MEDICAID 

LONG-TERM CARE

Information Obtained 

by States about 

Applicants’ Assets 

Varies and May Be 

Insufficient

Report to Congressional Requesters

July 2012

GAO-12-749

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United States Government Accountability Office

GAO
United States Government Accountability Office

Highlights of GAO-12-749, a report to 

congressional requesters

July 2012

MEDICAID LONG-TERM CARE

Information Obtained by States about Applicants’

Assets Varies and May Be Insufficient

Why GAO Did This Study

Medicaid—a joint federal-state health 

care financing program for certain lowincome individuals—paid for nearly half 

of the nation’s $263 billion long-term 

care expenditures in 2010. To be 

financially eligible for Medicaid 

coverage for long-term care, applicants 

cannot have assets—income and 

resources—above certain limits. 

Federal law discourages individuals 

from artificially impoverishing 

themselves in order to establish 

financial eligibility for Medicaid. 

Specifically, those who transfer assets 

for less than fair market value during a 

specified time period—or “look-back” 

period—before applying for Medicaid 

may be ineligible for coverage for longterm care for a period of time. The 

DRA extended the look-back period to 

60 months and introduced new 

requirements for the treatment of 

certain types of assets, such as 

annuities, in determining eligibility. 

States are responsible for assessing 

applicants’ eligibility for Medicaid, the 

criteria for which varies by state. 

GAO was asked to provide information 

on states’ requirements and practices 

for assessing the financial eligibility of 

applicants for Medicaid long-term care 

coverage. GAO examined the extent to 

which states (1) require documentation 

of assets from applicants, (2) obtain 

information from third parties to verify 

applicants’ assets, and (3) obtain 

information about applicants’ assets 

that could be used to implement 

eligibility-related DRA provisions. From 

October 2011 to November 2011, GAO 

surveyed Medicaid officials from each 

of the 50 states and the District of 

Columbia. GAO also interviewed 

officials from CMS, the agency within 

HHS that oversees Medicaid.

What GAO Found

States reported requiring applicants to provide documentation for most of the 

13 types of assets included in GAO’s survey. 

Number of States That Reported Requiring Documentation, by Type of Asset

Asset type Description Number of states 

Income Earned income 50

Unearned income 49

Resources Annuity, burial contract and prepaid funeral, financial and 

investment, life estate, and trust 51

Life insurance, promissory note or loan, and real property other 

than primary residence 50

Continuing care retirement community entrance fee 46

Vehicle 38

Primary residence 37

Source: GAO web-based survey administered to state Medicaid officials.

States varied in the extent to which they obtained information from third parties to 

verify applicants’ assets. For example, all states conducted data matches with 

the Social Security Administration but used other sources to a lesser extent. 

While states’ implementation of an electronic asset verification system (AVS) was 

required on a rolling basis beginning in 2009, no state had fully implemented an 

AVS at the time of GAO’s survey. Among the implementation challenges 

reported by states were lack of resources and getting financial institutions to 

participate. Officials from the Centers for Medicare & Medicaid Services (CMS) 

were aware of states’ progress and challenges and told GAO that they regularly 

communicated with states on AVS implementation. 

On the basis of states’ responses to questions about the extent of documentation 

required from applicants and information obtained from third parties, it is unclear 

whether some states obtain sufficient information to implement certain provisions 

of the Deficit Reduction Act of 2005 (DRA). For example, 31 states reported 

requiring less than 60 months of documentation from applicants and financial 

institutions. The results of GAO’s survey raise questions about states’ 

implementation of the DRA, but are not conclusive. CMS officials said that it is 

reasonable for states to only conduct reviews when there is reason to believe a 

transfer of assets occurred. GAO has additional work planned related to 

Medicaid long-term care financial eligibility. 

States must balance the costs of eligibility determination efforts with the need to 

ensure that those efforts provide sufficient information to implement federal 

requirements. Given the complexities involved, it may be reasonable for states to 

adhere to a risk-based approach and focus their eligibility determination efforts 

on applicants who appear to be more likely to have assets or to have transferred 

assets that would make them ineligible. It is too early to assess the effectiveness 

of the AVS; its utility will ultimately depend on the breadth of the financial 

institutions participating and the depth of the information obtained. 

The Department of Health and Human Services (HHS) concurred with GAO’s 

findings and commented that GAO’s comprehensive report will serve as a helpful 

resource for CMS and other interested parties.

View GAO-12-749. For more information, 

contact Carolyn L. Yocom at (202) 512-7114 

or yocomc@gao.gov.
Page i GAO-12-749 Medicaid Long-Term Care

Letter 1 

Background 5

States Required Applicants to Document Most Assets, but What 

Was Considered Acceptable Proof Varied 10

All States Obtained Some Amount of Asset Information from Third 

Parties, and No State Had Implemented an Asset Verification 

System 15

It Is Unclear Whether Some States Obtain Sufficient Information to 

Implement Certain DRA Provisions 22

Concluding Observations 26

Agency Comments 26

Appendix I GAO Analysis of State Applications 28

Appendix II States’ Asset Documentation Requirements 32

Appendix III States’ Use of Data Matches to Verify Applicants’ Assets 64

Appendix IV States’ Contact with Financial Institutions to Verify Applicants’ 

Assets 72

Appendix V States’ Use of Property Records Searches to Verify Applicants’ 

Assets 77

Appendix VI States’ Use of Vehicle Records Searches to Verify Applicants’ 

Assets 83

Appendix VII States’ Collection of Third-Party Information to Identify Transfers 

of Assets 89

Contents
Page ii GAO-12-749 Medicaid Long-Term Care

Appendix VIII GAO Analysis of Annuity Language Contained in States’ 

Application Forms 91

Appendix IX Comments from the Department of Health and Human Services 94

Appendix X GAO Contact and Staff Acknowledgments 96

Tables

Table 1: Types of Assets and Examples 6

Table 2: Summary of Selected Provisions in the Deficit Reduction 

Act of 2005 (DRA) Related to Medicaid Eligibility for LongTerm Care and Asset Transfers 8

Table 3: Asset Verification System Implementation Timeline, by 

Fiscal Year 10

Table 4: Example of States’ Variation in Treatment of Earned 

Income Documentation, by Type of Documentation 13

Table 5: Number of States That Reported Conducting Data Matches 

with Other Sources, the Proportion of Applicants 

Screened, and When Screened in Relation to Eligibility 

Determination, by Source of Data Match, 2011 17

Table 6: Number of States That Contact Financial Institutions to 

Verify Applicants’ Assets, by Financial Institutions 

Contacted and Proportion of Applicants, 2011 (n=24) 18

Table 7: Number of States That Conduct Property Searches to 

Verify Applicants’ Assets, by Geographic Area Covered and 

Proportion of Applicants, 2011 (n=35) 20

Table 8: Characteristics of Medicaid Long-Term Care Application 

Processes, by State, 2011 28

Table 9: Time Frame of Information on Transfers of Assets 

Requested in Medicaid Long-Term Care Application 

Forms, by State, 2011 30

Table 10a: Applicant Documentation Requirements for Medicaid 

Long-Term Care, by State and Type of Asset, 2011 32

Table 10b: Applicant Documentation Requirements for Medicaid 

Long-Term Care, by State and Type of Asset, 2011 

(continued) 35
Page iii GAO-12-749 Medicaid Long-Term Care

Table 11: States’ Treatment of Earned Income Documentation, by 

Type of Documentation, 2011 37

Table 12: States’ Treatment of Earned Income Documentation, by 

State and Type of Documentation, 2011 38

Table 13: States’ Treatment of Unearned Income Documentation, 

by Type of Documentation, 2011 40

Table 14a: States’ Treatment of Unearned Income Documentation, 

by State and Type of Documentation, 2011 41

Table 14b: States’ Treatment of Unearned Income Documentation, 

by State and Type of Documentation, 2011 (continued) 43

Table 15: States’ Treatment of Financial and Investment Resources 

Documentation, by Type of Documentation, 2011 45

Table 16: States’ Treatment of Financial and Investment Resources 

Documentation, by State and Type of Documentation, 2011 46

Table 17: States’ Treatment of Life Insurance Documentation, by 

Type of Documentation, 2011 48

Table 18: States’ Treatment of Life Insurance Documentation, by 

State and Type of Documentation, 2011 49

Table 19: States’ Treatment of Primary Residence Documentation, 

by Type of Documentation, 2011 51

Table 20: States’ Treatment of Primary Residence Documentation, 

by State and Type of Documentation, 2011 52

Table 21: States’ Treatment of Documentation of Real Property 

other than Primary Residence, by Type of Documentation, 

2011 54

Table 22: States’ Treatment of Documentation of Real Property 

other than Primary Residence, by State and Type of 

Documentation, 2011 55

Table 23: States’ Treatment of Vehicle Documentation, by Type of 

Documentation, 2011 57

Table 24: States’ Treatment of Vehicle Documentation, by State and 

Type of Documentation, 2011 58

Table 25: Amount of Required Documentation for Financial and 

Investment Resources, by State, 2011 60

Table 26: Proportion of Applicants for Which States Require 

Additional Documentation to Identify Assets Transferred 

for Less Than Fair Market Value, by State, 2011 62

Table 27a: Proportion of Applicants for which States Conduct Data 

Matches with Third Parties to Verify Applicants’ Assets, by 

State and Source of Data Match, 2011 64
Page iv GAO-12-749 Medicaid Long-Term Care

Table 27b: Proportion of Applicants for which States Conduct Data 

Matches with Third Parties to Verify Applicants’ Assets, by 

State and Source of Data Match, 2011 (continued) 66

Table 28a: Timing of State Data Matches in Relation to Eligibility 

Determination, by State and Source of Data Match, 2011 68

Table 28b: Timing of State Data Matches in Relation to Eligibility 

Determination, by State and Source of Data Match, 2011 

(continued) 70

Table 29: Proportion of Applicants for which States Contact 

Financial Institutions to Verify Applicants’ Assets, by State 

and Type of Financial Institution, 2011 72

Table 30: Types and Number of Months of Information Requested 

from Financial Institutions, by State, 2011 74

Table 31: Timing of States’ Contacts with Financial Institutions in 

Relation to Eligibility Determination, by State, 2011 76

Table 32: Proportion of Applicants for which States Conduct 

Property Records Searches to Verify Applicants’ Assets, by 

State and Geographic Area of Property Search Conducted, 

2011 77

Table 33: Types of Information That Can Be Used to Conduct 

Property Records Searches, by State, 2011 79

Table 34: Timing of States’ Property Records Searches in Relation 

to Eligibility Determination, by State, 2011 81

Table 35: Proportion of Applicants for Which States Conduct 

Records Searches with the Department of Motor Vehicles 

to Verify Applicants’ Assets, by State, 2011 83

Table 36: Types of Information That Can Be Used to Conduct 

Vehicle Records Searches, by State, 2011 85

Table 37: Timing of States’ Record Searches with the Department 

of Motor Vehicles in Relation to Eligibility Determination, 

by State, 2011 87

Table 38: Proportion of Applicants for Which States Take 

Additional Steps to Obtain Information from Third Parties 

to Identify Assets Transferred for Less Than Fair Market 

Value, by State, 2011 89

Table 39: Characteristics of Medicaid Long-Term Care Application 

Forms Related to Deficit Reduction Act of 2005 (DRA) 

Annuity Provisions, by State, 2011 91
Page v GAO-12-749 Medicaid Long-Term Care

Figures

Figure 1: Asset Documentation Requirements, by State, 2011 12

Figure 2: Number of States That Require Financial and Investment 

Resources Documentation, by Number of Months of 

Documentation Required, 2011 14

Figure 3: Number of States Requesting Applicant Asset Information 

from Financial Institutions, by Number of Months and 

Type of Information Requested, 2011 (n=24) 19

Abbreviations

ADL activities of daily living

AVS asset verification system

CCRC continuing care retirement community

CMS Centers for Medicare & Medicaid Services

DMV Department of Motor Vehicles

DRA Deficit Reduction Act of 2005

FMV fair market value

HHS Department of Health and Human Services

IADL instrumental activities of daily living

IEVS Income and Eligibility Verification System

PARIS Public Assistance Reporting Information System

This is a work of the U.S. government and is not subject to copyright protection in the 

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Page 1 GAO-12-749 Medicaid Long-Term Care

United States Government Accountability Office

Washington, DC 20548

July 26, 2012

The Honorable Orrin G. Hatch

Ranking Member

Committee on Finance

United States Senate

The Honorable Tom Coburn, M.D.

Ranking Member

Permanent Subcommittee on Investigations

Committee on Homeland Security and Governmental Affairs

United States Senate

Long-term care, particularly nursing home care, can be costly; in 2010, 

the average annual cost for care in a nursing home was about $79,000.1

Individuals applying for Medicaid coverage for long-term care must meet 

certain financial and functional eligibility criteria.

Nearly half of the nation’s $263 billion long-term care expenditures in 

2010 were paid by Medicaid, a joint federal-state health care financing 

program that covers certain categories of low-income individuals. Longterm care expenditures represent a significant portion of total Medicaid 

expenditures, comprising over one-quarter of the total $401 billion spent 

in fiscal year 2010. As the number of elderly Americans continues to grow 

and more individuals are likely to need long-term care, Medicaid spending 

for long-term care services is projected to increase. In light of the 

increased demand and associated burden that this places on already 

strained federal and state resources, it is important to ensure that only 

eligible individuals receive Medicaid coverage for long-term care.

2

 

1

Metlife Mature Market Institute, The 2011 MetLife Market Survey of Nursing Home, 

Assisted Living, Adult Day Services, and Home Care Costs (Westport, Conn.: October 

2011).

To meet the financial 

2

For this report, we focus on financial eligibility—specifically financial eligibility for 

Medicaid coverage for long-term care. However, individuals applying for Medicaid 

coverage for long-term care must also meet functional eligibility criteria that are 

established by each state and generally involve a degree of impairment measured by 

limitations in an individual’s ability to carry out activities of daily living—eating, bathing, 

dressing, using the toilet, getting in and out of bed, and getting around the house—and 

instrumental activities of daily living, such as preparing meals, shopping for groceries, and 

getting around outside. 

 
 

Page 2 GAO-12-749 Medicaid Long-Term Care

eligibility criteria, individuals must have assets that fall below established 

levels, which vary by state, but are within standards set by the federal 

government. Within the Medicaid program, assets have two broad 

categories: income, which includes any funds received during a calendar 

month that are used or could be used to meet food, clothing, or shelter 

needs; and resources, which include anything owned, such as savings 

accounts, stocks, or property, that can be converted to cash.3 Not all 

assets are counted in determining financial eligibility for Medicaid. For 

example, states generally exclude—within specified limits—the value of 

an individual’s primary residence, car, and prepaid burial arrangements. 

