1. Who is filling out this form?
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2. Who is applying for Medicaid?
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3. What is the applicant's marital status?
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Income and assets are counted differently for couples vs. single applicants.
4. Where does the person applying for Medicaid currently reside?
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5. What is the age of the person applying for Medicaid?
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Medicaid has different eligibility rules depending on the age of the applicant.
6. What is the primary reason for applying for Medicaid?
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Different eligibility criteria apply for nursing home vs. home care.
7. Is the person applying a veteran OR the widow / widower of a veteran? If so, did they serve during wartime?
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Applicants may also be eligible for VA benefits which could exceed the benefits of Medicaid.
8. What is the total monthly income of the individual applying (or couple, if both spouses are applying) applying for Medicaid?
Income is a major eligibility factor for Medicaid.
9. Does the applicant have life insurance with a cash value?
The CSV or Cash Surrender Value is the amount of cash a policyholder would receive if they were to cancel their policy. This is different from the Face Value / Death Benefit.
10. Does the person applying for Medicaid own a home and if so, what is the value of their home minus any outstanding mortgage?
Home ownership is permitted, but allowable home equity value changes by state.
11. What is the estimated total value of the applicants assets (excluding their home)?
Assets are a major eligibility factor for Medicaid.
12. What is the applicant's current estimated monthly, out-of-pocket care costs (if receiving care now)?
In some instances, out-of-pocket care costs can be deducted from income.
14. In what county does the applicant live?
15. Is the applicant considering applying for Medicaid in a different state?
16. What benefits and / or coverage does the person applying for Medicaid currently have? Check all that apply.
In some instances, applying for or receiving Medicaid can jeopardize current benefits.
17. How soon do you anticipate the need for Medicaid?
The application and approval process can be time-consuming but can also be expedited.
Is there anything else you'd like us to know about your situation?
Your Name
The name of the person filling out this form (not necessarily the Medicaid applicant)
First Name
Last Name
Your email address
Your phone number
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Best time to contact you?
Best way to contact you?
