Nevada Medicaid Application Packet — Long-Term Care, Frail Elderly Waiver, and Nursing Facility Medicaid

NEVADA MEDICAID APPLICATION PACKET — LONG-TERM CARE, FRAIL ELDERLY WAIVER, AND NURSING FACILITY MEDICAID

TABLE OF CONTENTS

1. Cover Letter to DWSS
2. Applicant Identification and Household
3. Program Selection
4. Categorical and Functional Eligibility
5. Income Schedule
6. Asset (Resource) Schedule
7. Spousal Impoverishment Worksheet
8. Sixty-Month Look-Back and Transfer Disclosures
9. Qualified Income Trust (Miller Trust) Designation
10. Primary Residence and Home Equity Treatment
11. Estate Recovery Acknowledgment
12. Authorized Representative Designation
13. Verification Documents Checklist
14. Applicant / Representative Signature and Penalty-of-Perjury Verification
15. Nevada Practice Notes
16. Sources and References

1. COVER LETTER TO DWSS

To: Nevada Division of Welfare and Supportive Services (DWSS)

Address: [________________________________] (DWSS District Office serving applicant's county of residence)

From: [________________________________] (Applicant or Authorized Representative)

Date: [__/__/____]

Re: Application for Medicaid Long-Term Care Benefits — [APPLICANT NAME]; DOB [__/__/____]; SSN xxx-xx-[____]

Dear DWSS Eligibility Worker:

Enclosed please find the application materials of [APPLICANT NAME] for Nevada Medicaid long-term care benefits. The applicant requests benefits effective [__/__/____] under the program(s) selected in Section 3, together with all retroactive coverage permitted under 42 C.F.R. § 435.915 (up to three months prior to the month of application).

This packet contains: (a) a completed Application for Assistance (DWSS Form 2101 / online ACCESS Nevada submission confirmation [____________]); (b) supporting income, asset, and identity verifications; (c) a fully executed Qualified Income Trust, if required by Section 9; and (d) the signed verifications described in Section 14.

Please direct all correspondence and notices of action to the authorized representative identified in Section 12.

Sincerely,

[________________________________]

[NAME / TITLE]

2. APPLICANT IDENTIFICATION AND HOUSEHOLD

3. PROGRAM SELECTION

The applicant requests the following Nevada Medicaid program(s) (check all that apply):

• ☐ Institutional / Nursing Facility (NF) Medicaid (MSM Chapter 500; vendor payment to facility)
• ☐ Home and Community Based Waiver for the Frail Elderly (FE Waiver) (jointly administered by DHCFP and ADSD; applicant must be 65 or older and meet NF level-of-care)
• ☐ HCBW for Persons with Physical Disabilities (WIN) (where applicable)
• ☐ Assisted Living Waiver / Group Care Waiver (where applicable)
• ☐ Medicaid for the Aged, Blind, and Disabled (MAABD) (regular community Medicaid)
• ☐ Medicare Savings Program (QMB / SLMB / QI), in addition to or in lieu of full Medicaid

Effective date requested: [__/__/____] (request retroactive coverage for the three preceding months: yes ☐ no ☐)

4. CATEGORICAL AND FUNCTIONAL ELIGIBILITY

4.1. Age / disability. Applicant qualifies as ☐ aged (65 or older), ☐ blind, ☐ disabled (per SSA determination or State Medical Review Team finding).

4.2. Nursing-facility level of care (NF-LOC). For NF Medicaid and the FE Waiver, the applicant must require an NF level of care as documented by ADSD/DHCFP using the Nevada level-of-care assessment instrument. Date of NF-LOC determination: [__/__/____].

4.3. Functional needs. Activities of daily living requiring hands-on assistance (check all): ☐ bathing ☐ dressing ☐ toileting ☐ transferring ☐ continence ☐ eating ☐ ambulation ☐ medication management ☐ meal preparation.

4.4. Diagnoses supporting eligibility (attach Form 4807 / Physician's Certification or comparable): [________________________________].

5. INCOME SCHEDULE

Report ALL income, regardless of source, received by or on behalf of the applicant in the calendar month prior to filing.

Income-cap test (long-term care programs). Applicable special-income limit: $[2,982 in 2026 — VERIFY current MSM figure] per month per individual (300% of the SSI Federal Benefit Rate). If TOTAL GROSS MONTHLY INCOME exceeds this figure, a Qualified Income Trust is required (Section 9).

