Medicaid Checklist

MEDICAID APPLICATION – CHECKLIST OF DOCUMENTS

1. Birth certificate
2. Social Security Card (front and back)
3. Health Insurance Provider Cards (front and back)
4. Deeds to property and current assessed value of property
5. Real Estate Tax Statement
6. Income Tax Returns (past two years, if filed)
7. Income – copies of check stub showing gross and net amount for pensions and income other than Social Security and copy of check or bank statements showing direct deposit verifying income from Social Security
8. Current Bank Statements – copies of bank statements showing balance on the day of admission to the nursing home as well as six months of statements prior to admission
9. Updated Passbooks and Checking Account Registers
10. Copies of any closed Passbooks, CDs, or other bank accounts (marked “closed”) during the last five (5) years
11. Life Insurance Policies – letter from insurance company stating owner of policy, beneficiaries, whether policy is term or whole life, face value and cash surrender value, if any
12. Trusts – copy of and listing of all assets (including transfers to or from a trust within past 5 years)
13. Burial Account Information – copy of Bank Passbook showing account set-up specifically as a burial account
14. Prepaid Funeral Information – copy of prepaid funeral contract from funeral home
15. Stocks/Bonds/Other – copies of stock certificates, savings bonds, brokerage house statements, etc.
16. Annuities – letter from insurance company stating owner, beneficiary, when established, amount of annuity, pay-out schedule and amount
17. Transfers of any assets within the past five (5) years – verification and date of transfer
18. Asset Assessment, if applicable
19. Expenses – including mortgage, rent, taxes, homeowner’s and health insurance premiums, utilities, etc.
20. Copy of Automobile Excise Tax Bill
21. Copies of current estate planning documents – Will, Health Care Proxy, Power of Attorney

PLEASE NOTE – MASSHEALTH IS ALLOWED TO REQUEST VERIFICATIONS OF ALL ASSETS FOR A PERIOD OF FIVE (5) YEAR PRECEDING THE APPLICATION FOR BENEFITS