Utah Medicaid Application Packet — Long-Term Care, Aging Waiver, New Choices Waiver, and Nursing Facility Medicaid

UTAH MEDICAID APPLICATION PACKET — LONG-TERM CARE, AGING WAIVER, NEW CHOICES WAIVER, AND NURSING FACILITY MEDICAID

TABLE OF CONTENTS

1. Cover Letter to DWS Medicaid Eligibility
2. Applicant Identification and Household
3. Program Selection
4. Categorical and Financial Eligibility — Utah Figures (2025/2026)
5. Resource Inventory and Documentation Schedule
6. Income Schedule and Patient Liability Worksheet
7. Spousal Impoverishment / Community Spouse Resource Allowance
8. 60-Month Look-Back, Transfer Penalty, and Cure Strategies
9. Medically Needy Spend-Down (Non-Institutional)
10. Primary Residence, Home Equity, and Estate Recovery
11. Authorized Representative Designation
12. Required Documents Checklist
13. Hearing and Appeal Rights
14. Signature, Verification, and Certificate of Service
15. Utah Practice Notes
16. Sources and References

1. COVER LETTER TO DWS MEDICAID ELIGIBILITY

[DATE]

Utah Department of Workforce Services
Eligibility Services Division — Medicaid Long-Term Care Unit
[LOCAL DWS OFFICE STREET ADDRESS]
[CITY], Utah [ZIP]

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

Dear Eligibility Specialist:

Enclosed please find the completed Form 902-LTC (or current DWS combined application), supporting documentation, and verifications in support of [APPLICANT NAME]'s application for [Nursing Facility Medicaid / Aging Waiver / New Choices Waiver / Medicaid for the Aged, Blind, and Disabled] benefits. The applicant entered [FACILITY NAME] on [__/__/____] and has remained or is expected to remain institutionalized for thirty (30) consecutive days or more. Coverage is requested retroactive to [__/__/____] pursuant to 42 U.S.C. § 1396a(a)(34) and Utah Admin. Code R414-308.

Please direct all correspondence to the Authorized Representative identified in Section 11 below.

Respectfully,

[________________________________]

[ATTORNEY OR APPLICANT NAME]

2. APPLICANT IDENTIFICATION AND HOUSEHOLD

3. PROGRAM SELECTION

Check each program for which coverage is requested:

• ☐ Nursing Facility Medicaid (Institutional) — long-term skilled or custodial nursing-facility care; level-of-care determination by Utah Medicaid (MDS 3.0 / Medicaid LTC PASRR).
• ☐ Aging Waiver (1915(c) HCBS) — community-based services for individuals age 65+ at nursing-facility level of care; administered by DHHS Division of Aging and Adult Services through the Area Agencies on Aging (AAAs).
• ☐ New Choices Waiver (1915(c) HCBS) — transition or community-based services for individuals previously residing in (or at imminent risk of admission to) a nursing facility, assisted living, or small healthcare facility.
• ☐ Medicaid for the Aged, Blind, and Disabled (ABD) — Non-Institutional — for community-residing individuals who meet age/disability and ABD income/asset rules.
• ☐ Medically Needy / Spend-Down (ABD) — for ABD applicants whose income exceeds the standard limit.
• ☐ Medicare Savings Program — QMB / SLMB / QI (concurrent enrollment recommended).
• ☐ Retroactive coverage — three (3) months prior to the application month per 42 U.S.C. § 1396a(a)(34).

4. CATEGORICAL AND FINANCIAL ELIGIBILITY — UTAH FIGURES (2025/2026)

4.1 Asset Limits

4.2 Income Standards

4.3 Other Key Figures

• 60-month look-back for Nursing Facility and HCBS Waiver applications (42 U.S.C. § 1396p(c)(1)(B); R414-305-9).
• Transfer penalty divisor — Utah's statewide average private-pay rate for nursing-facility care (calculated under R414-305-9). Verify the current daily/monthly figure from Table II-A on medicaid.utah.gov.
• Estate recovery — Utah pursues post-death recovery against the probate estate and certain non-probate assets of recipients age 55+ who received long-term-care services (42 U.S.C. § 1396p(b); Utah Code § 26B-3-178; R414-305 and R414-308).

