Medicaid Application Packet — West Virginia (Long-Term Care, Aged & Disabled Waiver, Take Me Home WV)

WEST VIRGINIA MEDICAID APPLICATION PACKET — LONG-TERM CARE, AGED & DISABLED WAIVER, AND TAKE ME HOME WV

TABLE OF CONTENTS

1. Cover Sheet and Filing Instructions
2. Applicant Information
3. Program Selection
4. Financial Eligibility — Income
5. Financial Eligibility — Resources / Assets
6. Spousal Impoverishment Protections
7. Transfer of Assets and 60-Month Look-Back
8. Primary Residence and Home-Equity Cap
9. Medically Needy / Spend-Down Pathway
10. Aged & Disabled Waiver (ADW) Supplement
11. Take Me Home, West Virginia (TMH) Supplement
12. Verification Documents Checklist
13. Authorized Representative and HIPAA Authorization
14. Applicant Certification and Signature
15. West Virginia Practice Notes
16. Sources and References

1. COVER SHEET AND FILING INSTRUCTIONS

State of West Virginia — Department of Human Services (DoHS) (formerly DHHR)

Bureau for Medical Services (BMS) — Medicaid

Local County Office: [________________________________]

Worker / Case Manager (if assigned): [________________________________]

Application Type: ☐ SSI-Related Aged, Blind, or Disabled (ABD) ☐ Long-Term Care Nursing Facility ☐ Aged & Disabled Waiver (ADW) ☐ Traumatic Brain Injury Waiver (TBIW) ☐ Take Me Home WV (TMH) Transition ☐ Medically Needy (Spend-Down)

Date Submitted: [__/__/____]

Method of Submission: ☐ In person ☐ Mail ☐ Fax ☐ inROADS online portal ☐ Phone (1-877-716-1212)

2. APPLICANT INFORMATION

Spouse (if applicable):

3. PROGRAM SELECTION

Select all programs for which the applicant requests determination:

☐ Nursing Facility (Institutional) Medicaid — payment of nursing-home services for an applicant requiring Nursing Facility Level of Care (NF-LOC).

☐ Aged & Disabled Waiver (ADW) — 1915(c) HCBS waiver providing personal attendant, skilled nursing, transportation, and other services to permit community living for persons who would otherwise require nursing-facility placement. Capped enrollment; waiting list possible.

☐ Traumatic Brain Injury Waiver (TBIW) — 1915(c) HCBS waiver for persons with a qualifying TBI.

☐ Take Me Home, West Virginia (TMH) — Money Follows the Person demonstration; transition services for persons leaving an inpatient facility (60+ consecutive days) to community living.

☐ Medically Needy (Spend-Down) Coverage Group — for applicants whose income exceeds the categorical limit but who incur sufficient medical expenses to "spend down" to the MNIL.

☐ SSI-Related Aged, Blind, or Disabled (ABD) — for individuals 65+, blind, or disabled who meet SSI-comparable resource and income tests but are not in long-term care.

☐ Medicare Savings Programs (QMB / SLMB / QI-1) — Medicare premium and cost-sharing assistance.

4. FINANCIAL ELIGIBILITY — INCOME

Monthly gross income — applicant:

Income test selected:

☐ Categorical (≤ $2,982/month, 2026 institutional/waiver cap — VERIFY)

☐ Medically Needy spend-down (income > cap; will spend down to $200/$275 MNIL)

☐ ABD SSI-related ($967 single / $1,450 couple, 2026 — VERIFY)

Patient-Pay / Post-Eligibility Treatment of Income (PETI) — Nursing Facility applicants:

5. FINANCIAL ELIGIBILITY — RESOURCES / ASSETS

Countable resource limit: $2,000 single / $3,000 couple (when both spouses apply).

Excluded (non-countable) resources — list with documentation:

• ☐ Primary residence (subject to home-equity cap and intent-to-return rules — see Section 8)
• ☐ One automobile (any value, if used for transportation)
• ☐ Household goods and personal effects
• ☐ Irrevocable burial contract / pre-need funeral
• ☐ Burial space and burial-space items
• ☐ Term life insurance (no cash value)
• ☐ Cash-value life insurance with face value ≤ $1,500 (combined)
• ☐ Property essential to self-support
• ☐ Tax-qualified retirement account in payout status (verify under current BMS policy)

6. SPOUSAL IMPOVERISHMENT PROTECTIONS

(Required for institutional or HCBS-waiver applicants with a community spouse — 42 U.S.C. § 1396r-5)

Snapshot date (date of first continuous 30-day period of institutionalization): [__/__/____]

Combined countable resources on snapshot date: $[____]

Community Spouse Resource Allowance (CSRA), 2026:

• Minimum: $32,532
• Maximum: $162,660
• WV uses the one-half methodology; CSRA = ½ of combined snapshot resources, subject to the floor and ceiling above.