Additionally, federal law includes provisions to discourage individuals 

from artificially impoverishing themselves—for example, by transferring 

their assets to certain family members—in order to establish financial 

eligibility for Medicaid. Specifically, those who transfer assets for less 

than fair market value (FMV) during a specified “look-back” period—a 

period of time before application in which an individual’s assets are 

reviewed—may be deemed ineligible for Medicaid coverage for long-term 

care for a period of time. The Deficit Reduction Act of 2005 (DRA), which 

was enacted in February 2006, amended certain existing provisions 

regarding asset transfers for less than FMV and introduced new 

requirements related to financial eligibility for Medicaid coverage for longterm care.4

As the day-to-day administrators of the Medicaid program, states are 

responsible for assessing applicants’ financial eligibility for Medicaid 

coverage for long-term care; that is, determining whether an applicant’s 

income and resources are below the state-established standards, and 

whether an applicant transferred assets for less than FMV during the 

look-back period. Our prior work and the work of others found that the 

For example, the DRA extended the look-back period from 

36 months to 60 months for transfers occurring on or after its enactment 

and introduced new requirements regarding how certain types of assets, 

such as an individual’s home, should be considered when determining 

Medicaid eligibility.

 

3

This terminology is based on definitions provided in The State Medicaid Manual issued 

by the Centers for Medicare & Medicaid Services (CMS), which specifies that assets

include both income and resources.

4

See Pub. L. No. 109-171, §§ 6011-6016, 120 Stat. 4, 61-67 (2006).
 

Page 3 GAO-12-749 Medicaid Long-Term Care

proportion of applicants deemed to be financially eligible for Medicaid 

coverage for long-term care varied both across and within states.5

Given the potential for state variation, you asked us for information on 

states’ requirements and practices for assessing the financial eligibility of 

individuals applying for Medicaid coverage for long-term care, including 

states’ implementation of relevant DRA provisions. In this report, we 

provide details on the extent to which states: (1) require individuals to 

document assets when applying for Medicaid coverage for long-term 

care; (2) obtain information from third parties to verify applicants’ assets; 

and (3) obtain information about applicants’ assets that could be used to 

implement DRA provisions related to eligibility for Medicaid coverage for 

long-term care.

To address all three objectives, from October 2011 through November 

2011, we administered a web-based survey to Medicaid officials from 

each of the 50 states and the District of Columbia.6

 

5

GAO, Medicaid Long-Term Care: Few Transferred Assets before Applying for Nursing 

Home Coverage; Impact of Deficit Reduction Act on Eligibility Is Uncertain, 

To ensure the clarity 

and precision of our survey questions, we interviewed officials from the 

Centers for Medicare & Medicaid Services (CMS), the agency within the 

Department of Health and Human Services (HHS) that oversees 

Medicaid; interviewed Medicaid officials from 3 states; reviewed states’ 

Medicaid applications for long-term care coverage; and pretested the 

survey with Medicaid officials from 3 states. The survey requested 

information about the types of documentation, if any, that states require 

applicants for Medicaid coverage for long-term care to submit for 13 types 

of assets: earned income, unearned income, financial and investment 

resources, life insurance, primary residence, real property other than 

primary residence, vehicles, annuities, burial contracts and prepaid 

funeral arrangements, continuing care retirement community (CCRC) 

GAO-07-280

(Washington, D.C.: Mar. 26, 2007); Nelson A. Rockefeller Institute of Government, 

Assessing Asset Transfer for Medicaid Eligibility in New York State (March 2009). 

6

Throughout this document, the term state refers to the 50 states and the District of 

Columbia.
 

Page 4 GAO-12-749 Medicaid Long-Term Care

entrance fees, life estates, promissory notes or loans, and trusts.7 In 

addition, the survey asked about the number of months of documentation 

states required for earned income, unearned income, and financial and 

investment resources.8 The survey also asked about states’ practices to 

obtain information from third parties to verify applicants’ assets, such as 

whether, and to what extent, states conduct data matches with 

10 sources, including the Social Security Administration and the Internal 

Revenue Service, which primarily allow states to verify applicants’ 

income. Finally, the survey asked about any additional documentation 

states require or additional steps states take to determine whether 

applicants transferred assets for less than FMV during the 60-month lookback period. We received survey responses from officials from all 

51 states, although not every official responded to every question. We 

relied on the data as reported by the state officials who were identified as 

the primary contact for states’ documentation requirements and practices 

for verifying the financial eligibility of applicants for Medicaid coverage for 

long-term care. We did not independently verify these data; however, we 

reviewed all responses for reasonableness and internal consistency, and 

followed up with state officials for clarification where necessary. On the 

basis of these activities, we determined these data were sufficiently 

reliable for the purposes of our report. In addition to administering a 

survey, we collected states’ application forms for Medicaid coverage for 

long-term care to assess the types of asset information asked about on 

the applications.9

 

7

A CCRC is generally a residential facility established in a campus-like setting that 

provides access for older individuals to three levels of housing and care: independent 

homes or apartments where residents live much as they did in their own homes; assisted 

living, which provides help with the daily tasks of living; and skilled nursing care for those 

with greater physical needs. Most residents must be able to live independently when they 

enter into a contract with a CCRC, with the intent of moving through the three levels of 

care as their needs change. A life estate is an interest in real property that gives the owner 

of the interest the right to use and possess the property only for the duration of the life of a 

person, usually the person who occupies the premises.

Finally, we interviewed CMS officials about federal 

requirements related to eligibility determinations for Medicaid coverage 

for long-term care, including the DRA provisions.

8

The survey did not ask about the number of months of documentation required for other 

types of assets, such as real property and trusts, as the documentation and value of these 

assets are less likely to fluctuate over time.

9

The application forms reviewed were those provided by the state officials who were 

identified as the contacts for our survey. See app. I for information on states’ application 

forms for Medicaid coverage for long-term care.
 

Page 5 GAO-12-749 Medicaid Long-Term Care

We conducted this performance audit from July 2011 to July 2012 in 

accordance with generally accepted government auditing standards. 

Those standards require that we plan and perform the audit to obtain 

sufficient, appropriate evidence to provide a reasonable basis for our 

findings and conclusions based on our audit objectives. We believe that 

the evidence obtained provides a reasonable basis for our findings and 

conclusions based on our audit objectives.

Long-term care includes many types of services needed by individuals 

who have a physical disability, a mental disability, or both. Long-term care 

services can be provided in a variety of settings, including an individual’s 

home or an institution, such as a nursing home. To be eligible for 

Medicaid coverage for long-term care, individuals must be within certain 

eligibility categories—such as those that are aged or disabled—and meet 

functional and financial criteria. Within broad federal standards, states 

determine whether an individual meets the functional criteria for long-term 

care coverage by assessing an individual’s ability to carry out activities of 

daily living (ADL), such as eating and getting around the house; and 

instrumental activities of daily living (IADL), such as preparing meals and 

shopping for groceries. The financial eligibility criteria are based on 

individuals’ assets—income and resources together. States are 

responsible for determining whether applicants meet the financial and 

other eligibility criteria for Medicaid coverage for long-term care.

To qualify for Medicaid coverage for long-term care, individuals must

have assets that fall below established standards, which vary by state, 

but are within standards set by the federal government. The Medicaid 

program bases its characterization of assets—income and resources—on 

that used in the Supplemental Security Income program.10

 

10The Supplemental Security Income program provides cash assistance to aged, blind, or 

disabled individuals with limited income and resources. 42 U.S.C. §§1381-1383f.

Income is 

something received during a calendar month, paid either in cash or inkind, that is used or could be used to meet food or shelter needs; 

resources are cash or real or personal property that are owned that can 

be converted to cash and be used for food or shelter. (See table 1 for 

examples of different types of income and resources.) In establishing 

policy for determining financial eligibility for Medicaid coverage for longBackground 

Financial Eligibility for 

Medicaid Coverage for 

Long-Term Care
 

Page 6 GAO-12-749 Medicaid Long-Term Care

term care, states can decide, within federal standards, which assets are 

countable. For example, states may disregard certain types or amounts of 

income, and may elect not to count certain resources.11 In most states, to 

be financially eligible for Medicaid coverage for long-term care, individuals 

must have $2,000 or less in countable resources ($3,000 for a married 

couple).12

Table 1: Types of Assets and Examples

Type of asset Examples

Income • Money earned from work

• Money generated from resources, such as interest, dividends, and 

annuity payments

• Money received from other sources, such as Social Security, 

worker’s compensation, and unemployment benefits

Resources • Cash

• Financial and investment resources, such as bank accounts, stocks, 

and bonds

• Trusts

• Annuities

• Real property

• Vehicles, such as automobiles and boats

• Life insurance

Source: GAO analysis of Supplemental Security Income requirements.

 

11Although noncountable resources vary by state, for purposes of determining Medicaid 

eligibility for long-term care, they generally include an individual’s home (typically if the 

individual expresses the intent to return home), an automobile, household goods and 

personal effects, burial spaces, and life insurance and burial arrangements up to a certain 

value, among other things.

12For married couples, the Medicaid statute requires states to use specific minimum and 

maximum resource standards in determining eligibility when one spouse is in an 

institution, such as a nursing home, and the other remains in the community (referred to 

as the community spouse). 42 U.S.C. § 1396r-5. The community spouse may retain an 

amount equal to one-half of the couple’s combined countable resources, up to a 

state-specified maximum level. States’ maximum resource levels cannot exceed the 

maximum federal standard ($113,640 in 2012). If one-half of the couple’s combined 

resources is less than a state-specified minimum resource level (which has to be at least 

$22,728 in 2012), then the community spouse may retain resources up to that minimum 

level.
 

Page 7 GAO-12-749 Medicaid Long-Term Care

Federal law limits Medicaid payment for long-term care services for 

persons who divest themselves of—or “transfer”—their assets for less 

than FMV within a specified time period.13 As a result, when an individual 

applies for Medicaid coverage for long-term care, states conduct a 

review, or “look back,” to determine whether the applicant (or his or her 

spouse, if married) transferred assets to another person or party. If the 

state determines an applicant transferred an asset for less than FMV 

during the look-back period, the individual may be ineligible for Medicaid 

coverage for long-term care for a period of time, called the penalty period. 

The DRA extended the look-back period for transfers made on or after 

February 8, 2006, to 60 months; prior to that, it was generally 

36 months.14

The DRA also specified circumstances under which the purchase of 

certain assets—such as an annuity, promissory note or loan, or life 

estate—is considered a transfer for less than FMV, and when entrance 

fees for CCRCs are countable for purposes of determining Medicaid 

eligibility. Additionally, while an individual’s primary residence is generally 

not a countable resource for determining Medicaid eligibility, the DRA 

specified when an individual with substantial equity interest in his or her 

home is to be excluded from eligibility for Medicaid payment for long-term 

care; the amount of allowable equity interest is established by each state 

within federal guidelines.15

 

13Federal law requires states to apply the transfer of asset provisions to institutionalized 

individuals, who are defined in the Social Security Act as individuals who are inpatients in 

a nursing facility or in a medical institution that is being paid based on a level of care 

received in a nursing home, or certain recipients of home and community-based services. 

42 U.S.C. § 1396p(h)(3). States have the option to apply such provisions to 

noninstitutionalized individuals.

See table 2 for a summary of these DRA 

14Among other things, the DRA also changed the beginning date of the penalty period; 

included provisions regarding how the penalty period was to be calculated; and 

established criteria and application, notice, and appeal requirements for undue hardship 

waivers. Undue hardship exists when the application of a penalty period would deprive an 

individual of (1) medical care such that the individual’s health or life would be endangered 

or (2) food, clothing, shelter, or other necessities of life. Prior to the DRA, the criteria for 

determining undue hardship had been established by the Secretary of HHS in Medicaid 

guidance, namely The State Medicaid Manual. These provisions regarding the penalty 

period and undue hardship are outside the scope of our study.

15The DRA also included a provision regarding how a married applicant’s income should 

be treated when determining how much of the applicant’s resources the community 

spouse is entitled to retain. This provision is outside the scope of our study.

Transfers of Assets and the 

DRA
 

Page 8 GAO-12-749 Medicaid Long-Term Care

provisions. Most, but not all, of these DRA provisions became applicable 

on the date the law was enacted, February 8, 2006.

Table 2: Summary of Selected Provisions in the Deficit Reduction Act of 2005 (DRA) Related to Medicaid Eligibility for LongTerm Care and Asset Transfers

DRA provision Description

Annuities • States are required to treat the purchase of an annuity as a transfer for less than fair 

market value (FMV) unless the annuity names the state as either (1) the remainder 

beneficiary in the first position for at least the total amount of Medicaid expenditures 

paid on behalf of the annuitant, or (2) a remainder beneficiary in the second position 

after the community spouse, or minor or disabled child (or in the first position if any of 

those individuals transfer the remainder of the annuity for less than FMV).

• Annuities purchased by or on the behalf of an individual who applied for Medicaid 

coverage for long-term care shall be treated as a transfer of assets for less than FMV 

unless the annuity is irrevocable, nonassignable, actuarially sound, and provides for 

payments in equal amounts during the term of the annuity, with no deferral and no 

balloon payments.

• Annuities purchased by or on the behalf of an individual who applied for Medicaid 

coverage for long-term care services that are defined as individual retirement 

accounts under federal tax code or purchased with the proceeds of certain retirement 

accounts and meet certain federal tax code requirements are not considered transfers 

for less than FMV.

• Applications for Medicaid coverage for long-term care shall: (1) describe any interest 

an applicant or community spouse may have in an annuity, regardless of whether the 

annuity is irrevocable or treated as an asset, and (2) include a statement that the 

state becomes a remainder beneficiary of an annuity purchased on or after enactment 

by virtue of the applicant’s receipt of Medicaid assistance for long-term care.

Continuing care retirement communities States are required to consider certain entrance fees for continuing care retirement 

communities or life care communities as countable resources.

Home equity An individual with an equity interest in his or her home of more than $500,000 is excluded 

from eligibility for Medicaid payment for long-term care unless his/her spouse, child under 

age 21, or child who is considered blind or disabled lives in the home. A state can elect to 

increase this value up to $750,000. Beginning in 2011, the limit was to be increased each 

year based on the percentage increase in the consumer price index for all urban 

consumers.a

Life estates States are required to consider a purchase of a life estate interest in another person’s 

home as a transfer of assets for less than FMV unless the purchaser lived in the home for 

at least 1 year after the date of purchase.

Promissory notes and loans States are required to consider funds used to purchase a promissory note, loan, or 

mortgage as a transfer of assets for less than FMV unless the repayment terms are 

actuarially sound, provide for payments to be made in equal amounts during the term of 

the loan with no deferral or balloon payments, and prohibit the cancellation of the balance 

upon the death of the lender.

Source: GAO analysis of the DRA.

a

In 2012, states’ home equity limits could range from $525,000 through $786,000.
 

Page 9 GAO-12-749 Medicaid Long-Term Care

To assess applicants’ financial eligibility for Medicaid coverage for longterm care, and to determine whether they transferred assets for less than 

FMV, states generally require applicants to submit applications and to 

provide documentation of certain assets reported on the applications. 

State Medicaid programs may also obtain information from third parties, 

such as financial institutions or other government agencies, such as the 

Social Security Administration. Such information helps states verify the 

accuracy of applicants’ reported assets, as well as determine whether 

applicants have assets they failed to report or transferred for less than 

FMV during the look-back period. The processing of Medicaid 

applications—including the collection of documentation and information 

from applicants and third parties—is generally performed by local or 

county-based eligibility workers.

