Wisconsin Medicaid Application Packet (Long-Term Care)

WISCONSIN MEDICAID APPLICATION PACKET — LONG-TERM CARE, EBD, AND BADGERCARE PLUS

TABLE OF CONTENTS

1. Caption / Cover Sheet
2. Program Selection Worksheet
3. Applicant and Household Information
4. Eligibility Snapshot — 2025/2026 Figures
5. Income Documentation
6. Asset Documentation and 60-Month Look-Back
7. Divestment / Transfer Penalty Analysis
8. Spend-Down (Medically Needy) Worksheet
9. Spousal Impoverishment Allocation
10. Primary Residence and Home Equity Treatment
11. Estate Recovery Disclosures
12. Functional Screen / Level-of-Care Confirmation
13. Authorized Representative and HIPAA Release
14. Filing Instructions and Submission Checklist
15. Wisconsin Practice Notes
16. Sources and References

1. CAPTION / COVER SHEET

STATE OF WISCONSIN

DEPARTMENT OF HEALTH SERVICES — DIVISION OF MEDICAID SERVICES

INCOME MAINTENANCE CONSORTIUM — [________________________________]

2. PROGRAM SELECTION WORKSHEET

☐ Institutional Medicaid — Applicant resides or expects to reside in a Medicaid-certified nursing facility. Requires Nursing Facility Level of Care (NFLOC) and meets categorical, financial, and 60-month divestment standards.

☐ Family Care — Capitated managed long-term care services for adults aged 65+ or 18+ with a qualifying disability who meet NFLOC. Administered through Managed Care Organizations (MCOs) under Wis. Stat. § 46.286.

☐ Family Care Partnership — Integrated medical, behavioral, and long-term care services delivered through an MCO; combines Medicaid and Medicare benefits.

☐ PACE (Program of All-Inclusive Care for the Elderly) — Available in select Wisconsin counties for persons aged 55+ meeting NFLOC.

☐ IRIS (Include, Respect, I Self-Direct) — Self-directed HCBS waiver alternative to Family Care for adults meeting NFLOC; participant manages an individualized budget.

☐ Medicaid for the Elderly, Blind, or Disabled (EBD) — Categorical Medicaid for individuals aged 65+, legally blind, or disabled who do not require long-term care services.

☐ BadgerCare Plus — Wisconsin's Medicaid program for low-income parents, caretakers, children, pregnant women, and childless adults under age 65.

3. APPLICANT AND HOUSEHOLD INFORMATION

3.1. Applicant legal name: [________________________________]

3.2. Mailing address: [________________________________]

3.3. Physical residence (if different): [________________________________]

3.4. Marital status: ☐ Single ☐ Married ☐ Domestic Partner ☐ Widowed ☐ Divorced

3.5. Spouse / domestic partner name: [________________________________]

3.6. Spouse / partner SSN: [___-__-____]

3.7. Spouse / partner date of birth: [__/__/____]

3.8. Citizenship / immigration status: [________________________________]

3.9. Dependents in household:

4. ELIGIBILITY SNAPSHOT — 2025/2026 FIGURES

5. INCOME DOCUMENTATION

5.1. Provide proof of all gross monthly income for the applicant and spouse, including:

• Social Security retirement, disability, or survivor benefits (SSA-1099, current award letter);
• Supplemental Security Income (SSI) award letter;
• Pension, annuity, IRA / 401(k) distributions (most recent 1099-R; current statement);
• VA benefits, including Aid and Attendance;
• Wages (most recent four (4) pay stubs);
• Self-employment income (most recent Schedule C or profit-and-loss statement);
• Rental, royalty, dividend, or interest income;
• Trust distributions;
• Annuity payments;
• Other: [________________________________].

5.2. Total monthly gross income — applicant: $[________________]

5.3. Total monthly gross income — spouse: $[________________]

6. ASSET DOCUMENTATION AND 60-MONTH LOOK-BACK

6.1. Look-back start date. The 60-month look-back commences on [__/__/____] (the date 60 months prior to the application date) per Wis. Stat. § 49.453(2)(a).

