Nebraska Medicaid Long-Term Care Application Packet

NEBRASKA MEDICAID LONG-TERM CARE APPLICATION PACKET

TABLE OF CONTENTS

1. Cover Letter to DHHS Medicaid
2. Applicant Identification and Household Composition
3. Program Selected
4. Categorical and Functional Eligibility
5. Income Statement
6. Resource (Asset) Statement
7. Spousal Impoverishment Calculation
8. Transfer of Assets Disclosure (60-Month Look-Back)
9. Primary Residence Treatment
10. Medically Needy / Share of Cost Election
11. Authorized Representative and Releases
12. Verification Documents Index
13. Applicant Certification and Signature
14. Nebraska Practice Notes
15. Sources and References

1. COVER LETTER TO DHHS MEDICAID

[DATE]

Nebraska Department of Health and Human Services

Division of Medicaid and Long-Term Care

P.O. Box 95026

Lincoln, Nebraska 68509-5026

Re: Application for Medicaid Long-Term Care Benefits

Applicant: [APPLICANT FULL LEGAL NAME]

Social Security No. (last 4): [XXX-XX-____]

Date of Birth: [__/__/____]

Master Case / ARP No. (if known): [________________________________]

To Whom It May Concern:

Enclosed please find the verified Medicaid application of [APPLICANT NAME] seeking long-term care benefits under the program(s) checked in Section 3, together with all supporting documentation listed in Section 12. Applicant requests that eligibility be determined effective [__/__/____] and, where applicable, retroactive to the three (3) months preceding the application month pursuant to 477 NAC.

Please direct all correspondence and requests for additional verification to the Authorized Representative identified in Section 11.

Respectfully,

[________________________________]

[NAME OF APPLICANT OR AUTHORIZED REPRESENTATIVE]

2. APPLICANT IDENTIFICATION AND HOUSEHOLD COMPOSITION

3. PROGRAM SELECTED

Applicant applies for the following program(s) (check all that apply):

• ☐ Nursing Facility Medicaid (Institutional Long-Term Care) — full coverage of nursing facility room, board, and medical services for individuals meeting nursing-facility level of care.
• ☐ Aged and Disabled (A&D) Medicaid Waiver / Home and Community-Based Services (HCBS) — services delivered in the community to prevent or delay institutional placement, including adult day services, home modifications, personal emergency response, respite, and home-delivered meals.
• ☐ Traumatic Brain Injury (TBI) Waiver — for eligible individuals with documented TBI.
• ☐ PACE (Program of All-Inclusive Care for the Elderly) — where available in applicant's county.
• ☐ Medically Needy / Share of Cost — applicant's income exceeds the categorical limit; applicant elects to spend down through incurred medical expenses.
• ☐ Three-month retroactive coverage — applicant requests retroactive eligibility for medical bills incurred in the three months preceding the application month.

4. CATEGORICAL AND FUNCTIONAL ELIGIBILITY

4.1. Categorical basis. Applicant qualifies as (check one):

• ☐ Aged (65 or older)
• ☐ Blind (meeting SSI / SSA blindness criteria)
• ☐ Disabled (meeting SSA disability criteria)

4.2. Level of care. Applicant requires nursing-facility level of care as documented by:

• ☐ DHHS-approved Level of Care assessment dated [__/__/____]
• ☐ Physician certification (Form [________]) dated [__/__/____]
• ☐ Minimum Data Set (MDS) submitted by the admitting facility

4.3. Anticipated 30-consecutive-day stay. Care is expected to be required for at least thirty (30) consecutive days, satisfying the institutional-stay threshold.

4.4. Nebraska residency and citizenship/immigration documentation attached (see Section 12).

5. INCOME STATEMENT

5.1. Income limit (verify). For 2026, the categorical income limit for nursing-facility Medicaid and the A&D Waiver in Nebraska is approximately $1,330 per month for a single applicant. Confirm against the current 477 NAC schedule.

5.2. Personal Needs Allowance. Institutionalized residents retain a Personal Needs Allowance (currently $75/month in Nebraska — verify) deducted from patient liability.

6. RESOURCE (ASSET) STATEMENT

6.1. Asset limit (verify). For 2026, the countable-resource limit is $4,000 for a single applicant under Nebraska nursing-facility Medicaid and the A&D Waiver. Confirm against current 477 NAC.

6.2. Burial exclusion. Verify Nebraska's irrevocable burial trust / pre-need contract exclusion limits.

7. SPOUSAL IMPOVERISHMENT CALCULATION

(Complete only if applicant is married and a community spouse remains in the community.)

7.1. Snapshot date. First continuous period of institutionalization beginning [__/__/____].

7.2. Combined countable resources at snapshot: $[____________].

7.3. Community Spouse Resource Allowance (CSRA, 2026): one-half of combined resources, subject to a federal floor and ceiling. The 2026 maximum CSRA is approximately $162,660 and the minimum floor is approximately $32,532 (verify).

