Medicaid Eligibility Welcome Worksheet

Who is applying for Medicaid? (check one)

Applicant

Spouse (if married — complete even if the spouse is not applying)

Person completing this form (if not the Applicant)

Legal documents currently in place (tell us what’s in place and who is named)

Medicaid pays for long-term care only when the applicant medically needs a nursing-facility level of care. Please describe the health of BOTH spouses — the applicant’s health determines medical eligibility, and the healthy spouse’s situation affects our planning.

Help needed with daily activities (check every activity the person needs help with)

Long-term care insurance

List the GROSS monthly amount (before Medicare premiums, taxes, or other deductions) that each spouse receives from every source. If an amount is received less often than monthly, note how often. Please bring award letters, pension statements, and recent tax returns if available.

List every asset owned by either spouse — individually, jointly with each other, or jointly with anyone else — including assets located in other states or countries. Do not leave anything out because you believe it “doesn’t count”; we will determine what is exempt.

5.1 Bank & credit union accounts (checking, savings, CDs, money market)

5.2 Brokerage & investment accounts (stocks, bonds, mutual funds, ETFs)

5.3 Cryptocurrency & digital assets

5.4 Retirement accounts (IRA, Roth IRA, 401(k), 403(b), TSP, deferred annuities)

5.5 Life insurance (list ALL policies — term and whole life — including group and burial policies)

5.6 Real estate (home, rentals, land, timeshares, mineral rights — anywhere)

5.7 Vehicles (cars, trucks, motorcycles)

5.8 Boats, ATVs, snowmobiles, RVs & trailers

5.9 Business & farm interests (LLCs, corporations, partnerships, sole proprietorships)

5.10 Other assets

Examples: prepaid funeral or burial plans, burial plots, promissory notes or money owed TO you, pending inheritances or lawsuit settlements, safe-deposit box contents, precious metals, collections or valuables, livestock or equipment.

5.11 Trusts

Medicaid reviews every transfer made by either spouse during the 60 months before applying. Transfers for less than fair market value — including ordinary gifts to family, charity, or church — can delay eligibility. Answering “Yes” does NOT mean you are disqualified; it simply tells us what we need to plan around. Please answer for BOTH spouses.

In the last 5 years, have you or your spouse…

Details of each transfer (use one line per transfer; attach extra sheets if needed)

Children in the household

Is there anything else you would like us to know about your family, health, finances, or goals?

Certification: I certify that the information provided in this worksheet is true, correct, and complete to the best of my knowledge. I understand that Metropolitan Law Group LLC will rely on this information in evaluating Medicaid eligibility and that incomplete or inaccurate information — especially regarding assets and transfers — may affect the advice provided and the outcome of any Medicaid application.

This worksheet is confidential and protected by the attorney–client privilege once representation begins. Completing this worksheet does not by itself create an attorney–client relationship. This form collects general information only; eligibility rules, limits, and exemptions vary by state.