New Hampshire Medicaid Application Packet (Long-Term Care)
NEW HAMPSHIRE MEDICAID APPLICATION PACKET — LONG-TERM CARE
TABLE OF CONTENTS
- Cover Letter to DHHS
- Applicant Identification and Authorized Representative
- Program Selection
- Categorical and Functional Eligibility
- Income Documentation
- Asset / Resource Documentation
- Spousal (Community Spouse) Information
- Five-Year Look-Back Disclosure of Transfers
- Treatment of the Primary Residence
- Medically Needy / Spend-Down Election
- Patient Liability and Income Allocation
- Estate Recovery and TEFRA Lien Notice
- Applicant Certification and Signatures
- Document Checklist
- New Hampshire Practice Notes
- Sources and References
1. COVER LETTER TO DHHS
Date: [__/__/____]
New Hampshire Department of Health and Human Services
Bureau of Family Assistance / District Office
[DISTRICT OFFICE STREET ADDRESS]
[CITY, NH ZIP]
Re: Application for NH Medicaid (Medical Assistance) — Long-Term Care
Applicant: [APPLICANT FULL LEGAL NAME]
Social Security No.: [XXX-XX-____]
Date of Birth: [__/__/____]
Dear Eligibility Specialist:
Enclosed please find the application for New Hampshire Medicaid medical assistance for the above-named applicant, together with supporting documentation as listed in the attached Document Checklist (Section 14). The applicant requests determination of eligibility under the program(s) selected in Section 3.
Please direct all correspondence regarding this application to the Authorized Representative identified in Section 2.
Respectfully,
[________________________________]
[AUTHORIZED REPRESENTATIVE / ATTORNEY]
2. APPLICANT IDENTIFICATION AND AUTHORIZED REPRESENTATIVE
2.1. Applicant.
| Field | Entry |
|---|---|
| Full legal name | [________________________________] |
| Date of birth | [__/__/____] |
| Social Security No. | [________________________________] |
| Marital status | ☐ Single ☐ Married ☐ Widowed ☐ Divorced ☐ Separated |
| Current residence | [________________________________] |
| Mailing address | [________________________________] |
| Telephone | [________________________________] |
| Citizenship / immigration status | [________________________________] |
| Medicare claim number (if any) | [________________________________] |
2.2. Authorized Representative (RSA 161:4-a; He-W 801).
| Field | Entry |
|---|---|
| Name | [________________________________] |
| Relationship to applicant | [________________________________] |
| Address | [________________________________] |
| Telephone | [________________________________] |
| [________________________________] |
The applicant (or applicant's legal representative) hereby designates the above-named person as Authorized Representative for purposes of this application, including the receipt of confidential information and the right to act on the applicant's behalf in all matters arising under this application:
[________________________________]
[APPLICANT or LEGAL REPRESENTATIVE SIGNATURE], Date: [__/__/____]
3. PROGRAM SELECTION
The applicant requests eligibility determination under the following long-term-care category(ies) (check all that apply):
- ☐ Nursing Facility (NF) Medicaid — institutional level of care in a Medicaid-certified nursing facility (He-W 841 et seq.).
- ☐ Choices for Independence (CFI) Waiver — Home and Community Based Services in lieu of institutional care (He-E 801; 1915(c) waiver).
- ☐ Old Age Assistance (OAA) — State Supplemental Program for individuals age 65 or older (RSA 167; He-W 600 series), with categorical Medicaid.
- ☐ APTD / Aid to the Permanently and Totally Disabled (RSA 167:6, V) — for applicants under age 65.
- ☐ Medically Needy / Spend-Down — In and Out Medical Assistance (He-W 854).
4. CATEGORICAL AND FUNCTIONAL ELIGIBILITY
4.1. Age / Disability category. The applicant is (check one):
- ☐ Age 65 or older (date of 65th birthday: [__/__/____]).
- ☐ Age 18-64 and disabled (impairment expected to last 48 months or longer per NH's 209(b) rule; SSA disability determination attached if available).
- ☐ Blind as defined in Title XVI.
