Minnesota Health Care Programs Asset Assessment for Medical Assistance for Long Term Care Services (MA-LTC)

In order for a married couple to be legally entitled to receive some special healthcare services in the State of Minnesota, the following form has to be completed and submitted by the married couple who wish to receive those services in the future.

Extracted Text for Proper Search

DHS-3340-ENG    6-16	
Minnesota Health Care Programs 	 	
Asset Assessment for Medical Assistance for 	 	
Long-Term-Care Services (MA-LTC)	
Who is this form for?
This form is for married people who received or expect to receive 30 uninterrupted days of long-term-
care (LTC) services.
What is this form for?
This form will help you and your spouse decide which assets your spouse can keep and how many 
assets you will need to spend, if any, before you are eligible for Medical Assistance for LTC services 
(MA-LTC).
You can ask to complete an asset assessment (this form) for planning pu\
rposes anytime you expect 
to receive 30 uninterrupted days of LTC services. LTC services include stays in an LTC facility (LTCF) 
or services through the Alternative Care (AC) program or one of the Home and Community-Based 
Services (HCBS) waiver programs:	
 ƒ	Brain Injury (BI)
 ƒ	Community Alternative Care (CAC)
 ƒ	Community Access for Disability Inclusion (CADI)
 ƒ	Developmental Disabilities (DD)
 ƒ	Elderly Waiver (EW)	
What do I need to do with this form?
1. 	Read the “Important Information” page (page B) at the end of this form. Tear off this page and 
keep it. 	
2. 	Answer all the questions on the form. If you need more space, write the number of the question and 
the answer on a separate piece of paper. Include it with the form.	
3. 	Attach proofs. Proofs we need are on page A at the end of the form. 	
4. 	Mail or take the form to your county agency. 	
Questions?
If you have questions or need help, call your county agency. You can ask to meet with a worker. If you 
are 60 years old or older, you can also call the Senior LinkAge Line® at 800-333-2433. Or, if you 
have a disability, you can call the Disability Linkage Line® at 866-333-2466.

651-431-2670 or 800-657-3739	
For accessible formats of this publication or assistance 
with additional equal access to human services, write to 
[email protected], call 800-657-3739, or use your 
preferred relay service.	
ADA1 (9-15)

*DHS-3340-ENG*DHS-3340-ENG 6-16	
1	
Minnesota Health Care Programs 	 	
Asset Assessment for Medical Assistance for 	 	
Long-Term-Care Services (MA-LTC)	
Office Use Only	
DATE RECEIVED	CASE NUMBER	WORKER NUMBER	
Fill in the information asked for below.
FIRST NAME	MI	LAST NAME	
DATE OF BIRTH	SEX	
MF	
SOCIAL SECURITY NUMBER	PHONE NUMBER	COUNTY	
STREET ADDRESS	CITY	STATE	ZIP CODE	
SPOUSE’S FIRST NAME	MI	LAST NAME	
DATE OF BIRTH	SEX	
MF	
SOCIAL SECURITY NUMBER	PHONE NUMBER	COUNTY	
SPOUSE’S STREET ADDRESS (if different)	CITY	STATE	ZIP CODE	
Answer the following questions about assets you and your spouse own. Include assets you or your spouse owns with 
another person.
1. How much cash do you or your spouse have on hand, in a safety 	
deposit box, at home and at the facility where you live?	$	
2. Do you or your spouse have savings or checking accounts, money market accounts or 	
certificates of deposit?    	No Yes – fill in below	
Owner Name(s)	Type of Account	Bank Name and Address	Account Number
See required proofs on Page A.	 	
If you need more space, write the question number and the answer on a separate piece of paper.

2	
3. Do you or your spouse have a postsecondary fund under section 529 of the Internal Revenue 	
Code on behalf of a child of either or both of you who is under the age of 25?	 	
    	No Yes – fill in below
Owner Name(s)	
Beneficiary’s Name 	 	
and Date of Birth	Company or Bank Name and Address	Account Number	
4. Do you or your spouse have stocks, bonds or retirement accounts?    	No Yes – fill in below	
Owner Name(s)	Type of Investment	Company or Bank Name and Address	Account Number	
5. Do you or your spouse own a tax-deferred retirement account?    	No Yes – fill in below	
Owner Name(s)	Type of Investment	Company or Bank Name and Address	Account Number	
6. Do you or your spouse own or co-own houses, condominiums, summer or winter homes, 	
cabins, mobile homes, time -shares, rental properties, any real estate, or life estate interests 
or remainder interests in real property?    	No Yes – fill in below	
Owner Name(s)	Type of Property	Property Address	
Do you or your spouse 
live here all year?	
Yes No
Yes  No	
7. Do you or your spouse own or co-own promissory notes, contracts for deed or other 	
property agreements?    	No Yes – fill in below	
Owner Name(s)	Type of Asset
See required proofs on Page A.	 	
If you need more space, write the question number and the answer on a separate piece of paper.

3	
8. Do you or your spouse have any vehicles in your name? 	Include cars, trucks, vans, motorcycles, motor 	
homes, campers, boats, snowmobiles, all-terrain vehicles, etc.	    	No Yes – fill in below	
Owner Name(s)	Type of Vehicle	Year, Make, Model	
9. Do you or your spouse have an interest in a trust or annuity?    	No Yes – fill in below	
Owner Name(s)	Type	
10. Do you or your spouse have life insurance?    	No Yes – fill in below	
Owner Name(s)	Policy Number	Insurance Company Name and Address	
11. Do you or your spouse have a prepaid burial account or burial trust?	 Include revocable and 	
irrevocable accounts, insurance -funded burials, annuity-funded burials, Cremation Society agreements, burial 
spaces, burial space items and other funds designated for burial.	    	No Yes – fill in below	
Owner Name(s)	Type of Burial Asset	Company or Bank Name and Address	
12. Do you or your spouse have assets currently used for self-employment or in a business in 	
which you or your spouse has an interest?    	No Yes – fill in below	
Owner Name(s)	Type of Asset
See required proofs on Page A.	 	
If you need more space, write the question number and the answer on a separate piece of paper.

