Checklist · Healthcare

Applying for Medicaid Long-Term Care Coverage: A Practical Checklist

42 U.S.C. § 1396

Type: Checklist
Jurisdiction: National
Date: 2026-07-26
Topic: Healthcare

This checklist takes a Medicaid long-term care case from the first family conversation through estate recovery after death. Phase 1 establishes the four state variables that determine every later answer, and Phase 2 covers the documents that must already exist, principally a power of attorney with express Medicaid planning authority. Phase 3 is the asset and transfer inventory, including the five-year records that take months to gather, and Phase 4 covers the married couple's snapshot and resource allowance. Phases 5 and 6 cover the spend-down plan and the application itself. Phase 7 covers denials, fair hearings, and the ten-day continuation window that families most often miss. Phases 8 and 9 cover the facility, its admission agreement, and estate recovery after death. Four model letters, a deadline table, and a ranked failure-mode list close the checklist.

Applying for Medicaid Long-Term Care Coverage: A Practical Checklist

Healthcare > Medicaid and Long-Term Care | Published 26 July 2026 - Updated 14 August 2026 | UpLaw - uplaw.us

Phase 2 is a signature and Phase 3 is a question asked without judgment. Together they decide more Medicaid cases than everything in Phases 4 through 9 combined.

Keywords: state variables, documents, transfers, snapshot, spend-down, application, hearings, recovery

How to use this checklist

Nine phases with - [ ] items and a Why it matters, and the traps note under each.

Doctrine is in Medicaid and Long-Term Care: A Comprehensive Guide to Eligibility, Transfers, Estate Recovery, and Appeals. The narrative is Six Thousand Dollars a Month: How Families Actually Pay for Long-Term Care. The forms are in The Medicaid and Long-Term Care Planning Toolkit.

Phase 1 — The four state variables

[ ] Income-cap state or medically needy state? If income-cap, a qualified income trust will be required.
[ ] How does this state treat retirement accounts — balance countable, or exempt in payout status?
[ ] Narrow or expanded estate recovery — probate estate only, or any interest held at death?
[ ] What is the home equity limit in this state?
[ ] What home and community based services waivers exist under 42 U.S.C. § 1396n, and what are the waiting lists?
[ ] Look up this year's community spouse resource allowance minimum and maximum.
[ ] Look up this year's minimum monthly maintenance needs allowance.
[ ] Look up the state's average monthly private-pay nursing facility cost — the divisor in the penalty formula.
[ ] Record all eight on the first page of the file.
[ ] Confirm the individual resource limit and the personal needs allowance.

Why it matters, and the traps. Never answer a Medicaid question from memory of another state. The federal structure at 42 U.S.C. § 1396a is uniform; every number is local and most adjust annually.

The estate recovery definition is the variable most often assumed. In an expanded-recovery state, a revocable trust protects nothing — and a family that paid for one believing otherwise will find out at the worst time.

Phase 2 — The documents that must exist

[ ] Durable power of attorney for finances, with express authority to make gifts, create and fund trusts, and transfer assets between spouses.
[ ] Health care power of attorney and advance directive.
[ ] HIPAA authorization.
[ ] Will, and — subject to Phase 1's recovery analysis — any trust.
[ ] Review beneficiary designations, which override the will.
[ ] Written personal care agreement if any family member is providing care.
[ ] Confirm the principal has capacity to sign, today.
[ ] If capacity is already lost and the power of attorney is insufficient, evaluate guardianship or conservatorship.
[ ] Locate any long-term care insurance policy — triggers, elimination period, daily benefit.
[ ] Assemble deeds, titles, and account ownership records.

Why it matters, and the traps. A general power of attorney without express gifting and Medicaid planning authority cannot do the planning this checklist describes. It is the single most consequential document in the field, and by the time its absence is discovered the principal usually cannot sign a better one.

The alternative is a court proceeding — public, slow, expensive, and supervised thereafter. See Petitioning for Guardianship or Conservatorship: A Practical Checklist.

Phase 3 — Assets and transfers

[ ] List every asset, its value, and how it is titled.
[ ] Classify each as countable or exempt.
[ ] Confirm the home's status — occupancy, intent to return, equity against the limit.
[ ] Value life insurance at face and cash value.
[ ] Determine the state's treatment of each retirement account.
[ ] Ask, neutrally: has anyone been given anything of value in the last five years?
[ ] Include: cash gifts · tuition payments · help with a down payment · adding a name to a deed or account · forgiven loans · below-market sales · and payments to a family caregiver without a written agreement.
[ ] For each transfer, record the date, the amount, the recipient, and the purpose.
[ ] Identify any permitted transfer exception under 42 U.S.C. § 1396p.
[ ] Begin gathering five years of statements for every account now — closed accounts take months.
[ ] Compute the likely penalty period: uncompensated value ÷ the state's average monthly cost.