6.2. Required statements. Provide every monthly statement from the look-back start date through the application date for each of the following:

• Checking accounts (all institutions);
• Savings and money-market accounts;
• Certificates of deposit;
• Brokerage and investment accounts;
• Retirement accounts (IRA, 401(k), 403(b), TSP, Roth);
• Health savings accounts;
• Life insurance — face value and current cash surrender value (Form CSV verification);
• Annuities — current statement, contract, and irrevocability declaration;
• Real property — deed, current tax-assessed value, mortgage statement, and home-equity loan documentation;
• Motor vehicles — title, current Kelley Blue Book / NADA value;
• Burial accounts and prepaid funeral contracts (must be irrevocable to be exempt);
• Trusts of any kind — full trust instrument plus all amendments;
• Business interests, partnership interests, LLC memberships;
• Safe-deposit box inventory.

6.3. Aggregate countable assets — applicant: $[________________]

6.4. Aggregate countable assets — community spouse: $[________________]

7. DIVESTMENT / TRANSFER PENALTY ANALYSIS

7.1. Have any assets been gifted, sold below fair market value, or transferred for less than fair consideration during the 60-month look-back period? ☐ Yes ☐ No

7.2. If yes, complete the transfer schedule:

7.3. Total uncompensated transfers: $[________________]

7.4. Divestment divisor (verify current figure): $[________________] / day

7.5. Calculated penalty period: [________] days

7.6. Exceptions to evaluate (Wis. Stat. § 49.453(8)):

• ☐ Transfer to spouse;
• ☐ Transfer to a child who is blind or permanently and totally disabled;
• ☐ Transfer to a trust solely for the benefit of a disabled individual under age 65;
• ☐ Transfer of a homestead to a "caretaker child" who resided in the home and provided care for at least two (2) years immediately before institutionalization that allowed the applicant to remain at home;
• ☐ Transfer of a homestead to a sibling with an equity interest who resided in the home for at least one (1) year prior to institutionalization;
• ☐ Transfer for a purpose other than to qualify for medical assistance (rebuttable);
• ☐ Undue hardship waiver (Wis. Admin. Code; MEH § 17.5).

8. SPEND-DOWN (MEDICALLY NEEDY) WORKSHEET

8.1. Applicable categorically-needy income limit: $[________________] / month

8.2. Applicant gross income: $[________________] / month

8.3. Excess income: $[________________] / month

8.4. Six-month deductible (excess × 6): $[________________]

8.5. Qualifying medical expenses applied to deductible:

8.6. Date deductible met: [__/__/____]

9. SPOUSAL IMPOVERISHMENT ALLOCATION

9.1. Snapshot date. The first day of continuous institutionalization or the start date of HCBS services equals the resource assessment date: [__/__/____].

9.2. Total countable resources at snapshot: $[________________]

9.3. Community Spouse Resource Allowance (CSRA): $[________________] (verify current federal minimum and maximum — see 42 U.S.C. § 1396r-5 and Wis. Stat. § 49.455).

9.4. Monthly Maintenance Needs Allowance (MMNA) for community spouse: $[________________] (verify current federal minimum and maximum).

9.5. Income allocation from institutionalized spouse to community spouse: $[________________] / month.

9.6. ☐ Fair-hearing request to increase CSRA or MMNA filed under Wis. Stat. § 49.455(8). Date filed: [__/__/____].

10. PRIMARY RESIDENCE AND HOME EQUITY TREATMENT

10.1. Does applicant own a primary residence? ☐ Yes ☐ No

10.2. Address: [________________________________]

10.3. Current assessed value: $[________________]

10.4. Mortgage / encumbrance balance: $[________________]

10.5. Net equity: $[________________]

10.6. Equity-exemption ceiling — verify current federal-adjusted figure (approximately $750,000 in 2026): $[________________]

10.7. Exemption analysis. The home is generally an exempt resource if any of the following applies:

• ☐ Spouse, minor child, or blind/disabled child of any age resides in the home;
• ☐ Applicant intends to return home (signed Intent-to-Return Statement attached);
• ☐ Sibling with equity interest residing in the home for at least one (1) year before institutionalization;
• ☐ Caretaker child residing in and providing care in the home for at least two (2) years before institutionalization.