4.2. Nursing-Facility Level of Care (NFLOC). Required for NF Medicaid and CFI Waiver. NFLOC is determined by a Registered Nurse using the Medical Eligibility Assessment (MEA). An applicant requiring assistance with two (2) or more Activities of Daily Living (ADLs) generally meets NFLOC.
- ☐ MEA completed on [__/__/____] by [RN NAME], finding NFLOC met.
- ☐ MEA pending; scheduled for [__/__/____].
4.3. Residency. The applicant resides in New Hampshire and intends to remain. Address: [________________________________].
5. INCOME DOCUMENTATION
5.1. Gross monthly income — applicant.
| Source | Monthly Gross | Verification Attached |
|---|---|---|
| Social Security (SSA / SSDI) | $ [________] | ☐ |
| SSI | $ [________] | ☐ |
| Pension / annuity | $ [________] | ☐ |
| VA benefits | $ [________] | ☐ |
| Wages / self-employment | $ [________] | ☐ |
| Rental income | $ [________] | ☐ |
| Interest / dividends | $ [________] | ☐ |
| Other: [________] | $ [________] | ☐ |
| TOTAL GROSS | $ [________] |
5.2. NF / CFI Income Cap (2025/2026). The applicant's gross monthly income is ☐ at or below ☐ above the current $2,982/month cap (300% FBR). If above the cap, the applicant ☐ has ☐ has not established a Qualified Income Trust ("Miller Trust" / 42 U.S.C. § 1396p(d)(4)(B)). Trust documentation attached: ☐.
5.3. Old Age Assistance (OAA) standard of need. Applicant gross income is ☐ at or below ☐ above the current OAA standard. Verify current Standard of Need on the DHHS BDS bulletin.
6. ASSET / RESOURCE DOCUMENTATION
6.1. Countable assets — applicant (and spouse if applicable).
| Asset | Owner | Account / ID | Balance as of [__/__/____] | Verification |
|---|---|---|---|---|
| Checking account(s) | [___] | [___] | $ [___] | ☐ |
| Savings account(s) | [___] | [___] | $ [___] | ☐ |
| Certificates of deposit | [___] | [___] | $ [___] | ☐ |
| Brokerage / mutual funds | [___] | [___] | $ [___] | ☐ |
| Stocks / bonds (non-retirement) | [___] | [___] | $ [___] | ☐ |
| Retirement accounts (IRA/401(k)) | [___] | [___] | $ [___] | ☐ |
| Cash value of life insurance (face value > $1,500) | [___] | [___] | $ [___] | ☐ |
| Real property other than homestead | [___] | [___] | $ [___] | ☐ |
| Vehicles beyond one excluded auto | [___] | [___] | $ [___] | ☐ |
| Burial accounts / pre-need contracts | [___] | [___] | $ [___] | ☐ |
| Other: [___] | [___] | [___] | $ [___] | ☐ |
| TOTAL COUNTABLE | $ [___] |
6.2. Excluded resources. The following are not counted toward the resource limit (verify against He-W 852):
- ☐ Primary residence (subject to home-equity cap and intent-to-return rules; see Section 9).
- ☐ One automobile of any value.
- ☐ Personal effects and household goods.
- ☐ Irrevocable burial trust / pre-need funeral contract within state limit.
- ☐ Burial space and burial fund up to the allowable amount.
- ☐ Term life insurance (no cash value) and life insurance with face value of $1,500 or less.
6.3. Resource limit. Single applicant: $2,500 countable resources (verify current). Married, both applying: confirm current standard. Married, one applying: see CSRA in Section 7.
7. SPOUSAL (COMMUNITY SPOUSE) INFORMATION
Complete this section only if applicant is married and one spouse is institutionalized or applying for CFI / NF Medicaid.
7.1. Community Spouse.
| Field | Entry |
|---|---|
| Name | [________________________________] |
| Date of birth | [__/__/____] |
| SSN | [________________________________] |
| Address | [________________________________] |
| Monthly gross income | $ [________] |
7.2. Spousal Resource Assessment (Snapshot). Date of first continuous period of institutionalization (or first CFI start): [__/__/____]. Total countable assets on snapshot date: $ [___].