Why it matters, and the traps. The transfer question is the one that determines whether there is a problem, and it must be asked without judgment or families do not answer it accurately.

The penalty begins when the applicant is otherwise eligible and receiving care — not when the transfer was made. A gift from three years ago produces a period of ineligibility starting now, with the money already spent by someone else.

The most common undisclosed transfer is not a gift at all in the family's mind: payments to a daughter who quit her job to provide care. Without a written agreement executed in advance, every payment is a gift.

Phase 4 — If married

[ ] Request a resource assessment and establish the snapshot date — the first continuous institutionalization of thirty days or more.
[ ] Note the snapshot date is frequently within some control; discuss timing before it happens.
[ ] Total the couple's countable resources as of that date.
[ ] Compute the community spouse resource allowance under 42 U.S.C. § 1396r-5.
[ ] Transfer that share to the community spouse — an expressly permitted transfer.
[ ] Compute the community spouse's minimum monthly maintenance needs allowance, including the excess shelter allowance.
[ ] Determine whether income must be diverted from the institutionalized spouse.
[ ] If the standard resource allowance will not generate enough income, request a fair hearing to increase it.
[ ] Confirm the community spouse's own income is not counted toward the applicant's eligibility.
[ ] Update the community spouse's own estate plan and beneficiary designations.

Why it matters, and the traps. This is the most protective provision in the field and it requires nothing to have been done in advance. A well spouse does not spend down to nothing.

The fair hearing to increase the resource allowance is available, is granted, and is almost never requested. It exists precisely for the case where the standard allowance produces too little income.

And update the community spouse's own plan. A well spouse who dies first, leaving everything outright to the institutionalized spouse, undoes the entire arrangement.

Phase 5 — The spend-down plan

[ ] Compute the target: countable resources that must be eliminated.
[ ] Retire debt — mortgage, credit cards, auto loans, medical bills.
[ ] Home repairs and improvements — roof, HVAC, plumbing, electrical.
[ ] Accessibility modifications — ramps, grab bars, walk-in shower, stair lift, widened doorways.
[ ] Replace the vehicle, where one vehicle is exempt.
[ ] Irrevocable prepaid funeral and burial contracts — for the applicant and, in many states, for family members.
[ ] Purchase needed household goods and personal effects.
[ ] Pay for care already received and professional fees.
[ ] Execute a personal care agreement before any further payments to a family caregiver.
[ ] In an income-cap state, establish the qualified income trust, irrevocable, with the state as remainder beneficiary.
[ ] Time the expenditures so resources are below the limit on the first moment of the target month.
[ ] Keep receipts for everything.

Why it matters, and the traps. Spending money on things is not a transfer. There is no penalty for receiving fair value, which makes spend-down a planning exercise rather than a loss.

The timing trap is real. A resource above the limit on the first day of a month generally disqualifies for that whole month.

And the personal care agreement must precede the payments. A retroactive agreement will not be respected — the payments already made remain gifts.

Phase 6 — The application

[ ] Gather: identity, citizenship or immigration status, residency.
[ ] Gather five years of statements for every account, including closed ones.
[ ] Gather property records, deeds, and mortgage statements.
[ ] Gather life insurance policies with face and cash values.
[ ] Gather vehicle titles, income verification, and health and long-term care insurance policies.
[ ] Gather burial contracts and trust documents.
[ ] Document every transfer in the look-back period, with the exception claimed where one applies.
[ ] Apply for a level-of-care determination.
[ ] Consider whether a waiver slot under 42 U.S.C. § 1396n is preferable to institutional care — and get on the waiting list regardless.
[ ] Check the retroactive coverage window and do not apply so late that it is forfeited.
[ ] Track the determination deadline; failure to act with reasonable promptness is appealable under 42 C.F.R. Part 435.
[ ] Respond to every request for information by its deadline, in writing, keeping copies.

Why it matters, and the traps. Disclose every transfer. Non-disclosure is far worse than the transfer itself, and the records will be requested.

Five years of statements from a closed account takes months. Start before applying, not after a request arrives with a deadline.