10.8. Intent-to-Return Statement. I, [________________________________], intend to return to my primary residence located at [________________________________]. Signed: [________________________________] Date: [__/__/____].

11. ESTATE RECOVERY DISCLOSURES

11.1. Applicant acknowledges receipt of the Wisconsin Estate Recovery Program Handbook (DHS Pub. P-13032). ☐ Yes ☐ No

11.2. Applicant has been advised that the Estate Recovery Program may seek repayment from:

• Probate estate assets;
• Non-probate transfers (e.g., joint tenancies, life estates, transfer-on-death deeds, revocable trust assets) created on or after the date the applicant became a Medicaid member;
• Real estate subject to a lien filed under Wis. Stat. § 49.496(2).

11.3. Applicant acknowledges that liens on real property are deferred from enforcement during the lifetime of a surviving spouse, minor child, or permanently disabled child.

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

12. FUNCTIONAL SCREEN / LEVEL-OF-CARE CONFIRMATION

12.1. The Wisconsin Long-Term Care Functional Screen (LTC-FS) is required for Family Care, Family Care Partnership, PACE, IRIS, and institutional Medicaid eligibility.

12.2. ADRC contact: [________________________________]

12.3. Functional Screen completion date: [__/__/____]

12.4. Outcome:

• ☐ Nursing Home Level of Care (NHLOC);
• ☐ Non-Nursing Home Level of Care;
• ☐ Pending review.

12.5. Functional Screener name and credential: [________________________________]

13. AUTHORIZED REPRESENTATIVE AND HIPAA RELEASE

13.1. I, [APPLICANT NAME], designate [________________________________] as my Authorized Representative pursuant to 42 C.F.R. § 435.923 and the Wisconsin Medicaid Eligibility Handbook to act on my behalf in connection with this application, including submitting documents, receiving notices, and requesting fair hearings.

13.2. I authorize the release to my Authorized Representative of all protected health information, financial records, and Medicaid eligibility records pursuant to 45 C.F.R. § 164.508.

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

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

14. FILING INSTRUCTIONS AND SUBMISSION CHECKLIST

14.1. Where to file. Online at https://access.wi.gov; by paper Form F-10101 to the local Income Maintenance Consortium; or in person at the county Income Maintenance / ADRC office.

14.2. Long-term care additional steps. Schedule the Long-Term Care Functional Screen with the local ADRC. For IRIS, contact an IRIS Consultant Agency (ICA). For Family Care / Partnership / PACE, MCO enrollment proceeds through the ADRC.

14.3. Submission checklist:

• ☐ Completed application (paper or ACCESS);
• ☐ Identity verification (state ID, passport, or birth certificate);
• ☐ SSN verification;
• ☐ Citizenship / immigration documentation;
• ☐ All income documents (Section 5);
• ☐ All asset / 60-month look-back documents (Section 6);
• ☐ Transfer schedule (Section 7) plus copies of deeds, gift tax returns, account closure statements;
• ☐ Spousal impoverishment worksheet (Section 9), if married;
• ☐ Primary residence documentation and Intent-to-Return Statement (Section 10);
• ☐ Estate Recovery acknowledgment (Section 11);
• ☐ Long-Term Care Functional Screen results (Section 12);
• ☐ Authorized Representative form (Section 13);
• ☐ Power of attorney for finances and health care (if applicable);
• ☐ Most recent federal and state tax returns;
• ☐ Health insurance cards (Medicare and any private supplements).

