Oregon Medicaid Application Packet — Long-Term Care (OHP / APD)

OREGON MEDICAID APPLICATION PACKET — LONG-TERM CARE (OHP / APD)

TABLE OF CONTENTS

1. Cover Sheet and Application Identification
2. Applicant and Household Information
3. Program(s) Applied For
4. Citizenship, Residency, and Identity
5. Medical / Functional Eligibility
6. Income Information
7. Income Cap Trust (Miller Trust) Determination
8. Resources / Asset Information
9. Transfer / Look-Back Disclosure (60 Months)
10. Spousal Impoverishment / Community Spouse
11. Primary Residence Treatment
12. Estate Recovery Acknowledgment
13. Authorized Representative / Power of Attorney
14. Document Verification Checklist
15. Applicant / Representative Certification
16. Oregon Practice Notes
17. Sources and References

1. COVER SHEET AND APPLICATION IDENTIFICATION

2. APPLICANT AND HOUSEHOLD INFORMATION

2.1. Applicant.

2.2. Spouse (if any).

2.3. Other Household Members / Dependents. [________________________________]

3. PROGRAM(S) APPLIED FOR

Select all that apply:

• ☐ Nursing Facility (NF) Medicaid — long-term institutional care.
• ☐ APD Waiver / 1915(c) — community-based services in adult foster home, residential care facility, assisted living, or memory care.
• ☐ K Plan / Community First Choice (1915(k)) — in-home attendant services and supports, ADL/IADL assistance.
• ☐ OHP Plus — full-benefit health coverage (categorically needy).
• ☐ Medicare Savings Programs — ☐ QMB ☐ SLMB ☐ QI.
• ☐ PACE (Program of All-Inclusive Care for the Elderly), if available in county.
• ☐ Hospice Medicaid Benefit.

3.1. Care Setting (current or anticipated): [________________________________]

3.2. Date Care/Services Needed: [__/__/____]

4. CITIZENSHIP, RESIDENCY, AND IDENTITY

4.1. U.S. Citizenship: ☐ U.S. Citizen ☐ Qualified Non-Citizen (attach documentation).

4.2. Oregon Residency: Applicant resides in Oregon and intends to remain. Date Oregon residency established: [__/__/____].

4.3. Identity Verification Documents Attached: ☐ Driver's license/Oregon ID ☐ Passport ☐ Birth certificate ☐ Other: [________________________________]

5. MEDICAL / FUNCTIONAL ELIGIBILITY

5.1. Level of Care. Applicant requires nursing-facility level of care or service-priority-level (SPL) eligibility under Oregon's APD assessment system. Applicant's current SPL: [____].

5.2. Functional Assessment. A CAPS (Client Assessment and Planning System) assessment ☐ has been ☐ will be completed by the local APD/AAA office.

5.3. Diagnoses (Primary): [________________________________]

5.4. Treating Physician: Name [________________________________] | Phone [________________________________]

5.5. ADL / IADL Limitations. Applicant requires assistance with the following: ☐ Bathing ☐ Dressing ☐ Toileting ☐ Transferring ☐ Eating ☐ Mobility ☐ Cognition/Behavior ☐ Medication management ☐ Meal preparation.

5.6. Cognitive Impairment / Dementia Diagnosis: ☐ Yes (date diagnosed: [__/__/____]) ☐ No.

6. INCOME INFORMATION

6.1. Applicant's Gross Monthly Income (all sources, before deductions).

6.2. Spouse's Gross Monthly Income (community spouse, if applicable). Total: $[____________]

6.3. Income Cap Comparison. Current Oregon Medicaid income cap (verify): $[____________] / month. Applicant's income is: ☐ Below cap (no ICT required) ☐ At or above cap (Income Cap Trust REQUIRED — see Section 7).

7. INCOME CAP TRUST (MILLER TRUST) DETERMINATION

7.1. Income Cap Trust required? ☐ Yes ☐ No.

7.2. Trust Established? ☐ Yes ☐ No. Date established: [__/__/____].

7.3. Trustee: [________________________________]

7.4. Trust Account (financial institution and account number — last 4): [________________________________]

7.5. Required Trust Provisions Confirmed: ☐ Irrevocable ☐ Trustee is not the applicant ☐ Income deposited monthly ☐ Distributions limited to allowed categories ☐ Medicaid payback provision (state Medicaid agency as remainder beneficiary up to the amount of medical assistance paid).

