New Mexico Medicaid Long-Term Care Application Packet (Turquoise Care / MLTSS Community Benefit)

NEW MEXICO MEDICAID LONG-TERM CARE APPLICATION PACKET — TURQUOISE CARE / MLTSS COMMUNITY BENEFIT

TABLE OF CONTENTS

1. Cover Sheet and Filing Instructions
2. Applicant Identification and Household Composition
3. Categorical and Functional Eligibility
4. Financial Eligibility — 2026 Limits
5. Income Diversion Trust (Miller Trust / QIT)
6. Asset Inventory and Verification
7. Sixty-Month Look-Back and Transfer Disclosures
8. Primary Residence and Home Equity
9. Spousal Impoverishment Protections
10. Authorized Representative and Power of Attorney
11. Estate Recovery Acknowledgment
12. Document Checklist
13. Signature, Verification, and Penalty-of-Perjury
14. New Mexico Practice Notes
15. Sources and References

1. COVER SHEET AND FILING INSTRUCTIONS

2. APPLICANT IDENTIFICATION AND HOUSEHOLD COMPOSITION

2.1. Applicant. [FULL LEGAL NAME], residing at [STREET, CITY, NM, ZIP], County of [COUNTY].

2.2. Marital status. ☐ Single ☐ Married (community spouse at home) ☐ Married (both institutionalized) ☐ Widowed ☐ Divorced ☐ Legally separated.

2.3. Community spouse (if any). Name [________________________________], DOB [__/__/____], SSN xxx-xx-[____], residence [________________________________].

2.4. Dependent children / disabled adult children. [LIST OR "NONE"].

2.5. Citizenship / immigration status. ☐ U.S. citizen ☐ Qualified non-citizen — attach evidence per 8 U.S.C. § 1641 and 8.200.410 NMAC.

2.6. Tribal membership. ☐ Enrolled member of [TRIBE/PUEBLO/NATION] ☐ Not applicable. (Tribal members may elect Native American Medical Services rather than MCO enrollment.)

3. CATEGORICAL AND FUNCTIONAL ELIGIBILITY

3.1. Categorical basis (check one):

• ☐ Aged (65 or older)
• ☐ Blind (statutory definition, 8.200.520 NMAC)
• ☐ Disabled (SSA disability determination or state determination)

3.2. Functional eligibility — Nursing Facility Level of Care (NF LOC). Required for Institutional Care Medicaid and for the Community Benefit. Assessment is completed by the MCO using the Long-Term Care Assessment Abstract (LTCAA) under 8.314.2 NMAC.

• Date of NF LOC assessment: [__/__/____]
• Assessor: [________________________________]
• Outcome: ☐ Meets NF LOC ☐ Does not meet NF LOC ☐ Pending

3.3. Setting of care.

• ☐ Skilled nursing facility — [FACILITY NAME, ADDRESS]
• ☐ Assisted living / community residence — [ADDRESS]
• ☐ Own home with HCBS — [ADDRESS]
• ☐ PACE site — [ADDRESS]

4. FINANCIAL ELIGIBILITY — 2026 LIMITS

4.1. Applicant gross monthly income.

4.2. ☐ Total exceeds Special Income Standard — Income Diversion Trust REQUIRED (see Section 5).

4.3. ☐ Total at or below Special Income Standard — Income Diversion Trust not required.

5. INCOME DIVERSION TRUST (MILLER TRUST / QIT)

5.1. New Mexico is one of the income-cap states recognized under 42 U.S.C. § 1396a(a)(10)(A)(ii)(V) and 42 U.S.C. § 1396p(d)(4)(B). An applicant whose gross monthly income exceeds the Special Income Standard CANNOT qualify for Institutional Care Medicaid or Community Benefit services unless excess income is diverted into a Qualified Income Trust, which New Mexico HCA refers to as an Income Diversion Trust.

