
• 2026 CSRA Maximum: $162,660
• 2026 CSRA Minimum: $31,584
• Community Spouse Resource Allowance: $[__________]
• Resources to spend down before applicant qualifies: $[__________] (couple total – CSRA – $4,000 applicant allowance)

Income Allowance (MMMNA):

• Community spouse gross income: $[__________]
• 2026 MMMNA minimum: $2,643.75
• 2026 MMMNA maximum: $3,948
• Excess shelter allowance (if any): $[__________]
• Monthly income transfer from applicant to spouse: $[__________]

10. QUALIFIED INCOME TRUST (MILLER TRUST) ELECTION

☐ Applicant's gross monthly income exceeds the income cap; a Mississippi Qualified Income Trust ("QIT," Miller Trust, or Mississippi Income Trust) is being established under 42 U.S.C. § 1396p(d)(4)(B) and Miss. Admin. Code Title 23, Part 103.

QIT Requirements:

• Composed solely of pension, Social Security, and other income of the applicant.
• Irrevocable.
• Names the State of Mississippi (DOM) as remainder beneficiary up to total Medicaid paid on applicant's behalf.
• Disbursements limited to: (a) personal needs allowance; (b) MMMNA to community spouse; (c) family allowance; (d) medical expenses not covered by Medicaid; and (e) patient-pay liability to the facility.

QIT Information:

• Trustee: [________________________________]
• Trustee Address: [________________________________]
• Trust Bank Account #: [________________________________]
• Trust Effective Date: [__/__/____]
• Income Sources Directed to QIT: ☐ Social Security ☐ Pension #1 ☐ Pension #2 ☐ Other: [____________]

11. AUTHORIZED REPRESENTATIVE DESIGNATION

I, [________________________________] (applicant), authorize the following individual to act as my Authorized Representative to file this application, receive notices, and respond to requests for information from the Mississippi Division of Medicaid:

• Representative Name: [________________________________]
• Relationship: [________________________________]
• Address: [________________________________]
• Phone / Email: [________________________________]
• Authority: ☐ Power of Attorney (attach) ☐ Court-appointed guardian/conservator (attach Letters) ☐ DOM-303 designation only

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

12. DOCUMENT CHECKLIST

Attach legible copies. Do NOT send originals.

Identity and Citizenship:

• ☐ Birth certificate or U.S. passport
• ☐ Social Security card
• ☐ Mississippi driver's license / state ID
• ☐ Proof of citizenship or qualified-noncitizen status

Income (most recent 3 months unless otherwise noted):

• ☐ Social Security award letter (current year)
• ☐ Pension award letters / 1099-Rs
• ☐ VA benefit letter
• ☐ Pay stubs (if applicable)
• ☐ Annuity contracts and payment schedules

Resources (most recent 3 months of statements):

• ☐ Bank statements (all accounts, all owners)
• ☐ Brokerage statements
• ☐ Retirement account statements
• ☐ Life-insurance policies (face and current cash value)
• ☐ Vehicle titles
• ☐ Real-property deeds and most recent tax assessment
• ☐ Burial-fund / pre-need contracts
• ☐ Trust instruments (revocable AND irrevocable)

Transfers / Look-Back:

• ☐ Five years of bank statements
• ☐ Documentation supporting any exempt transfer
• ☐ Promissory notes / loan documents
• ☐ Closing statements for real-property transfers

Long-Term Care:

• ☐ Medical records establishing nursing-facility level of care
• ☐ InterRAI LTSS assessment (HCBS waiver)
• ☐ Admission contract from nursing facility
• ☐ Physician certification (PASRR Level I/II if applicable)

Legal:

• ☐ Power of Attorney
• ☐ Guardianship / conservatorship Letters
• ☐ Divorce decree / separation agreement
• ☐ Spouse's death certificate

Trust (if QIT):

• ☐ Executed Mississippi Qualified Income Trust instrument
• ☐ QIT bank account opening confirmation
• ☐ First-month funding evidence

13. APPLICANT CERTIFICATION AND SIGNATURE

I certify under penalty of perjury under the laws of the State of Mississippi that the information provided in this application and attachments is true, accurate, and complete to the best of my knowledge. I understand that knowingly making a false statement to obtain Medicaid benefits is a crime under Miss. Code Ann. § 43-13-213 and federal law, and may result in repayment, fines, imprisonment, and disqualification.

