Tip for State-specific

Disclose ALL transfers — undisclosed transfers discovered later can result in application denial, fraud referrals, and recovery actions

Tip for State-specific

Transfers to a spouse are generally exempt from the look-back penalty

Tip for State-specific

Transfers of a home to a child who is blind, disabled, or lived in the home for 2+ years providing care may be exempt

Long-Term Carevery hard

Asset Transfer / Look-Back Documentation

State-specific · State Medicaid agencies

Documentation of all asset transfers in the 60 months (5 years) before Medicaid application. Uncompensated transfers may result in a penalty period of Medicaid ineligibility.

Form Details

Total fields: 80
Auto-fillable: 20 (25%)
Time without BeneFill: 120 minutes
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Time saved: 90 minutes
Filled by: patient
Frequency: one time
State-specific: Yes — form may vary by state

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Where to Submit This Form

📬

Submit to the state Medicaid agency with your LTC Medicaid application

🏢

Provide to your Medicaid caseworker during the application process

Filing Deadline

Required as part of the LTC Medicaid application. All transfers within the 5-year look-back period must be disclosed and documented.

Required Attachments

📎 Complete documentation of all asset transfers in the past 5 years (60 months)
📎 Bank statements for all accounts for the entire 5-year period
📎 Deeds, transfer documents, and closing statements for real property transfers
📎 Trust documents and amendments
📎 Life insurance policy information (for policies with cash value)
📎 Documentation of gifts, including holiday/birthday gifts
📎 Explanation letters for each transfer describing the purpose

Processing Time

Review as part of the Medicaid application — 45-90 days or longer for complex asset situations.

What Happens Next

The Medicaid agency reviews all transfers to determine if any trigger a penalty period. Transfers for fair market value, transfers to a spouse, transfers of a home to certain family members, and other exempt transfers do not incur penalties. Non-exempt transfers result in a period of Medicaid ineligibility.

Tips for This Form

✓ Disclose ALL transfers — undisclosed transfers discovered later can result in application denial, fraud referrals, and recovery actions
✓ Transfers to a spouse are generally exempt from the look-back penalty
✓ Transfers of a home to a child who is blind, disabled, or lived in the home for 2+ years providing care may be exempt
✓ A Medicaid-compliant annuity may help protect some assets — consult an elder law attorney

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Application for Medicaid coverage of nursing facility care. Includes detailed financial disclosure of income, assets, and transfers. A five-year look-back period for asset transfers applies.

Spousal Impoverishment Protection Forms

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Documentation establishing the Community Spouse Resource Allowance (CSRA) and Monthly Maintenance Needs Allowance (MMNA) protecting the non-institutionalized spouse's assets and income.

LTC Partnership Policy Application

Insurer-specific · Private LTC insurance carriers (partnership states)

Application for a qualified state LTC partnership insurance policy. Allows the policyholder to protect assets equal to benefits received when applying for Medicaid. Available in most states.

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Disclaimer: BeneFill™ provides form-filling assistance and informational guidance only. It is not affiliated with, endorsed by, or sponsored by the State Medicaid agencies or any government agency. The information provided is for general informational purposes and does not constitute legal, medical, financial, or tax advice. Always verify form requirements and submission details directly with the issuing agency.