7.4. Minimum Monthly Maintenance Needs Allowance (MMMNA). For the period 7/1/2025 – 6/30/2026, the MMMNA floor is approximately $2,644/month with a maximum of approximately $4,067/month (verify). The community spouse may retain enough of the institutionalized spouse's income to bring the community spouse to the MMMNA.

7.5. Home equity. The 2026 home-equity cap for Medicaid long-term care purposes is approximately $752,000 in Nebraska (verify). Equity above the cap renders the homestead countable unless a spouse, minor, or disabled child resides there.

8. TRANSFER OF ASSETS DISCLOSURE (60-MONTH LOOK-BACK)

8.1. Look-back start date: [__/__/____] (60 months before the later of application or institutionalization).

8.2. Disclosure of transfers. During the look-back period, applicant or applicant's spouse made the following transfers for less than fair market value:

• ☐ No disqualifying transfers were made within the 60-month look-back period.

8.3. Penalty period calculation (where applicable). Total uncompensated transfers $[____] ÷ current Nebraska penalty divisor $[____]/month = [____] months of ineligibility, beginning on the date applicant is otherwise eligible and receiving institutional services.

8.4. Asserted exceptions and rebuttals. Applicant asserts the following statutory exceptions to the transfer penalty (check and document):

• ☐ Transfer to spouse (no penalty)
• ☐ Transfer to blind or disabled child of any age
• ☐ Transfer to a "caregiver child" residing in the home for at least two years and providing care that delayed institutionalization
• ☐ Transfer to a sibling with an equity interest who resided in the home for at least one year
• ☐ Transfer into a (d)(4)(A) self-settled special needs trust for a disabled person under 65
• ☐ Transfer into a (d)(4)(C) pooled trust
• ☐ Transfer made exclusively for a purpose other than to qualify for Medicaid (rebuttal evidence attached)
• ☐ Transfer fully returned (cure)
• ☐ Undue hardship waiver requested

9. PRIMARY RESIDENCE TREATMENT

9.1. Address of homestead: [________________________________].

9.2. Equity value: $[____________] (per assessor / appraisal dated [__/__/____]).

9.3. Occupancy status:

• ☐ Community spouse resides in the home (homestead exempt without regard to equity cap)
• ☐ Minor child or blind/disabled child resides in the home (exempt)
• ☐ Sibling with equity interest resided in home for at least one year preceding institutionalization (exempt)
• ☐ Applicant intends to return home (signed Intent to Return statement attached)
• ☐ Home is on the market for sale (listing agreement attached)

9.4. Estate recovery notice acknowledged. Applicant acknowledges that under Neb. Rev. Stat. § 68-919 and 42 U.S.C. § 1396p(b), DHHS may recover correctly paid Medicaid benefits from the applicant's estate after death, subject to statutory exemptions and hardship waivers.

10. MEDICALLY NEEDY / SHARE OF COST ELECTION

(Complete only if applicant's gross income exceeds the categorical limit but qualifies under the medically needy / spend-down standard.)

10.1. Applicant's gross monthly income: $[________].

10.2. Nebraska medically needy income standard (verify; approx. $392/month single in 2026): $[________].

10.3. Monthly share-of-cost / spend-down obligation: $[________].

10.4. Incurred medical expenses applied to spend-down:

11. AUTHORIZED REPRESENTATIVE AND RELEASES

11.1. Authorized Representative. Applicant designates the following individual to receive notices, submit verifications, and act on applicant's behalf in all matters relating to this application and ongoing eligibility:

11.2. HIPAA / financial release. Applicant authorizes DHHS to obtain and verify medical, financial, and benefit information from any provider, financial institution, employer, SSA, VA, IRS, or other source necessary to determine eligibility.

[________________________________]

[APPLICANT OR AUTHORIZED REPRESENTATIVE]

Date: [__/__/____]

12. VERIFICATION DOCUMENTS INDEX

The following supporting documents are attached:

• ☐ Photo identification (driver's license / state ID / passport)
• ☐ Social Security card / SSA award letter
• ☐ Medicare card / MBI
• ☐ Birth certificate / proof of age
• ☐ Citizenship / lawful immigration documentation
• ☐ Marriage certificate / divorce decree / death certificate of prior spouse
• ☐ Power of Attorney / Guardianship order
• ☐ Five (5) years of bank statements (all accounts, both spouses)
• ☐ Brokerage / IRA / 401(k) statements (60 months)
• ☐ Life insurance policies and current cash-value statements
• ☐ Annuity contracts and amortization schedules
• ☐ Deeds for all real property; property tax statements
• ☐ Vehicle titles / registrations
• ☐ Funeral / burial pre-need contracts
• ☐ Trust documents (revocable and irrevocable)
• ☐ Most recent federal and Nebraska income tax returns (3 years)
• ☐ Pension / VA / Railroad Retirement award letters
• ☐ Health-insurance premiums and other deductible expenses
• ☐ Level of Care assessment / physician certification
• ☐ Facility admission agreement (if institutionalized)
• ☐ Documentation of any transfers within 60-month look-back