In 2008, Congress passed legislation that required states to implement 

electronic asset verification systems (AVS) to verify the assets of aged, 

blind, or disabled applicants for Medicaid, including those seeking 

Medicaid coverage for long-term care, with financial institutions.16 An AVS 

would provide states with an electronic mechanism to contact multiple 

financial institutions, including those not reported by an applicant, to 

determine if an applicant has, or had, an account and the value of any 

existing accounts.17 The law provides for states’ implementation of these 

systems to occur on a rolling basis; the first systems were to be 

implemented by the end of fiscal year 2009, with all states implementing 

systems by the end of fiscal year 2013.18

 

16Supplemental Appropriations Act, 2008, Pub. L. No. 110-252, § 7001(d)(1), 122 Stat. 

2323, 2391 (codified at 42 U.S.C. § 1396w).

(See table 3.)

17According to guidance issued by CMS, verification requests through a state’s AVS must 

be sent to financial institutions not identified by applicants based on some logic, such as 

geographic proximity to the applicant’s home address, or other reasonable factors 

whenever the state determines that such requests are needed for eligibility determination. 

Additionally, per CMS guidance, the verification requests must include a request for 

information on both open and closed accounts, going back for a period up to 5 years, as 

determined by the state.

18The Supplemental Appropriations Act, 2008, required California, New Jersey, and New 

York to implement an AVS for aged, blind, and disabled applicants by the end of fiscal 

year 2009 and directed the Secretary of HHS to require the remaining states to implement 

their systems in a manner that results in a specified percentage of aged, blind, and 

disabled Medicaid applicants being subject to this type of asset verification each year over 

the 5-year period of fiscal year 2009 through fiscal year 2013.

States’ Determination of 

Applicants’ Financial 

Eligibility
 

Page 10 GAO-12-749 Medicaid Long-Term Care

Table 3: Asset Verification System Implementation Timeline, by Fiscal Year 

Fiscal year

Number 

of states States 

2009 9 California, Missouri, New Hampshire, New Jersey, New 

Mexico, New York, Oregon, South Carolina, Washington

2010 9 Connecticut, Georgia, Kentucky, Mississippi, Nevada, 

Oklahoma, Rhode Island, Vermont, Wisconsin 

2011 7 Hawaii, Indiana, Michigan, Maryland, North Carolina, Ohio, 

Wyoming 

2012 11 Alaska, Arizona, Florida, Iowa, Illinois, North Dakota, South 

Dakota, Tennessee, Texas, Utah, West Virginia 

2013 15 Alabama, Arkansas, Colorado, District of Columbia, 

Delaware, Idaho, Kansas, Louisiana, Massachusetts, Maine, 

Minnesota, Montana, Nebraska, Pennsylvania, Virginia

Source: Supplemental Appropriations Act, 2008, Pub. L. No. 110-252, § 7001(d)(1), 122 Stat. 2323, 2391 (codified at 42 U.S.C. 

§ 1396w) and the Centers for Medicare & Medicaid Services.

Note: The Supplemental Appropriations Act, 2008, required California, New Jersey, and New York to 

implement an asset verification system for aged, blind, and disabled applicants by the end of fiscal 

year 2009 and directed the Secretary of the Department of Health and Human Services to require the 

remaining states to implement their systems in a manner that results in a specified percentage of 

aged, blind, and disabled Medicaid applicants being subject to this type of asset verification each year 

over the 5-year period of fiscal year 2009 through fiscal year 2013.

States reported requiring applicants to provide documentation for most of 

the 13 types of assets contained in our survey; however, the types and 

number of months of documentation that the states considered to be 

acceptable proof for determining an applicant’s financial eligibility for 

Medicaid coverage for long-term care varied.19

 

19As previously noted, the 13 types of assets included in our survey were: earned income, 

unearned income, financial and investment resources, life insurance, primary residence, 

real property other than primary residence, vehicles, annuities, burial contracts and 

prepaid funeral arrangements, CCRC entrance fees, life estates, promissory notes or 

loans, and trusts.

Specifically, 44 states 

required documentation for at least 12 of the 13 types of assets. All states 

reported requiring documentation of annuities, burial contracts and 

prepaid funeral arrangements, financial and investment resources, life 

estates, and trusts, while fewer states reported requiring documentation 

of other types of assets. States were least likely to require documentation 

of vehicles (38 states) and primary residence (37 states), resources that 

States Required 

Applicants to 

Document Most 

Assets, but What Was 

Considered 

Acceptable Proof 

Varied 
 

Page 11 GAO-12-749 Medicaid Long-Term Care

states may choose not to count for purposes of determining financial 

eligibility for Medicaid coverage for long-term care.20

 

20Officials from several states reported not requiring documentation of an applicant’s 

vehicle, primary residence, or both because the state does not count them for purposes of 

determining financial eligibility for Medicaid coverage for long-term care. 

(See fig. 1.)
Number of asset types 

that require documentation

9

10

11

12

13

12

9

12

9 13

12

13

11

13

12

12

12

12

11

13

13

13 13

13

13

13

13

10

12

12

12

13

12

12

13

12

12

13

13 13

13

13

11

13

13

13

12

13

12

12

13

13

12

12

AL

AZ

AR

CA CO

FL

GA

ID

IL IN

IA

KS KY

LA

ME

MI

MN

MS

MO

MT

NE NV

VT -

NH -

MA -

RI -

CT -

NJ -

DE -

MD - 

DC -

NM

NC

ND

OH

OK

OR

PA

SC

SD

TN

TX

UT

VA

WA

WV

WI

Source: GAO web-based survey administered to state Medicaid officials (data); Map Resources (map).

WY

13

HI

11

AK

12

NY

INTERACTIVE

INSTRUCTIONS

Roll your mouse over 

the state name to see 

more information. 

To print expanded 

information, see 

appendix II.

Type of asset

Income

Earned 50

Unearned 49

Resources

Annuity 51

Burial contract and pre-paid funeral 51

Financial and investment 51

Life estate 51

Trust 51

Life insurance 50

Promissory note or loana 50

Real property other than primary residence 50

Continuing care retirement community entrance fee 46

Vehicle 38

Primary residence 37

Total number of states that require

documentation for this asset type

Page L2 GAO-12-749

Figure 1: Asset Documentation Requirements, by State, 2011

aThe District of Columbia did not respond to the question about whether or not documentation of 

promissory notes or loans is required.

Page 12 GAO-12-749 Medicaid Long-Term Care
 

Page 13 GAO-12-749 Medicaid Long-Term Care

Officials from several states reported not requiring documentation for a 

particular type of asset because the state was able to obtain the 

necessary information from a third party. For example, while 50 states 

reported requiring applicants to submit documentation of earned income, 

one state did not have such a requirement because the amount of earned 

income was verified through an interface with the state’s Department of 

Labor. It was less clear how states assessed other assets—such as 

vehicles or CCRC entrance fees—absent documentation.

Our survey also showed that states varied in how they treated specific 

types of documentation; that is, whether the documentation was required, 

acceptable as proof by itself, acceptable as proof with other 

documentation, or not acceptable as proof of an applicant’s assets. For 

example, while states generally found a written statement of earnings 

from an employer as acceptable documentation of earned income, there 

was more variation in how they treated other types of documentation. 

(See table 4.)

Table 4: Example of States’ Variation in Treatment of Earned Income 

Documentation, by Type of Documentation

Number of states

Type of documentation Required

Acceptable as 

proof itself

Acceptable 

with other 

documentation

Not 

acceptable

Copy of check or check 

stuba 3 33 9 4 

Itemized bank statementa 1 6 20 22

Written statement of 

earnings from employer 0 49 1 0 

Source: GAO web-based survey administered to state Medicaid officials.

Notes: This table only includes responses from the 50 states that required documentation of earned 

income.

a

One state did not specify the level of acceptability for this type of documentation.

States also varied in the number of months of documentation required 

from applicants, especially as it related to financial and investment 

resources. Although all 51 states reported requiring documentation of 

financial and investment resources, 27 required only current 

documentation, while the remaining 24 required both current and past 

documentation. Of the 24 states that required documentation of both 

current and past financial and investment resources, most required 

60 months of documentation, while the remaining states required fewer 
 

Page 14 GAO-12-749 Medicaid Long-Term Care

months of documentation. (See fig. 2.) There was some variation, but to a 

lesser extent, in the amount of documentation of earned and unearned 

income that states required from applicants. Of the 50 states that required 

applicants to provide earned income documentation, 47 required only 

current documentation. Of the 3 remaining states, 2 required 3 months of 

documentation and 1 required 2 months of documentation.21 Of the 

49 states that required unearned income documentation, 47 only required 

documentation of current unearned income. The other 2 states required 

3 months of documentation.22

Figure 2: Number of States That Require Financial and Investment Resources 

Documentation, by Number of Months of Documentation Required, 2011

a

One state reported it required both current and past documentation for financial and investment 

resources, but did not specify the number of months of documentation required because it is 

determined on a case-by-case basis. In some cases, the state may require up to 60 months of 

documentation.

 

21Missouri and Montana required 3 months of earned income documentation and 

Tennessee required 2 months of earned income documentation.

22The 2 states are New Hampshire and Vermont.
 

Page 15 GAO-12-749 Medicaid Long-Term Care

In addition to the documentation required to assess whether applicants’ 

assets were within state financial eligibility levels, 38 states reported 

requiring additional documentation from at least some applicants to 

identify assets transferred for less than FMV. Of these 38 states, 

16 indicated they required additional documentation only if an applicant 

reported making a transfer, 5 reported doing so only if an applicant’s 

information was questionable, and 8 reported both of these reasons. Of 

the remaining 9 states, 7 required additional documentation from all 

applicants, and 2 did not specify the circumstances that would result in a 

request for additional documentation.

Appendix II provides additional information on states’ asset 

documentation requirements for individuals applying for Medicaid 

coverage for long-term care.

All 51 states reported that they obtained some amount of asset 

information from third parties, although the extent of the screenings 

conducted varied by state. No state had implemented an electronic AVS, 

which would allow them to contact multiple financial institutions—

including those not reported by an applicant—to determine the existence 

and value of any accounts belonging to an applicant. States reported 

challenges to implementing an AVS including not having sufficient 

resources.

To varying degrees, states reported obtaining information from third 

parties through a variety of mechanisms, including data matches, direct 

contact with financial institutions, and property and vehicle records 

searches. Some states also reported taking additional verification steps to 

determine if an applicant transferred assets for less than FMV during the 

look-back period.

All States Obtained 

Some Amount of 

Asset Information 

from Third Parties, 

and No State Had 

Implemented an Asset 

Verification System

States Varied in the Extent 

to Which They Obtained 

Information from Third 

Parties
 

Page 16 GAO-12-749 Medicaid Long-Term Care

All 51 states reported that they conduct data matches with the Social 

Security Administration to verify at least some applicants’ assets. 

However, states’ use of data matches with other sources of asset 

information—primarily related to income—varied, ranging from 48 states 

reporting data matches with state unemployment records, to as few as 

6 states reporting data matches with state tax records. On average, 

states conducted data matches with 6 of the 10 sources included in our 

survey; the number of sources states reported using ranged from 1 to 9.23

In addition to variations in the use of data match sources, states varied in 

terms of the proportion of applicants screened, and when during the 

eligibility process the state conducted the screen. For example, most 

states reported conducting a data match with the Social Security 

Administration generally before determining an applicant’s eligibility. In 

contrast, of the 30 states that reported conducting a data match with the 

Internal Revenue Service for at least some applicants, 21 reported doing 

so generally after determining eligibility. (See table 5 for summary 

information and app. III for more detailed information about the data 

matches conducted by states.)

 

23While all states provided some information about their use of data matches, some states 

did not provide responses about their use of all 10 of the sources included in our survey.

Conduct Data Matches
 

Page 17 GAO-12-749 Medicaid Long-Term Care

Table 5: Number of States That Reported Conducting Data Matches with Other Sources, the Proportion of Applicants 

Screened, and When Screened in Relation to Eligibility Determination, by Source of Data Match, 2011

Proportion of applicantsb When screened in relation to 

eligibility determinationc

Source of the data match

States that 

conduct data 

matcha All Mostd Some None

Generally 

before Variede Generally after 

Social Security Administration 51 43 6 2 0 40 6 2 

State unemployment records 48 31 5 12 2 29 7 6 

Income and Eligibility Verification 

Systemf 44 36 4 4 6 21 6 14

Public Assistance Reporting 

Information Systemg 42 31 2 9 6 4 6 30

State wage files/directory of new hires 41 26 7 8 8 20 9 8 

Internal Revenue Service 30 22 1 7 20 6 2 21

Department of Veterans Affairs 22 9 0 13 26 11 6 3 

State workman’s compensation 

records 

17 7 1 9 30 6 5 4 

National Directory of New Hiresh 14 9 2 3 33 7 3 4 

State tax records 6 2 1 3 42 3 1 2 

Source: GAO web-based survey administered to state Medicaid officials.

a

Represents the number of states that reported conducting the data match for at least some 

applicants.

b

In each row, the number of states may not add to 51 because not all states answered the question 

regarding the proportion of applicants, if any, for the respective data match source.

c

In each row, the number of states may not add to the total number that conduct a data match with 

that source because not all states specified when the screening occurred in relation to eligibility 

determination.

d

“Most” is more than half of applicants.

e

“Varied” is sometimes before and sometimes after eligibility determination.

f

Each state is required to operate an Income and Eligibility Verification System that allows the state to 

match applicant-reported income information with data from the Internal Revenue Service, the Social 

Security Administration, and state wage and unemployment insurance benefit records. States that 

reported using this system to verify applicants’ assets may use some or all of the data available.

g

The Public Assistance Reporting Information System (PARIS) is an electronic data matching and 

information exchange system that is designed to match state enrollment information, including 

Medicaid enrollment, with data from other participating states and from a selected group of federal 

databases. The federal databases include, among other things, information on individuals’ receipt of 

income from the Department of Veterans Affairs, the Department of Defense, and the Office of 

Personnel Management. States that reported conducting a PARIS data match may use some or all of 

the data available.

h

The National Directory of New Hires is a national database of employment wage and unemployment 

insurance information for use by federal and state agencies.
 

Page 18 GAO-12-749 Medicaid Long-Term Care

Twenty-four states reported that they contact financial institutions to verify 

at least some applicants’ financial and investment resources, while the 

remaining 27 did not. However, these 24 states varied in terms of the 

range of financial institutions they contacted and the proportion of 

applicants about whom they inquired. (See table 6.)

Table 6: Number of States That Contact Financial Institutions to Verify Applicants’ 

Assets, by Financial Institutions Contacted and Proportion of Applicants, 2011 

(n=24) 

Proportion of applicants

Type of financial institution Total All Most Some

Institutions with accounts reported by applicant 24 11 0 13

Local institutions that were not reported by applicant 11 4 1 6 

Statewide institutions that were not reported by 

applicant 7 3 1 3 

National institutions that were not reported by 

applicant 5 1 2 2 

Source: GAO web-based survey administered to state Medicaid officials.