Personal Needs Allowance (PNA) — institutionalized resident: $[VERIFY — currently $35/month under NRS 422.27179 and DHCFP MSM, subject to legislative change] retained by the resident; balance applied as "patient liability" to the facility.

6. ASSET (RESOURCE) SCHEDULE

Report ALL assets owned by the applicant (and community spouse, if married) as of the first moment of the month for which eligibility is sought.

Resource limits — VERIFY against current DWSS Eligibility & Payments Information Manual:

• Single applicant (NF Medicaid / FE Waiver): $2,000 countable.
• Married couple — both applying: $3,000 combined.
• Community Spouse Resource Allowance (CSRA) for 2026 (one-spouse case): up to $162,660 (federal maximum).
• Home equity limit (single applicant, no community spouse / dependent): $752,000 in 2026 (federal floor under 42 U.S.C. § 1396p(f)).

7. SPOUSAL IMPOVERISHMENT WORKSHEET

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

7.1. Snapshot date (first day of first continuous period of institutionalization of 30 or more days, per 42 U.S.C. § 1396r-5(c)(1)(B)): [__/__/____].

7.2. Total countable resources of the couple as of snapshot date: $[__________].

7.3. Spousal share (one-half of 7.2): $[__________].

7.4. Community Spouse Resource Allowance (CSRA): the lesser of 7.3 or the federal maximum ($[162,660 in 2026 — VERIFY]), but not less than any applicable state minimum: $[__________].

7.5. Resources attributable to the institutionalized spouse: $[__________] (which must be reduced to $2,000 by the first day of the month of eligibility).

7.6. Minimum Monthly Maintenance Needs Allowance (MMMNA) for the community spouse (2026 floor — VERIFY against current SSA and CMS spousal-impoverishment standards; commonly cited Nevada figure: $[4,066.50/month effective 7/1/2026 — VERIFY]): $[__________].

7.7. Community spouse's gross monthly income: $[__________].

7.8. Income shortfall (7.6 minus 7.7, not less than zero): $[__________]. The institutionalized spouse may divert this amount from his or her income to the community spouse before computing patient liability.

7.9. Fair-hearing reservation. The institutionalized spouse, the community spouse, or their representative may request a fair hearing under 42 U.S.C. § 1396r-5(e) to seek an increased CSRA where the standard CSRA generates insufficient income to meet the MMMNA.

8. SIXTY-MONTH LOOK-BACK AND TRANSFER DISCLOSURES

Pursuant to 42 U.S.C. § 1396p(c) and the Nevada MSM, applicant discloses every transfer of assets for less than fair-market value occurring during the 60 calendar months immediately preceding the month of application or institutionalization, whichever is later.

Penalty calculation. Penalty period (in months) equals the total uncompensated value divided by Nevada's current monthly transfer-penalty divisor. Nevada's penalty divisor is published by DHCFP and is currently approximately $[9,949.26/month — VERIFY against current MSM Chapter 500]. The penalty period begins on the later of (a) the date of the transfer or (b) the date the applicant is otherwise eligible for Medicaid and would be receiving institutional-level care but for the transfer.

Exempt transfers asserted (check all that apply):

• ☐ Transfer to spouse or to another for the sole benefit of spouse (42 U.S.C. § 1396p(c)(2)(B)(i))
• ☐ Transfer to blind or disabled child or to trust for sole benefit of such child (§ 1396p(c)(2)(B)(iii))
• ☐ Transfer to a special-needs trust under § 1396p(d)(4)(A) for individual under 65
• ☐ Transfer to a pooled trust under § 1396p(d)(4)(C)
• ☐ Transfer of home to: caretaker child / sibling with equity / minor or disabled child (§ 1396p(c)(2)(A))
• ☐ Hardship waiver requested (§ 1396p(c)(2)(D))
• ☐ Transfer not made for purpose of qualifying for Medicaid (rebuttable presumption)

9. QUALIFIED INCOME TRUST (MILLER TRUST) DESIGNATION

Required where total gross monthly income (Section 5) exceeds the Nevada special-income limit (currently $[2,982/month for 2026 — VERIFY]).

9.1. Trust name: The [________________________________] Qualified Income Trust.

9.2. Date of execution: [__/__/____] (must be on or before the first day of the month for which Medicaid is sought).

9.3. Grantor: [APPLICANT NAME].

9.4. Trustee: [________________________________] (may not be the applicant; commonly a spouse, adult child, or professional fiduciary).

