Medicaid Planning Questionnaire

Purpose

This comprehensive questionnaire gathers the information necessary to evaluate Medicaid eligibility and develop a Medicaid planning strategy. Please complete all sections as thoroughly as possible. Bring supporting documents to your consultation.

Date Completed: _______________
Completed By: _______________
Relationship to Client: _______________

PART 1: APPLICANT INFORMATION

1.1 Personal Information

Full Legal Name: _______________________________________________

Also Known As (maiden name, aliases): ___________________________

Date of Birth: _________________ Age: _______

Social Security Number: _______________

Current Address:
_______________________________________________
_______________________________________________

Phone: _________________ Email: _________________________

Marital Status:
☐ Single/Never Married
☐ Married
☐ Divorced (Date: _____________)
☐ Widowed (Date of spouse's death: _____________)
☐ Separated (Date: _____________)

1.2 Citizenship and Residency

Citizenship Status:
☐ U.S. Citizen by birth
☐ Naturalized U.S. Citizen (Date: _____________)
☐ Permanent Resident (Green Card holder)
☐ Other qualified alien status: _______________

How long have you resided in this state? _______________

Do you intend to remain in this state? ☐ Yes ☐ No

1.3 Current Living Situation

Where does the applicant currently reside?
☐ Own home
☐ Family member's home (specify relationship): _______________
☐ Assisted living facility
☐ Nursing home/skilled nursing facility
☐ Hospital
☐ Rehabilitation facility
☐ Other: _______________

Facility Name (if applicable): _______________

Date of admission: _______________

Is this expected to be a long-term placement? ☐ Yes ☐ No ☐ Uncertain

PART 2: SPOUSE INFORMATION (if married)

2.1 Spouse's Personal Information

Full Legal Name: _______________________________________________

Date of Birth: _________________ Age: _______

Social Security Number: _______________

Current Address (if different from applicant):
_______________________________________________

Phone: _________________ Email: _________________________

2.2 Spouse's Living Situation

Where does the spouse currently reside?
☐ Family home (community spouse)
☐ Same facility as applicant
☐ Different nursing facility
☐ Assisted living
☐ Other: _______________

2.3 Spouse's Health Status

Is the spouse in good health? ☐ Yes ☐ No

Does the spouse have significant health issues? ☐ Yes ☐ No
If yes, describe: _______________________________________________

Is the spouse likely to need long-term care in the near future? ☐ Yes ☐ No ☐ Uncertain

PART 3: FAMILY INFORMATION

3.1 Children

3.2 Grandchildren

Number of grandchildren: _______

Names and ages (if relevant to planning):
_______________________________________________

3.3 Other Dependents

Does the applicant or spouse support any other persons financially?
☐ Yes ☐ No

If yes, identify: _______________________________________________

PART 4: MEDICAL INFORMATION

4.1 Current Health Status

Primary Diagnosis/Condition:
_______________________________________________

Other Medical Conditions:
_______________________________________________
_______________________________________________

Cognitive Status:
☐ Fully competent and oriented
☐ Mild cognitive impairment
☐ Moderate dementia/Alzheimer's
☐ Severe dementia/Alzheimer's
☐ Other cognitive condition: _______________

4.2 Functional Abilities (Activities of Daily Living)

Does the applicant need assistance with:

4.3 Level of Care

Has a level of care assessment been completed? ☐ Yes ☐ No

Has the applicant been certified as needing nursing home level of care? ☐ Yes ☐ No

Current care needs:
☐ Skilled nursing (24-hour nursing care)
☐ Assisted living level care
☐ Home health care
☐ Adult day care
☐ Other: _______________

4.4 Health Insurance

Medicare:
☐ Part A (Hospital) ☐ Part B (Medical) ☐ Part D (Prescription)
Medicare Number: _______________

Medicare Supplement (Medigap) Policy:
☐ Yes ☐ No
Company: _______________ Policy #: _______________

Medicare Advantage Plan:
☐ Yes ☐ No
Company: _______________ Plan Name: _______________

Long-Term Care Insurance:
☐ Yes ☐ No
Company: _______________ Policy #: _______________
Daily/Monthly Benefit: $_______________
Benefit Period: _______________
Elimination Period: _______________
Has the policy been used? ☐ Yes ☐ No

VA Benefits:
☐ Yes ☐ No
Type: _______________

Other Insurance:
_______________________________________________

PART 5: INCOME INFORMATION

5.1 Applicant's Monthly Income

5.2 Spouse's Monthly Income (if married)

5.3 Income Questions

Is any income expected to change in the next 12 months? ☐ Yes ☐ No
If yes, explain: _______________________________________________

Are any pension benefits reduced upon the pensioner's death? ☐ Yes ☐ No
If yes, explain: _______________________________________________

Is the applicant receiving or expecting to receive any inheritance? ☐ Yes ☐ No
If yes, amount and source: _______________________________________________

PART 6: ASSET INFORMATION

6.1 Bank Accounts

6.2 Investment Accounts

6.3 Retirement Accounts

6.4 Real Estate

Primary Residence:

Address: _______________________________________________

Title held by: _______________________________________________

Current fair market value: $_______________

Mortgage balance (if any): $_______________

Home equity: $_______________

Is there a life estate deed? ☐ Yes ☐ No

Is the home held in a trust? ☐ Yes ☐ No

Other Real Property:

6.5 Vehicles

6.6 Life Insurance

6.7 Annuities

6.8 Burial/Funeral Arrangements

Prepaid Funeral Contract:
☐ Yes ☐ No

If yes:
Funeral Home: _______________
Amount Prepaid: $_______________
Is it irrevocable? ☐ Yes ☐ No

Burial Plot:
☐ Yes ☐ No
Location: _______________

Burial Fund Set Aside: $_______________

6.9 Other Assets

6.10 Asset Summary

PART 7: MONTHLY EXPENSES

7.1 Current Monthly Expenses

PART 8: TRANSFER HISTORY (LOOKBACK PERIOD)

8.1 Transfers Within Past 60 Months

Have any assets been transferred, gifted, or sold for less than fair market value in the past 60 months (5 years)? ☐ Yes ☐ No

If yes, list all transfers:

8.2 Specific Transfer Questions

Have you or your spouse made any of the following transfers in the past 60 months?