Some states reported contacting multiple types of financial institutions, 

such as institutions applicants reported having accounts with, and some 

that applicants did not report. However, 13 of the 24 states reported 

contacting only financial institutions with whom the applicant reported 

having an account; of these 13 states, 3 states contacted financial 

institutions for all applicants, while the other 10 states did so for some 

applicants. These 13 states, and the 27 that reported not contacting any 

financial institutions, are unlikely to identify accounts that an applicant 

failed to report. Of the remaining 11 states that reported contacting 

financial institutions not reported by an applicant, 3 reported contacting 

only local institutions, whereas the other 8 contacted a combination of 

local, statewide, and national institutions. Regarding the proportion of 

applicants for which states contact financial institutions, half of the 

24 states reported they only contact financial institutions if an applicant 

submits insufficient information or provides questionable information.

Of the 24 states that reported they contact financial institutions to request 

information, the type of information—account balances or itemized 

statements—and the number of months they request varied. (See fig. 3.) 

Specifically, half of these states requested itemized statements that 

include information on each transaction, while the other half requested 

monthly account balances. Most of the states that requested account 

balances did so for 3 or fewer months. Of the 12 states that requested 

Contact Financial Institutions
 

Page 19 GAO-12-749 Medicaid Long-Term Care

itemized statements, 5 requested 60 months of statements, 3 requested 

only the statement for the current month, and the other 4 states requested 

between 3 and 36 months of information.

Figure 3: Number of States Requesting Applicant Asset Information from Financial 

Institutions, by Number of Months and Type of Information Requested, 2011 (n=24)

a

One state reported that it requests the current balance for any open accounts and the closing 

balance for any accounts that were closed within the past 60 months.

b

Twelve states reported that they request account balances from financial institutions; however, one 

of these states did not specify the number of months of information it requested and noted it would 

request whatever amount is needed.

Most of the states (20 of 24) reported that they contact financial 

institutions for asset information before determining eligibility. Appendix IV 

provides additional information about states’ contact with financial 

institutions to verify applicants’ assets. 
 

Page 20 GAO-12-749 Medicaid Long-Term Care

Thirty-five states reported that they conduct some type of property 

records search to verify at least some applicants’ real property. The 

extent of the searches varied in terms of the geographic area covered 

and the proportion of applicants for which property searches were 

conducted. (See table 7.)

Table 7: Number of States That Conduct Property Searches to Verify Applicants’ 

Assets, by Geographic Area Covered and Proportion of Applicants, 2011 (n=35)

Proportion of 

applicants

Geographic area of property search conducted Total All Most Some 

Applicant’s county of residence 34 16 7 11

Some other counties in state 31 6 3 22

All counties in state 19 6 1 12

Locations in other states 16 2 0 14

Source: GAO web-based survey administered to state Medicaid officials.

Of the 35 states that reported conducting property searches, 2 states 

conduct property searches only within an applicant’s county of residence. 

Of the 33 states that reported conducting property searches beyond an 

applicant’s county of residence, 8 do so only if they have reason to 

believe the applicant lived in another county or state. Additionally, 12 of 

the 35 states indicated they conduct property searches only when an 

applicant submits questionable or insufficient information, an applicant 

reports the property, or a combination of both factors.

States reported being able to conduct property searches using several 

types of information, including an applicant’s name (33 states), property 

address (32 states), property zip code (12 states), or an applicant’s Social 

Security number (10 states). Most of the states (29 of the 35) reported 

that they generally conduct property searches before determining 

eligibility. Appendix V provides additional information about the property 

searches conducted by states.

Thirty states reported that they conduct searches of Department of Motor 

Vehicles’ (DMV) records to verify at least some applicants’ vehicles. 

Specifically, 14 states reported conducting vehicle searches for all 

applicants and 1 state reported conducting searches for most of its 

applicants. The remaining 15 reported conducting such searches for less 

than half of their applicants; of these 15 states, 6 indicated that they only 

conduct searches of vehicle records if they receive information from an 

Search Property Records

Search Vehicle Records
 

Page 21 GAO-12-749 Medicaid Long-Term Care

applicant that they deem questionable. States reported being able to 

search these records using several types of information, including an 

applicant’s name (29 states), a vehicle identification number (20 states), 

and an applicant’s driver’s license or license plate number (18 states 

each). Most of the states (25 of the 30 states) reported that they generally 

conduct DMV searches before determining eligibility. Appendix VI 

provides additional information about the vehicle searches conducted by 

states.

Twenty-two states reported taking additional steps to obtain information 

from third parties, such as conducting additional property searches, to 

identify assets transferred for less than FMV; 7 states reported doing this 

for all applicants; and 15 states reported doing this for some applicants. 

Of the 15 states that reported taking additional verification steps for just 

some applicants, most of them indicated they do so only if they question 

the information provided by applicants or have reason to believe a 

transfer may have occurred, such as if an applicant reported making a 

transfer. Appendix VII provides information on the proportion of applicants 

for which each state reported taking additional verification steps to identify 

assets transferred for less than FMV during the look-back period.

Although 25 states were supposed to have implemented their electronic 

AVS to obtain information from financial institutions by the end of fiscal 

year 2011, no state had implemented one at the time of our survey. 

Eighteen states reported that they were in the process of implementing an 

AVS, while the remaining 33 states had yet to begin implementation.

When asked about the challenges to implementing an AVS, 32 states 

reported that they did not have enough resources—such as money, staff, 

or time—required to implement such a system, and 18 states reported 

that it had been or would be challenging to get financial institutions to 

participate and provide information. One state reported that it had initially 

planned to have its AVS implemented by December 2011, but was unable 

to do so because financial institutions in the state were unwilling to 

participate in the AVS until state legislation is passed that releases the 

financial institutions from any liability, ensures they are fairly reimbursed 

for their services, and makes the process voluntary. The state Medicaid 

program is seeking such legislation during the state’s 2012 legislative 

session and then plans to proceed with implementing its AVS.

Take Additional Steps to 

Identify Asset Transfers 

No State Had Implemented 

an Asset Verification 

System to Obtain 

Information from Financial 

Institutions 
 

Page 22 GAO-12-749 Medicaid Long-Term Care

CMS acknowledged that states may have challenges that could affect 

their ability to implement an AVS as scheduled. CMS officials were aware 

of states’ progress in implementing the AVS and told us that the agency 

was regularly communicating with states regarding AVS implementation.

On the basis of states’ responses to questions about the documentation 

required from applicants and the asset information obtained from third 

parties, it is unclear whether some states obtain sufficient information to 

implement certain DRA provisions, particularly the provisions related to 

the look-back period and home equity. The results of our survey raise 

questions about some states’ implementation of the DRA, but are not 

conclusive, and we have additional work planned related to Medicaid 

long-term care financial eligibility.

• Look-back Period. We asked states about (1) the number of months 

of financial and investment resources documentation required to 

determine eligibility, (2) additional documentation required to identify 

assets transferred for less than fair market value, and (3) number of 

months of documentation obtained directly from financial institutions. 

When considering states’ responses to those questions, we found that 

31 states reported obtaining less than 60 months of information about 

at least some applicants’ assets.24 Three of the 31 states reported 

requiring a single month of documentation from applicants and did not 

obtain any information from financial institutions.25

 

24The 31 states are: Alaska, Arizona, Arkansas, California, Colorado, District of Columbia, 

Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Massachusetts, 

Michigan, Minnesota, Nebraska, New Mexico, North Dakota, Oklahoma, Pennsylvania, 

Rhode Island, South Dakota, Tennessee, Texas, Virginia, Washington, West Virginia, 

Wisconsin, and Wyoming. Ten of these states reported they may require up to 60 months 

of additional documentation from at least some applicants to identify assets that were 

transferred for less than FMV or may request additional information from financial 

institutions or a combination of both factors, in situations where, for example, an applicant 

reported making a transfer or submitted insufficient information.

CMS officials noted 

that it is costly and time consuming to conduct a review for the 

60 month look-back period. Thus, these officials stated, it was 

understandable for states to use discretion and only conduct reviews 

when there is reason to believe that a transfer could have been made 

during the look-back period. For example, a state might determine the 

need to conduct a more thorough review as a result of red flags found 

25The 3 states are: Arkansas, District of Columbia, and Minnesota.

It Is Unclear Whether 

Some States Obtain 

Sufficient Information 

to Implement Certain 

DRA Provisions
 

Page 23 GAO-12-749 Medicaid Long-Term Care

through other checks, such as when an applicant has very high 

income and no resources. However, the application forms in 6 of the 

31 states did not ask about transfers made during the entire look-back 

period.26 Thus, it is unclear how these 6 states would know whether 

assets were transferred for less than FMV in the 60 months prior to 

application, and how all 31 states would be able to detect unreported 

transfers of assets made during the entire look-back period. In 

contrast, 20 states reported requiring 60 months of documentation 

from all applicants, 5 of which also requested 60 months of 

information from financial institutions for at least some applicants.27

• Home Equity. Fourteen states reported not requiring documentation 

of a primary residence. Of these 14 states, 8 indicated that they 

conduct property record searches in the county of residence for at 

least some applicants to try to obtain information about property the 

applicant may own.28 Additionally, 1 state indicated that it could obtain 

information about an applicant’s primary residence from a third 

party.29

 

26The 6 states are: Arizona, Arkansas, California, District of Columbia, Georgia, and 

Indiana. These states’ application forms either did not ask about transfers of assets or 

asked about transfers made for a period of time less than 60 months. Our review was 

limited to state application forms for Medicaid coverage for long-term care provided to us 

by state officials. Some states might ask about transfers made during the look-back period 

through other means, such as a form other than the long-term care application form or 

through an interview conducted as part of the application process.

The remaining 5 states reported they did not conduct property 

records searches; as such, it is unclear how these states would 

determine if an applicant owns a home that he or she failed to report, 

27The 20 states are: Alabama, Connecticut, Delaware, Hawaii, Illinois, Maine, Maryland, 

Mississippi, Missouri, Montana, Nevada, New Hampshire, New Jersey, New York, North 

Carolina, Ohio, Oregon, South Carolina, Utah, and Vermont.

28Of the 8 states, 4 conduct searches of property records from the county of residence for 

all applicants (Louisiana, Maine, Montana, and Oklahoma); 1 conducts such searches for 

most applicants (Iowa); and 3 do so for less than half of applicants (Alaska, New York, 

and Vermont). Additionally, although Vermont reported not requiring documentation of a 

primary residence, the state indicated that documentation would be required if it appeared 

as though an applicant’s equity interest in his or her primary residence might exceed the 

allowable amount.

29The state is Minnesota.
 

Page 24 GAO-12-749 Medicaid Long-Term Care

and the value of an applicant’s equity interest in the home.30 Of the 

37 states that reported requiring applicants to submit documentation 

of a primary residence, only 3 reported requiring documentation that 

could provide the state with information on the value of the home or 

an applicant’s equity interest in the home.31 The remaining 

34 states reported requiring documentation about applicants’ primary 

residence, but the documentation received may not provide all of the 

information necessary to determine if applicants’ equity interest in 

their homes exceeds the state’s allowable amount.

• Life Estates. Among the 32 states that provided information on our 

survey about life estates, 2 states reported not assessing the length of 

time an applicant with a life estate resided in the property.32 The 

remaining 30 states reported requiring some type of proof in order to 

determine the amount of time an applicant resided in the property 

after the purchase of the life estate interest.33

 

30The 5 states are: Arkansas, California, District of Columbia, Tennessee, and Virginia. 

Although Arkansas reported not requiring documentation of a primary residence and not 

conducting property searches, the state indicated that documentation would be required if 

it appeared as though an applicant’s equity interest in his or her primary residence might 

exceed the allowable amount.

On the basis of our 

analysis of state responses, 7 of the 30 states reported relying only on 

a statement from an applicant or another person who owns the 

residence to determine the length of time an applicant resided in the 

property; however, 2 of these 7 states said that they would require 

more documentation if they determined that the information they 

received was questionable. The remaining 23 states reported relying 

on documentation, such as a utility bill; a statement from an applicant; 

31The 3 states are: Delaware, Indiana, and Nebraska. Delaware and Indiana reported 

requiring applicants to provide documentation of the current assessed value of their 

primary residence; this documentation should provide the states with sufficient information 

to know if a home is valued above the states’ home equity limit and thus whether 

additional information about an applicant’s equity interest is needed. Nebraska required 

applicants to submit mortgage statements and property tax assessments; this combination 

of documentation should provide the state with sufficient information to determine if an 

applicant’s equity interest exceeds the state-specified maximum level.

32The 2 states are Iowa and Maine; it is unclear how these 2 states would have the 

necessary information to implement the DRA provision that life estates are to be 

considered a transfer for less than FMV unless the purchaser resided in the home for at 

least a year after the date of purchase.

33Nineteen states either did not provide an answer to this question or they did not provide 

a response that adequately answered the question.
 

Page 25 GAO-12-749 Medicaid Long-Term Care

a statement from a third party; or some combination of these sources 

to determine the length of time an applicant lived in the property.

• CCRCs. On the basis of our survey results, most states—46 of 

51—reported requiring applicants to provide documentation of CCRC 

or life care community entrance fees, such as a copy of the contract 

or agreement. Thus, these states should have sufficient information to 

determine if, under the DRA, an applicant’s entrance fees should be 

countable resources for determining Medicaid eligibility. However, it is 

unclear how the remaining 5 states would be able to determine if an 

applicant has paid such fees, and whether they should be counted 

toward the applicant’s Medicaid long-term care eligibility 

determination.

• Promissory Notes. Fifty states reported on our survey that they 

require applicants to provide documentation of promissory notes or 

loans; such documentation should allow the state to determine if a 

note meets the requirements specified in the DRA, such as providing 

for payments to be made in equal installments throughout the course 

of the loan, or if a note should be treated as a transfer of assets for 

less than FMV.34

• Annuities. In responding to our survey, all states reported requiring 

documentation of annuities and thus should have sufficient 

information to determine whether an annuity should be considered a 

transfer of assets for less than FMV under the DRA. Additionally, our 

review of 49 states’ long-term care application forms found that 

45 required the disclosure of any interest the applicant or spouse has 

in an annuity and 27 contained statements regarding the state 

becoming a remainder beneficiary of such annuities. (See app. VIII.)35

 

34One state, the District of Columbia, did not indicate whether documentation of 

promissory notes was required.

35Two states, Arizona and Kentucky, collected information from applicants through an 

interview rather than a paper application form and, as such, were not included in our 

analysis. Our review was limited to state application forms for Medicaid coverage for longterm care provided to us by state officials. Some states might require disclosure of an 

interest in an annuity or include a statement regarding the need to name the state as a 

remainder beneficiary through other means, such as a form other than the long-term care 

application form or through an interview conducted as part of the application process. 
 

Page 26 GAO-12-749 Medicaid Long-Term Care

As the demand for long-term care services increases and federal and 

state resources continue to be strained, it is important to ensure that only 

eligible individuals receive Medicaid coverage for long-term care. Since 

each state is responsible for day-to-day implementation of its Medicaid 

program, variation in policies and practices for determining financial 

eligibility is expected. However, some of the variation we found may raise 

questions regarding how states determine Medicaid eligibility for longterm care and enforce certain provisions of the DRA.