Phase 7 — Denials, hearings, and appeals

[ ] Read the notice for the specific ground and the appeal deadline.
[ ] If the notice terminates or reduces existing benefits, appeal within the short window — commonly ten days — so benefits continue pending the hearing.
[ ] Request the complete case file in advance.
[ ] For a transfer penalty: raise the applicable exception · the transfer's purpose · any return of assets · and, in the alternative, undue hardship.
[ ] For a resource determination: raise exemption · valuation · availability · and, if married, an increase in the resource allowance.
[ ] For a level-of-care denial: obtain a physician's statement addressing the specific criteria.
[ ] Bring documents, not assertions.
[ ] Preserve every objection with its ground — the hearing record is the record on review.
[ ] Note the procedural framework at 42 C.F.R. Part 431 and the constitutional backdrop of Goldberg v. Kelly, 397 U.S. 254 (1970) and Mathews v. Eldridge, 424 U.S. 319 (1976).
[ ] Calendar the deadline for judicial review of an adverse decision.

Why it matters, and the traps. The ten-day continuation window is the shortest deadline in the process and the one families most often miss, because a termination notice does not look like a deadline.

Everything must be in the hearing record. A document produced for the first time on judicial review is a document nobody will consider.

Phase 8 — The facility

[ ] Read the admission agreement completely.
[ ] Strike any provision making a family member personally liable or guaranteeing payment — a facility may not require a third-party guarantee as a condition of admission.
[ ] Confirm the facility participates in Medicaid and will retain the resident on conversion from private pay.
[ ] Confirm the resident's rights under 42 U.S.C. § 1396r and 42 C.F.R. Part 483.
[ ] Participate in care planning, as the resident and as the designated representative.
[ ] Watch for unnecessary physical or chemical restraints.
[ ] For any proposed transfer or discharge, demand written notice, the stated ground, and the appeal — and appeal.
[ ] Note that these rights are enforceable under 42 U.S.C. § 1983 after Health and Hospital Corporation of Marion County v. Talevski, 599 U.S. 166 (2023).
[ ] Contact the long-term care ombudsman — free, independent, and effective.
[ ] Where community placement is appropriate, invoke Olmstead v. L.C., 527 U.S. 581 (1999) and 42 U.S.C. § 12132.

Why it matters, and the traps. Third-party guarantee provisions are routinely presented and routinely signed, and they create personal liability nobody intended.

Involuntary discharge on conversion to Medicaid is unlawful in a participating facility, and it happens anyway — which is exactly the situation Talevski addresses.

Phase 9 — Estate recovery

[ ] Confirm from Phase 1 whether the state's definition of "estate" is narrow or expanded.
[ ] Identify anyone whose survival prohibits recovery: a spouse · a child under twenty-one · a child who is blind or has a disability.
[ ] Identify anyone whose residence defers it: a sibling with an equity interest · a caretaker child.
[ ] On receiving a recovery notice, calendar the response deadline immediately.
[ ] Request a hardship waiver where the estate is the sole income-producing asset of survivors, the property is of modest value, or recovery would force a survivor onto public assistance.
[ ] Verify the amount claimed against the benefits actually paid.
[ ] Verify the claim covers only services provided at fifty-five or older, where that limit applies.
[ ] Check for any lien recorded during life and its validity.
[ ] Where a tort settlement is involved, confirm the allocation under Ahlborn and Gallardo.
[ ] Coordinate with the probate administration.

Why it matters, and the traps. The home is exempt during life and exposed after death. Tell the family at the outset, not at the end.

The hardship waiver must be requested. It exists in every state, it is granted, and nobody volunteers it.

Model letters

A. Resource assessment request

"Re: [institutionalized spouse] and [community spouse]. I request a resource assessment under 42 U.S.C. § 1396r-5 as of [date], the beginning of the first continuous period of institutionalization of at least thirty days. Enclosed is documentation of all countable resources held by both spouses on that date. Please confirm the total countable resources, the community spouse resource allowance, and the amount the institutionalized spouse must spend down."

B. Undue hardship waiver request

"Re: [applicant]. A transfer penalty of [] months has been imposed based on transfers totaling $[]. I request an undue hardship waiver. The transferred assets are unrecoverable: [explain]. The applicant has no remaining resources, as the enclosed documentation shows. [Facility] has advised that it cannot continue to provide care without payment, as its enclosed letter states. Denial of eligibility would deprive the applicant of medical care necessary to health and life, and of shelter. Enclosed: the facility's letter, a physician's statement, financial documentation, and evidence of efforts to recover the transferred assets."

