Montana Medicaid Long-Term Care Application Packet

MONTANA MEDICAID LONG-TERM CARE APPLICATION PACKET

TABLE OF CONTENTS

1. Cover Sheet and Filing Caption
2. Applicant Information
3. Program(s) Requested
4. Categorical and Functional Eligibility
5. Financial Eligibility — Income
6. Financial Eligibility — Resources / Assets
7. Transfers of Assets and 60-Month Look-Back
8. Spousal Impoverishment Protections (Married Applicants)
9. Treatment of the Primary Residence
10. Spend-Down and Patient Liability
11. Documentation Checklist
12. Authorizations and Signatures
13. Notice of Rights, Appeals, and Estate Recovery
14. Montana Practice Notes
15. Sources and References

1. COVER SHEET AND FILING CAPTION

STATE OF MONTANA

DEPARTMENT OF PUBLIC HEALTH AND HUMAN SERVICES (DPHHS)

SENIOR AND LONG-TERM CARE DIVISION / OFFICE OF PUBLIC ASSISTANCE

APPLICATION FOR LONG-TERM CARE MEDICAL ASSISTANCE

2. APPLICANT INFORMATION

2.1. Legal Name: [________________________________]

2.2. Other Names Used (Maiden, Aliases): [________________________________]

2.3. Current Mailing Address: [________________________________]

2.4. Physical Address (if different): [________________________________]

2.5. Telephone: [________________________________]

2.6. Marital Status: ☐ Single ☐ Married ☐ Widowed ☐ Divorced ☐ Legally Separated

2.7. Spouse's Legal Name (if any): [________________________________]

2.8. Spouse Date of Birth: [__/__/____]

2.9. Authorized Representative / Power of Attorney: [________________________________]

2.10. Relationship to Applicant: [________________________________]

2.11. Representative Contact: [________________________________]

3. PROGRAM(S) REQUESTED

The Applicant hereby applies for the following Montana Medicaid program(s) (check all that apply):

☐ Nursing Facility (NF) Medicaid — institutional long-term care in a Medicaid-certified nursing home.

☐ Big Sky Waiver (BSW) — 1915(c) HCBS — home- and community-based services for seniors (65+) or adults with physical disabilities who meet nursing facility level of care.

☐ Community First Choice / Personal Assistance Services (PAS) — state-plan in-home services.

☐ Medically Needy / Spend-Down Medicaid — for applicants with income above the categorical limit.

☐ Medicare Savings Program (QMB / SLMB / QI) — premium and cost-sharing assistance.

3.1. Anticipated Date Services Begin: [__/__/____]

3.2. Facility / Provider Name (if known): [________________________________]

3.3. Facility Medicaid Provider No.: [________________________________]

4. CATEGORICAL AND FUNCTIONAL ELIGIBILITY

4.1. Citizenship / Immigration: Applicant is ☐ U.S. Citizen ☐ Qualified Non-Citizen. Documentation attached: ☐ Birth certificate ☐ Passport ☐ Naturalization papers ☐ I-551.

4.2. Montana Residency: Applicant resides in Montana with the intent to remain. Length of residency: [________________________________].

4.3. Age / Disability Basis: ☐ Age 65 or older (DOB above) ☐ Determined disabled by SSA ☐ Determined disabled by State Review Team. Disability determination date: [__/__/____].

4.4. Functional / Level-of-Care (LOC) Determination: For NF and BSW, Applicant requires nursing facility level of care as documented by a Pre-Admission Screening (PAS) / Mountain-Pacific Quality Health LOC review. Date of LOC screen: [__/__/____].

4.5. Other Health Coverage: ☐ Medicare Part A ☐ Part B ☐ Part D ☐ Private/employer plan ☐ TRICARE/VA ☐ None. Insurer & policy no.: [________________________________].

5. FINANCIAL ELIGIBILITY — INCOME

5.1. Gross Monthly Income — Applicant:

5.2. Gross Monthly Income — Spouse (if married): $[____________]

5.3. Income Limit Applied:

• Big Sky Waiver / ABD Medicaid: 100% FBR — [approximately $994/month single, 2025-2026].
• Nursing Facility Medicaid: no categorical cap; income applied to patient liability per § 10.
• Medically Needy Spend-Down: monthly need standard determined by DPHHS.

