In last month’s column, I focused on the history of Medicaid and discussed some of the difficulties that arise when dealing with Medicaid’s many laws, rules and policies. I also told you about some of the problems that people have encountered when applying for Medicaid on their own or without proper guidance.

In this column, I’ll go over the steps you will have to take when applying for Long-Term Care Medicaid on your own.


In order to qualify for LTC Medicaid, you must meet the following criteria:

  • Be a United States citizen or a “qualified alien” (permanent resident for five years).
  • Be a resident of the state of Hawai‘i.
  • Have a Social Security number.
  • Be age 65 or older, or blind or disabled.
  • Require nursing facility level of care.
  • Meet asset requirements.

Once you are certain that you meet all of the aforementioned criteria, you can submit your Medicaid application. There are a number of required and optional forms to fill out when applying for LTC Medicaid, starting with the Hawai‘i Department of Human Services’ Form 1100. This is the basic Medicaid assistance application form. When applying for long-term care, you will also have to submit all of the following forms:

  • DHS 1100B: Supplemental form for long-term care services.
  • DHS 1167: Statement of intent for applicants in long- term care facilities.
  • DHS 1169: Evaluation for placement of liens.
  • DHS 8003: Reporting requirements for individuals with annuities.
  • Statement regarding assets in trust.

If someone is helping you fill out and submit your application (or if you are helping someone with their application process), you must also submit:

  • A copy of any power of attorney or guardianship appointment.
  • DHS 1121: Form to designate authorized representative.
  • DHS 1123: Authorization to disclose confidential information by the Med-Quest Division.

You must submit your application in your home county. There are two Medicaid offices on O‘ahu, two on Hawai‘i Island, and one each on Kaua‘i, Maui, Moloka‘i and Lana‘i.


You are required to provide proof or verification of the information on your application, so, in addition to the Department of Human Services forms, you must also submit the following documents: proof of citizenship; proof of identity; all medical insurance and Medicare cards with policy numbers and start dates; all bank statements (a minimum of three months, although five years’ worth is sometimes required); proof of income; Social Security award letters; pension or veteran’s award letters; cash value of life insurance policies; purchase price and current cash value of all burial plans and burial plots; trust documents (including any amendments); power of attorney (if any) and marriage certificate (if married).

A Medicaid eligibility worker will interview you as well, asking additional questions and verifying the information you provided. The interview may be conducted in person at the Medicaid office or by phone, or you can have someone represent you in the interview. Sometimes, DHS will request that you provide more information or documentation. If you do not provide it within the allotted time, your application will be denied and you will have to submit a new application and begin the process all over again.

If you did not transfer or sell assets for less than their fair market value in the past five years, your application should be approved. If you did transfer assets, you should obtain a denial letter indicating the period of time that you will not be eligible based on the value of the transferred assets. That penalty period should start on the day you submit a complete application.

Appeals Process

If your application is denied and you believe that the decision was in err, you may request an informal appeal to the supervisor. Sometimes mistakes are made and applications are denied when they should have been approved under the law. Oftentimes, a meeting with the supervisor will result in the misunderstanding being cleared up and the application being approved. However, if your application is denied even after you have met with the supervisor, you may request an administrative hearing by filling out DHS Form 1161. If the hearing officer rules against you at the administrative hearing, you can appeal your case to the Circuit Court.


Once you have been approved and Medicaid has started paying for your nursing home care costs, you will have to submit the following forms annually:

  • DHS 1169A: Maintenance of lien status, and
  • DHS 8004: Annual home equity survey for long term care applicants.

Additionally, if there is a change in your household or financial circumstances, you must report it to the Medicaid office within 10 days using DHS 1179A — Change of Circumstance Report Form.

Yes, there are quite a few forms to fill out and lots of verification documentation to submit, but with careful preparation and/or good legal guidance, you can eventually be qualified for Medicaid to pay for your long-term care.