C. Request to increase the community spouse resource allowance

"Re: [community spouse]. I request a fair hearing to increase the community spouse resource allowance under 42 U.S.C. § 1396r-5. The community spouse's own monthly income is $[]. The minimum monthly maintenance needs allowance, including the excess shelter allowance, is $[], leaving a shortfall of $[]. **The standard resource allowance of $[], invested at prevailing rates, will not generate income sufficient to eliminate that shortfall.** An allowance of $[___] is required. Enclosed: income documentation, shelter cost documentation, and a computation."

D. Fair hearing request

"Re: [applicant], case [], notice dated []. I request a fair hearing under 42 C.F.R. Part 431. This request is made within the period during which benefits continue pending the hearing, and I request that benefits continue. The issues are: [the transfer penalty determination and the applicable exception / the classification of [asset] as countable / the level-of-care determination / the failure to act with reasonable promptness]. I request the complete case file in advance of the hearing, including all documents the agency intends to rely upon, and I request that the hearing be recorded."

The deadline table

Item	Timing	Consequence of missing it
Personal care agreement	Before any payment	Every payment becomes a gift
Power of attorney with planning authority	While capacity exists	Guardianship proceeding
Waiver waiting list	As early as possible	Institutional care by default
Resource assessment / snapshot	First 30-day institutionalization	Fixes the community spouse allowance
Look-back	60 months before application	Every transfer inside it examined
Retroactive coverage	Limited period before application	Months of care unpaid
Appeal of a denial	State deadline from the notice	No review
Appeal of a termination or reduction	~10 days for benefits to continue	Benefits stop during the appeal
Response to a request for information	As stated	Denial for failure to verify
Estate recovery response	As stated in the notice	Hardship waiver forfeited

The first row prevents the most common avoidable disaster in this field. The eighth row is the shortest deadline in the process.

Who does what

The family, before a crisis. Phase 2's documents and Phase 3's honest inventory. Neither requires a lawyer to begin, and both determine what a lawyer can accomplish later.

An elder law attorney. Phases 3 through 6. The transfer analysis and the spend-down plan are specialist work, and the annuity, promissory note, and trust instruments described in Medicaid and Long-Term Care: A Comprehensive Guide to Eligibility, Transfers, Estate Recovery, and Appeals fail entirely if a statutory condition is missed.

A geriatric care manager. The level-of-care question, the facility selection, and the waiver application — frequently the most useful non-legal professional in the case.

An estate planner. Phase 2 and Phase 9 together, because the estate recovery definition determines whether the plan works — see Wills, Trusts, and Probate: A Comprehensive Estate Planning Guide and The Estate Planning and Wealth Transfer Toolkit.

The long-term care ombudsman. Phase 8. Free, independent, and effective, and almost nobody calls.

A personal injury lawyer, where relevant. The allocation problem under Ahlborn and Gallardo is solved in the settlement, not afterward — see Documenting and Presenting a Car Accident Claim: A Practical Checklist.

And where the coverage question is Medicare rather than Medicaid — a skilled nursing termination, for instance — see Appealing a Health Insurance or Medicare Denial: A Practical Checklist and The Health Coverage Appeal Toolkit. Those notices have their own very short clocks.

Failure modes, ranked

Gifts made without advice, generating a penalty that begins when the family is broke and in a facility.
Paying a family caregiver without a written agreement executed in advance.
A power of attorney lacking express gifting and Medicaid planning authority.
Missing the ten-day window to appeal a termination and keep benefits running.
Never requesting an increase in the community spouse resource allowance.
Assuming a revocable trust defeats estate recovery in an expanded-recovery state.
Never applying for a waiver slot, or applying only when the need is urgent.
Failing to disclose a transfer.
Signing an admission agreement with a third-party payment guarantee.
Applying before assembling five years of records, and losing the case on a verification deadline.
Missing retroactive coverage by applying too late.
Not requesting the estate recovery hardship waiver.
Settling an injury case without allocating medical and non-medical damages.
Accepting an involuntary discharge on conversion to Medicaid, which is generally unlawful in a participating facility.

Items 1, 2, and 3 are the expensive ones, and all three are prevented by a conversation held before anything happens.

Applying for Medicaid Long-Term Care Coverage: A Practical Checklist

How to use this checklist

Phase 1 — The four state variables

Phase 2 — The documents that must exist

Phase 3 — Assets and transfers

Phase 4 — If married

Phase 5 — The spend-down plan

Phase 6 — The application

Phase 7 — Denials, hearings, and appeals

Phase 8 — The facility

Phase 9 — Estate recovery

Model letters

A. Resource assessment request

B. Undue hardship waiver request

C. Request to increase the community spouse resource allowance

D. Fair hearing request

The deadline table

Who does what

Failure modes, ranked

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