I authorize the Mississippi Division of Medicaid and its agents to verify all information provided, including financial accounts, real-property records, tax returns, and asset-transfer history during the 60-month look-back period.

I acknowledge that, upon my death, the State of Mississippi may seek recovery from my probate estate for Medicaid benefits paid on my behalf for long-term-care services, pursuant to Miss. Code Ann. § 43-13-317 and 42 U.S.C. § 1396p(b).

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

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

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

Notarization (recommended for QIT and transfer disclosures):

State of Mississippi
County of [________________________________]

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

[________________________________]
Notary Public — My commission expires: [_______________]

14. MISSISSIPPI PRACTICE NOTES

• Income-cap state with no medically needy income pathway. Mississippi requires a QIT for any applicant whose income equals or exceeds 300% of the SSI Federal Benefit Rate. Failure to fund the QIT in any month destroys eligibility for that month.
• Asset limit is $4,000 — among the lowest in the nation. Spend-down planning, exempt-asset conversion (e.g., to homestead improvements, prepaid burial, or a Medicaid-compliant annuity benefiting a community spouse) is often required.
• Penalty divisor changes. DOM updates the statewide average private-pay nursing-facility rate periodically; the 2026 figure is approximately $9,430/month. Confirm the current divisor via the DOM Eligibility Manual or DOM bulletin before computing transfer penalties.
• Annuity treatment. A Medicaid-compliant annuity must be irrevocable, non-assignable, actuarially sound under the Social Security Administration's life-expectancy tables, pay equal monthly installments, and name DOM as primary or contingent beneficiary up to total Medicaid paid (42 U.S.C. § 1396p(c)(1)(F)).
• Estate Recovery. Mississippi limits estate recovery to the probate estate (Miss. Code Ann. § 43-13-317) and applies hardship waivers. TEFRA liens are NOT used in Mississippi for living recipients in most circumstances; verify current DOM policy.
• Application processing. DOM has 45 days to process most LTC applications and 90 days for disability determinations. Begin gathering five years of records EARLY — incomplete documentation is the leading cause of delay or denial.
• Hearings and appeals. Denials, terminations, and transfer-penalty determinations may be appealed through a DOM administrative fair hearing under Miss. Admin. Code Title 23, Part 300, Chapter 1. The hearing request must be filed within 30 days of the notice of action.
• Coordination with VA Aid & Attendance. A&A is countable income for Medicaid; pension portions may be excluded depending on type. Coordinate VA benefits with QIT funding to avoid eligibility loss.

15. SOURCES AND REFERENCES

• Mississippi Division of Medicaid — https://medicaid.ms.gov/
• DOM "LTC ABD Nursing Home" Fact Sheet (Jan. 2026) — https://medicaid.ms.gov/wp-content/uploads/2025/12/LTC-ABD-Nursing-Home.January-2026.pdf
• DOM Eligibility Policy and Procedures Manual, Chapter 306 — https://medicaid.ms.gov/wp-content/uploads/2015/02/Chapter-306.05.pdf
• DOM Q1 2026 Nursing Facility Rates — https://medicaid.ms.gov/wp-content/uploads/2025/12/Q1-2026-NF-Rates.pdf
• DOM Elderly and Disabled Waiver — https://medicaid.ms.gov/programs/elderly-and-disabled-waiver/
• Miss. Code Ann. Title 43, Chapter 13 — https://law.justia.com/codes/mississippi/title-43/chapter-13/
• Miss. Admin. Code Title 23 — https://www.medicaid.ms.gov/resources/administrative-code/
• 42 U.S.C. § 1396p (Federal transfer/trust/lien statute) — https://www.ssa.gov/OP_Home/ssact/title19/1917.htm
• Mississippi Bar Elder Law Section — https://www.msbar.org/
• Mississippi Access to Care Network — https://www.mississippiaccesstocare.org/

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. A Mississippi-licensed attorney must review and customize this packet before submission. Medicaid eligibility figures, divisors, and policy change frequently; verify all authorities against current DOM publications before filing.