States must balance the costs of eligibility determination efforts with the 

need to ensure that those efforts provide sufficient information to 

implement federal requirements. While third-party verification of 

applicants’ financial information likely provides states with the best 

assurance of having a complete picture of an applicant’s financial status, 

it can be a complex and costly process that requires a significant amount 

of information and review. Given the complexities involved, it may be 

reasonable for states to adhere to a risk-based approach and focus their 

eligibility determination efforts on applicants who appear to be more likely 

to have assets or to have transferred assets that would make them 

ineligible. The electronic AVS that is required by law may help states 

identify some unreported or transferred assets. However, it is too early to 

assess its overall effectiveness, which will ultimately depend on the 

breadth of the financial institutions participating and the depth of the 

information obtained.

We provided a draft of this report to HHS for its review, and HHS provided 

written comments (see app. IX). HHS concurred with our findings and 

noted that the results of our comprehensive report will serve as a 

resource for all interested parties. Further, HHS indicated that the report 

will be helpful for targeting CMS’s ongoing technical assistance and 

oversight efforts with states.

As agreed with your offices, unless you publicly announce the contents of 

this report earlier, we plan no further distribution until 30 days from the 

report date. At that time, we will send copies to the Administrator of CMS 

and other interested parties. In addition, the report will be available at no 

charge on the GAO website at http://www.gao.gov. 

Concluding 

Observations 

Agency Comments
 

Page 27 GAO-12-749 Medicaid Long-Term Care

If you or your staff have any questions about this report, please contact 

me at (202) 512-7114 or yocomc@gao.gov. Contact points for our Offices 

of Congressional Relations and Public Affairs may be found on the last 

page of this report. GAO staff who made key contributions to this report 

are listed in appendix X.

Carolyn L. Yocom

Director, Health Care
Appendix I: GAO Analysis of State 

Applications

Page 28 GAO-12-749 Medicaid Long-Term Care

Table 8: Characteristics of Medicaid Long-Term Care Application Processes, by 

State, 2011

Level of information on 

assets requested on 

application form

Whether interviews are 

conducted for

State Comprehensivea General All applicants

Some 

applicants

Alabama ● ●

Alaska ● ●

Arizona b ●

Arkansas ● ●

California ● ●

Colorado ● ●

Connecticut ●

Delaware ● ●

District of 

Columbia

●

Florida ● ●

Georgia ● ●

Hawaii ● ●

Idaho ● ●

Illinois ●

Indiana ● ●

Iowa ● ●

Kansas ●

Kentucky c c ●

Louisiana ● ●

Maine ● ●

Maryland ● ●

Massachusetts ● ●

Michigan ● ●

Minnesota ● ●

Mississippi ● ●

Missouri ● ●

Montana ● ●

Nebraska ● ●

Nevada ●

New Hampshire ● ●

New Jersey ● ●

Appendix I: GAO Analysis of State 

Applications 
Appendix I: GAO Analysis of State 

Applications

Page 29 GAO-12-749 Medicaid Long-Term Care

Level of information on 

assets requested on 

application form

Whether interviews are 

conducted for

State Comprehensivea General All applicants

Some 

applicants

New Mexico ● ●

New York ●

North Carolina ●

North Dakota ● ●

Ohio ● ●

Oklahoma ● ●

Oregon ● ●

Pennsylvania ● ●

Rhode Island ● ●

South Carolina ● ●

South Dakota ● ●

Tennessee ● ●

Texas ● ●

Utah ● ●

Vermont ● ●

Virginia ● ●

Washington ● ●

West Virginia ● ●

Wisconsin ● ●

Wyoming ● ●

Total 44 5 23 21

Source: GAO analysis of state application forms for Medicaid coverage for long-term care and GAO web-based survey administered to 

state Medicaid officials.

a

Application forms requesting comprehensive information on assets asked applicants to provide 

detailed information on several types of assets, such as specifically requesting or referencing 

checking and savings accounts, stocks and bonds, retirement accounts, burial insurance, real 

property, and vehicles.

b

State collected information from applicants through an interview rather than a paper application form. 

A state official provided the form eligibility workers use during their interviews with applicants, and this 

form requests comprehensive information on applicants’ assets.

c

State collected information from applicants through an interview rather than a paper application form.
Appendix I: GAO Analysis of State 

Applications

Page 30 GAO-12-749 Medicaid Long-Term Care

Table 9: Time Frame of Information on Transfers of Assets Requested in Medicaid 

Long-Term Care Application Forms, by State, 2011

Application form requested information on transfers

State Within previous 60 months Within another time frame

Alabama ●

Alaska ●

Arizona a

Arkansas b b

California ●c

Colorado ●

Connecticut ●d

Delaware ●

District of Columbia ●e

Florida ●

Georgia f f

Hawaii ●

Idaho ●

Illinois ●d

Indiana f f

Iowa ●

Kansas ●

Kentucky g g

Louisiana ●h

Maine ●

Maryland ●

Massachusetts ●

Michigan ●

Minnesota ●

Mississippi ●

Missouri ●

Montana ●

Nebraska ●

Nevada ●

New Hampshire ●

New Jersey ●i

New Mexico ●

New York ●
Appendix I: GAO Analysis of State 

Applications

Page 31 GAO-12-749 Medicaid Long-Term Care

Application form requested information on transfers

State Within previous 60 months Within another time frame

North Carolina ●d

North Dakota ●

Ohio f f

Oklahoma ●

Oregon ●

Pennsylvania ●

Rhode Island ●

South Carolina ●

South Dakota ●

Tennessee ●

Texas ●

Utah ●

Vermont ●

Virginia ●

Washington ●

West Virginia ●

Wisconsin ●

Wyoming ●

Total 38 7 

Source: GAO analysis of state application forms for Medicaid coverage for long-term care.

Notes: Our review was limited to state application forms for Medicaid coverage for long-term care 

provided to us by state officials. Some states might ask about transfers of assets through other 

means, such as a form other than the long-term care application form or through an interview 

conducted as part of the application process.

a

State collected information from applicants through an interview rather than a paper application form. 

A state official provided the form eligibility workers use during their interviews with applicants, and this 

form asked about transfers made in the last 36 months; 60 months for trusts.

b

State’s application form did not ask about transfers, but did ask whether the applicant or his/her 

spouse sold or gave away a home or other real property.

c

State’s application form asked about transfers made in the last 30 months; 60 months for trusts.

d

State’s application form asked about transfers made in the last 36 months; 60 months for trusts.

e

State’s application form asked about transfers greater than $1,000 that were made during the last 

36 months.

f

State’s application form did not ask about transfers.

g

State collected information from applicants through an interview rather than a paper application form.

h

State’s application form asked about transfers ever made.

i

State’s application form asked about transfers made in the last 36 months.
Appendix II: States’ Asset Documentation 

Requirements

Page 32 GAO-12-749 Medicaid Long-Term Care

Table 10a: Applicant Documentation Requirements for Medicaid Long-Term Care, by State and Type of Asset, 2011

Earned 

income

Unearned 

income

Financial and 

investment 

resources

Life 

insurance

Primary 

residence

Other real 

property Vehicles

Alabama ● ● ● ● ● ● ●

Alaska ● ●a ● ● b ●

Arizona ● ● ● ● ● ● ●

Arkansas ● ● ● ● c ● ●

California ● ● ● ● d ● ●

Colorado e ● ● ● ● ● ●

Connecticut ● ● ● ● ● ● ●

Delaware ● ● ● ● ● ● ●

District of Columbia ● ● ●f ● g ●

Florida ● ● ● ● ● ● ●

Georgia ● ● ● ● ● ● ●

Hawaii ● ● ● ● ● ● ●

Idaho ● ●a ●f ● ● ● h

Illinois ● ●a ● ● ● ● ●

Indiana ● ● ● ● ● ● ●

Iowa ● ● ● ● i i

Kansas ● ● ● ● ● ●

Kentucky ● ● ● ● ● ● ●

Louisiana ● i ● j ●

Maine ● ● ● ● ● ●

Maryland ● ● ● ● ●i ● ●k

Massachusetts ● ● ● ● ● ● ●

Michigan ● ●a ● ● ● ● ●

Minnesota ● ● ● ● i ● ●

Mississippi ● ●a ● ● ● ●

Missouri ● ● ● ● ● ● ●

Montana ● ● ● ● i ● ●

Nebraska ● ● ● ● ● ● ●

Nevada ● ● ● ● ● ● ●

New Hampshire ● ● ● ● ● ● ●

New Jersey ● ● ● ● ● ● ●

New Mexico ● i ● ● ● ● ●

New York ● ● ● ● d ● ●

North Carolina ● ● ● ● ● ● ●

Appendix II: States’ Asset Documentation 

Requirements
Appendix II: States’ Asset Documentation 

Requirements

Page 33 GAO-12-749 Medicaid Long-Term Care

Earned 

income

Unearned 

income

Financial and 

investment 

resources

Life 

insurance

Primary 

residence

Other real 

property Vehicles

North Dakota ● ● ● ● ● ●

Ohio ● ● ● ● ● ● ●

Oklahoma ● ● ● ● i ● ●

Oregon ● ● ● ● ● ● ●

Pennsylvania ● ● ● ● ● ● ●

Rhode Island ● ● ● ● ● ● ●

South Carolina ● ● ● ● ● ● ●

South Dakota ● ● ● ● ● ●

Tennessee ● ●a ● ● c ●

Texas ● ● ● ● ● ● ●

Utah ● ● ●l ● ● ●

Vermont ● ● ● ●m n ● ●

Virginia ● ●a ● ● b ●

Washington ● ● ●o ● ● ●

West Virginia ● ● ● ● ● ● ●

Wisconsin ● ●i ● ● ● ● ●

Wyoming ● ● ● ● ● ● ●

Total 50 49 51 50 37 50 38

Source: GAO web-based survey administered to state Medicaid officials.

a

State reported it did not require documentation of at least some types of unearned income that could 

be verified with third parties.

b

State reported it did not count a primary residence when determining an applicant’s eligibility—and 

therefore did not require documentation—if an applicant was living in the home or intended to return 

home.

c

State reported it did not require documentation of primary residence unless it appeared as though 

the primary residence could exceed the allowable amount of equity interest. 

d

State reported it did not require documentation of primary residence because it was not countable 

when determining an applicant’s eligibility.

e

State reported it did not require documentation of earned income because it was verified through an 

interface with the state’s Department of Labor.

f

State reported it did not require documentation of financial and investment resources if reported 

resources were below a designated level.

g

State reported it did not count a primary residence when determining an applicant’s eligibility—and 

therefore did not require documentation—if an applicant’s spouse, child under 20 years old, or 

disabled child was living in the home.

h

State reported requiring documentation of vehicle loan value only if it affected eligibility 

determination.

i

State reported it did not require documentation of this type of asset if it could be verified with a third 

party.

j

State reported requiring documentation of a life insurance policy if the applicant reported that it had a 

face value of $10,000 or more.

k

State reported only requiring documentation of vehicles other than automobiles.
Appendix II: States’ Asset Documentation 

Requirements

Page 34 GAO-12-749 Medicaid Long-Term Care

l

State reported it may not require documentation of financial and investment resources if applicant 

reported having resources valued at well below the standard.

mState reported it did not require documentation of term life insurance policies. State also did not 

require documentation of a life insurance policy if the applicant reported that it had a face value of 

$1,500 or less.

n

State reported it did not require documentation of primary residence unless the applicant reported 

the value of the residence was within $200,000 of the allowable amount of equity interest.

o

State reported requiring documentation of financial and investment resources if the applicant was 

applying for the first time, was previously denied coverage, had not received benefits in many years, 

or if the applicant’s reported resources were deemed questionable; otherwise, state did not require 

documentation.
Appendix II: States’ Asset Documentation 

Requirements

Page 35 GAO-12-749 Medicaid Long-Term Care

Table 10b: Applicant Documentation Requirements for Medicaid Long-Term Care, by State and Type of Asset, 2011 

(continued)

State Annuity Burial contracta CCRC entrance feeb Life estatec Promissory note or loan Trust

Alabama ● ● ● ● ● ●

Alaska ● ● ● ● ● ●

Arizona ● ● ● ● ● ●

Arkansas ● ● ● ● ● ●

California ● ● ● ● ●

Colorado ● ● ● ● ● ●

Connecticut ● ● ● ● ●

Delaware ● ● ● ● ●

District of Columbia ● ● ● — ●

Florida ● ● ● ● ● ●

Georgia ● ● ● ● ● ●

Hawaii ● ● ● ● ● ●

Idaho ● ● ● ● ● ●

Illinois ● ● ● ● ● ●

Indiana ● ● ● ● ● ●

Iowa ● ● ● ● ● ●

Kansas ● ● ● ● ● ●

Kentucky ● ● ● ● ● ●

Louisiana ● ● ● ● ● ●

Maine ● ● ● ● ● ●

Maryland ● ● ● ● ● ●

Massachusetts ● ● ● ● ● ●

Michigan ● ● ● ● ● ●

Minnesota ● ● ● ● ● ●

Mississippi ● ● ● ● ● ●

Missouri ● ● ● ● ● ●

Montana ● ● ● ● ● ●

Nebraska ● ● ● ● ● ●

Nevada ● ● ● ● ● ●

New Hampshire ● ● ● ● ● ●

New Jersey ● ● ● ● ● ●

New Mexico ● ● ● ● ● ●

New York ● ● ● ● ● ●

North Carolina ● ● ● ● ● ●

North Dakota ● ● ● ● ● ●
Appendix II: States’ Asset Documentation 

Requirements

Page 36 GAO-12-749 Medicaid Long-Term Care

State Annuity Burial contracta CCRC entrance feeb Life estatec Promissory note or loan Trust

Ohio ● ● ● ● ● ●

Oklahoma ● ● ● ● ● ●

Oregon ● ● ● ● ● ●

Pennsylvania ● ● ● ● ● ●

Rhode Island ● ● ● ● ●

South Carolina ● ● ● ● ● ●

South Dakota ● ● ● ● ● ●

Tennessee ● ● ● ● ● ●

Texas ● ● ● ● ● ●

Utah ● ● ● ● ● ●

Vermont ● ● ● ● ● ●

Virginia ● ● ● ● ● ●

Washington ● ● ● ● ● ●

West Virginia ● ● ● ● ● ●

Wisconsin ● ● ● ● ● ●

Wyoming ● ● ● ● ● ●

Total 51 51 46 51 50 51

Source: GAO web-based survey administered to state Medicaid officials.

Legend:

— = Response not provided.

a

Includes burial contracts and prepaid funeral arrangements.

b

CCRC is an abbreviation for continuing care retirement community.

c

A life estate is an interest in real property that gives the owner of the interest the right to use and 

possess the property only for the duration of the life of a person, usually the person who occupies the 

premises.
Appendix II: States’ Asset Documentation 

Requirements

Page 37 GAO-12-749 Medicaid Long-Term Care

Table 11: States’ Treatment of Earned Income Documentation, by Type of Documentation, 2011 

Number of states

Type of documentation Required

Acceptable as 

proof itself

Acceptable 

with other 

documentation Not acceptable 

Earning statement or pay stub 4 45 1 0 

Copy of check or check stuba 3 33 9 4 

Itemized bank statementa 1 6 20 22

Income tax returna 0 20 25 4 

W-2 tax forma 0 17 16 16

1099 tax formb 0 16 17 15

Written statement of earnings from employer 0 49 1 0 

Source: GAO web-based survey administered to state Medicaid officials.