7.3. Community Spouse Resource Allowance (CSRA), 2025/2026.
- Minimum CSRA: $32,532
- Maximum CSRA: $162,660
- Calculated CSRA: $ [________]
7.4. Minimum Monthly Maintenance Needs Allowance (MMMNA). The Community Spouse may retain a portion of the institutionalized spouse's income up to the MMMNA, with possible enhancement by a Fair Hearing or court support order. Verify the current MMMNA on the dhhs.nh.gov bulletins.
8. FIVE-YEAR LOOK-BACK DISCLOSURE OF TRANSFERS
8.1. The Medicaid look-back period is 60 months preceding the application date pursuant to 42 U.S.C. § 1396p(c)(1)(B)(i). Earliest reviewable date: [__/__/____].
8.2. Transfers for less than fair market value. List every gift, uncompensated transfer, sale below fair market value, addition of a joint owner, or transfer to a trust during the look-back period. Attach separate sheets if necessary.
| Date of Transfer | Asset / Amount | Transferee | Relationship | FMV at Transfer | Compensation Received | Documentation |
|---|---|---|---|---|---|---|
| [__/__/____] | [___] | [___] | [___] | $ [___] | $ [___] | ☐ |
| [__/__/____] | [___] | [___] | [___] | $ [___] | $ [___] | ☐ |
| [__/__/____] | [___] | [___] | [___] | $ [___] | $ [___] | ☐ |
8.3. Transfers exempt from penalty (42 U.S.C. § 1396p(c)(2)). Indicate any exempt transfer claimed:
- ☐ Transfer to spouse or for sole benefit of spouse.
- ☐ Transfer to disabled child (any age) or to a (d)(4)(A) or (d)(4)(C) trust for that child.
- ☐ "Caretaker child" exception — child resided in the home for at least 2 years immediately before institutionalization and provided care that delayed institutionalization.
- ☐ Sibling with equity interest who resided in the home for at least 1 year prior to institutionalization.
- ☐ Transfer was for purpose other than to qualify for Medicaid (rebuttal of presumption).
- ☐ Asset returned in full / undue hardship waiver requested.
8.4. Penalty period calculation. If a non-exempt transfer is identified, the penalty period equals the value transferred divided by NH's current penalty divisor. Penalty begins on the later of (i) the date of the transfer or (ii) the date the applicant is otherwise eligible and would be receiving institutional level care but for the penalty (42 U.S.C. § 1396p(c)(1)(D)). Confirm current divisor with the DHHS Bureau of Family Assistance before computing.
9. TREATMENT OF THE PRIMARY RESIDENCE
9.1. Homestead. Address: [________________________________]. Equity value: $ [___].
9.2. Equity interest cap. Per 42 U.S.C. § 1396p(f), home equity above the federal cap (adjusted annually; verify current NH-applied figure) renders the applicant ineligible unless a spouse, minor child, or blind/disabled child resides in the home.
9.3. Intent to return. For NF Medicaid applicants, the home remains an excluded asset only if the applicant has executed a written declaration of intent to return home or a qualifying family member resides there. Declaration attached: ☐.
9.4. TEFRA lien (RSA 167:13-a; 42 U.S.C. § 1396p(a)). For institutionalized applicants not reasonably expected to return home, DHHS may impose a lien on real property. The lien is dissolved if the recipient is discharged and returns home.
9.5. Estate recovery (RSA 167:14-a; 42 U.S.C. § 1396p(b)). Upon death, NH may recover from the estate of a deceased recipient (age 55 or older when assistance was received) the cost of medical assistance paid. See Section 12.
10. MEDICALLY NEEDY / SPEND-DOWN ELECTION
10.1. The applicant elects ☐ does not elect ☐ to be considered under the Medically Needy / In and Out Medical Assistance program (He-W 854).
10.2. Protected Income Level (PIL). The current PIL for a single individual is $591/month (verify). Income above the PIL must be applied ("spent down") to incurred medical expenses to qualify within a six-month spend-down period.