☐ Gifts of cash to family members
Amount: $_______________ To whom: _______________

☐ Transferred real estate
Description: _______________ To whom: _______________

☐ Added anyone to bank accounts or property deeds
Details: _______________________________________________

☐ Placed assets in trust
Trust name/type: _______________________________________________

☐ Paid for improvements to property owned by others
Amount: $_______________ Property owner: _______________

☐ Paid off debts of family members
Amount: $_______________ For whom: _______________

☐ Made charitable donations exceeding normal giving
Amount: $_______________ Charity: _______________

☐ Purchased annuities
Amount: $_______________ For whom: _______________

☐ Purchased life insurance policies
Amount: $_______________ For whom: _______________

☐ Forgiven or not collected on loans to family
Amount: $_______________ Borrower: _______________

☐ Made any other transfers not for fair value
Details: _______________________________________________

PART 9: LEGAL DOCUMENTS

9.1 Existing Documents

Does the applicant have the following documents?

Does the spouse have the following documents?

9.2 Fiduciary Appointments

Who is named as Power of Attorney (financial)?
Name: _______________ Phone: _______________

Who is named as Healthcare Agent?
Name: _______________ Phone: _______________

Is there a court-appointed guardian or conservator? ☐ Yes ☐ No
If yes, name and relationship: _______________

9.3 Trust Information

If either spouse is a grantor, trustee, or beneficiary of any trust, provide details:
_______________________________________________
_______________________________________________
_______________________________________________

PART 10: VETERAN STATUS

10.1 Applicant's Military Service

Did the applicant serve in the military? ☐ Yes ☐ No

If yes:
Branch: _______________
Dates of Service: _______________ to _______________
Discharge Status: _______________

Did the applicant serve during a wartime period? ☐ Yes ☐ No
☐ WWII (12/7/1941 - 12/31/1946)
☐ Korean War (6/27/1950 - 1/31/1955)
☐ Vietnam War (8/5/1964 - 5/7/1975)
☐ Gulf War (8/2/1990 - present)

Is the applicant currently receiving VA benefits? ☐ Yes ☐ No
Type: _______________ Monthly Amount: $_______________

Has the applicant applied for VA Aid & Attendance? ☐ Yes ☐ No

10.2 Spouse's Military Service

Did the spouse serve in the military? ☐ Yes ☐ No

If yes:
Branch: _______________
Dates of Service: _______________ to _______________

PART 11: GOALS AND CONCERNS

11.1 Primary Goals

What are the primary goals of Medicaid planning? (Check all that apply)

☐ Qualify for Medicaid to pay for nursing home care
☐ Protect assets for the community spouse
☐ Preserve assets for children/heirs
☐ Protect the family home
☐ Reduce spend-down of assets
☐ Plan for potential future care needs (pre-planning)
☐ Other: _______________________________________________

11.2 Timeline

How urgent is the need for Medicaid benefits?

☐ Currently in nursing home and private pay funds running low
☐ Entering nursing home soon
☐ Planning ahead (no immediate need)
☐ Other: _______________________________________________

Estimated time until Medicaid needed: _______________

11.3 Specific Concerns

What specific concerns do you have about Medicaid planning?
_______________________________________________
_______________________________________________
_______________________________________________

PART 12: ADDITIONAL INFORMATION

12.1 Professional Advisors

12.2 Other Relevant Information

Is there any other information that may be relevant to Medicaid planning?
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________

PART 13: DOCUMENT CHECKLIST

Please bring the following documents to your consultation:

Financial Documents

• ☐ 60 months of bank statements (all accounts)
• ☐ 60 months of investment/brokerage statements
• ☐ Most recent retirement account statements (IRA, 401k)
• ☐ Annuity contracts and statements
• ☐ Life insurance policies and cash value statements
• ☐ Most recent tax returns (3 years)

Income Documents

• ☐ Social Security benefit statements (SSA-1099)
• ☐ Pension statements
• ☐ 1099 forms for interest/dividends

Property Documents

• ☐ Deed to real property
• ☐ Mortgage statements
• ☐ Property tax bills
• ☐ Homeowner's insurance declarations
• ☐ Vehicle titles

Legal Documents

• ☐ Wills
• ☐ Trust documents
• ☐ Power of Attorney documents
• ☐ Healthcare directives
• ☐ Divorce decrees (if applicable)
• ☐ Prenuptial/postnuptial agreements (if applicable)

Other Documents

• ☐ Prepaid funeral contracts
• ☐ Long-term care insurance policies
• ☐ Military discharge papers (DD-214)
• ☐ Guardianship/conservatorship orders (if applicable)

CERTIFICATION

I certify that the information provided in this questionnaire is true, complete, and accurate to the best of my knowledge. I understand that this information will be used for Medicaid planning purposes and that incomplete or inaccurate information may result in delays or adverse consequences.

Signature: _________________________________

Printed Name: _________________________________

Date: _________________

Relationship to Applicant (if not applicant): _________________________________

This questionnaire is designed to gather information for Medicaid planning consultation. The information provided is confidential and protected by attorney-client privilege. Medicaid rules are complex and vary by state. An elder law attorney should review your specific situation to provide personalized advice.