South Carolina Medicaid Application Packet — Long-Term Care / Community Choices Waiver

SOUTH CAROLINA MEDICAID APPLICATION PACKET — LONG-TERM CARE / COMMUNITY CHOICES WAIVER

TABLE OF CONTENTS

1. Cover Letter to SCDHHS
2. Applicant and Household Identification
3. Program Selection and Level of Care
4. 2026 Eligibility Snapshot — South Carolina
5. Income Documentation Checklist
6. Resource (Asset) Documentation Checklist
7. Primary Residence and Real Property
8. Transfers Within the 60-Month Look-Back
9. Qualified Income Trust (Miller Trust) Section
10. Spousal Impoverishment Calculations
11. Spend-Down Plan
12. Authorized Representative / HIPAA Release
13. Applicant Signature and Verification
14. South Carolina Practice Notes
15. Sources and References

1. COVER LETTER TO SCDHHS

Date: [__/__/____]

To: South Carolina Department of Health and Human Services
Healthy Connections — Long-Term Care Eligibility
P.O. Box 100101
Columbia, SC 29202-3101

Re: Application for Medicaid Long-Term Care / Community Choices Waiver
Applicant: [APPLICANT FULL LEGAL NAME]
SSN (last 4): xxx-xx-[____]
Date of Birth: [__/__/____]
Healthy Connections / Medicaid ID (if any): [________________________________]

Enclosed please find the application materials for [APPLICANT NAME] seeking Medicaid coverage under [☐ Nursing Facility (Institutional) Medicaid ☐ Community Choices Waiver (HCBS) ☐ Other: ____________]. The packet includes SCDHHS Form 3400 (and Form 3402 long-term-care addendum), supporting income and resource documentation, a 60-month transfer history, and (where applicable) the executed Qualified Income Trust.

Please direct all correspondence to the Authorized Representative identified in Section 12 of this packet.

Respectfully,

[________________________________]
[AUTHORIZED REPRESENTATIVE / ATTORNEY NAME]

2. APPLICANT AND HOUSEHOLD IDENTIFICATION

3. PROGRAM SELECTION AND LEVEL OF CARE

☐ Nursing Facility Medicaid (Institutional / Vendor Payment). Requires nursing-facility level of care determined by the Community Long-Term Care (CLTC) office.

☐ Community Choices (CC) Waiver — HCBS § 1915(c). Home and community-based services; applicant must meet nursing-facility level of care but elects to remain at home, in an adult foster home, or in a community residential care facility.

☐ Community Supports Waiver / HASCI / MR-RD Waiver / Other DDSN Waiver: [__________]

☐ Optional State Supplementation (OSS) for Community Residential Care Facilities.

☐ Healthy Connections Aged, Blind, or Disabled (ABD) Medicaid (non-LTC).

Level-of-Care (LOC) Status:

• LOC assessment requested from CLTC: [__/__/____]
• LOC determination received: [__/__/____]
• Determination: ☐ Meets NF LOC ☐ Does not meet ☐ Pending

4. 2026 ELIGIBILITY SNAPSHOT — SOUTH CAROLINA

5. INCOME DOCUMENTATION CHECKLIST

Provide the most recent three (3) months for each income source unless noted:

☐ Social Security / SSDI award letter (current year)

☐ Pension / retirement / annuity statements

☐ VA benefits award letter (including Aid & Attendance, if any)

☐ Railroad Retirement statement

☐ Wages — last 3 paystubs and most recent W-2

☐ Self-employment — most recent 2 years of Schedules C/SE

☐ Rental income — lease + last 3 months of receipts

☐ Interest / dividend statements (IRS Form 1099-INT, 1099-DIV)

☐ IRA / 401(k) Required Minimum Distribution (RMD) schedule

☐ Trust distributions (provide trust instrument)

☐ Alimony / spousal support order

☐ Other: [________________________________]

Gross Monthly Income (Applicant): $[____________]

Gross Monthly Income (Spouse): $[____________]

6. RESOURCE (ASSET) DOCUMENTATION CHECKLIST

Provide statements covering the FULL 60-month look-back unless noted:

☐ Checking account(s) — last 60 months of statements (every page)

☐ Savings account(s) — last 60 months of statements

☐ Money market / CDs

☐ Brokerage / investment accounts (taxable)

☐ IRAs, 401(k), 403(b), TSP — most recent statement and beneficiary designation

☐ Cash value of life insurance — Form 712 or insurer letter (face value > $10,000 counts toward resource limit; verify SCDHHS treatment)

☐ Burial accounts — irrevocable burial contracts and burial-fund designations (up to $10,000 generally exempt; verify)

☐ Vehicles — title/registration for each (one auto generally exempt)

☐ Real property other than homestead — deeds, tax cards, fair market value support

☐ Business interests — K-1s, valuations, partnership/operating agreements

☐ Trusts — copy of trust instrument and current trust accounting

☐ Promissory notes / loans receivable

☐ Safe deposit box inventory

☐ Other: [________________________________]

Total Countable Resources (Applicant): $[____________]

Total Countable Resources (Spouse): $[____________]

7. PRIMARY RESIDENCE AND REAL PROPERTY

• Address of homestead: [________________________________]
• Owner(s) of record: [________________________________]
• Form of title: ☐ Sole ☐ Joint with spouse ☐ Tenancy in common ☐ Life estate ☐ Trust
• Current fair market value: $[____________]
• Mortgage balance: $[____________]
• Equity: $[____________]

Homestead Exemption Status:

☐ Applicant intends to return home (signed Intent to Return statement attached) — homestead remains non-countable.