13. APPLICANT CERTIFICATION AND SIGNATURE

I, [APPLICANT NAME], declare under penalty of perjury under the laws of the State of Nebraska that the information provided in this application and supporting documents is true, accurate, and complete to the best of my knowledge. I understand that knowingly providing false information may result in denial of benefits, recoupment of benefits paid, and criminal prosecution under Neb. Rev. Stat. § 68-1017 and applicable federal law. I authorize DHHS to verify the information provided and to share information with other agencies as necessary to administer the program.

[________________________________]

[APPLICANT NAME]

Date: [__/__/____]

(Signed before me on [__/__/____].)

[________________________________]

Notary Public — State of Nebraska

(My Commission Expires: [__/__/____])

14. NEBRASKA PRACTICE NOTES

• Where to file. Apply online at ACCESSNebraska (https://iserve.nebraska.gov), in person at a local DHHS office, by mail, or by telephone (1-855-632-7633). Long-term care applications are processed by DHHS Division of Medicaid and Long-Term Care.
• Processing timelines. DHHS must determine eligibility within 45 days for non-disability applications and 90 days for disability-based applications under federal regulations. Delays beyond those windows may be appealed.
• Medically needy state. Nebraska is a medically needy state operating a "Share of Cost" program under 477 NAC. Applicants whose income exceeds the categorical limit may still qualify by spending down through incurred medical expenses to the medically needy income standard (verify the current standard each year).
• 60-month look-back. All transfers within the 60-month period preceding the later of (a) application or (b) institutional admission must be disclosed. Failure to disclose may result in fraud findings. The penalty period begins on the date the applicant is otherwise eligible and receiving institutional services, not on the date of transfer.
• Penalty divisor. Nebraska's transfer-penalty divisor is the statewide average monthly private-pay nursing-facility cost as published by DHHS. Confirm the current divisor before computing penalty periods. Historical examples ($4,200/month range) are illustrative only and may be outdated.
• Annuities. A spousal annuity must be irrevocable, non-assignable, actuarially sound, and name the State of Nebraska as remainder beneficiary up to the amount of Medicaid paid (DRA 2005 / 42 U.S.C. § 1396p(c)(1)(F)).
• Estate recovery. DHHS will recover from the probate estate of a Medicaid beneficiary aged 55 or older for nursing-facility, HCBS, and related medical services. Hardship waivers are available under 477 NAC.
• Spousal refusal. Nebraska recognizes the federal "just-cause" framework but practical use of spousal refusal is fact-specific; consult counsel before relying on it.
• Estate planning interaction. Coordinate with a Nebraska-licensed elder law attorney regarding Miller / Qualified Income Trusts (Nebraska does not require a QIT because it is medically needy), irrevocable Medicaid Asset Protection Trusts, caregiver-child transfers, and life-estate deeds.
• Appeal rights. A denied applicant may request a fair hearing within 90 days of the notice of action under Neb. Rev. Stat. § 68-1018 and 477 NAC.

15. SOURCES AND REFERENCES

• Neb. Rev. Stat. § 68-901 et seq. (Medical Assistance Act) — https://nebraskalegislature.gov/laws/browse-statutes.php
• Neb. Rev. Stat. § 68-919 (Medicaid; rules and regulations; estate recovery)
• Title 477 Neb. Admin. Code (Medicaid Eligibility) — https://rules.nebraska.gov/
• 477 NAC 21 (Aged, Blind, Disabled / LTC); 477 NAC 23 (Transfer of Resources)
• 42 U.S.C. § 1396p (federal transfer-of-asset and estate-recovery rules)
• 42 U.S.C. § 1396r-5 (spousal impoverishment)
• DHHS Division of Medicaid and Long-Term Care — https://dhhs.ne.gov/Pages/Medicaid-and-Long-Term-Care.aspx
• DHHS Medicaid Public Notices (figure updates) — https://dhhs.ne.gov/Pages/Medicaid-Public-Notices.aspx
• ACCESSNebraska online application portal — https://iserve.nebraska.gov
• DHHS Aged & Disabled (A&D) Waiver — https://dhhs.ne.gov/Pages/Aged-and-Disabled-Waiver.aspx
• DHHS Form 477-000-012 (Medicaid eligibility issuance) — https://dhhs.ne.gov/Documents/477-000-012.pdf
• American Council on Aging — Nebraska Medicaid Eligibility (figure tracker) — https://www.medicaidplanningassistance.org/medicaid-eligibility-nebraska/

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. An attorney licensed in Nebraska must review and customize this document before filing. Medicaid figures and regulations change frequently; verify all citations and dollar amounts against current 477 NAC issuances and DHHS public notices before use.