CSRA calculated for this case: $[____]

Minimum Monthly Maintenance Needs Allowance (MMMNA), 2026:

• Floor: $2,643.75/month
• Ceiling: $4,066.50/month
• Excess shelter standard: $793.13/month

Community spouse's monthly income: $[____]

Calculated MMMNA shortfall (income transferred from institutionalized spouse): $[____]

☐ Fair Hearing requested to seek increased CSRA or MMMNA based on exceptional circumstances (W. Va. C.S.R. § 78-1; 42 U.S.C. § 1396r-5(e)).

7. TRANSFER OF ASSETS AND 60-MONTH LOOK-BACK

(W. Va. Code § 9-5-11a; 42 U.S.C. § 1396p(c))

Look-back period: 60 months immediately preceding the application date or the date of institutionalization (whichever is later).

Look-back start date: [__/__/____]

Were any assets sold, given, or transferred for less than fair market value during the look-back period? ☐ Yes ☐ No

If yes, list each transfer:

Penalty calculation:

• WV Average Private-Pay Nursing-Facility Cost (penalty divisor), most recent figure: $11,903/month (2025 — VERIFY current BMS divisor before relying)
• Total uncompensated transfers: $[____]
• Penalty period (months) = uncompensated total ÷ divisor = [____] months
• Penalty period begins on the later of (a) the date of transfer or (b) the date the applicant is otherwise eligible and would receive Medicaid LTC services but for the transfer.

Exempt transfers (check all that apply):

• ☐ Transfer to spouse
• ☐ Transfer to a child under 21 or a blind/disabled child of any age
• ☐ Transfer to a sibling with equity interest who lived in the home for ≥ 1 year before institutionalization
• ☐ Transfer to a "caregiver child" who lived in the home for ≥ 2 years and provided care permitting the applicant to remain home
• ☐ Transfer to a sole-benefit (d)(4)(A) or (d)(4)(C) trust for a disabled individual under 65
• ☐ Transfer for a purpose other than to qualify for Medicaid (rebuttal evidence attached)
• ☐ Asset returned in full

☐ Undue Hardship Waiver requested — applicant attaches statement showing application of penalty would deprive applicant of medical care endangering life or health, or food, clothing, shelter, or other necessities of life (W. Va. Code § 9-5-11a(c); 42 U.S.C. § 1396p(c)(2)(D)).

8. PRIMARY RESIDENCE AND HOME-EQUITY CAP

Home-equity cap (federal FY2026): $752,000 (default; some states elect the higher tier — confirm current WV election).

☐ Net equity is at or below cap; home is excluded.

☐ Net equity exceeds cap; LTC services unavailable absent reduction or hardship waiver.

Home is automatically excluded (regardless of equity) where:

• ☐ A spouse resides there
• ☐ A child under 21 resides there
• ☐ A blind or disabled child of any age resides there
• ☐ A sibling with equity interest who lived there ≥ 1 year before institutionalization

Otherwise: ☐ Applicant declares Intent to Return Home (statement attached). Home remains excluded so long as intent persists, subject to estate-recovery liability under W. Va. Code § 9-5-11.

9. MEDICALLY NEEDY / SPEND-DOWN PATHWAY

West Virginia is a Section 1902(a)(10)(C) Medically Needy state.

Medically Needy Income Level (MNIL): $200/month single, $275/month couple (verify).

Spend-down period: ☐ One month ☐ Six months (state option — verify current WV practice)

Calculation:

• Gross monthly income: $[____]
• MNIL: $[____]
• Excess income to spend down: $[____]
• Allowable medical expenses paid or incurred during the period: $[____]

Once incurred medical expenses equal or exceed the excess, the applicant is eligible for Medicaid for the remainder of the period.