☐ Community spouse continues to reside in homestead — homestead non-countable regardless of value.

☐ Minor, blind, or disabled child resides in home — homestead non-countable.

☐ Applicant has equity in excess of $752,000 (2026 limit) with NO spouse / minor / disabled child exception — applicant is INELIGIBLE absent reverse mortgage or home-equity loan to bring equity below cap.

Other Real Property: [Address / Use / FMV / Mortgage / Status]

8. TRANSFERS WITHIN THE 60-MONTH LOOK-BACK

List every transfer of assets (gift, below-FMV sale, addition of joint owner, contribution to trust, forgiveness of debt) made by Applicant or Spouse on or after [DATE = APPLICATION DATE − 60 MONTHS]:

Exempt Transfers (assert if applicable):

☐ Transfer to spouse or for sole benefit of spouse (42 U.S.C. § 1396p(c)(2)(B)(i))

☐ Transfer to blind or disabled child (any age) or to a trust for sole benefit of disabled child

☐ Transfer of homestead to: (a) spouse; (b) child under 21; (c) blind/disabled child; (d) sibling with equity interest who resided in home for at least 1 year prior; or (e) "caretaker child" who resided in home for at least 2 years prior and provided care that delayed institutionalization

☐ Transfer to a (d)(4)(A) Special Needs Trust or (d)(4)(C) Pooled Trust for a disabled individual under 65

☐ Transfer for fair market value (attach appraisal / bill of sale)

☐ Transfer made for purpose other than to qualify for Medicaid (rebuttable presumption applies)

Penalty Period Calculation (if any uncompensated transfer):

• Total uncompensated value: $[____________]
• ÷ Penalty Divisor ($5,130.99 / mo): = [____] months of ineligibility
• Penalty start date: the later of (i) date of transfer or (ii) date Applicant would otherwise be eligible for LTC services and is "otherwise eligible" but for the transfer.

9. QUALIFIED INCOME TRUST (MILLER TRUST) SECTION

☐ Not Required. Applicant's gross income $[____________] ≤ Medicaid Cap ($2,982 in 2026).

☐ Required. Applicant's gross income $[____________] > Medicaid Cap.

QIT Establishment Checklist:

☐ Trust executed before first month of intended eligibility — Date executed: [__/__/____]

☐ Trustee: [________________________________] (cannot be Applicant; spouse generally permitted)

☐ Separate trust bank account opened — Bank: [________________] Account #: **[____]

☐ Trust names "State of South Carolina (SCDHHS)" as remainder beneficiary up to total Medicaid paid

☐ Direct deposit of qualifying income into QIT account established (Social Security, pension)

☐ Monthly disbursement order: PNA → health insurance premiums → MMMNA to community spouse → balance to facility (patient liability)

☐ Copy of executed trust + bank signature card included with packet

10. SPOUSAL IMPOVERISHMENT CALCULATIONS

(Complete only if Applicant is married and Spouse is NOT applying.)

Step 1 — Snapshot Date. First continuous period of institutionalization (or HCBS LOC qualification) ≥ 30 days: [__/__/____]

Step 2 — Resource Assessment.

• Total countable resources of couple on snapshot date: $[____________]
• One-half: $[____________]
• CSRA = lesser of one-half OR federal max ($157,920 for 2026), but not less than minimum ($31,584): $[____________]
• Resources allocated to Applicant: $[____________] (must be reduced to $2,000 by month of eligibility)

Step 3 — Income Allocation.

• Spouse's gross monthly income: $[____________]
• Spouse's shelter expenses: $[____________]
• MMMNA (calculated, capped at $4,066.50 for 2026): $[____________]
• Monthly spousal allowance from Applicant's income: $[____________]

11. SPEND-DOWN PLAN

(For applicants whose countable resources exceed the limit. All spend-down expenditures must be for FAIR MARKET VALUE and for the applicant's benefit. Track every dollar.)

Total Planned Spend-Down: $[____________]

Target Resource Level (≤ $2,000 single / ≤ CSRA + $2,000 married): $[____________]

12. AUTHORIZED REPRESENTATIVE / HIPAA RELEASE

I, [APPLICANT NAME], authorize the following individual to act as my Authorized Representative before the South Carolina Department of Health and Human Services and any related agency, to receive notices, request hearings, and submit documentation on my behalf:

I further authorize SCDHHS, my financial institutions, my health-care providers, and any state agency to release records concerning my application to the Authorized Representative.

