Monthly income of Medicaid applicant*

Monthly income of Medicaid applicant’s spouse*

Monthly private pay cost of the nursing home that the applicant is in or expected to go in one shortly?*

Please enter a number from 0 to 30000.

Monthly private pay cost of the nursing home that the spouse is in or expected to go in one shortly?*

Does applicant (and/or spouse, if married) own a home in Hawaii?*

Yes
No

What is the fair market value of the home?*

What is the outstanding mortgage, home-equity line of credit & any liens?*

Are there any other owners other than applicant (and spouse, if married)?*

No
Yes

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Home Fully Owned

Please enter a number from 1 to 100.

What percent does the Medicaid applicant (and/or spouse, if married) own?*

Please enter a number from 1 to 100.

Check all that apply

Applicant has a minor child (under age 21)
Applicant has a blind or disabled child
Applicant has a sibling (brother or sister) who has lived in the same home as applicant for at least 1 year before applicant went (or will go) to nursing home
Applicant has an adult child who has lived in the same home as applicant for at least 2 years before applicant went (or will go) to nursing home

Does applicant (and/or spouse, if married) own any other real estate anywhere?

Yes
No

What is the total market value of all properties (other than primary residence)*

What is the outstanding mortgage balances of all properties (other than primary residence)*

What is the total net worth of all of your other assets? (Include assets of spouse if married)

Include checking account, savings, CDs, stock bonds, mutual funds, IRAs, 401ks, cash value of life insurance & annuity, but excluding vehicles.

Any debts other than mortgage, home-equity line of credit or lien on primary residence or any other other real estate.

Total estimated value of all gifts & donations made by you (and/or spouse, if married) over the last 5 years.

Rough estimate ok. Ignore small birthday or Christmas gifts you normally give.

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Assets Value

Applicant & spouses assets - debts (excluding primary home debts)

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Applicant in Nursing Home

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Spouse in Nursing Home

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Total in Nursing Home

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House Value - Someone Living In It

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Spouse In NH Months Divisor

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Number of Months

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Negative Number of Months

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Positive Number of Months

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60+ Number of Months

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Adj Num of Months

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Amount Returned For Care

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Medicaid Savings Calculator

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