Allowable spend-down expenses include:

• Hospital, physician, dental, vision, hearing
• Prescription drugs
• Health-insurance premiums (Medicare, supplement, LTC)
• Medically necessary supplies and equipment
• Transportation for medical care
• Old, paid medical bills (per BMS policy)

10. AGED & DISABLED WAIVER (ADW) SUPPLEMENT

Functional eligibility — Pre-Admission Screening (PAS):

• ☐ Applicant has at least 5 functional deficits on the PAS instrument administered by a Medical Necessity Review Contractor
• ☐ Applicant requires a Nursing Facility Level of Care (NF-LOC) but elects to receive services at home

Services requested (check all):

☐ Personal attendant ☐ Skilled nursing ☐ Case management ☐ Environmental modifications ☐ Transportation ☐ Pest eradication ☐ Medical alert ☐ Community transition ☐ Other: [________________________________]

Primary caregiver / responsible party: [________________________________]

Provider agency selection: [________________________________]

Wait-list status: ☐ Active enrollment ☐ Managed wait list — date placed: [__/__/____]

11. TAKE ME HOME, WEST VIRGINIA (TMH) SUPPLEMENT

Eligibility prerequisites — applicant must satisfy ALL:

• ☐ Currently a resident of a Medicaid-certified nursing facility, hospital, ICF/IID, or Institution for Mental Disease (IMD)
• ☐ Continuous institutional stay of at least 60 consecutive days (verify current MFP statutory minimum)
• ☐ Determined medically and financially eligible for ADW or TBIW (or other qualifying HCBS)
• ☐ Wishes to transition to a qualified community residence (own or family home, apartment, or small group home of ≤ 4 unrelated residents)

TMH Transition Navigator assigned: [________________________________]

Anticipated transition date: [__/__/____]

Qualifying community residence (address): [________________________________]

Transition services requested:

☐ Security / utility deposits ☐ Household furnishings ☐ Moving expenses ☐ Pre-transition assessment ☐ Tenancy supports ☐ Telehealth equipment ☐ Other: [________________________________]

12. VERIFICATION DOCUMENTS CHECKLIST

Attach copies (not originals). Check items submitted:

☐ Photo identification (driver's license, state ID, passport)

☐ Social Security card (applicant and spouse)

☐ Medicare card / MBI

☐ Birth certificate or proof of age

☐ Proof of U.S. citizenship or qualified-immigrant status

☐ Proof of WV residency (lease, utility bill, voter card)

☐ Marriage certificate / divorce decree / death certificate of spouse

☐ Most recent 60 months of bank, brokerage, and retirement-account statements (all owners)

☐ Most recent property-tax statements and deeds

☐ Vehicle titles and registrations

☐ Most recent two months of pay stubs / pension / SSA award letter / VA award letter

☐ Federal and state tax returns — most recent two years

☐ Health-insurance cards and premium statements

☐ Life-insurance policy declarations (face value and current cash value)

☐ Pre-need burial / funeral contracts

☐ Trust instruments (revocable and irrevocable)

☐ Annuity contracts

☐ Power of Attorney / Guardianship Order / MOST form

☐ Documentation of every uncompensated transfer in the look-back period (deeds, gift letters, cancelled checks, account statements)

☐ Pre-Admission Screening (PAS) results — for ADW / nursing facility

☐ Physician's certification of need (Form MNER for ADW)

13. AUTHORIZED REPRESENTATIVE AND HIPAA AUTHORIZATION

I, [________________________________] (applicant), authorize the following individual to act as my Authorized Representative for this Medicaid application, including the right to file the application, provide and receive information, attend interviews, request fair hearings, and receive notices on my behalf:

I authorize DoHS, BMS, and their contractors to obtain and disclose protected health information and financial information to and from banks, employers, insurers, the Social Security Administration, the Veterans Administration, the Internal Revenue Service, nursing facilities, and providers, to the extent necessary to determine and redetermine my eligibility (45 C.F.R. § 164.508; W. Va. Code § 9-5-1).

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

14. APPLICANT CERTIFICATION AND SIGNATURE

I declare under penalty of perjury under the laws of West Virginia that the information provided in this application and its attachments is true, correct, and complete to the best of my knowledge. I understand that:

• Medicaid is a needs-based program; assets and income above the limits will disqualify me unless properly excluded or reduced.
• Uncompensated transfers in the 60-month look-back may result in a penalty period of ineligibility.
• The State of West Virginia may seek estate recovery for Medicaid services correctly paid on my behalf at age 55+ or for any age while in a long-term care institution (W. Va. Code § 9-5-11; 42 U.S.C. § 1396p(b)).
• I must report any change in income, resources, household composition, residence, or insurance within 10 days.
• Knowingly providing false information may result in denial, recoupment, civil penalties, and criminal prosecution under W. Va. Code § 9-5-4 and 18 U.S.C. § 1001.

Applicant signature: [________________________________]

Printed name: [________________________________]

Date: [__/__/____]

Witness / Authorized Representative signature: [________________________________]

Date: [__/__/____]

Notary acknowledgment (optional):

State of West Virginia, County of [________________________________]

Sworn to and subscribed before me this [____] day of [_______________], 20[____].