5.2. Mandatory trust terms (8.281.500 NMAC; 42 U.S.C. § 1396p(d)(4)(B)):

• The trust is irrevocable.
• The trust corpus consists ONLY of the applicant's income (Social Security, pension, VA, annuity, wages, etc.). No assets may be placed in the trust.
• The trust is funded each month BEFORE the month for which Medicaid eligibility is sought (no retroactive funding).
• The State of New Mexico is named the residual beneficiary up to the total Medicaid expenditures paid on the applicant's behalf, with any remainder to other named beneficiaries.
• A separate, dedicated bank account in the name of the trust is required.

5.3. Trust execution data.

• Trust name: [________________________________]
• Date of execution: [__/__/____]
• Trustee: [________________________________]
• Trustee relationship to applicant: [________________________________]
• EIN: [__-_______]
• Account institution / number (last four): [________________________________]
• First funded month: [__/__]

5.4. ☐ Copy of trust instrument attached. ☐ Copy of trustee EIN letter attached. ☐ Copy of first month's deposit attached.

6. ASSET INVENTORY AND VERIFICATION

6.1. Total countable assets — applicant (and one-half marital, if applicable). $[________].

6.2. Verification documents. Attach two (2) most recent statements for each financial account, vehicle titles, deed, life-insurance illustrations, and annuity contracts.

7. SIXTY-MONTH LOOK-BACK AND TRANSFER DISCLOSURES

7.1. The look-back period for this application begins [__/__/____] (60 months prior to application date) and ends [__/__/____] (application date).

7.2. Transfers within the look-back. List EVERY transfer, gift, sale below market value, addition or removal of a joint owner, contribution to a trust, or asset distribution. Disclose even small or family transfers — undisclosed transfers discovered later cause penalty re-determination, recoupment, and possible fraud referral.

7.3. Transfer-penalty calculation.

• Aggregate uncompensated value of transfers: $[________]
• New Mexico transfer-penalty divisor (HCA-published statewide average monthly private-pay NF cost): $[________] [VERIFY CURRENT FIGURE WITH HCA]
• Penalty months = aggregate ÷ divisor = [____] months
• Penalty start date = the later of the date of transfer or the date the applicant is otherwise eligible and receiving institutional / waiver services (DRA 2005 / 42 U.S.C. § 1396p(c)(1)(D)(ii)).

7.4. Exempt transfers (assert if applicable):

• ☐ Transfer to community spouse
• ☐ Transfer to blind or disabled child of any age
• ☐ Transfer to a (d)(4)(A) or (d)(4)(C) trust for a disabled person under 65
• ☐ Caregiver-child homestead transfer (child resided in home and provided care preventing institutionalization for two-plus years immediately prior — 42 U.S.C. § 1396p(c)(2)(A)(iv))
• ☐ Sibling-equity homestead transfer
• ☐ Transfer for fair market value
• ☐ Hardship waiver requested (8.281.500 NMAC)

8. PRIMARY RESIDENCE AND HOME EQUITY

8.1. Address of homestead. [________________________________].

8.2. Title held. ☐ Sole — applicant ☐ Joint with community spouse ☐ Joint with non-spouse ☐ Life estate ☐ Transfer-on-death deed (NMSA § 45-6-401 et seq.) ☐ Trust.

8.3. Equity calculation. Fair market value $[________] less encumbrances $[________] = equity $[________].

8.4. Home-equity exemption. The home is excluded from countable assets if (a) the community spouse, a minor child, or a blind/disabled child resides there; OR (b) the equity interest does not exceed $752,000 (2026 federal limit, indexed annually) and the applicant or representative declares an intent to return home.

8.5. Intent-to-return statement.

I, [APPLICANT NAME], intend to return to my home at [ADDRESS] if and when my medical condition permits.

8.6. Estate-recovery exposure. The home, even if exempt during life, is subject to Medicaid Estate Recovery under NMSA § 27-2A-1 et seq. and 42 U.S.C. § 1396p(b) following the death of the recipient (and the death of any surviving spouse / minor or disabled child). Discuss probate-avoidance and equity-protection strategies with counsel.

9. SPOUSAL IMPOVERISHMENT PROTECTIONS

9.1. Snapshot date. First continuous period of institutionalization (or HCBS enrollment) began [__/__/____]. CSRA is computed as of this date (8.281.500 NMAC; 42 U.S.C. § 1396r-5).