Notes: This table only includes responses from the 50 states that reported requiring documentation of 

earned income. In each row, the number of states may not add to 50 because not all states specified 

the level of acceptability for the respective type of documentation.

a

One state did not specify the level of acceptability for this type of documentation.

b

Two states did not specify the level of acceptability for this type of documentation.
Appendix II: States’ Asset Documentation 

Requirements

Page 38 GAO-12-749 Medicaid Long-Term Care

Table 12: States’ Treatment of Earned Income Documentation, by State and Type of Documentation, 2011 

State 

Earning 

statement or 

pay stub

Copy of 

check or 

check stub

Itemized 

bank 

statement

Income 

tax return W-2 tax form

1099 

tax form

Written 

statement of 

earnings from 

employer

Alabama       

Alaskaa,b       

Arizonaa,b       

Arkansas       

Californiac       

Connecticut       

Delaware       

District of Columbia       

Floridad       

Georgiaa,d       

Hawaii       

Idahod       

Illinois       

Indiana       

Iowab       

Kansas       

Kentuckya   — — —  

Louisiana       

Maine       

Maryland       

Massachusetts       

Michigana,b       

Minnesotad       

Mississippi       

Missouri       

Montana       

Nebraska       

Nevada       

New Hampshire       

New Jersey       

New Mexico       

New Yorkc       

North Carolinac       
Appendix II: States’ Asset Documentation 

Requirements

Page 39 GAO-12-749 Medicaid Long-Term Care

State 

Earning 

statement or 

pay stub

Copy of 

check or 

check stub

Itemized 

bank 

statement

Income 

tax return W-2 tax form

1099 

tax form

Written 

statement of 

earnings from 

employer

North Dakota       

Ohio       

Oklahoma       

Oregon      — 

Pennsylvania       

Rhode Island       

South Carolina      — 

South Dakota       

Tennesseed       

Texasc       

Utah       

Vermontd       

Virginiad  —     

Washington       

West Virginia       

Wisconsinb       

Wyoming       

Source: GAO web-based survey administered to state Medicaid officials.

Legend:

 = Required.

 = Acceptable as proof by itself.

 = Acceptable as proof with other documentation.

 = Not acceptable as proof.

— = Response not provided.

Notes: This table only includes responses from the 50 states that reported requiring documentation of 

earned income. One state—Colorado—reported it did not require documentation of earned income.

a

State reported that it verified applicants’ earned income using The Work Number, which is a national 

database of employment and income information contributed directly by over 2,200 employers. The 

state considered The Work Number acceptable as proof by itself for documenting earned income.

b

State reported that it verified applicants’ earned income by contacting the employer directly, which it 

considered acceptable as proof by itself for documenting earned income.

c

State reported that it may accept applicants’ self-attestation in lieu of earned income documentation.

d

State reported that tax forms are acceptable only to show proof of earned income for self-employed 

applicants.
Appendix II: States’ Asset Documentation 

Requirements

Page 40 GAO-12-749 Medicaid Long-Term Care

Table 13: States’ Treatment of Unearned Income Documentation, by Type of Documentation, 2011

Number of states

Type of documentation Required

Acceptable as 

proof itself

Acceptable 

with other 

documentation Not acceptable 

Statement or letter from Social Security Administrationa 1 45 0 1 

Statement or letter from Veterans Administration 4 45 0 0 

Pension statement 3 44 2 0 

Retirement statement 3 41 5 0 

Statement of investment earnings 3 40 5 1 

Copy of check or check stubb 1 25 16 6 

Itemized bank statement 1 10 23 15

Income tax return 0 13 27 9 

Tax form showing interest, dividends, etc. 1 18 21 9 

Annuity schedule of payments 3 33 11 2 

Promissory note schedule of payments/interestb 2 30 15 1 

Copy of court documents 2 30 17 0 

Source: GAO web-based survey administered to state Medicaid officials.

Notes: This table only includes responses from the 49 states that reported requiring documentation of 

unearned income. In each row, the number of states may not add to 49 because not all states 

specified the level of acceptability for the respective type of documentation.

a

Two states did not specify the level of acceptability for this type of documentation.

b

One state did not specify the level of acceptability for this type of documentation.
Appendix II: States’ Asset Documentation 

Requirements

Page 41 GAO-12-749 Medicaid Long-Term Care

Table 14a: States’ Treatment of Unearned Income Documentation, by State and Type of Documentation, 2011

State 

Statement or 

letter from SSAa Statement or 

letter from VAb Pension statement

Retirement 

statement

Statement of 

investment 

earnings

Copy of check 

or check stub

Alabama      

Alaska      

Arizona      

Arkansas      

California      

Colorado      

Connecticut      

Delaware      

District of Columbia      

Florida      

Georgia      

Hawaii      

Idaho      

Illinois      

Indiana —     

Iowa      

Kansas      

Kentucky      

Maine      

Maryland      

Massachusetts      

Michigan      

Minnesota      

Mississippi      

Missouri      

Montana      

Nebraska      

Nevada      

New Hampshire      

New Jersey      

New York      

North Carolina      

North Dakota —     

Ohio      
Appendix II: States’ Asset Documentation 

Requirements

Page 42 GAO-12-749 Medicaid Long-Term Care

State 

Statement or 

letter from SSAa Statement or letter from VAb Pension statement

Retirement 

statement

Statement of 

investment 

earnings

Copy of check 

or check stub

Oklahoma      

Oregon      

Pennsylvania      

Rhode Island      

South Carolina      — 

South Dakota      

Tennessee      

Texas      

Utah      

Vermont      

Virginia      

Washington      

West Virginia      

Wisconsin      

Wyoming      

Source: GAO web-based survey administered to state Medicaid officials.

Legend:

 = Required.

 = Acceptable as proof by itself.

 = Acceptable as proof with other documentation.

 = Not acceptable as proof.

— = Response not provided.

Notes: This table only includes responses from the 49 states that reported requiring documentation of 

unearned income. The two states that reported they generally did not require documentation of 

unearned income were Louisiana and New Mexico.

a

SSA is an abbreviation for the Social Security Administration.

b

VA is an abbreviation for the Veterans Administration.
Appendix II: States’ Asset Documentation 

Requirements

Page 43 GAO-12-749 Medicaid Long-Term Care

Table 14b: States’ Treatment of Unearned Income Documentation, by State and Type of Documentation, 2011 (continued)

State 

Itemized bank 

statement

Income tax 

return

Tax form 

showing 

interest/ 

dividends

Annuity 

schedule of 

payments

Promissory 

note schedule 

of payments/ 

interest

Copy of court 

documents

Alabama      

Alaska      

Arizona      

Arkansas      

California      

Colorado      

Connecticut      

Delaware      

District of Columbia      

Florida      

Georgia      

Hawaii      

Idaho      

Illinois      

Indiana      

Iowa      

Kansas      

Kentucky      

Maine      

Maryland     — 

Massachusetts      

Michigan      

Minnesota      

Mississippi      

Missouri      

Montana      

Nebraska      

Nevada      

New Hampshire      

New Jersey      

New York      

North Carolina      

North Dakota      
Appendix II: States’ Asset Documentation 

Requirements

Page 44 GAO-12-749 Medicaid Long-Term Care

State 

Itemized bank 

statement

Income tax 

return

Tax form 

showing 

interest/ 

dividends

Annuity 

schedule of 

payments

Promissory 

note schedule 

of payments/ 

interest

Copy of court 

documents

Ohio      

Oklahoma      

Oregon      

Pennsylvania      

Rhode Island      

South Carolina      

South Dakota      

Tennessee      

Texas      

Utah      

Vermont      

Virginia      

Washington      

West Virginia      

Wisconsin      

Wyoming      

Source: GAO web-based survey administered to state Medicaid officials.

Legend:

 = Required.

 = Acceptable as proof by itself.

 = Acceptable as proof with other documentation.

 = Not acceptable as proof.

— = Response not provided.

Note: This table only includes responses from the 49 states that reported requiring documentation of 

unearned income. The two states that reported they generally did not require documentation of 

unearned income were Louisiana and New Mexico.
Appendix II: States’ Asset Documentation 

Requirements

Page 45 GAO-12-749 Medicaid Long-Term Care

Table 15: States’ Treatment of Financial and Investment Resources Documentation, by Type of Documentation, 2011

Number of states

Type of documentation Required

Acceptable as 

proof itself

Acceptable 

with other 

documentation Not acceptable 

Bank statement showing monthly balance 7 31 8 5 

Itemized bank statement 4 41 4 2 

Income tax returna 1 10 21 18

Retirement account statement 7 39 5 0 

Retirement account award letter 1 30 16 4 

Statement or letter from investment brokeragesa 1 40 8 1 

Certificate of stock or bond ownership 4 29 16 2 

Source: GAO web-based survey administered to state Medicaid officials.

a

One state did not specify the level of acceptability for this type of documentation.
Appendix II: States’ Asset Documentation 

Requirements

Page 46 GAO-12-749 Medicaid Long-Term Care

Table 16: States’ Treatment of Financial and Investment Resources Documentation, by State and Type of Documentation, 

2011 

State 

Bank 

statement 

showing 

monthly 

balance

Itemized 

bank 

statement

Income tax 

return

Retirement 

account 

statement

Retirement 

account 

award letter

Statement or 

letter from 

investment 

brokerages

Certificate of 

stock or bond 

ownership

Alabama       

Alaska       

Arizona       

Arkansas       

California      — 

Colorado       

Connecticut       

Delaware       

District of Columbia       

Florida       

Georgia       

Hawaii       

Idaho       

Illinois       

Indiana       

Iowa       

Kansas       

Kentucky       

Louisiana       

Maine       

Maryland       

Massachusetts       

Michigan       

Minnesota       

Mississippi       

Missouri       

Montana       

Nebraska       

Nevada       

New Hampshire       

New Jersey       

New Mexico       
Appendix II: States’ Asset Documentation 

Requirements

Page 47 GAO-12-749 Medicaid Long-Term Care

State 

Bank 

statement 

showing 

monthly 

balance

Itemized 

bank 

statement

Income tax 

return

Retirement 

account 

statement

Retirement 

account 

award letter

Statement or 

letter from 

investment 

brokerages

Certificate of 

stock or bond 

ownership

New York       

North Carolina       

North Dakota       

Ohio       

Oklahoma       

Oregon       

Pennsylvania       

Rhode Island       

South Carolina   —    

South Dakota       

Tennessee       

Texas       

Utah       

Vermont       

Virginia       

Washington       

West Virginia       

Wisconsin       

Wyoming       

Source: GAO web-based survey administered to state Medicaid officials.

Legend:

 = Required.

 = Acceptable as proof by itself.

 = Acceptable as proof with other documentation.

 = Not acceptable as proof.

— = Response not provided.
Appendix II: States’ Asset Documentation 

Requirements

Page 48 GAO-12-749 Medicaid Long-Term Care

Table 17: States’ Treatment of Life Insurance Documentation, by Type of Documentation, 2011

Number of states

Type of documentation Required

Acceptable as 

proof itself

Acceptable 

with other 

documentation Not acceptable

Copy of life insurance policya 4 33 12 0 

Written statement from insurance company showing 

current/face value of life insurance policy 5 39 6 0 

Source: GAO web-based survey administered to state Medicaid officials.

Notes: This table only includes responses from the 50 states that reported requiring documentation of 

life insurance. In each row, the number of states may not add to 50 because not all states specified 

the level of acceptability for the respective type of documentation.

a

One state did not specify the level of acceptability for this type of documentation.
Appendix II: States’ Asset Documentation 

Requirements

Page 49 GAO-12-749 Medicaid Long-Term Care

Table 18: States’ Treatment of Life Insurance Documentation, by State and Type of 

Documentation, 2011 

State 

Copy of life insurance 

policy

Written statement from 

insurance company showing 

current/face value of life 

insurance policy

Alabama  

Alaska  

Arizonaa  

Arkansas  

California  

Colorado  

Connecticut  

Delaware  

District of Columbia  

Florida  

Georgia  

Hawaii  

Idaho  

Illinois  

Indiana  

Iowa  

Kansas  

Kentucky  

Maine  

Maryland  

Massachusetts  

Michigana  

Minnesota  

Mississippi  

Missouri  

Montana  

Nebraska  

Nevada  

New Hampshire  

New Jersey  

New Mexico  

New York  
Appendix II: States’ Asset Documentation 

Requirements

Page 50 GAO-12-749 Medicaid Long-Term Care

State 

Copy of life insurance 

policy

Written statement from 

insurance company showing 

current/face value of life 

insurance policy

North Carolina  

North Dakota  

Ohio  

Oklahoma  

Oregon  

Pennsylvania  

Rhode Island  

South Carolinaa  

South Dakota  

Tennessee  

Texasa  

Utah  

Vermonta — 

Virginia  

Washington  

West Virginia  

Wisconsin  

Wyoming  

Source: GAO web-based survey administered to state Medicaid officials.

Legend:

 = Required.

 = Acceptable as proof by itself.

 = Acceptable as proof with other documentation.

— = Response not provided.

Notes: This table only includes responses from the 50 states that reported requiring documentation of 

life insurance. One state—Louisiana—reported it generally did not require documentation of life 

insurance.

a

State reported it would contact insurance companies directly to verify ownership and value of life 

insurance.
Appendix II: States’ Asset Documentation 

Requirements

Page 51 GAO-12-749 Medicaid Long-Term Care

Table 19: States’ Treatment of Primary Residence Documentation, by Type of Documentation, 2011

Number of states

Type of documentation Required

Acceptable as 

proof itself

Acceptable 

with other 

documentation Not acceptable

Property deed 3 20 13 1 

Property tax assessment statement or billa 1 23 12 0 

Assessment of current valuea 2 26 8 0 

Mortgage statementa 1 14 15 6 

Income tax returnb 0 4 9 21

Purchase or sale agreement 1 16 16 4 

Source: GAO web-based survey administered to state Medicaid officials.