[________________________________]

Notary Public — My commission expires: [_______________]

15. WEST VIRGINIA PRACTICE NOTES

• Filing offices and channels. Applications for SSI-related, ABD, and long-term care Medicaid are filed with the local Department of Human Services (DoHS — formerly DHHR Bureau for Children and Families). The state online portal is inROADS (https://www.wvinroads.org/). The statewide Customer Service Center is 1-877-716-1212.

• Administering agency. The Bureau for Medical Services (BMS) is the State Medicaid Agency under 42 C.F.R. § 431.10. Eligibility is determined by DoHS workers; covered services are administered by BMS.

• Standard processing times. 45 days for a non-disability application; 90 days where a disability determination is required (42 C.F.R. § 435.912).

• Medically Needy. WV operates a 1902(a)(10)(C) Medically Needy program. The MNIL is low ($200 single / $275 couple), so most over-income LTC applicants will rely on the institutional/waiver special-income limit ($2,982) rather than spend-down for nursing-facility services. Spend-down is more commonly used for community ABD applicants with substantial recurring medical bills.

• No QIT / Miller Trust requirement. Unlike "income-cap-only" states, WV's Medically Needy framework permits spend-down and does not require a Qualified Income Trust for LTC eligibility. Confirm current policy before relying on this point.

• Penalty divisor. The 2025 average private-pay nursing-facility cost used as the divisor was $11,903/month. BMS updates this figure periodically; always pull the current divisor from the Member Eligibility Manual (Chapter 400) before calculating a transfer penalty.

• Estate recovery. WV recovers under W. Va. Code § 9-5-11 against the probate estate of a deceased recipient who received Medicaid LTC services or services at age 55+, subject to the federal exemptions (42 U.S.C. § 1396p(b)(2)) and undue-hardship waiver. Liens on real property are limited under § 9-5-11.

• Annuities and DRA compliance. Annuities purchased after 2/8/2006 must be irrevocable, non-assignable, actuarially sound, and name the State of West Virginia as primary remainder beneficiary (or secondary after a community spouse or minor/disabled child) to avoid being treated as an uncompensated transfer.

• Promissory notes, life estates, and personal-services contracts. All are scrutinized and must comply with W. Va. C.S.R. policy and DRA standards. Document carefully.

• DHHR reorganization (effective 1/1/2024). The legacy "Department of Health and Human Resources" was split into the Department of Human Services (DoHS), Department of Health (DH), and Department of Health Facilities (DHF). Most published forms, statutes, and federal CMS waivers still refer to "DHHR." BMS remains under DoHS.

• Fair hearings. Adverse decisions may be appealed under W. Va. C.S.R. § 78-2 and 42 C.F.R. Part 431, Subpart E. Request a hearing within 90 days of the notice of action; benefits may continue pending hearing if request is made within 13 days for a termination/reduction.

16. SOURCES AND REFERENCES

• West Virginia Bureau for Medical Services — https://bms.wv.gov/
• BMS Provider and Eligibility Policy Manuals — https://bms.wv.gov/providers/policy-manuals
• BMS, Your Guide to Medicaid 2025 — https://bms.wv.gov/media/25241/download?inline=
• BMS, Your Guide to Medicaid 2026 — https://bms.wv.gov/media/41130/download?inline=
• WV Department of Human Services — https://dhhr.wv.gov/ (legacy URL still in use)
• inROADS Self-Service Portal — https://www.wvinroads.org/
• Take Me Home, West Virginia — https://bms.wv.gov/take-me-home-tmh-transition-program
• TMH Procedures Manual (Transition Navigator) — https://dhhr.wv.gov/bms/Programs/Takemehome/Documents/TN%20Procedures%20Manual%20-%20Version%206.pdf
• Aged & Disabled Waiver Helpline — 1-866-767-1575
• WV Bureau of Senior Services — http://www.wvseniorservices.gov/
• W. Va. Code Chapter 9 (Human Services) — https://code.wvlegislature.gov/9/
• W. Va. C.S.R. Title 78 (DoHS / Income Maintenance) — https://apps.sos.wv.gov/adlaw/csr/
• 42 U.S.C. § 1396p (transfers, liens, estate recovery) — https://www.govinfo.gov/
• 42 U.S.C. § 1396r-5 (spousal impoverishment)
• CMS Spousal Impoverishment Standards (annual) — https://www.medicaid.gov/medicaid/eligibility/spousal-impoverishment/

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. Medicaid asset and income limits, the transfer-penalty divisor, the home-equity cap, and the spousal-impoverishment standards change at least annually. Verify every figure with current BMS policy and consult a West Virginia-licensed elder-law attorney before filing or relying on this packet.