9.2. Snapshot countable resources of the couple. $[________].

9.3. CSRA allocation. ☐ One-half snapshot, capped at $162,660 ☐ Minimum $32,532 ☐ Spousal-share fair-hearing increase requested.

9.4. Income allocation to community spouse. If community spouse's gross monthly income is below the MMMNA ($2,643.75 baseline; up to $4,066.50 with shelter-cost excess), a Monthly Income Allowance is diverted from the institutionalized spouse before the patient-pay liability is computed.

10. AUTHORIZED REPRESENTATIVE AND POWER OF ATTORNEY

10.1. Authorized representative (HCA Form 100-AR or equivalent):

• Name: [________________________________]
• Capacity: ☐ Agent under durable POA ☐ Court-appointed guardian/conservator ☐ Family member ☐ Attorney
• Address: [________________________________]
• Phone: [________________________________]
• Email: [________________________________]

10.2. ☐ Copy of Durable Power of Attorney (NMSA § 45-5B-101 et seq., Uniform Power of Attorney Act) attached.

10.3. ☐ Copy of guardianship / conservatorship Letters (NMSA § 45-5-101 et seq.) attached.

10.4. ☐ HIPAA authorization attached.

11. ESTATE RECOVERY ACKNOWLEDGMENT

11.1. I acknowledge that under NMSA § 27-2A-1 et seq. (Medicaid Estate Recovery Act) and 42 U.S.C. § 1396p(b), New Mexico will seek recovery against my probate estate after my death (and after the death of a surviving spouse, if any, and absent a surviving minor or disabled child) for Medicaid services correctly paid for nursing facility care, HCBS, and related hospital and prescription costs received at age 55 or older.

11.2. I acknowledge that recovery may be deferred or waived only on the limited grounds in NMSA § 27-2A-7 (undue hardship, surviving spouse, qualifying child, or low-equity / income-producing homestead criteria).

Applicant initial: [____] Representative initial: [____]

12. DOCUMENT CHECKLIST

• ☐ HCA-100 application (or YES NM submission confirmation)
• ☐ ISD-379 Long-Term Care Supplement
• ☐ Photo ID and Social Security card (applicant and community spouse)
• ☐ Birth certificate / proof of citizenship
• ☐ Marriage certificate / divorce decree / death certificate of prior spouse
• ☐ Current Medicare card and supplemental insurance cards
• ☐ Sixty months of bank, brokerage, IRA, and credit union statements (every account)
• ☐ Deeds, mortgages, and tax statements for all real property
• ☐ Vehicle titles
• ☐ Life insurance policies with cash-value statements
• ☐ Annuity contracts and most recent statements
• ☐ Pension / retirement award letters
• ☐ Social Security and SSI award letters
• ☐ VA benefit award letters
• ☐ Income Diversion Trust instrument and bank statements
• ☐ Durable Power of Attorney / Guardianship Letters
• ☐ Funeral / burial contracts
• ☐ Medical records supporting NF LOC
• ☐ NF LOC assessment (LTCAA)
• ☐ Authorized Representative form (HCA-100-AR)
• ☐ HIPAA authorization

13. SIGNATURE, VERIFICATION, AND PENALTY-OF-PERJURY

I declare under penalty of perjury under the laws of the State of New Mexico and the United States of America that the information provided in this application and all attachments is true, correct, and complete to the best of my knowledge. I understand that a knowingly false statement may constitute Medicaid fraud under NMSA § 30-44-7 and 42 U.S.C. § 1320a-7b, may result in denial or termination of benefits, recoupment of paid claims, and criminal prosecution. I authorize the New Mexico Health Care Authority and its contractors to verify all information through Federal Data Services Hub matches, financial-institution inquiries (42 U.S.C. § 1396w), Social Security Administration records, employer reports, and other sources permitted by law.