Notes: This table only includes responses from the 37 states that reported requiring documentation of 

a primary residence. In each row, the number of states may not add to 37 because not all states 

specified the level of acceptability for the respective type of documentation.

a

One state did not specify the level of acceptability for this type of documentation.

b

Three states did not specify the level of acceptability for this type of documentation.
Appendix II: States’ Asset Documentation 

Requirements

Page 52 GAO-12-749 Medicaid Long-Term Care

Table 20: States’ Treatment of Primary Residence Documentation, by State and Type of Documentation, 2011

State Property deed

Property tax 

assessment 

statement or bill

Assessment of 

current value

Mortgage 

statement

Income tax 

return

Purchase or sale 

agreement

Alabama      

Arizona      

Colorado      

Connecticut      

Delaware      

Florida      

Georgia      

Hawaii      

Idaho      

Illinois      

Indiana     — 

Kansas      

Kentucky      

Maryland      

Massachusetts      

Michigan      

Mississippi      

Missouri      

Nebraska      

Nevada      

New Hampshire      

New Jersey      

New Mexico      

North Carolina      

North Dakota      

Ohio      

Oregon      

Pennsylvania      

Rhode Island  — — — — 

South Carolina     — 

South Dakota      

Texas      

Utah      

Washington      
Appendix II: States’ Asset Documentation 

Requirements

Page 53 GAO-12-749 Medicaid Long-Term Care

State Property deed

Property tax 

assessment 

statement or bill

Assessment of 

current value

Mortgage 

statement

Income tax 

return

Purchase or sale 

agreement

West Virginia      

Wisconsin      

Wyoming      

Source: GAO web-based survey administered to state Medicaid officials.

Legend:

 = Required.

 = Acceptable as proof by itself.

 = Acceptable as proof with other documentation.

 = Not acceptable as proof.

— = Response not provided.

Note: This table only includes responses from the 37 states that reported requiring documentation of 

a primary residence. The following 14 states reported they generally did not require documentation of 

a primary residence: Alaska, Arkansas, California, District of Columbia, Iowa, Louisiana, Maine, 

Minnesota, Montana, New York, Oklahoma, Tennessee, Vermont, and Virginia.
Appendix II: States’ Asset Documentation 

Requirements

Page 54 GAO-12-749 Medicaid Long-Term Care

Table 21: States’ Treatment of Documentation of Real Property other than Primary Residence, by Type of Documentation, 

2011

Number of states

Type of documentation Required

Acceptable as 

proof itself

Acceptable 

with other 

documentation Not acceptable 

Property deed 7 24 16 3 

Property tax assessment statement or billa 2 32 14 1 

Assessment of current value 4 34 10 2 

Mortgage statementb 1 13 23 11

Income tax returnc 0 3 14 30

Purchase or sale agreementa 3 20 25 1 

Source: GAO web-based survey administered to state Medicaid officials.

Notes: This table only includes responses from the 50 states that reported requiring documentation 

of real property other than a primary residence. In each row, the number of states may not add to 

50 because not all states specified the level of acceptability for the respective type of documentation.

a

One state did not specify the level of acceptability for this type of documentation.

b

Two states did not specify the level of acceptability for this type of documentation.

c

Three states did not specify the level of acceptability for this type of documentation.
Appendix II: States’ Asset Documentation 

Requirements

Page 55 GAO-12-749 Medicaid Long-Term Care

Table 22: States’ Treatment of Documentation of Real Property other than Primary Residence, by State and Type of 

Documentation, 2011 

State Property deed

Property tax 

assessment 

statement or bill

Assessment of 

current value

Mortgage 

statement

Income tax 

return

Purchase or 

sale agreement

Alabama      

Alaska      

Arizona      

Arkansas      

California      

Colorado      

Connecticut      

Delaware      

District of Columbia    —  

Florida      

Georgia      

Hawaii      

Idaho      

Illinois      

Indiana  —  — — 

Kansas      

Kentucky     — — 

Louisiana      

Maine      

Maryland      

Massachusetts      

Michigan      

Minnesotaa      

Mississippi      

Missouri      

Montanab      

Nebraska      

Nevada      

New Hampshire      

New Jersey      

New Mexico      

New York      

North Carolina      
Appendix II: States’ Asset Documentation 

Requirements

Page 56 GAO-12-749 Medicaid Long-Term Care

State Property deed

Property tax 

assessment 

statement or bill

Assessment of 

current value

Mortgage 

statement

Income tax 

return

Purchase or 

sale agreement

North Dakota      

Ohio      

Oklahoma      

Oregon      

Pennsylvania      

Rhode Island      

South Carolina     — 

South Dakota      

Tennessee      

Texas      

Utah      

Vermont      

Virginiac      

Washington      

West Virginia      

Wisconsin      

Wyoming      

Source: GAO web-based survey administered to state Medicaid officials.

Legend:

 = Required.

 = Acceptable as proof by itself.

 = Acceptable as proof with other documentation.

 = Not acceptable as proof.

— = Response not provided.

Notes: This table only includes responses from the 50 states that reported requiring documentation of 

real property other than a primary residence. One state—Iowa—generally did not require 

documentation of real property other than the primary residence.

a

State reported requiring a statement from a licensed appraiser if there was no online access to 

property tax statements or if the applicant disputed the property tax value.

b

State reported requiring documentation of value, but verified ownership of property with a third party.

c

State reported requiring a purchase or sale agreement only if the applicant sold the property.
Appendix II: States’ Asset Documentation 

Requirements

Page 57 GAO-12-749 Medicaid Long-Term Care

Table 23: States’ Treatment of Vehicle Documentation, by Type of Documentation, 2011

Number of states

Type of documentation Required

Acceptable as 

proof itself

Acceptable 

with other 

documentation Not acceptable 

Vehicle title 3 25 8 2 

Vehicle registration documenta 1 25 9 1 

Statement of vehicle loan balance 2 13 17 6 

Written assessment of vehicle value from vehicle dealer 2 23 12 1 

Source: GAO web-based survey administered to state Medicaid officials.

Notes: This table only includes responses from the 38 states that reported requiring documentation of 

vehicles. In each row, the number of states may not add to 38 because not all states specified the 

level of acceptability for the respective type of documentation.

a

Two states did not specify the level of acceptability for this type of documentation.
Appendix II: States’ Asset Documentation 

Requirements

Page 58 GAO-12-749 Medicaid Long-Term Care

Table 24: States’ Treatment of Vehicle Documentation, by State and Type of Documentation, 2011 

State Vehicle title

Vehicle registration 

document

Statement of vehicle 

loan balance

Written assessment of 

vehicle value from 

vehicle dealer

Alabama    

Arizona    

Arkansas    

California    

Colorado    

Connecticut    

Delaware    

Florida    

Georgia    

Hawaii    

Illinois    

Indiana  —  

Kentucky    

Maine    

Maryland    

Massachusetts    

Michigan    

Minnesota    

Missouri    

Montana    

Nebraska  —  

Nevada    

New Hampshire    

New Jersey    

New Mexico    

New York    

North Carolina    

Ohio    

Oklahoma    

Oregon    

Pennsylvania    

Rhode Island    

South Carolina    

Texas    
Appendix II: States’ Asset Documentation 

Requirements

Page 59 GAO-12-749 Medicaid Long-Term Care

State Vehicle title

Vehicle registration 

document

Statement of vehicle 

loan balance

Written assessment of 

vehicle value from 

vehicle dealer

Vermont    

West Virginia    

Wisconsin    

Wyoming    

Source: GAO web-based survey administered to state Medicaid officials.

Legend:

 = Required.

 = Acceptable as proof by itself.

 = Acceptable as proof with other documentation.

 = Not acceptable as proof.

— = Response not provided.

Note: This table only includes responses from the 38 states that reported requiring documentation of 

vehicles. The following 13 states reported they generally did not require documentation of vehicles:

Alaska, District of Columbia, Idaho, Iowa, Kansas, Louisiana, Mississippi, North Dakota, South 

Dakota, Tennessee, Utah, Virginia, and Washington.
Appendix II: States’ Asset Documentation 

Requirements

Page 60 GAO-12-749 Medicaid Long-Term Care

Table 25: Amount of Required Documentation for Financial and Investment 

Resources, by State, 2011

Current and past months

State 

Current 

month 2 months 3 months 36 months 60 months

Alabama ●

Alaska ●

Arizona ●

Arkansas ●

California ●

Colorado ●

Connecticut ●

Delaware ●

District of Columbia ●

Florida ●

Georgia ●

Hawaii ●

Idaho ●

Illinois ●

Indianaa

Iowa ●

Kansas ●

Kentucky ●

Louisiana ●

Maine ●

Maryland ●

Massachusetts ●

Michigan ●

Minnesota ●

Mississippi ●

Missouri ●

Montana ●

Nebraska ●

Nevada ●

New Hampshire ●

New Jersey ●

New Mexico ●

New York ●
Appendix II: States’ Asset Documentation 

Requirements

Page 61 GAO-12-749 Medicaid Long-Term Care

Current and past months

State 

Current 

month 2 months 3 months 36 months 60 months

North Carolina ●

North Dakota ●

Ohio ●

Oklahoma ●

Oregon ●

Pennsylvania ●

Rhode Island ●

South Carolina ●

South Dakota ●

Tennessee ●

Texas ●

Utah ●

Vermont ●

Virginia ●

Washington ●

West Virginia ●

Wisconsin ●

Wyoming ●

Total 27 1 4 1 17

Source: GAO web-based survey administered to state Medicaid officials.

a

State reported it required both current and past documentation for financial and investment 

resources, but did not specify the number of months of documentation required because it is 

determined on a case-by-case basis. In some cases, the state may require up to 60 months of 

documentation.
Appendix II: States’ Asset Documentation 

Requirements

Page 62 GAO-12-749 Medicaid Long-Term Care

Table 26: Proportion of Applicants for Which States Require Additional 

Documentation to Identify Assets Transferred for Less Than Fair Market Value, by 

State, 2011

State Proportion of applicants

Alabama 

Alaskaa 

Arizona 

Arkansas 

Californiaa 

Coloradoa 

Connecticut 

Delaware 

District of Columbia 

Floridaa 

Georgiaa 

Hawaii 

Idahoa 

Illinoisb 

Indiana — 

Iowaa,b 

Kansasa 

Kentuckya,b 

Louisianaa 

Maine 

Maryland 

Massachusetts 

Michigana,b 

Minnesota 

Mississippi 

Missouria 

Montanaa,b 

Nebraskaa,b 

Nevadab 

New Hampshire 

New Jersey 

New Mexicoa 

New York 

North Carolina 
Appendix II: States’ Asset Documentation 

Requirements

Page 63 GAO-12-749 Medicaid Long-Term Care

State Proportion of applicants

North Dakotab 

Ohio 

Oklahoma 

Oregon 

Pennsylvaniaa 

Rhode Islanda,b 

South Carolina 

South Dakotaa 

Tennesseeb 

Texasa,b 

Utaha 

Vermont 

Virginiaa 

Washingtonb 

West Virginiaa,b 

Wisconsina 

Wyominga 

Source: GAO web-based survey administered to state Medicaid officials.

Legend:

 = All applicants.

 = Some applicants.

 = No applicants.

— = Response not provided.

a

State reported requiring additional documentation only if an applicant reported a transfer.

b

State reported requiring additional documentation only if it questioned the applicant’s information or 

had reason to believe a transfer may have occurred.
Appendix III: States’ Use of Data Matches to 

Verify Applicants’ Assets

Page 64 GAO-12-749 Medicaid Long-Term Care

Table 27a: Proportion of Applicants for which States Conduct Data Matches with Third Parties to Verify Applicants’ Assets, by 

State and Source of Data Match, 2011

State 

Social Security 

Administration

State 

unemployment 

records IEVSa PARISb

State wage 

files/directory of 

new hires

Alabama     

Alaska     

Arizona     

Arkansas    — 

California     

Colorado     

Connecticut     

Delaware  — — — — 

District of Columbia     

Florida     

Georgia     

Hawaii     

Idaho     

Illinois     

Indiana    — 

Iowa     

Kansas     

Kentucky     

Louisiana     

Maine     

Maryland     

Massachusetts     — 

Michigan     

Minnesota     

Mississippi     

Missouri     

Montana     

Nebraska     

Nevada     

New Hampshire     

New Jersey     

New Mexico     

New York     

Appendix III: States’ Use of Data Matches to 

Verify Applicants’ Assets
Appendix III: States’ Use of Data Matches to 

Verify Applicants’ Assets

Page 65 GAO-12-749 Medicaid Long-Term Care

State 

Social Security 

Administration

State 

unemployment 

records IEVSa PARISb

State wage 

files/directory of 

new hires

North Carolina     

North Dakota     

Ohio     

Oklahoma     

Oregon     

Pennsylvania     

Rhode Island     

South Carolina     

South Dakota     

Tennessee     

Texas  c   c

Utah     

Vermont     

Virginia     

Washington     

West Virginia     

Wisconsin     

Wyoming     

Source: GAO web-based survey administered to state Medicaid officials.

Legend:

 = All applicants.

 = Most (more than half) applicants.

 = Some applicants.

 = No applicants.

— = Response not provided.

a

IEVS is an abbreviation for Income and Eligibility Verification System; this system allows a state to 

match applicant-reported income information with data from the Internal Revenue Service, the Social 

Security Administration, and state wage and unemployment insurance benefit records. States that 

reported using this system to verify applicants’ assets may use some or all of the data available.

b

PARIS is an abbreviation for Public Assistance Reporting Information System. PARIS is an 

electronic data matching and information exchange system that is designed to match state enrollment 

information, including Medicaid enrollment, with data from other participating states and from a 

selected group of federal databases. The federal databases include, among other things, information 

on individuals’ receipt of income from the Department of Veterans Affairs, the Department of Defense, 

and the Office of Personnel Management. States that reported conducting a PARIS data match may 

use some or all of the data available.

c

State contracted with a data broker to perform various data matches including matches with state 

wage, unemployment, and workman’s compensation sources.
Appendix III: States’ Use of Data Matches to 

Verify Applicants’ Assets

Page 66 GAO-12-749 Medicaid Long-Term Care

Table 27b: Proportion of Applicants for which States Conduct Data Matches with Third Parties to Verify Applicants’ Assets, 

by State and Source of Data Match, 2011 (continued) 

State 

Internal Revenue 

Service

Department of 

Veterans Affairs

State workman’s 

compensation 

records

National Directory 

of New Hiresa State tax records

Alabama     

Alaska     

Arizona     

Arkansas    — 

California     

Colorado     

Connecticut     

Delaware — — — — — 

District of Columbia     

Florida     

Georgia     

Hawaii     

Idaho     

Illinois     

Indiana     

Iowa  — — — — 

Kansas     

Kentucky     

Louisiana     

Maine     

Maryland     

Massachusetts   —  — 

Michigan     

Minnesota     

Mississippi     

Missouri     

Montana     

Nebraska     

Nevada     

New Hampshire     

New Jersey  — —  

New Mexico     

New York     
Appendix III: States’ Use of Data Matches to 

Verify Applicants’ Assets

Page 67 GAO-12-749 Medicaid Long-Term Care

State 

Internal Revenue 

Service

Department of 

Veterans Affairs

State workman’s 

compensation 

records

National Directory 

of New Hiresa State tax records

North Carolina     

North Dakota     

Ohio     

Oklahoma     

Oregon     

Pennsylvania     

Rhode Island     

South Carolina     

South Dakota     

Tennessee     

Texas   b  

Utah     

Vermont    — 

Virginia     

Washington     

West Virginia     

Wisconsin     

Wyoming     

Source: GAO web-based survey administered to state Medicaid officials.

Legend:

 = All applicants.

 = Most (more than half) applicants.

 = Some applicants.

 = No applicants.

