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

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

TABLE OF CONTENTS

1. Applicant Identification and Program Selection
2. Eligibility Snapshot — Wyoming Long-Term Care Medicaid
3. Income Documentation
4. Asset / Resource Documentation
5. Five-Year (60-Month) Look-Back Disclosure
6. Primary Residence and Home Equity
7. Spousal Impoverishment Worksheet
8. Qualified Income (Miller) Trust Determination
9. Functional / Level-of-Care Documentation
10. Authorized Representative and Designation of Counsel
11. Applicant Certifications and Signatures
12. Document Checklist
13. Wyoming Practice Notes
14. Sources and References

1. APPLICANT IDENTIFICATION AND PROGRAM SELECTION

Program Applied For (check all that apply):

• ☐ Institutional (Nursing Home) Medicaid — Wyo. Dep't of Health Rules, Ch. 3
• ☐ Community Choices Waiver (CCW) — 1915(c) HCBS waiver for ages 65+ or 19–64 with qualifying disability
• ☐ Program of All-Inclusive Care for the Elderly (PACE) [if available in county]
• ☐ Aged, Blind & Disabled (ABD) Medicaid (non-LTC)
• ☐ Medicare Savings Program (QMB / SLMB / QI) — separate determination

2. ELIGIBILITY SNAPSHOT — WYOMING LONG-TERM CARE MEDICAID

The figures below summarize commonly cited 2025 thresholds. Verify each figure with the Wyoming Department of Health, Division of Healthcare Financing, and SSA Cost-of-Living updates before filing.

3. INCOME DOCUMENTATION

Attach proof for every source of gross monthly income for both the applicant and (if married) the spouse.

Required documents: SSA award letter, twelve months of bank statements, pension statements, Wyoming mineral-interest royalty statements (if any), and any rental ledgers.

4. ASSET / RESOURCE DOCUMENTATION

List ALL assets owned by the applicant and (if married) the spouse as of the first moment of the application month. Wyoming counts assets as of 12:00 a.m. on the first day of the month.

Exempt resources commonly recognized in Wyoming: primary residence (subject to equity cap), one motor vehicle, household goods and personal effects, irrevocable burial trust up to $1,500 plus burial space, term life insurance, and certain Native American trust assets.

5. FIVE-YEAR (60-MONTH) LOOK-BACK DISCLOSURE

The applicant certifies that the following lists ALL transfers of assets for less than fair market value made by the applicant or the applicant's spouse in the 60 months immediately preceding this application (per 42 U.S.C. § 1396p(c)).

Exempt transfers (no penalty under 42 U.S.C. § 1396p(c)(2)): transfers to a spouse; to a blind or disabled child; to a "caretaker child" who lived in the home 2+ years and provided care that delayed institutionalization; to a sibling with an equity interest who resided in the home 1+ year before institutionalization; into a (d)(4)(A) or (d)(4)(C) special-needs trust for a disabled person under 65; or transfers shown to have been made exclusively for a purpose other than to qualify for Medicaid.

6. PRIMARY RESIDENCE AND HOME EQUITY

The home is exempt during the applicant's lifetime if (a) the applicant intends to return, OR (b) a qualifying relative occupies the home, AND (c) the applicant's equity interest does not exceed the federal home-equity limit (approx. $730,000 for 2025; verify). On the applicant's death, the home is subject to Wyoming Medicaid Estate Recovery under Wyo. Stat. § 42-4-206 and Wyo. Dep't of Health Medicaid Rules Ch. 16.

7. SPOUSAL IMPOVERISHMENT WORKSHEET

Complete only if applicant is married and the spouse is not also applying.

8. QUALIFIED INCOME (MILLER) TRUST DETERMINATION

Wyoming is an income-cap state. If the applicant's gross monthly income exceeds the program income cap (approx. $2,901/month for 2025), the applicant must establish a Qualified Income Trust ("QIT" / Miller Trust) under 42 U.S.C. § 1396p(d)(4)(B) before Medicaid eligibility can be granted.

Trust requirements:

• ☐ Irrevocable
• ☐ Funded only with the applicant's income (Social Security, pension, etc.)
• ☐ Trustee other than the applicant (typically spouse, adult child, or fiduciary)
• ☐ Names the State of Wyoming, Department of Health, as remainder beneficiary up to the total amount of medical assistance paid
• ☐ Distributions limited to (i) PNA, (ii) MMMNA / spousal allowance, (iii) health-insurance premiums, and (iv) cost share / patient liability

9. FUNCTIONAL / LEVEL-OF-CARE DOCUMENTATION

Wyoming requires a Nursing Facility Level of Care (NFLOC) determination for both Institutional Medicaid and the Community Choices Waiver. The assessment is performed using the LT101 tool by a Wyoming public-health nurse or designee.

10. AUTHORIZED REPRESENTATIVE AND DESIGNATION OF COUNSEL

I, [APPLICANT NAME], designate the following individual as my Authorized Representative for purposes of this application under 42 C.F.R. § 435.923:

Counsel of Record (if any):

11. APPLICANT CERTIFICATIONS AND SIGNATURES

I certify under penalty of perjury under the laws of the State of Wyoming that:

1. The information contained in this packet is true, complete, and correct to the best of my knowledge.
2. I have disclosed all assets, all transfers within the 60-month look-back, and all income sources for myself and my spouse.
3. I understand that any intentional misstatement may result in denial of benefits, recovery of benefits paid, civil penalties, and/or criminal prosecution under Wyo. Stat. § 42-4-114 and 42 U.S.C. § 1320a-7b.
4. I authorize the Wyoming Department of Health and the Department of Family Services to verify all information through banks, employers, the IRS, SSA, VA, and other state agencies.
5. I assign to the State of Wyoming any rights to medical-support payments and third-party medical recovery to the extent of Medicaid paid on my behalf, per 42 U.S.C. § 1396k.
6. I acknowledge that on my death, the State may pursue Medicaid Estate Recovery against my probate estate under Wyo. Stat. § 42-4-206.