5.4. Allowable Deductions / Diversions:

• Personal Needs Allowance (NF resident): $50.00/month (Montana standard).
• Medicare Part B / Part D premiums: actual amount.
• Health insurance premiums: actual amount.
• Court-ordered support obligations: actual amount.
• Spousal MMNA (see § 8): up to maximum.
• Family maintenance allowance for dependents: per DPHHS formula.

6. FINANCIAL ELIGIBILITY — RESOURCES / ASSETS

6.1. Countable Resources (snapshot as of application date and, for married couples, as of the date of institutionalization):

6.2. Excluded / Non-Countable Resources:

• Primary residence (subject to home-equity cap; see § 9).
• One vehicle of any value (used by household).
• Personal effects and household goods.
• Burial plot / pre-paid irrevocable burial contract.
• Burial fund up to $1,500 (reduced by face value of life insurance).
• Term life insurance (no cash value) and small whole life policies with face value at or below $1,500.
• Property essential to self-support (limited).

6.3. Resource Limit Applied:

• Single applicant: $2,000 (2026).
• Married — both applying: $4,000 (2026).
• Married — one applying: applicant may retain $2,000; community spouse may retain CSRA (see § 8).

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

7.1. Has the Applicant or Applicant's Spouse, within the 60 months immediately preceding this application, transferred any asset for less than fair market value (gifts, sales below FMV, additions to joint accounts, payments on behalf of family members, irrevocable trusts)?

☐ No ☐ Yes — itemize below:

7.2. Penalty Computation (illustrative): Total uncompensated transfers ÷ Montana monthly transfer divisor = months of ineligibility. The penalty period begins on the date the applicant is otherwise eligible and would be receiving institutional or waiver services but for the transfer.

7.3. Statutory Exceptions Asserted (if any):

☐ Transfer to community spouse.
☐ Transfer to a child under 21, blind, or disabled.
☐ Transfer to a sibling with equity interest who resided in the home ≥ 1 year before institutionalization.
☐ Transfer to a "caretaker child" who resided in the home ≥ 2 years before institutionalization and provided care that delayed institutionalization.
☐ Transfer for purpose other than to qualify for Medicaid (rebuttal evidence attached).
☐ Return of transferred asset (cure).

7.4. Trust Disclosures: Identify all trusts established by, or for the benefit of, the Applicant or spouse within the past 60 months: [________________________________]

8. SPOUSAL IMPOVERISHMENT PROTECTIONS (MARRIED APPLICANTS)

8.1. Date of Initial Continuous Institutionalization (or BSW LOC): [__/__/____]

8.2. Resource Assessment Snapshot. A snapshot of the couple's countable resources is taken as of the first day of the first 30-day period of continuous institutionalization. Total countable: $[____________]. One-half (computed CSRA): $[____________].

8.3. Community Spouse Resource Allowance (CSRA) Claimed: $[____________]

8.4. Minimum Monthly Maintenance Needs Allowance (MMMNA):

• Community spouse gross monthly income: $[____________]
• Excess shelter expenses (rent/mortgage + property tax + insurance + utility allowance − shelter standard): $[____________]
• MMMNA claimed (capped at federal maximum): $[____________]

8.5. Court Order or Fair Hearing for Increased CSRA / MMMNA: ☐ None ☐ Pending ☐ Issued (attach copy).

9. TREATMENT OF THE PRIMARY RESIDENCE

9.1. Address: [________________________________]

9.2. Title / Owners: [________________________________]

9.3. Estimated Fair Market Value: $[____________]

9.4. Outstanding Mortgage / Liens: $[____________]

9.5. Net Equity: $[____________]

9.6. Home Equity Limit. Per 42 U.S.C. § 1396p(f), Montana applies a home-equity cap of approximately $752,000 (2026). Applicants with equity above the cap are ineligible for LTSS unless: ☐ a spouse, ☐ a child under 21, or ☐ a blind or disabled child resides in the home.

9.7. Intent-to-Return Statement. Applicant ☐ does ☐ does not intend to return to the home. While intent-to-return is preserved, the home is excluded from countable resources.