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

Authorized representative signature: [________________________________] Date: [__/__/____]

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

14. NEW MEXICO PRACTICE NOTES

• Income-cap state. New Mexico applies the 300% SSI federal-benefit-rate cap and does NOT permit medical spend-down to reach LTC eligibility. Establishing and properly funding an Income Diversion Trust BEFORE the eligibility month is the dispositive step in nearly every over-cap case.
• Turquoise Care MCO selection. Effective July 1, 2024, Centennial Care became Turquoise Care. Members select among Blue Cross Blue Shield NM, Molina Healthcare of New Mexico, Presbyterian Health Plan, and UnitedHealthcare Community Plan. The MCO performs the NF LOC assessment, authorizes Community Benefit (HCBS) services, and coordinates dual eligibility with Medicare.
• Community Benefit (HCBS). The Section 1115 demonstration consolidates several legacy waivers. Available services include personal care, adult day health, home modifications, respite, assisted living, emergency response, and self-direction (Mi Via and Self-Directed Community Benefit).
• Annuity rules. Single-premium immediate annuities owned by the institutionalized spouse must be irrevocable, non-assignable, actuarially sound, and name New Mexico as primary remainder beneficiary up to Medicaid expenditures (Deficit Reduction Act of 2005; 42 U.S.C. § 1396p(c)(1)(F)–(G); 8.281.500 NMAC).
• Caregiver-child homestead transfer. A homestead transfer to an adult child who lived in the home for at least two years immediately before institutionalization and provided care that delayed institutionalization is exempt from the transfer penalty.
• Native American applicants. Tribal members may opt out of MCO enrollment and receive services through Indian Health Service / Tribal 638 facilities under the Section 1115 STCs.
• Retroactive eligibility. Up to three months of retroactive coverage is available if the applicant met all eligibility criteria during the retroactive months (42 C.F.R. § 435.915).
• Fair hearings. A denial, termination, or transfer-penalty determination may be appealed to the HCA Fair Hearings Bureau within ninety (90) days (8.352.2 NMAC). Aid-pending continues if the appeal is filed within the advance-notice period.
• Estate recovery scope. New Mexico recovers from the probate estate only — assets passing by operation of law (joint tenancy, beneficiary designation, transfer-on-death deed, properly drafted trust) are generally outside reach. Plan accordingly with counsel.

15. SOURCES AND REFERENCES

• New Mexico Health Care Authority — Eligibility Pamphlet (Jan. 2025) — https://www.hca.nm.gov/wp-content/uploads/Eligibility-Pamphlet-1.1.2025.pdf
• New Mexico Health Care Authority — Turquoise Care — https://www.hca.nm.gov/turquoise-care/
• CMS — New Mexico Turquoise Care Section 1115 Demonstration approval (Oct. 16, 2024) — https://www.medicaid.gov/medicaid/section-1115-demonstrations/downloads/nm-turquoise-care-dmnstrtn-aprvl-10162024.pdf
• New Mexico Administrative Code Title 8 (Social Services), especially 8.281 NMAC and 8.291 NMAC — https://www.srca.nm.gov/nmac-home/
• NMSA § 27-2A-1 et seq. (Medicaid Estate Recovery Act)
• NMSA § 45-5B-101 et seq. (Uniform Power of Attorney Act)
• 42 U.S.C. § 1396p (transfers, trusts, look-back, estate recovery)
• 42 U.S.C. § 1396p(d)(4)(B) (Qualified Income Trust authority)
• 42 U.S.C. § 1396r-5 (spousal impoverishment)
• 42 C.F.R. Parts 431, 435, 441, 447 (Medicaid administration and eligibility)
• Medicaid Planning Assistance — New Mexico 2026 income/asset limits — https://www.medicaidplanningassistance.org/medicaid-eligibility-new-mexico/
• New Mexico Aging & Long-Term Services Department — Long-Term Care resources — https://www.aging.nm.gov/long-term-care/
• YES NM applicant portal — https://yes.state.nm.us/

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. An attorney licensed in New Mexico (and ideally a Certified Elder Law Attorney or Certified Medicaid Planner) must review and customize this document before submission. Eligibility figures, divisors, and rules change frequently — verify all authorities and current dollar amounts before use.