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

[APPLICANT — print and sign]

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

[SPOUSE — print and sign, if married]

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

[AUTHORIZED REPRESENTATIVE — if applicable]

12. DOCUMENT CHECKLIST

Submit the application together with the following:

• ☐ Government photo ID (driver's license / Wyoming State ID / passport)
• ☐ Birth certificate or proof of age
• ☐ Social Security card
• ☐ Proof of Wyoming residency
• ☐ Proof of citizenship / lawful immigration status
• ☐ Marriage certificate / divorce decree / death certificate of prior spouse
• ☐ Medicare card and supplemental insurance card(s)
• ☐ Sixty (60) months of statements for every bank, brokerage, retirement, and investment account
• ☐ Most recent statements for life-insurance cash value, annuities, pensions
• ☐ Deeds, titles, and tax assessments for all real property
• ☐ Mineral, royalty, oil-and-gas divisional orders (Wyoming-specific)
• ☐ Vehicle titles
• ☐ Funeral / burial-fund contract (irrevocable)
• ☐ Trust instruments (revocable / irrevocable / QIT)
• ☐ Power of Attorney / guardianship orders
• ☐ Five years of federal tax returns
• ☐ Gift / transfer documentation for look-back period
• ☐ LT101 assessment results
• ☐ Physician's statement / level-of-care attestation
• ☐ Choice-of-case-management form (CCW only)
• ☐ Verification of QIT establishment and bank account (income-cap applicants)

13. WYOMING PRACTICE NOTES

• Filing channels. Apply through the Wyoming Eligibility System (WES) at wesystem.wyo.gov, by paper at the local Department of Family Services office, or by phone at 1-855-294-2127. CCW intake routes through DOH HCBS at 1-800-510-0280.
• Decision timeframes. Federal regulations require eligibility determinations within 45 days for ABD applicants and 90 days when disability must be verified (42 C.F.R. § 435.912). Wyoming generally adheres to these timeframes.
• Fair hearings. Adverse determinations are appealable under Wyo. Stat. § 16-3-107 and Wyo. Dep't of Health Medicaid Rules, Ch. 4. The fair-hearing request must be filed within 30 days of the adverse notice; benefits-pending status requires filing within 10 days.
• Income-cap state. Wyoming uses the 300%-of-SSI categorically-needy income standard. There is no medically-needy "spend-down" pathway for LTC; QIT funding is the standard remedy for over-cap applicants.
• Estate recovery. Wyoming pursues recovery against the probate estate of deceased Medicaid recipients age 55+ for LTC services (Wyo. Stat. § 42-4-206; Medicaid Rules Ch. 16). Hardship waivers exist; petition the Department in writing.
• Annuities. A Medicaid-compliant single-premium immediate annuity must be irrevocable, non-assignable, actuarially sound under SSA life-expectancy tables, name the State as primary remainder beneficiary up to amounts paid, and pay equal monthly amounts.
• Caretaker-child exception. Common in rural Wyoming counties; document residency and care with affidavits, utility bills, medical-records correspondence, and physician attestation that care delayed institutionalization for at least two years.
• Mineral interests. Frequently retained as countable family assets in Wyoming; attempts to gift, sell, or place into closely-held LLCs within the look-back period may trigger transfer penalties absent documentation of fair-market consideration.

14. SOURCES AND REFERENCES

• Wyoming Department of Health, Division of Healthcare Financing — https://health.wyo.gov/healthcarefin/medicaid/
• Wyoming Medicaid Income Requirements — https://health.wyo.gov/healthcarefin/medicaid/programs-and-eligibility/medicaid-income-requirements/
• Wyoming Home and Community Based Services (HCBS) — https://health.wyo.gov/healthcarefin/hcbs/
• Wyoming Community Choices Waiver Program Application & Fact Sheet — https://health.wyo.gov/wp-content/uploads/2024/06/CCW-Form-01-CCW-Program-Application-and-Fact-Sheet-Fillable.pdf
• Wyoming CCW Participant Handbook — https://health.wyo.gov/wp-content/uploads/2025/04/CCW-Reference-14-Participant-Handbook-2024.pdf
• Wyoming EOM (Eligibility Operations Manual) — Aged, Blind, or Disabled / HCBS Waivers — https://ecom.wyo.gov/m1000-aged-blind-or-disabled-program/m1002-hcbs-waivers/m1002a-community-choices-home-community-based-waiver
• Wyoming Department of Family Services — https://dfs.wyo.gov
• 42 U.S.C. § 1396p (transfers, look-back, estate recovery) — https://www.law.cornell.edu/uscode/text/42/1396p
• Wyoming Statutes Title 42, Chapter 4 (Medical Assistance and Services) — https://wyoleg.gov/statutes/compress/title42.pdf
• Wyoming LSO 24FS035 — Medicaid Nursing Home Care Application Process — https://wyoleg.gov/LSOResearch/2024/24FS035%20w%20appendix.pdf
• CMS Wyoming Waiver Factsheet — https://www.medicaid.gov/medicaid/section-1115-demo/demonstration-and-waiver-list/Waiver-Descript-Factsheet/WY

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. All dollar figures, statutory citations, and procedural rules are subject to change. A Wyoming-licensed elder law attorney must review and customize this packet before submission. Verify current figures with the Wyoming Department of Health, Division of Healthcare Financing.