7.6. Trust Document Attached: ☐ Yes ☐ No.

8. RESOURCES / ASSET INFORMATION

8.1. Liquid Assets (countable).

8.2. Retirement Accounts. IRA / 401(k) / 403(b) / pension — list each and indicate whether in payout status: [________________________________]

8.3. Life Insurance. List each policy with face value and current cash surrender value. (Aggregate face value over $1,500 may render cash value countable.) [________________________________]

8.4. Real Property (other than primary residence). Address, ownership interest, fair market value, and encumbrances: [________________________________]

8.5. Vehicles. One vehicle of any value is excluded; additional vehicles are countable. List each: [________________________________]

8.6. Burial / Funeral Assets. Pre-need / irrevocable burial trust, burial space, burial fund (up to $1,500). Provider and value: [________________________________]

8.7. Annuities. Carrier, type, balance, and whether actuarially sound and irrevocable with state Medicaid agency as remainder beneficiary: [________________________________]

8.8. Trusts (other than ICT). Type, date created, grantor, trustee, value: [________________________________]

8.9. Business Interests. [________________________________]

8.10. TOTAL COUNTABLE RESOURCES — APPLICANT: $[____________]

8.11. TOTAL COUNTABLE RESOURCES — COMMUNITY SPOUSE (if any): $[____________]

9. TRANSFER / LOOK-BACK DISCLOSURE (60 MONTHS)

9.1. Look-back start date (60 months before application): [__/__/____].

9.2. Within the look-back period, has the applicant or spouse transferred, sold below market value, gifted, or otherwise disposed of any asset (cash, real property, vehicles, securities, business interest, life insurance, etc.)?

☐ No transfers within look-back.

☐ Yes — list each transfer:

9.3. Exempt Transfers Asserted (if any): ☐ Spouse ☐ Disabled child ☐ Caregiver child (with documentation of 2+ years of care preventing institutionalization) ☐ Sibling with equity interest residing in home 1+ year ☐ Trust for sole benefit of disabled person under 65 ☐ Other: [________________________________]

9.4. Documentation Attached: ☐ Deeds ☐ Cancelled checks ☐ Caregiver affidavits ☐ Medical records supporting caregiver-child exception ☐ Other: [________________________________]

10. SPOUSAL IMPOVERISHMENT / COMMUNITY SPOUSE

10.1. Community Spouse Resource Allowance (CSRA). For 2026, federal maximum is $162,660 (verify current figure). Community spouse may retain up to this amount of countable resources at the snapshot date.

10.2. Snapshot Date (first day of first continuous period of institutionalization of 30+ days): [__/__/____].

10.3. Snapshot Resource Total: $[____________]

10.4. Community Spouse Allocation: $[____________] (not to exceed CSRA).

10.5. Minimum Monthly Maintenance Needs Allowance (MMMNA). Verify current figures with ODHS. Community spouse may receive an income allocation from the institutionalized spouse to bring total income up to the MMMNA.

10.6. Fair Hearing Request to Increase CSRA / MMMNA? ☐ Yes ☐ No.

11. PRIMARY RESIDENCE TREATMENT

11.1. Primary Residence Address: [________________________________]

11.2. Ownership Interest: ☐ Sole ☐ Joint with spouse ☐ Tenants in common ☐ Life estate ☐ Trust ☐ Other: [____________]

11.3. Current Equity Value: $[____________] (Fair market value [____________] minus encumbrances [____________])

11.4. Equity Within Federal Cap? ☐ Yes ☐ No.

11.5. Home-Maintenance Exemption Asserted (e.g., spouse, dependent relative, intent to return): [________________________________]

11.6. Intent-to-Return Statement Attached? ☐ Yes ☐ No ☐ N/A.

12. ESTATE RECOVERY ACKNOWLEDGMENT

12.1. Applicant acknowledges that Oregon will pursue recovery against the estate of a deceased Medicaid recipient age 55 or older for the cost of long-term care services received, pursuant to 42 U.S.C. § 1396p(b), ORS 411.708, ORS 411.795, and OAR Chapter 461, Division 135.

12.2. Applicant has been informed of available hardship waivers and exceptions (surviving spouse, disabled child, sibling equity, caregiver child).

12.3. Applicant Initials: [____________]

13. AUTHORIZED REPRESENTATIVE / POWER OF ATTORNEY

13.1. Authorized Representative.

13.2. Authority Document Attached: ☐ POA ☐ Conservatorship Letters ☐ Trustee Certification ☐ ODHS Authorized Representative form ☐ Other: [____________]

14. DOCUMENT VERIFICATION CHECKLIST

Attach legible copies of the following:

• ☐ Photo identification (applicant and spouse)
• ☐ Social Security cards
• ☐ Medicare card
• ☐ Birth certificate or naturalization papers
• ☐ Marriage certificate / divorce decree / death certificate of spouse
• ☐ Five years of bank statements (all accounts, all months) — 60-month look-back
• ☐ Most recent statements for brokerage, retirement, and annuity accounts
• ☐ Deeds and titles for all real property
• ☐ Vehicle titles and registration
• ☐ Life insurance policies and most recent cash-value statements
• ☐ Burial trust / pre-need contract
• ☐ Pension / Social Security / VA award letters
• ☐ Most recent federal and state tax returns (with all schedules)
• ☐ Health insurance cards (Medicare, Medigap, employer/retiree)
• ☐ Trust instruments (Income Cap Trust, special needs trust, revocable trust, etc.)
• ☐ Power of attorney / conservatorship / guardianship documents
• ☐ Documentation of all transfers within 60-month look-back

15. APPLICANT / REPRESENTATIVE CERTIFICATION

I declare under penalty of perjury under the laws of the State of Oregon that the information provided in this application and its attachments is true, correct, and complete to the best of my knowledge. I understand that providing false information may result in denial, termination of benefits, recovery of assistance paid, and civil or criminal penalties under ORS 411.630 and applicable federal law (42 U.S.C. § 1320a-7b).