10.3. Spend-down calculation.
- Gross monthly income: $ [___]
- Less PIL: $ [___]
- Excess income (per month): $ [___]
- Six-month spend-down requirement: $ [___]
10.4. Anticipated medical expenses to be applied against spend-down:
| Expense | Provider | Date Incurred | Amount |
|---|---|---|---|
| [___] | [___] | [__/__/____] | $ [___] |
| [___] | [___] | [__/__/____] | $ [___] |
11. PATIENT LIABILITY AND INCOME ALLOCATION
11.1. For NF Medicaid recipients, monthly income is allocated as follows:
| Allocation | Monthly Amount |
|---|---|
| Personal Needs Allowance (PNA — verify current NH amount, generally ~$75) | $ [___] |
| Medicare Part B premium / health insurance | $ [___] |
| Spousal (MMMNA) allowance, if any | $ [___] |
| Dependent family member allowance | $ [___] |
| Court-ordered support | $ [___] |
| Allowable medical expenses | $ [___] |
| Patient liability (paid to facility) | $ [___] |
11.2. For CFI Waiver participants in their own home, no patient liability is assessed; the participant retains income subject to the categorical limits.
12. ESTATE RECOVERY AND TEFRA LIEN NOTICE
The applicant hereby acknowledges receipt of notice that:
- New Hampshire is required by 42 U.S.C. § 1396p(b) and RSA 167:14-a to seek recovery from the estate of a deceased Medicaid recipient (age 55+) for medical assistance correctly paid.
- Recovery is deferred while a surviving spouse is living, while a minor child is living, or while a blind or disabled child of any age is living.
- TEFRA liens may be imposed on real property of an institutionalized recipient who is not reasonably expected to return home (RSA 167:13-a).
- Hardship waivers may be available pursuant to RSA 167:14-a, IV.
[________________________________]
[APPLICANT / LEGAL REPRESENTATIVE] — Acknowledged: [__/__/____]
13. APPLICANT CERTIFICATION AND SIGNATURES
I, the undersigned, declare under penalty of perjury under the laws of the State of New Hampshire and the United States that the information contained in this application packet, including all attachments, is true, complete, and accurate to the best of my knowledge. I understand that knowingly making a false statement to obtain Medicaid is a felony under federal and New Hampshire law (RSA 167:17; 42 U.S.C. § 1320a-7b).
I authorize DHHS to verify the information provided through any source, including financial institutions, the Social Security Administration, the IRS, the New Hampshire Department of Revenue Administration, and employers.
[________________________________]
[APPLICANT NAME], Applicant — Date: [__/__/____]
[________________________________]
[REPRESENTATIVE NAME], Authorized Representative — Date: [__/__/____]
State of New Hampshire, County of [___]:
Subscribed and sworn before me on [__/__/____].
[________________________________]
Justice of the Peace / Notary Public — Commission expires: [__/__/____]
14. DOCUMENT CHECKLIST
Attach the following with the application:
- ☐ Birth certificate or other proof of age and U.S. citizenship / lawful immigration status.
- ☐ Social Security card and Medicare card (if any).
- ☐ Photo ID (driver's license or non-driver ID).
- ☐ Marriage certificate, divorce decree, or death certificate of spouse (as applicable).
- ☐ Most recent SSA / SSI / pension / VA award letters.
- ☐ Three (3) months of pay stubs (if working).
- ☐ Sixty (60) months of statements for every checking, savings, brokerage, retirement, and investment account.
- ☐ Deeds, mortgages, and recent tax bills for all real property owned in the look-back period.
- ☐ Titles and registrations for all motor vehicles owned in the look-back period.
- ☐ Life-insurance policies (face page and current cash-value statement).
- ☐ Burial-account / pre-need funeral contract.
- ☐ Federal and NH tax returns for the past five (5) years.
- ☐ Trust instruments (revocable and irrevocable).
- ☐ Power of Attorney (durable financial) and Advance Directive (Durable Power of Attorney for Health Care).
- ☐ Documentation supporting any uncompensated transfer or claimed exemption.
- ☐ Medical Eligibility Assessment (MEA) result (NF / CFI applicants).
- ☐ Long-term care insurance policy and benefit ledger (if any) — note the NH Long-Term Care Partnership program asset disregard.
