Tip for State-specific

The 5-year look-back period means ANY asset transfers (gifts, property transfers, trust funding) in the past 60 months will be scrutinized

Tip for State-specific

Penalty periods for improper transfers are calculated based on the value transferred divided by the average monthly cost of nursing facility care in your state

Tip for State-specific

Consult an elder law attorney BEFORE transferring any assets — improper planning can result in devastating penalty periods

Long-Term Carevery hard

Long-Term Care Medicaid Application

State-specific · State Medicaid agencies

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.

Form Details

Total fields: 150
Auto-fillable: 60 (40%)
Time without BeneFill: 180 minutes
Time with BeneFill: 40 minutes
Time saved: 140 minutes
Filled by: patient
Frequency: one time
State-specific: Yes — form may vary by state

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Where to Submit This Form

🏢

Apply at your local Department of Social Services or Medicaid office

📬

Mail to your state's Medicaid agency

🌐

Apply online through your state's Medicaid portal (if available for LTC)

Not all states accept online LTC Medicaid applications. Check your state's Medicaid website.

Filing Deadline

Apply as early as possible — Medicaid eligibility can be backdated up to 3 months before the application date. The look-back period for asset transfers is 5 years (60 months).

Required Attachments

📎 Completed Medicaid application (state-specific form)
📎 Proof of identity and citizenship/immigration status
📎 Proof of income (Social Security, pension, investment income)
📎 Documentation of ALL assets (bank statements, investments, real estate, life insurance, vehicles) for 5 years
📎 Proof of medical expenses and health insurance
📎 Level of care assessment (or it will be scheduled)
📎 Trust documents (if applicable)
📎 Proof of any asset transfers in the past 5 years

Processing Time

45-90 days for initial determination. Complex cases with asset transfer issues can take longer. Emergency Medicaid may be available while the application is pending.

What Happens Next

The state Medicaid agency will verify all financial information, apply the 5-year look-back for asset transfers, and determine eligibility. If approved, Medicaid coverage begins retroactively (up to 3 months before the application). If denied, you have the right to a fair hearing.

Tips for This Form

✓ The 5-year look-back period means ANY asset transfers (gifts, property transfers, trust funding) in the past 60 months will be scrutinized
✓ Penalty periods for improper transfers are calculated based on the value transferred divided by the average monthly cost of nursing facility care in your state
✓ Consult an elder law attorney BEFORE transferring any assets — improper planning can result in devastating penalty periods
✓ The community spouse (if applicable) has protections under spousal impoverishment rules — do not assume all assets must be spent down

More Long-Term Care Forms

MDS 3.0 (Minimum Data Set)

MDS 3.0 · CMS

Standardized health status screening and assessment tool required for all residents of Medicare/Medicaid-certified nursing facilities. Used for care planning and Medicare payment calculation. Must be completed within 14 days of admission and periodically thereafter.

PASRR Level 1 Screening

State-specific · CMS / State Medicaid agencies

Federally mandated preadmission screening for all individuals entering Medicaid-certified nursing facilities to identify those with mental illness, intellectual disability, or related conditions who may need specialized services.

PASRR Level 2 Evaluation

State-specific · State mental health / developmental disability agencies

Comprehensive evaluation for individuals identified in Level 1 screening. Determines if nursing facility placement is appropriate and what specialized services are needed.

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.

Spousal Impoverishment Protection Forms

State-specific · State Medicaid agencies

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.