9.5. Trust account: Bank name [________________________________]; routing/account [____]; titled in the name of the trust with the trustee's tax-identification number.

9.6. Required terms (verify against MSM Chapter 500 and 42 U.S.C. § 1396p(d)(4)(B)):

• Funded only with the applicant's income (Social Security, pension, annuity payments, and similar);
• Irrevocable;
• Provides that upon the death of the applicant, the State of Nevada receives all amounts remaining in the trust up to the total medical assistance paid on the applicant's behalf;
• Permitted disbursements: personal needs allowance; community-spouse MMMNA; guardian/representative-payee fees up to the cap; health-insurance premiums; medical expenses not paid by Medicaid; patient liability to the facility; trustee fees and bank fees as approved.

9.7. Funding plan. The trustee will deposit each month: $[__________] of Social Security; $[__________] of pension; $[__________] of other income — sufficient to bring countable income at or below the cap.

10. PRIMARY RESIDENCE AND HOME EQUITY TREATMENT

10.1. Address: [________________________________].

10.2. Title vesting: ☐ sole ☐ joint with spouse ☐ joint with non-spouse ☐ tenancy-in-common ☐ life estate ☐ trust.

10.3. Equity value (current fair-market value minus encumbrances): $[__________].

10.4. Home-equity exclusion under 42 U.S.C. § 1396p(f). The home is excluded as a countable resource so long as: (a) the applicant has equity of $752,000 or less (2026 federal floor — VERIFY); AND (b) the applicant or a qualifying relative resides there OR (c) the applicant intends to return home (signed Intent to Return must be on file).

10.5. Excepted occupants (§ 1396p(f)(1)(A)): ☐ spouse residing in home ☐ minor child ☐ blind or disabled child of any age — equity cap inapplicable.

10.6. Statement of intent to return. ☐ The applicant signs the Intent-to-Return statement at Exhibit A and the home remains exempt during continuous institutionalization.

11. ESTATE RECOVERY ACKNOWLEDGMENT

Pursuant to 42 U.S.C. § 1396p(b) and Nevada MSM, the State of Nevada is required to seek recovery from the estate of a Medicaid recipient age 55 or older for medical assistance correctly paid. Recovery is deferred during the lifetime of a surviving spouse, a surviving child under 21, and a surviving blind or disabled child. Hardship waivers may be available.

Applicant has been advised of and acknowledges the State's estate-recovery rights:

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

[APPLICANT / AUTHORIZED REPRESENTATIVE]

12. AUTHORIZED REPRESENTATIVE DESIGNATION

I, [APPLICANT NAME], designate the following individual as my authorized representative under 42 C.F.R. § 435.923 and applicable Nevada policy to act on my behalf in all matters relating to this application, including receipt of notices, submission of documents, and appeal rights:

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

[APPLICANT SIGNATURE]

13. VERIFICATION DOCUMENTS CHECKLIST

• ☐ Photo identification (driver's license / Nevada ID / passport)
• ☐ Social Security card and Medicare card
• ☐ Birth certificate or naturalization papers
• ☐ Marriage certificate / divorce decree / death certificate of prior spouse
• ☐ Proof of Nevada residency
• ☐ All bank statements (checking, savings, CDs, money market) — most recent 60 months
• ☐ Brokerage and IRA / 401(k) statements — most recent 60 months
• ☐ Life insurance policies (face sheet, cash-value statement)
• ☐ Annuity contracts and most recent statement
• ☐ Vehicle titles
• ☐ Deed(s) and most recent property-tax assessment for all real estate
• ☐ Mortgage statement / equity loan statement
• ☐ Burial-contract and burial-plot documentation
• ☐ Trust instrument(s)
• ☐ Closing statements / gift documentation for any transfer in last 60 months
• ☐ Income verifications (SSA award letter, pension stubs, 1099s)
• ☐ Tax returns (most recent 5 years)
• ☐ Health-insurance cards (Medicare A/B/D, supplemental, LTC insurance)
• ☐ Physician's NF-LOC certification / ADSD level-of-care assessment
• ☐ Executed Qualified Income Trust and bank account opening confirmation (if applicable)
• ☐ Power of attorney / guardianship order
• ☐ Intent-to-Return statement (if home retained)

14. APPLICANT / REPRESENTATIVE SIGNATURE AND PENALTY-OF-PERJURY VERIFICATION

I declare under penalty of perjury under the laws of the State of Nevada and the United States that the information set forth in this packet, including all attachments, is true and correct to the best of my knowledge. I understand that knowingly making a false statement in connection with this application is punishable under NRS 422.450 and 18 U.S.C. § 1001.