9.8. Lady-Bird / Transfer-on-Death Deed. Applicant ☐ has ☐ has not executed a TOD or enhanced-life-estate deed regarding the residence. (Note: Montana enacted a statutory transfer-on-death deed under Mont. Code Ann. § 72-6-401 et seq.; consult counsel regarding estate-recovery implications.)

9.9. Estate Recovery. Applicant acknowledges that Mont. Code Ann. § 53-6-167 authorizes DPHHS to recover correctly-paid Medicaid benefits from the estate of a deceased recipient age 55 or older, including property that passes outside probate (e.g., joint tenancy, life estates, certain trusts), subject to hardship waiver and surviving-spouse / dependent-child deferral.

10. SPEND-DOWN AND PATIENT LIABILITY

10.1. Resource Spend-Down (if total countable assets exceed limit):

• Pay legitimate debts (medical, utility, tax obligations).
• Pre-pay funeral / burial through irrevocable contract.
• Make exempt purchases (home repair, medically necessary equipment, replacement vehicle).
• Establish a Special Needs Trust under 42 U.S.C. § 1396p(d)(4) for a disabled applicant under 65.

10.2. Income Spend-Down (Medically Needy): Document monthly medical expenses to satisfy the spend-down standard for the budget period.

10.3. Patient Liability (Cost of Care) Worksheet — Nursing Facility:

11. DOCUMENTATION CHECKLIST

The Applicant attaches the following verifications. ☐ box indicates included; N/A indicates not applicable.

☐ Signed DPHHS HCS-100 (or current) Application form
☐ Photo identification (driver's license / Montana ID / passport)
☐ Social Security card or printout
☐ Proof of Montana residency (utility bill, lease, voter registration)
☐ Proof of citizenship / qualified non-citizen status
☐ Marriage certificate (if married)
☐ Divorce decree or death certificate of prior spouse (if applicable)
☐ Power of Attorney / guardianship letters
☐ Last five years of bank statements (every account, every page)
☐ Last five years of brokerage / IRA / 401(k) statements
☐ Life insurance policies (face page + cash-value statement)
☐ Burial contract / cemetery deed
☐ Vehicle titles
☐ Real-property deeds and current tax bill / appraisal
☐ Mortgage / lien statements
☐ Five years of federal income tax returns
☐ Pension / annuity award letters
☐ Social Security / VA / Railroad Retirement award letters
☐ Medicare card; private insurance cards
☐ Pre-Admission Screening / LOC determination
☐ Documentation supporting transfer exceptions (§ 7.3)
☐ Trust instruments (revocable and irrevocable)
☐ Any pending fair-hearing or court order on CSRA / MMMNA

12. AUTHORIZATIONS AND SIGNATURES

12.1. Penalty Statement. I declare under penalty of perjury under the laws of the State of Montana and the United States that the information provided in this application and its attachments is true, correct, and complete to the best of my knowledge. I understand that knowingly providing false information may result in denial of benefits, recovery of incorrectly paid benefits, civil penalties, and criminal prosecution under Mont. Code Ann. § 45-7-202 (false swearing) and § 53-6-160 (Medicaid fraud).

12.2. Authorization to Release Information. I authorize DPHHS, the Office of Public Assistance, and Mountain Pacific Quality Health to obtain and verify information from financial institutions, employers, the Social Security Administration, the IRS, the Montana Department of Revenue, insurance companies, medical providers, and any other source necessary to determine eligibility and process this application.

12.3. Assignment of Rights. As a condition of eligibility, I assign to the State of Montana my rights to medical support and third-party medical payments to the extent of Medicaid expenditures.

12.4. Acknowledgment of Estate Recovery. I acknowledge that I have received notice that the State may recover correctly paid medical assistance from my estate after my death pursuant to Mont. Code Ann. § 53-6-167 and 42 U.S.C. § 1396p(b).

Date: [__/__/____]

[________________________________]

Applicant Signature

[________________________________]

Authorized Representative Signature (and capacity)

13. NOTICE OF RIGHTS, APPEALS, AND ESTATE RECOVERY

13.1. Right to Apply. Any individual may apply for Medicaid; DPHHS must process within 45 days for non-disability cases and 90 days for disability determinations.