5. RESOURCE INVENTORY AND DOCUMENTATION SCHEDULE

6. INCOME SCHEDULE AND PATIENT LIABILITY WORKSHEET

Patient Liability ("Share of Cost") Calculation — Nursing Facility Medicaid

7. SPOUSAL IMPOVERISHMENT / COMMUNITY SPOUSE RESOURCE ALLOWANCE

7.1. Pursuant to 42 U.S.C. § 1396r-5 and Utah Admin. Code R414-305-7, the institutionalized spouse's countable resources are determined by a "snapshot" as of the first continuous period of institutionalization of thirty (30) days or more ("Snapshot Date").

7.2. Snapshot Date: [__/__/____]

7.3. Total countable resources on Snapshot Date: $[________________________________]

7.4. CSRA = greater of (a) one-half of countable resources up to the federal maximum, or (b) the federal minimum.

7.5. Community Spouse Monthly Income Allowance (CSMIA) — increase the community spouse's income to the MMMNA ($2,644 effective 7/1/2025) up to the maximum ($4,066.50 in CY 2026), subject to "shelter excess" calculation under 42 U.S.C. § 1396r-5(d)(3).

7.6. Right to fair hearing under 42 U.S.C. § 1396r-5(e) and R414-308 to seek expanded CSRA (income-first vs. resource-first analysis) or expanded CSMIA based on exceptional circumstances.

8. 60-MONTH LOOK-BACK, TRANSFER PENALTY, AND CURE STRATEGIES

8.1. Look-back period. All transfers of assets for less than fair market value made within sixty (60) months prior to the later of (a) the application date or (b) the institutionalization date are subject to disclosure and penalty review. 42 U.S.C. § 1396p(c)(1)(B); R414-305-9.

8.2. Penalty calculation. Penalty period = (uncompensated value of transfer) ÷ (Utah statewide average private-pay rate divisor). The penalty begins on the later of (a) the date of transfer or (b) the date the applicant is otherwise eligible and would be receiving long-term-care services but for the transfer. 42 U.S.C. § 1396p(c)(1)(D)(ii).

8.3. Verification of divisor. The current Utah statewide average private-pay rate is published in Table II-A of the Utah Medicaid Provider Manual. [ENTER CURRENT DAILY DIVISOR: $___ / month: $___] as of [__/__/____].

8.4. Disclosure of all transfers. List every gift, sale below FMV, addition/removal of joint owner, irrevocable trust funding, annuity purchase, and life-estate creation in the 60-month window:

8.5. Statutory exceptions and cures (42 U.S.C. § 1396p(c)(2); R414-305-9):

• ☐ Transfer to spouse (or to another for the sole benefit of the spouse).
• ☐ Transfer to a child under age 21 or a child of any age who is blind or permanently disabled.
• ☐ Transfer to a "caregiver child" who lived in the home for at least two years and provided care that delayed institutionalization.
• ☐ Transfer to a "sibling with equity interest" who resided in the home for at least one year prior to institutionalization.
• ☐ Transfer to a special-needs trust under 42 U.S.C. § 1396p(d)(4)(A) or pooled trust under (d)(4)(C).
• ☐ Transfer for a purpose other than to qualify for Medicaid (rebut the presumption with documentary evidence of intent).
• ☐ Return of transferred assets ("cure") prior to penalty start date.
• ☐ Undue-hardship waiver under 42 U.S.C. § 1396p(c)(2)(D); R414-305-9.

8.6. Annuities. Any annuity purchased on or after February 8, 2006 must (a) be irrevocable and non-assignable, (b) be actuarially sound, (c) provide equal payments without deferral or balloon, and (d) name the State of Utah as remainder beneficiary (or as second remainder after a community spouse / minor / disabled child). 42 U.S.C. § 1396p(c)(1)(F)–(G).

9. MEDICALLY NEEDY SPEND-DOWN (NON-INSTITUTIONAL)

9.1. Utah operates a Medically Needy / spend-down option for ABD coverage. Applicants whose countable income exceeds the ABD income standard may obligate the excess to incurred medical expenses (the "spend-down obligation"). Coverage commences when incurred, paid, or projected medical expenses equal or exceed the spend-down amount for the budget month.

9.2. Spend-down worksheet:

9.3. Allowable expenses include (a) Medicare and other health-insurance premiums; (b) deductibles and co-pays; (c) physician, hospital, prescription, dental, vision, hearing, mental-health, durable medical equipment, and necessary home care; (d) past medical bills not previously used to meet a spend-down.

10. PRIMARY RESIDENCE, HOME EQUITY, AND ESTATE RECOVERY

10.1. Primary residence exclusion. The home is excluded from countable resources during the applicant's lifetime if (a) the applicant intends to return home (declaration of intent to return), or (b) a community spouse, minor child, or disabled adult child resides in the home, or (c) a sibling with equity interest who resided there for at least one year prior to institutionalization remains in the home.