4	
13. Do you or your spouse own or co-own any other assets you have not listed?	 	
    	No Yes – fill in below	
Owner Name(s)	Type of Asset	
14. Do you or your spouse live in a continuing care retirement community?    	No Ye s	
I have attached all necessary proofs.	
I declare that I have read and understand the information on this form. I believe all the information entered on this form is true 
and correct.
YOUR SIGNATURE	SPOUSE’S SIGNATURE	DATE	
SIGNATURE OF PERSON ACTING ON YOUR BEHALF	RELATIONSHIP	DATE	
PERSON’S ADDRESS	PERSON’S DAYTIME PHONE NUMBER
See required proofs on Page A.	 	
If you need more space, write the question number and the answer on a separate piece of paper.

A	
Page A	 	
Required Proofs	
Send proof of how much each asset listed on this form is worth. Proof can	 	
be any of the following:	
 „	Bank accounts 	 	
Bank statements or a written statement from the bank showing the balance or value of accounts.
 „	Stocks, bonds and retirement accounts 	 	
Copies of bonds, stock ownership statements, retirement account statements or other documents showing 
the value.
 „	Real estate	 	
Property tax statement. Include documents showing the loan balance owed against the property.
 „	Promissory notes, contracts for deed or other property agreements	 	
Copies of promissory notes, contract for deed or other property agreement documents. 
 „	Vehicles	 	
Documents showing the loan balance owed against the vehicle.
 „	Trusts and annuities	 	
Copies of trust documents, documents showing an accounting of the trust corpus for each trust, and 
annuity contracts.  
 „	Life insurance	 	
Life insurance statements showing the face and cash surrender value.
 „	Burial contracts	 	
Burial contract and statement of goods and services from the company or funeral home that holds 
the contract.
 „	Self-employment assets	 	
Documents showing the value of assets.  Include documents showing the loan balance owed against 
each asset.
 „	Continuing care retirement community entrance fee  	 	
Documents showing the available amount of the entrance fee.
 „	Other assets 	 	
Documents showing the value of assets. Include documents showing the loan balance owed against each asset.	
If you want a county worker to help you get the proofs, you can sign a release of information form. The form will 
allow others to release proofs to the worker.	
Send copies of proofs. Do not send original documents.
Keep this page.

B	
Page B 	 	
Important Information	
What is an asset assessment? 
An asset assessment determines the total value of assets 
you and your spouse own.
We use the information on the asset assessment form to 
help you decide the assets your spouse can keep. As of June 
1, 2016, your spouse is able to keep the maximum amount 
of assets for a community spouse that is allowed under 
federal law and is in effect at the time of your application 
for long-term-care services. We will not count the assets 
your spouse can keep toward your asset limit for Medical 
Assistance for long-term-care services (MA-LTC).
When should I complete an asset 
assessment?
You can ask to complete an asset assessment anytime you 
expect to receive 30 uninterrupted days of LTC services.
What assets should I list on the asset 
assessment?
List these:
 „	Assets in your name
 „	Assets in your spouse’s name
 „	Assets in both your and your spouse’s names 	
Also list assets that you or your spouse owns jointly with a 
person or people other than each other.
Does my home count as an asset when 
completing the asset assessment?
Usually, your home does not count as an asset for an asset 
assessment. Other assets that do not count include these:
 „	Personal property and household goods 
 „	One vehicle 
 „	Capital assets needed to operate a trade or business 
 „	Money set aside for a burial space and burial space 
items for you, your spouse and other members of 
your immediate family
 „	Retirement annuities funded by a pension fund 
or retirement plan unless you can get all or part of 
the funds
 „	Certain assets if you are an American Indian	
You must tell us about all assets you and your spouse 
own or co-own. A worker will determine whether an 
asset counts.	
What assets count? 
Counted assets include but are not limited to these:
 „	Cash 
 „	Bank accounts (savings, checking, money 
market, and credit union accounts; certificates of 
deposit; etc.)
 „	Stocks and bonds 
 „	Individual retirement accounts (IRAs) and other 
retirement accounts 
 „	College 529 savings plans
 „	Cash surrender value of life insurance policies if the 
face value of all policies is more than $1,500 
 „	Contracts for deed 
 „	Certain trust funds
 „	Life estate interests 
 „	Annuities in the accumulation phase 
 „	If you have more than one vehicle, the other 
vehicle(s). Vehicles include cars, vans, motor homes, 
motorcycles, trucks, campers, etc.
 „	Boats, trailers, machinery, snowmobiles, all-terrain 
vehicles, etc.
 „	Lake homes, cabins, summer and winter homes, 
time-shares, life estates, etc.	
You must tell us about all assets you and your spouse 
own or co-own. A worker will determine whether an 
asset counts.
What happens after I complete the asset 
assessment form?
Give the completed form to your county agency. A worker 
will look at the information on the form and determine 
the amount of assets you may need to spend before you 
can be eligible for MA-LTC.
Can the results of the asset assessment 
change?
Results can change if other assets are discovered or you 
get other assets that were not included in the assessment 
or if the value of an asset changes before you apply for 
MA-LTC.
Keep this page.