15. WISCONSIN PRACTICE NOTES

• Medically needy state. Wisconsin uses a deductible-based spend-down under § 49.47 rather than a Qualified Income Trust. Confirm current categorically-needy thresholds in the Medicaid Eligibility Handbook before submission.
• Divestment divisor. The divestment penalty divisor equals the statewide average daily nursing home rate, updated periodically. As of January 1, 2025, the divisor is $352.06/day per DHS Pub. P-10058. Confirm the current divisor with DHS before calculating penalties.
• Penalty start date. The penalty period does NOT begin until the applicant is otherwise eligible for Medicaid and would be receiving institutional or waiver services but for the divestment. Strategic transfers therefore must be evaluated against the applicant's anticipated entry to long-term care.
• Spousal impoverishment. CSRA and MMNA figures change annually. Wisconsin permits resource and income allowances within the federal range; a fair hearing under § 49.455(8) can support a higher MMNA where the community spouse demonstrates exceptional circumstances.
• Annuities. Wisconsin requires the State of Wisconsin to be named primary remainder beneficiary (or secondary behind a community spouse / minor or disabled child) on annuities purchased on or after the look-back start date for the annuity to avoid being treated as a divestment. See § 49.453(4c) and 42 U.S.C. § 1396p(c)(1)(F).
• Estate recovery scope. Wisconsin recovers from probate estates and from a defined set of non-probate transfers under § 49.496. Estate recovery applies to Medicaid services received at age 55 or older, or by any age for nursing home / inpatient care recipients required to contribute to cost of care.
• Fair hearings. A denial, reduction, or termination notice can be appealed to the Division of Hearings and Appeals within forty-five (45) days under Wis. Stat. § 49.45(5) and Wis. Admin. Code DHS 104.01(5). Continued benefits may be available if the appeal is filed within ten (10) days of the adverse notice.
• Functional Screen. Long-term care eligibility is gated by the LTC-FS. The screen must be administered by a certified screener and reviewed periodically. Medical eligibility is independent of financial eligibility — both must be satisfied.
• Family Care MCO changes. DHS announced 2026 Family Care MCO contract changes affecting western, southwestern, and Milwaukee County regions; verify current MCO assignments before enrollment.

16. SOURCES AND REFERENCES

• Wisconsin Statutes Chapter 49 — https://docs.legis.wisconsin.gov/statutes/statutes/49
• Wis. Stat. § 49.453 (Divestment) — https://docs.legis.wisconsin.gov/statutes/statutes/49/iv/453
• Wis. Stat. § 49.455 (Spousal Impoverishment) — https://docs.legis.wisconsin.gov/statutes/statutes/49/iv/455
• Wis. Stat. § 49.496 (Estate Recovery Program) — https://docs.legis.wisconsin.gov/statutes/statutes/49/iv/496
• Wisconsin Medicaid Eligibility Handbook — https://www.emhandbooks.wisconsin.gov/meh-ebd/meh.htm
• Wisconsin Medicaid Divestment (DHS Pub. P-10058) — https://www.dhs.wisconsin.gov/publications/p1/p10058.pdf
• Wisconsin Estate Recovery Program Handbook (DHS Pub. P-13032) — https://www.dhs.wisconsin.gov/publications/p1/p13032.pdf
• Medicaid Spousal Impoverishment Protection — https://www.dhs.wisconsin.gov/medicaid/spousal-impoverishment.htm
• Family Care, Partnership, and PACE — https://www.dhs.wisconsin.gov/familycare/index.htm
• IRIS (Include, Respect, I Self-Direct) Program — https://www.dhs.wisconsin.gov/iris/index.htm
• Aging and Disability Resource Centers (ADRC) — https://www.dhs.wisconsin.gov/adrc/index.htm
• Wisconsin ACCESS application portal — https://access.wi.gov
• 42 U.S.C. § 1396p (federal transfer of assets, liens, estate recovery) — https://www.govinfo.gov/

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. A Wisconsin-licensed elder law attorney must review and customize this document before use. Eligibility figures, divisors, and program rules change at least annually; verify all authorities against the current Medicaid Eligibility Handbook before filing.