10.2. Home-equity limit. For 2026, the home is countable if the applicant's equity interest exceeds $752,000, unless (a) a spouse, minor, or disabled child lawfully resides in the home, or (b) a hardship waiver is granted.

10.3. Intent-to-return declaration.

I, [APPLICANT NAME], hereby declare under penalty of perjury under the laws of the State of Utah that as of [__/__/____] I intend to return to and reside in my home located at [ADDRESS], and that this declaration is made for purposes of Medicaid eligibility under 42 U.S.C. § 1396p(f) and Utah Admin. Code R414-305.

10.4. Estate recovery. Upon the recipient's death, the State of Utah will assert a claim for the total amount of medical assistance paid for nursing-facility, HCBS, and related services, against (a) the recipient's probate estate, and (b) certain non-probate assets to the extent allowed by Utah law. Recovery is deferred while a surviving spouse, a minor child, or a blind or disabled child resides in the home, and is subject to the undue-hardship waiver.

10.5. Lien and TEFRA notice. Pre-death liens are limited to permanently institutionalized recipients per 42 U.S.C. § 1396p(a). Verify whether the State has recorded a TEFRA lien against the residence prior to closing any home sale.

11. AUTHORIZED REPRESENTATIVE DESIGNATION

I, [APPLICANT FULL LEGAL NAME], hereby designate the following person as my Authorized Representative to act on my behalf with respect to this Medicaid application, including signing forms, requesting hearings, and receiving notices and protected health information, pursuant to 42 C.F.R. § 435.923 and Utah Admin. Code R414-308:

[________________________________]

[APPLICANT NAME] — Date: [__/__/____]

12. REQUIRED DOCUMENTS CHECKLIST

• ☐ Form 902-LTC or current DWS combined application (signed and dated)
• ☐ Photo identification (driver license, state ID, or passport)
• ☐ Social Security card
• ☐ Birth certificate or other proof of citizenship
• ☐ Medicare card (red, white, and blue)
• ☐ Marriage certificate (if applicable)
• ☐ Death certificate of prior spouse (if applicable)
• ☐ Divorce decree (if applicable)
• ☐ Power of Attorney / Guardianship order (if applicable)
• ☐ Sixty (60) months of bank statements (every account held by applicant or jointly)
• ☐ Brokerage and retirement account statements (60 months)
• ☐ Life-insurance policies showing face value and CSV
• ☐ Real-property deeds, tax notices, and mortgage statements
• ☐ Vehicle titles and registrations
• ☐ Burial-trust agreement and pre-need contract
• ☐ Annuity contracts and payment schedules
• ☐ Trust instruments (revocable and irrevocable)
• ☐ Verifications of all transfers within 60-month look-back
• ☐ Most recent four (4) pay stubs
• ☐ SSA award letter and most recent SSA-1099
• ☐ Pension / VA / annuity award letters and 1099-Rs
• ☐ Health-insurance cards and premium statements
• ☐ Most recent federal tax return
• ☐ Facility admission contract and current statement of charges
• ☐ Physician's statement and Level-of-Care (PASRR / MDS) determination
• ☐ Authorized-Representative designation (Section 11)

13. HEARING AND APPEAL RIGHTS

13.1. An applicant has ninety (90) days from the date of the adverse notice to request a fair hearing under 42 C.F.R. § 431.220 and Utah Admin. Code R414-308. R410-14 governs administrative hearings before the Utah Department of Health and Human Services.

13.2. To preserve continuing benefits during appeal, a redetermination appeal must be filed within ten (10) days of the notice of adverse action.

13.3. Hearing requests should be addressed to:

Utah Department of Health and Human Services
Office of Administrative Hearings
[CURRENT ADDRESS]

13.4. After exhaustion of administrative remedies, judicial review lies in the Utah district court for the county of residence under the Utah Administrative Procedures Act, Utah Code § 63G-4-401 et seq.

14. SIGNATURE, VERIFICATION, AND CERTIFICATE OF SERVICE

I declare under penalty of perjury under the laws of the State of Utah that the foregoing application and supporting documents are true and correct to the best of my knowledge, information, and belief, and that I understand willful misstatements may subject me to civil and criminal penalties under Utah Code § 26B-3-1101 et seq. and 42 U.S.C. § 1320a-7b.