I authorize ODHS, OHA, and their contractors to verify the information provided, including through electronic data matches with the Social Security Administration, Internal Revenue Service, financial institutions, and other agencies.

Date: [__/__/____]

[________________________________]

[APPLICANT NAME] (or Authorized Representative — print name and capacity)

Signature: [________________________________]

16. OREGON PRACTICE NOTES

• Income cap state. Oregon does not allow income spend-down for long-term care Medicaid. If gross income exceeds the cap, an Income Cap Trust under OAR 461-145-0540 (mirroring 42 U.S.C. § 1396p(d)(4)(B)) is the only path to eligibility. Do not file without one if the cap is exceeded.
• One.Oregon.gov. Applications are processed through the integrated ONE eligibility system (replacing the legacy ACCESS Oregon system). Track status and upload documents through the ONE portal.
• APD vs. AAA. Counties are served by the Aging and People with Disabilities (APD) office of ODHS or by an Area Agency on Aging (AAA) acting as APD's agent under Type B contracts. Confirm the correct office before filing.
• K Plan / Community First Choice. Oregon was the second state in the nation to implement 1915(k). The K Plan provides ADL/IADL attendant services, skills training, and back-up support. K Plan services are an entitlement once the applicant is financially and functionally eligible; no waiver waitlist.
• APD Waiver. The 1915(c) APD waiver covers community-based residential care, adult foster homes, assisted living, and memory care for those eligible for nursing-facility level of care.
• Look-back and penalty divisor. The 60-month look-back applies to all uncompensated transfers. The penalty divisor is the ODHS-published statewide average private-pay nursing facility rate. Verify the current rate before quantifying any penalty.
• Annuities. Annuities purchased after February 8, 2006 must be irrevocable, non-assignable, actuarially sound, and name the State of Oregon as primary remainder beneficiary (or contingent after a community spouse/disabled child) to avoid being treated as a transfer.
• Estate recovery. Oregon recovers under ORS 411.708 and ORS 411.795 against probate estates. Hardship waivers and exceptions are available; raise them at the recovery stage, not during application.
• Fair hearings. Adverse decisions are appealable to an ODHS administrative hearing under ORS Chapter 183 (Oregon Administrative Procedures Act). Notice deadlines are short (typically 90 days; 10 days to preserve continuing benefits).
• Non-discrimination and language access. ODHS provides interpretation and translation at no cost. Request via the local APD office.

17. SOURCES AND REFERENCES

• Oregon Revised Statutes (ORS) Chapter 411 — Public Assistance — https://www.oregonlegislature.gov/bills_laws/ors/ors411.html
• ORS 411.706 (Oregon Supplemental Income Program) — https://oregon.public.law/statutes/ors_411.706
• ORS 411.708 (Estate recovery) — https://oregon.public.law/statutes/ors_411.708
• Oregon Administrative Rules (OAR) Chapter 461 (Eligibility) — https://secure.sos.state.or.us/oard/displayChapterRules.action?selectedChapter=140
• OAR 461-145-0540 (Income Cap Trust treatment)
• OAR 461-160-0620 (Asset transfer / penalty period)
• OAR Chapter 411, Division 030 (APD Service Eligibility)
• ODHS Aging and People with Disabilities — https://www.oregon.gov/odhs/aging-disability-services/
• ODHS APD K Plan / Waivers — https://www.oregon.gov/odhs/providers-partners/seniors-disabilities/pages/waivers-kplan.aspx
• ONE Oregon eligibility portal — https://one.oregon.gov/
• 42 U.S.C. § 1396p (transfers, trusts, estate recovery) — https://www.ssa.gov/OP_Home/ssact/title19/1917.htm
• 42 U.S.C. § 1396n(k) (Community First Choice / K Plan) — https://www.medicaid.gov/medicaid/home-community-based-services/home-community-based-services-authorities/community-first-choice-cfc-1915-k
• Oregon State Bar Elder Law Section — https://elderlaw.osbar.org/
• ODHS APD branch locator — https://www.oregon.gov/odhs/Pages/office-finder.aspx

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. Eligibility figures (income cap, CSRA, MMMNA, penalty divisor, home equity cap, and personal needs allowance) change annually or more frequently. Verify all figures against current ODHS APD policy and OAR Chapter 461 before filing. An Oregon-licensed elder law attorney must review this packet before submission.