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

13. APPLICANT SIGNATURE AND VERIFICATION

I declare under penalty of perjury under the laws of the State of South Carolina and the United States that the information provided in this application packet is true, accurate, and complete to the best of my knowledge. I understand that knowingly making a false statement, concealing information, or making a prohibited transfer to qualify for Medicaid may result in denial of benefits, recovery of benefits paid, civil money penalties, and criminal prosecution under 42 U.S.C. § 1320a-7b and S.C. Code Ann. § 43-7-60.

[________________________________]

[APPLICANT NAME] — Applicant

Date: [__/__/____]

[________________________________]

[AUTHORIZED REPRESENTATIVE / GUARDIAN / AGENT UNDER POA]

Date: [__/__/____]

(If signed by agent under POA, attach durable power of attorney with Medicaid-application authority.)

14. SOUTH CAROLINA PRACTICE NOTES

• Income-cap state. South Carolina applies the 300% SSI rule (not the medically needy "spend-down" pathway for institutional Medicaid). If gross income exceeds the cap by even one dollar, the applicant must establish a Qualified Income Trust under 42 U.S.C. § 1396p(d)(4)(B) before the month of eligibility. Funding the QIT mid-month does NOT cure ineligibility for that month.
• Application form. SCDHHS Form 3400 is the master Healthy Connections application; long-term-care applicants must also complete the LTC supplement. Applications may be filed online at apply.scdhhs.gov, mailed, faxed, or filed in-person at a county DSS office. Phone: 1-888-549-0820 (Healthy Connections Member Services).
• Level-of-care determination. SCDHHS Community Long-Term Care (CLTC) staff conduct LOC assessments for both nursing-facility Medicaid and Community Choices Waiver. Without an NF-LOC determination, no LTC vendor payment will issue.
• Transfer penalty divisor. SCDHHS publishes the transfer penalty divisor in the MPPM. As of the most recent publication, the divisor is approximately $5,130.99 / month (~$171.03 / day). VERIFY before computing penalty periods.
• Look-back is 60 months for both NF and HCBS waivers per 42 U.S.C. § 1396p(c)(1)(B)(i).
• Estate recovery. S.C. Code §§ 43-7-410 to 43-7-490 require SCDHHS to recover from the probate estate of any Medicaid recipient age 55 or older who received long-term care services. Recovery is deferred while a surviving spouse, minor child, or disabled child of any age survives. Hardship waivers exist (S.C. Code § 43-7-460).
• Annuities. A spousal-refuge or single-premium immediate annuity used as a Medicaid-planning tool must comply with the Deficit Reduction Act of 2005 (DRA): irrevocable, non-assignable, actuarially sound, equal monthly payments, and naming the State of South Carolina as primary remainder beneficiary up to the amount of Medicaid paid (or secondary if community spouse / minor / disabled child is primary).
• Caretaker-child exception. A transfer of the homestead to a child who lived in the home for at least two years immediately preceding institutionalization and who provided care that allowed the parent to remain at home is exempt from the transfer-penalty rule. Document the care with affidavits, physician letters, and contemporaneous records.
• Fair hearings. Adverse eligibility determinations may be appealed to the SCDHHS Division of Appeals and Hearings under S.C. Code § 44-6-190 and 42 C.F.R. § 431.200 et seq. Hearing must be requested within 30 days of the notice of action (verify current MPPM deadline; some adverse actions allow continuation of benefits if appeal is filed within 10 days).
• Special Needs Trusts. Self-settled (d)(4)(A) and pooled (d)(4)(C) trusts under 42 U.S.C. § 1396p(d)(4) are recognized in South Carolina. Verify trust draft against current SCDHHS Trust Review unit standards before funding.

15. SOURCES AND REFERENCES

• South Carolina Department of Health and Human Services (Healthy Connections) — https://www.scdhhs.gov
• SCDHHS Program Eligibility and Income Limits — https://www.scdhhs.gov/members/program-eligibility-and-income-limits
• SCDHHS Community Choices (CC) Waiver — https://www.scdhhs.gov/resources/waivers/community-choices-cc-waiver
• SCDHHS Medicaid Policy and Procedures Manual (MPPM), Long-Term Care chapter — https://www.scdhhs.gov/internet/policy
• 42 U.S.C. § 1396p (transfers, trusts, liens, recovery) — https://www.law.cornell.edu/uscode/text/42/1396p
• 42 U.S.C. § 1396p(d)(4)(B) (Qualified Income / Miller Trust authorization)
• S.C. Code Title 44, Chapter 6 (South Carolina Medicaid Program) — https://www.scstatehouse.gov/code/t44c006.php
• S.C. Code Title 43, Chapter 7, Article 5 (Medical Assistance / Estate Recovery) — https://www.scstatehouse.gov/code/t43c007.php
• Apply for Healthy Connections — https://apply.scdhhs.gov
• South Carolina Department on Aging (SCDOA) — https://aging.sc.gov
• Healthy Connections Member Services: 1-888-549-0820

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. Medicaid figures, divisors, and citations change at least annually. Verify all amounts against the current SCDHHS MPPM and have this packet reviewed and customized by a South Carolina-licensed elder law attorney before submission.