Date: [__/__/____]

[________________________________]

[APPLICANT NAME]

[________________________________]

[AUTHORIZED REPRESENTATIVE NAME] (if signing)

Certificate of Service. I hereby certify that on [__/__/____] I delivered the foregoing application and exhibits to the Utah Department of Workforce Services Eligibility Services Division by ☐ in-person filing ☐ U.S. Mail ☐ MyCase upload ☐ fax to [___-___-____].

[________________________________]

[FILER NAME]

15. UTAH PRACTICE NOTES

• Title 26B recodification. Utah's 2022 S.B. 84 consolidated former Title 26 (Health) and Title 62A (Human Services) into a unified Title 26B effective in stages between July 2022 and July 2024. Utah Medicaid is now codified at Utah Code § 26B-3-101 et seq. Older citations to Title 26 Chapter 18 or Title 62A Chapter 3 are obsolete; verify every citation against the current Utah Code on le.utah.gov.
• Income cap vs. medically needy. Utah is NOT a strict income-cap state. There is no Miller / Qualified Income Trust requirement for Nursing Facility Medicaid. Applicants whose income exceeds standards qualify either by (a) the institutional patient-liability framework (Nursing Facility), or (b) the Medically Needy spend-down (community ABD).
• Aging Waiver vs. New Choices Waiver. The Aging Waiver targets community-residing seniors at NF level of care. The New Choices Waiver targets individuals transitioning out of (or at imminent risk of admission to) a nursing facility, assisted living, or small healthcare facility. Both have separate slot caps and waitlists; verify availability with the local Area Agency on Aging.
• Application portal. Applications are filed online through jobs.utah.gov/mycase, by paper Form 902 (or current combined ABD/LTC application), or in person at any DWS Employment Center. Telephonic signature and ePOC document upload are accepted.
• Estate recovery. Utah pursues estate recovery aggressively under Utah Code § 26B-3-178 (former § 26-19-405). The State files claims against probate and against certain joint and life-estate interests; counsel should evaluate whether a "lady-bird" deed (enhanced life estate) or irrevocable income-only trust is appropriate.
• Spousal refusal. Utah does not formally recognize "spousal refusal" as in New York, but a non-cooperating community spouse triggers assignment-of-rights analysis; the institutionalized spouse may still qualify if the community spouse refuses to make resources available, subject to Utah's right of recovery against the community spouse under 42 U.S.C. § 1396r-5(c)(3) and Utah Code § 26B-3-178.
• Caregiver-child exception. Document continuous co-residence and demonstrated need for care; obtain physician statement that the care provided by the child delayed institutionalization for at least two years.

16. SOURCES AND REFERENCES

• 42 U.S.C. § 1396 et seq. (Medicaid) — https://www.law.cornell.edu/uscode/text/42/chapter-7/subchapter-XIX
• 42 U.S.C. § 1396p (transfers, look-back, estate recovery) — https://www.law.cornell.edu/uscode/text/42/1396p
• 42 U.S.C. § 1396r-5 (spousal impoverishment) — https://www.law.cornell.edu/uscode/text/42/1396r-5
• 42 C.F.R. Part 435 (Medicaid eligibility) — https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-435
• Utah Code Title 26B Chapter 3 (Medical Assistance) — https://le.utah.gov/xcode/Title26B/Chapter3/26B-3.html
• Utah Admin. Code R414-301 et seq. — https://rules.utah.gov/publicat/code/r414/
• Utah Admin. Code R414-305-9 (Transfer of Resources) — https://rules.utah.gov/publicat/code/r414/r414-305.htm
• Utah Medicaid main site — https://medicaid.utah.gov
• Utah Medicaid Provider Manual and Long-Term Care Resources — https://medicaid.utah.gov/stplan/longtermcarenfra/
• Utah DWS Eligibility Services / MyCase — https://jobs.utah.gov/mycase
• Utah Department of Health and Human Services — https://dhhs.utah.gov
• Utah Division of Aging and Adult Services (Aging Waiver) — https://daas.utah.gov
• CMS Spousal Impoverishment Standards — https://www.medicaid.gov/medicaid/eligibility/spousal-impoverishment/index.html
• 2026 Utah Medicaid LTC eligibility figures — https://www.medicaidplanningassistance.org/medicaid-eligibility-utah/

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. An attorney licensed in Utah must review and customize this document before filing. Medicaid figures, statutory citations, and form references change frequently; verify all authorities and dollar amounts against current DHHS, DWS, and Utah Medicaid publications before use.