15. NEW HAMPSHIRE PRACTICE NOTES
- Section 209(b) status. New Hampshire is a 209(b) state under 42 U.S.C. § 1396a(f). SSI receipt does not produce automatic Medicaid eligibility; financial and categorical determinations are made independently by DHHS. For applicants ages 18–64 claiming disability, NH applies a 48-month minimum impairment duration in lieu of the SSI 12-month standard.
- Medically needy. NH operates a medically needy / spend-down program (He-W 854) using a Protected Income Level (PIL) — verify the current single PIL on dhhs.nh.gov before drafting.
- Choices for Independence (CFI). The 1915(c) HCBS waiver is administered under He-E 801. NFLOC is required. CFI provides personal care, adult medical day, home-delivered meals, environmental modifications, and case management.
- Penalty divisor. NH's transfer-penalty divisor is published periodically by DHHS and tracks the average statewide private-pay nursing-home per diem. As of recent published bulletins, the NH average private-pay rate has been among the highest in the Northeast — confirm the current divisor with the Bureau of Family Assistance before any planning calculation.
- Long-Term Care Partnership. NH participates in the LTC Partnership program; benefits paid under a qualifying policy give the recipient a dollar-for-dollar disregard against countable resources and against estate-recovery claims. Attach the policy insurance ledger.
- Fair hearings. Adverse determinations are appealable to the DHHS Administrative Appeals Unit under RSA 161:4-c and He-C 200. The request must be filed within thirty (30) days of the notice.
- NH EASY. The fastest filing path for most applicants is the NH EASY portal (https://nheasy.nh.gov), which routes the application to the appropriate District Office.
- County contribution. NH counties contribute to the non-federal share of NF Medicaid for some recipients (RSA 167:18-a). This may affect the District Office assignment but not eligibility.
16. SOURCES AND REFERENCES
- New Hampshire Department of Health and Human Services — https://www.dhhs.nh.gov
- NH Medicaid (Medical Assistance) Eligibility for Adults — https://www.dhhs.nh.gov/programs-services/medicaid/nh-medicaid-medical-assistance-eligibility/nh-medicaid-medical-0
- Choices for Independence (CFI) Waiver — https://www.dhhs.nh.gov/programs-services/adult-aging-care/nh-choices-independence-waiver-renewal-and-amendments-2022-2027
- Old Age Assistance (OAA) — https://www.dhhs.nh.gov/programs-services/adult-aging-care/old-age-assistance
- N.H. Admin. Code He-W 800 (Eligibility for Medical Assistance) — https://gc.nh.gov/rules/state_agencies/he-w800.html
- N.H. Admin. Code He-E 801 (CFI Waiver rule) — https://gc.nh.gov/rules/state_agencies/he-e800.html
- RSA Chapter 167 — https://www.gencourt.state.nh.us/rsa/html/NHTOC/NHTOC-XII-167.htm
- 42 U.S.C. § 1396p (transfers, liens, recovery) — https://www.law.cornell.edu/uscode/text/42/1396p
- NH EASY portal — https://nheasy.nh.gov
- DHHS Standard of Need bulletin — https://www.dhhs.nh.gov/sites/g/files/ehbemt476/files/documents2/bdsstandardofneed.pdf
- DHHS toll-free customer service: 1-844-275-3447
Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. Medicaid eligibility rules, dollar limits, and the NH penalty divisor change at least annually and sometimes mid-year. Verify every figure and citation on dhhs.nh.gov and gencourt.state.nh.us before use, and have the application reviewed by a New Hampshire-licensed elder law attorney.
About This Template
Elder law covers the legal needs that come with aging: planning for long-term care costs, protecting assets from being wiped out by a nursing home stay, handling incapacity, and responding to elder abuse or financial exploitation. The paperwork often has to coordinate with Medicaid rules, tax treatment, and state guardianship requirements, which is why small mistakes can cost a family a great deal of money or control over decisions.
Important Notice
This template is provided for informational purposes. It is not legal advice. We recommend having an attorney review any legal document before signing, especially for high-value or complex matters.
Last updated: May 2026