13.2. Right to a Fair Hearing. Pursuant to Mont. Code Ann. § 53-6-111 and Admin. R. Mont. 37.5.304 et seq., an applicant or recipient may request a fair hearing within 90 days of any adverse action (denial, reduction, termination). Hearings are conducted by the DPHHS Office of Fair Hearings.

13.3. Continuation of Benefits. Recipients may request continuation of benefits pending appeal if the request is filed before the effective date of the adverse action.

13.4. Estate Recovery Hardship Waiver. Mont. Code Ann. § 53-6-167 authorizes a hardship waiver where recovery would deprive heirs of the means of self-support; written request must be submitted to DPHHS within the timeframe provided in the recovery notice.

13.5. Non-Discrimination. DPHHS does not discriminate on the basis of race, color, national origin, sex, age, religion, or disability.

14. MONTANA PRACTICE NOTES

• Filing channels. Apply (a) online via apply.mt.gov, (b) by mail/in-person at the County Office of Public Assistance, or (c) by phone at the DPHHS Public Assistance Helpline 1-888-706-1535. For BSW, request a referral to Mountain Pacific Quality Health: 1-800-219-7035.
• Categorical income limit. ABD Medicaid and BSW use 100% FBR (~$994/month single, 2025-2026). Nursing Facility Medicaid has no categorical income cap (post-eligibility patient-liability rules apply).
• Resource limit. $2,000 single / $4,000 both spouses applying (2026).
• Look-back. 60 months. The Montana penalty divisor (transfer divisor) is published by DPHHS — confirm current figure; ~$306/day was reported for 2025-2026.
• Spousal protection. CSRA up to $162,660 (2026); minimum $32,532. MMMNA $2,644 (eff. 7/1/25 – 6/30/26), maximum $3,948 with excess-shelter.
• Personal Needs Allowance. $50/month for institutionalized residents.
• Home equity cap. ~$752,000 (2026).
• Annuities. Must be irrevocable, non-assignable, actuarially sound, and name the State of Montana as remainder beneficiary up to the amount of Medicaid paid; review under 42 U.S.C. § 1396p(c)(1)(F).
• Trusts. Self-settled (d)(4)(A) and pooled (d)(4)(C) special needs trusts may shelter resources for disabled applicants; community spouse may also use a "sole benefit" trust for disabled adult children. Strict drafting and DPHHS review apply.
• Estate recovery. Recovery is from the probate and non-probate estate of recipients age 55+; deferred while a spouse, minor child, or blind/disabled child survives.
• Annual recertification. Eligibility is redetermined at least annually; report changes within 10 days.
• Penalty for fraud. Mont. Code Ann. § 53-6-160 (Medicaid fraud) and § 45-7-202 (false swearing).

15. SOURCES AND REFERENCES

• Montana DPHHS — Senior and Long-Term Care Division: https://dphhs.mt.gov/sltc/
• Big Sky Waiver Program: https://dphhs.mt.gov/sltc/csb/BSW/BigSkyWaiverProgram
• Big Sky Waiver Policy Manual: https://dphhs.mt.gov/SLTC/bigskywaiverpolman
• Combined Medicaid Manual (CMA): https://dphhs.mt.gov/assets/hcsd/mamanual/CMATOC.pdf
• Apply Online: https://apply.mt.gov/
• Mont. Code Ann. Title 53, Chapter 6 (Medical Assistance — Medicaid): https://mca.legmt.gov/bills/mca/title_0530/chapter_0060/sections_index.html
• Admin. R. Mont., Title 37 (DPHHS): https://rules.mt.gov/
• 42 U.S.C. § 1396 et seq. (Title XIX — Medicaid)
• 42 U.S.C. § 1396p (Transfers, liens, estate recovery)
• 42 U.S.C. § 1396r-5 (Spousal impoverishment)
• Centers for Medicare & Medicaid Services — Federal Poverty Level / FBR updates: https://www.medicaid.gov/

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. A Montana-licensed attorney must review and customize this packet before submission. Medicaid figures change at least annually (some semi-annually); verify all amounts at dphhs.mt.gov before filing.