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

[APPLICANT NAME]

Authorized Representative (if signing on behalf of applicant): [________________________________] Date: [__/__/____]

[REPRESENTATIVE NAME, TITLE, SOURCE OF AUTHORITY]

15. NEVADA PRACTICE NOTES

• Income-cap state. Nevada is one of the minority of states that applies a hard "income cap" (300% of the SSI FBR) to its long-term care Medicaid programs. Without a Qualified Income Trust, an applicant whose gross income exceeds the cap is ineligible regardless of medical or financial need — even by $1.
• Two agencies, one application. DWSS performs financial eligibility; DHCFP and ADSD perform NF level-of-care and waiver-slot determination. Coordinate both tracks; functional approval without financial approval (or vice versa) does not produce coverage.
• Frail Elderly Waiver capacity. The FE Waiver is capped by CMS-approved slots. While Nursing Home Medicaid is an entitlement (no waitlist), the FE Waiver may have a wait list; verify slot availability with ADSD at the time of filing.
• Penalty divisor and how it bites. Nevada's transfer-penalty divisor is among the highest in the country (approximately $9,949/month in 2026; VERIFY). Because penalty months only begin to run when the applicant is otherwise eligible AND institutionalized, late-game gifting strategies frequently fail; pre-planning at least 60 months in advance is essential.
• Annuities. A Medicaid-compliant annuity must be irrevocable, non-assignable, actuarially sound, and name the State of Nevada as primary remainder beneficiary up to total medical assistance paid (or as secondary if a community spouse, minor child, or disabled child is named first). 42 U.S.C. § 1396p(c)(1)(F); see DHCFP MSM Chapter 500.
• Personal Care Services and Community Choice. PCS is a state-plan benefit (not a waiver) that can be combined with the FE Waiver in many cases; assess concurrent eligibility.
• Estate recovery. Nevada's estate recovery program reaches probate estates of recipients 55 or older. Non-probate transfers (TOD deeds, joint tenancy with right of survivorship, transfer-on-death securities) currently fall outside the federal-minimum estate definition Nevada has elected to apply, but this policy can change; verify against current MSM.
• Filing channel. Applications may be filed online via ACCESS Nevada (https://accessnevada.dwss.nv.gov) or in person at any DWSS district office. Retain submission confirmation and date-stamped receipts.
• Appeal rights. A denial, termination, or reduction may be appealed within 90 days of notice. To preserve benefits during appeal of a termination or reduction, file within 10 days of the notice (42 C.F.R. § 431.230). Hearings are conducted by a State Hearing Officer.

16. SOURCES AND REFERENCES

• Nevada Division of Health Care Financing and Policy (DHCFP) — https://dhcfp.nv.gov
• Nevada Medicaid Services Manual (MSM) — https://dhcfp.nv.gov/Resources/AdminSupport/Manuals/MSM/MSMHome/
• Nevada Division of Welfare and Supportive Services (DWSS) — https://dwss.nv.gov
• DWSS Eligibility & Payments Information Manual (Income Limit Charts) — https://www.dss.nv.gov/access-nv/eligibility-payments-info-manual/income-limit-charts/
• Nevada Aging and Disability Services Division (ADSD) — https://adsd.nv.gov
• Frail Elderly Waiver — https://dhcfp.nv.gov/Pgms/LTSS/LTSSWaiverFrailElderly/
• ACCESS Nevada online application portal — https://accessnevada.dwss.nv.gov
• Nevada Revised Statutes Chapter 422 (Health Care Financing and Policy) — https://www.leg.state.nv.us/NRS/NRS-422.html
• Nevada Administrative Code Chapter 422 — https://www.leg.state.nv.us/NAC/NAC-422.html
• 42 U.S.C. § 1396p (transfer of assets, look-back, QITs, estate recovery)
• 42 U.S.C. § 1396r-5 (spousal impoverishment)
• CMS State Medicaid Manual / SHO-letter guidance on QITs and spousal impoverishment standards

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. Medicaid eligibility figures, divisors, and policy rules change frequently; verify all dollar amounts and citations against the current Nevada Medicaid Services Manual and DWSS Eligibility & Payments Information Manual before filing. A Nevada-licensed elder-law attorney must review and customize this document.