— = Response not provided.

a

The National Directory of New Hires is a national database of employment wage and unemployment 

insurance information for use by federal and state agencies.

b

State contracted with a data broker to perform various data matches including matches with state 

wage, unemployment, and workman’s compensation sources.
Appendix III: States’ Use of Data Matches to 

Verify Applicants’ Assets

Page 68 GAO-12-749 Medicaid Long-Term Care

Table 28a: Timing of State Data Matches in Relation to Eligibility Determination, by State and Source of Data Match, 2011

State 

Social Security 

Administration

State 

unemployment 

records IEVSa PARISb

State wage 

files/directory 

of new hires

Alabama  —   — 

Alaska     — 

Arizona   —  

Arkansas    N/A 

California     

Colorado  N/A   

Connecticut    — — 

Delaware  — — — — 

District of Columbia     — 

Florida  —   

Georgia    — 

Hawaii     

Idaho     

Illinois   N/A  

Indiana  — —  — 

Iowa     

Kansas   N/A  

Kentucky     

Louisiana     

Maine — — — — — 

Maryland —    

Massachusetts     N/A 

Michigan   N/A  

Minnesota     

Mississippi  —   — 

Missouri    N/A 

Montana     — 

Nebraska — — — — — 

Nevada     

New Hampshire     

New Jersey     

New Mexico     

New York   —  

North Carolina    — 
Appendix III: States’ Use of Data Matches to 

Verify Applicants’ Assets

Page 69 GAO-12-749 Medicaid Long-Term Care

State 

Social Security 

Administration

State 

unemployment 

records IEVSa PARISb

State wage 

files/directory 

of new hires

North Dakota     

Ohio     

Oklahoma     

Oregon     

Pennsylvania     

Rhode Island  —   — 

South Carolina    — — 

South Dakota     

Tennessee   — — 

Texas     

Utah     

Vermont     

Virginia     — 

Washington     

West Virginia    — 

Wisconsin     

Wyoming     

Source: GAO web-based survey administered to state Medicaid officials.

Legend:

 = Generally before eligibility determination.

 = Sometimes before and sometimes after eligibility determination.

 = Generally after eligibility determination.

N/A = Not applicable, state did not conduct data match with respective source.

— = Response not provided.

a

IEVS is an abbreviation for Income and Eligibility Verification System; this system allows a state to 

match applicant-reported income information with data from the Internal Revenue Service, the Social 

Security Administration, and state wage and unemployment insurance benefit records. States that 

reported using this system to verify applicants’ assets may use some or all of the data available.

b

PARIS is an abbreviation for Public Assistance Reporting Information System. PARIS is an 

electronic data matching and information exchange system that is designed to match state enrollment 

information, including Medicaid enrollment, with data from other participating states and from a 

selected group of federal databases. The federal databases include, among other things, information 

on individuals’ receipt of income from the Department of Veterans Affairs, the Department of Defense, 

and the Office of Personnel Management. States that reported conducting a PARIS data match may 

use some or all of the data available.
Appendix III: States’ Use of Data Matches to 

Verify Applicants’ Assets

Page 70 GAO-12-749 Medicaid Long-Term Care

Table 28b: Timing of State Data Matches in Relation to Eligibility Determination, by State and Source of Data Match, 2011 

(continued)

State 

Internal Revenue 

Service

Department of 

Veterans Affairs

State workman’s 

compensation 

records

National Directory 

of New Hiresa State tax records

Alabama —  — — — 

Alaska  — — — — 

Arizona —  — — — 

Arkansas   — N/A — 

California —  — — 

Colorado N/A N/A N/A N/A N/A

Connecticut   — — — 

Delaware — — — — — 

District of Columbia — — —  — 

Florida  N/A —  — 

Georgia    — — 

Hawaii   — — — 

Idaho  — — — — 

Illinois  N/A N/A  N/A

Indiana  — —  

Iowa  — — — — 

Kansas N/A N/A N/A N/A N/A

Kentucky  N/A N/A  N/A

Louisiana N/A N/A N/A N/A N/A

Maine — — — — — 

Maryland — — —  — 

Massachusetts — — N/A — N/A

Michigan  — N/A N/A N/A

Minnesota — —   

Mississippi — — — — — 

Missouri    — — 

Montana  — — — — 

Nebraska — — — N/A — 

Nevada N/A    — 

New Hampshire    N/A N/A

New Jersey  — —  

New Mexico —    — 

New York — — — — — 
Appendix III: States’ Use of Data Matches to 

Verify Applicants’ Assets

Page 71 GAO-12-749 Medicaid Long-Term Care

State 

Internal Revenue 

Service

Department of 

Veterans Affairs

State workman’s 

compensation 

records

National Directory 

of New Hiresa State tax records

North Carolina N/A    N/A

North Dakota  N/A N/A N/A N/A

Ohio  —  N/A — 

Oklahoma     — 

Oregon    N/A 

Pennsylvania   N/A  N/A

Rhode Island — — — — — 

South Carolina    — — 

South Dakota  N/A  N/A N/A

Tennessee  — —  — 

Texas —   — — 

Utah  N/A N/A N/A N/A

Vermont   — — — 

Virginia — — — — — 

Washington    — — 

West Virginia  — — — 

Wisconsin  — — — — 

Wyoming N/A   N/A N/A

Source: GAO web-based survey administered to state Medicaid officials.

Legend:

 = Generally before eligibility determination.

 = Sometimes before and sometimes after eligibility determination.

 = Generally after eligibility determination.

N/A = Not applicable, state did not conduct data match with respective source.

— = Response not provided.

a

The National Directory of New Hires is a national database of employment wage and unemployment 

insurance information for use by federal and state agencies.
Appendix IV: States’ Contact with Financial 

Institutions to Verify Applicants’ Assets

Page 72 GAO-12-749 Medicaid Long-Term Care

Table 29: Proportion of Applicants for which States Contact Financial Institutions to 

Verify Applicants’ Assets, by State and Type of Financial Institution, 2011

Institutions not reported by applicant

State 

Institutions with 

accounts reported 

by applicant Local Statewide National

Alaskaa    

Arizonaa    

Connecticut    

Illinoisa    

Indianaa   — — 

Kentucky    

Louisianaa    

Maine    

Marylanda    

Michigana    

Missouri    

New Jerseya    

New York    

North Carolina    

Oklahoma    

Pennsylvania    

Rhode Island    

South Carolinaa    

Texasa    

Vermont    

Virginia    

Washingtona    

Wisconsina    

Wyoming    

Source: GAO web-based survey administered to state Medicaid officials.

Legend:

 = All applicants.

 = Most (more than half) applicants.

 = Some applicants.

 = No applicants.

— = Response not provided.

Appendix IV: States’ Contact with Financial 

Institutions to Verify Applicants’ Assets
Appendix IV: States’ Contact with Financial 

Institutions to Verify Applicants’ Assets

Page 73 GAO-12-749 Medicaid Long-Term Care

Notes: This table only includes responses from the 24 states that reported contacting financial 

institutions. The following 27 states reported they did not contact financial institutions: Alabama, 

Arkansas, California, Colorado, Delaware, District of Columbia, Florida, Georgia, Hawaii, Idaho, Iowa, 

Kansas, Massachusetts, Minnesota, Mississippi, Montana, Nebraska, Nevada, New Hampshire, New 

Mexico, North Dakota, Ohio, Oregon, South Dakota, Tennessee, Utah, and West Virginia. Although 

Oregon reported that it generally did not contact financial institutions, the state noted it may request 

information from financial institutions with which an applicant reported having an account if an 

applicant did not provide sufficient documentation.

a

State reported only contacting financial institutions if an applicant submitted questionable or 

insufficient information.
Appendix IV: States’ Contact with Financial 

Institutions to Verify Applicants’ Assets

Page 74 GAO-12-749 Medicaid Long-Term Care

Table 30: Types and Number of Months of Information Requested from Financial 

Institutions, by State, 2011

Type of information requested

State Itemized statements Account balances

Number of 

months requested

Alaska ● 3 

Arizona ● 1 

Connecticut ● 60

Illinois ● 60

Indiana ● 3 

Kentucky ● 3 

Louisiana ● 3 

Maine ● 60

Maryland ● 60

Michigan ● 1 

Missouri ● 3 

New Jersey ● 60

New York ● 1 

North Carolina ● 1 

Oklahoma ● 12

Pennsylvania ● 1 

Rhode Island ● 6 

South Carolina ● 12

Texas ● 3 

Vermont ● 1a

Virginia ● 3 

Washington ● —b

Wisconsin ● 36

Wyoming ● 1 

Total 12 12

Source: GAO web-based survey administered to state Medicaid officials.

Legend:

— = Response not provided.
Appendix IV: States’ Contact with Financial 

Institutions to Verify Applicants’ Assets

Page 75 GAO-12-749 Medicaid Long-Term Care

Notes: This table only includes responses from the 24 states that reported contacting financial 

institutions. The following 27 states reported they did not contact financial institutions: Alabama, 

Arkansas, California, Colorado, Delaware, District of Columbia, Florida, Georgia, Hawaii, Idaho, Iowa, 

Kansas, Massachusetts, Minnesota, Mississippi, Montana, Nebraska, Nevada, New Hampshire, New 

Mexico, North Dakota, Ohio, Oregon, South Dakota, Tennessee, Utah, and West Virginia.

a

State reported that it requested the current balance for any open accounts and the closing balance 

for any accounts that were closed within the past 60 months.

b

State did not specify the number of months of information it requested and noted it would request 

whatever amount is needed.
Appendix IV: States’ Contact with Financial 

Institutions to Verify Applicants’ Assets

Page 76 GAO-12-749 Medicaid Long-Term Care

Table 31: Timing of States’ Contacts with Financial Institutions in Relation to 

Eligibility Determination, by State, 2011

State Point during eligibility determination process

Alaska 

Arizona 

Connecticut 

Illinois 

Indiana 

Kentucky 

Louisiana 

Maine 

Maryland 

Michigan 

Missouri 

New Jersey 

New York 

North Carolina 

Oklahoma 

Pennsylvania 

Rhode Island 

South Carolina 

Vermont 

Virginia 

Texas 

Washington 

Wisconsin 

Wyoming 

Source: GAO web-based survey administered to state Medicaid officials.

Legend:

 = Generally before eligibility determination.

 = Sometimes before and sometimes after eligibility determination.

 = Generally after eligibility determination.

Note: This table only includes responses from the 24 states that reported contacting financial 

institutions. The following 27 states reported they did not contact financial institutions: Alabama, 

Arkansas, California, Colorado, Delaware, District of Columbia, Florida, Georgia, Hawaii, Idaho, Iowa, 

Kansas, Massachusetts, Minnesota, Mississippi, Montana, Nebraska, Nevada, New Hampshire, New 

Mexico, North Dakota, Ohio, Oregon, South Dakota, Tennessee, Utah, and West Virginia.
Appendix V: States’ Use of Property Records 

Searches to Verify Applicants’ Assets

Page 77 GAO-12-749 Medicaid Long-Term Care

Table 32: Proportion of Applicants for which States Conduct Property Records 

Searches to Verify Applicants’ Assets, by State and Geographic Area of Property 

Search Conducted, 2011

State 

Applicant’s 

county of 

residence

Some other 

counties in 

state 

All counties 

in state

Locations in 

other states

Alabama    

Alaskaa    

Arizonab    

Coloradoa    

Connecticuta    

Delaware    

Georgia    

Hawaii    

Illinoisa    

Iowac    

Kansasa,b    — 

Kentucky   — — 

Louisianaa    

Maine    

Maryland    

Michigana    

Mississippi    

Missouria    

Montana    

Nevadad    

New Hampshiree    

New York    

North Carolina   — — 

Ohioa    

Oklahoma    

Oregonb    

Pennsylvaniaa    

Rhode Island    

South Carolina   — 

South Dakota    

Texas    

Vermont    

Appendix V: States’ Use of Property Records 

Searches to Verify Applicants’ Assets
Appendix V: States’ Use of Property Records 

Searches to Verify Applicants’ Assets

Page 78 GAO-12-749 Medicaid Long-Term Care

State 

Applicant’s 

county of 

residence

Some other 

counties in 

state 

All counties 

in state

Locations in 

other states

Washington    

Wisconsin    

Wyoming    

Source: GAO web-based survey administered to state Medicaid officials.

Legend:

 = All applicants.

 = Most (more than half) applicants.

 = Some applicants.

 = No applicants.

— = Response not provided.

Notes: This table only includes responses from the 35 states that reported conducting property 

searches. The following 16 states reported they did not conduct property searches: Arkansas, 

California, District of Columbia, Florida, Idaho, Indiana, Massachusetts, Minnesota, Nebraska, New 

Jersey, New Mexico, North Dakota, Tennessee, Utah, Virginia, and West Virginia.

a

State reported conducting a property search only if an applicant submits questionable or insufficient 

information.

b

State reported conducting a property search only if an applicant reports a property.

c

State reported it did not conduct a property search when an applicant intended to return home, was 

receiving Supplemental Security Income, or was already receiving Medicaid and had an apartment as 

a home address.

d

State reported it did not conduct a property search when an applicant was already receiving 

Medicaid or other government assistance.

e

State contracted with a company that conducted nationwide property searches.
Appendix V: States’ Use of Property Records 

Searches to Verify Applicants’ Assets

Page 79 GAO-12-749 Medicaid Long-Term Care

Table 33: Types of Information That Can Be Used to Conduct Property Records 

Searches, by State, 2011 

State 

Applicant’s 

name

Applicant’s 

Social Security 

number

Property street 

address

Property 

zip code

Alabama ● ● ●

Alaska ● ●

Arizona ● — ● — 

Colorado ● — ● — 

Connecticut ● ●

Delaware ● ● ●

Georgia ● ●

Hawaii ●

Illinois ● ● ● ●

Iowa ● ●

Kansas ● ●

Kentucky ● — ● — 

Louisiana ● ●

Maine ● ● ● ●

Maryland ● ● ●

Michigan ● ● ● ●

Mississippi ● ●

Missouri ● ● ●

Montana ●

Nevada ● ●

New 

Hampshire

● ● ● ●

New York ● — — — 

North Carolina ● ●

Ohio ● ● ●

Oklahoma ● ● ●

Oregon ● ●

Pennsylvania ● — ● — 

Rhode Island ● ● ●

South Carolina ● — ● ●

South Dakota ● ● ● ●

Texas ● ● ●

Vermont — — — — 
Appendix V: States’ Use of Property Records 

Searches to Verify Applicants’ Assets

Page 80 GAO-12-749 Medicaid Long-Term Care

State 

Applicant’s 

name

Applicant’s 

Social Security 

number

Property street 

address

Property 

zip code

Washington ● ●

Wisconsin ● ● ● ●

Wyoming ● ● ●

Total 33 10 32 12

Source: GAO web-based survey administered to state Medicaid officials.

Legend:

— = Response not provided.

Note: This table only includes responses from the 35 states that reported conducting property 

searches. The following 16 states reported they did not conduct property searches: Arkansas, 

California, District of Columbia, Florida, Idaho, Indiana, Massachusetts, Minnesota, Nebraska, New 

Jersey, New Mexico, North Dakota, Tennessee, Utah, Virginia, and West Virginia.
Appendix V: States’ Use of Property Records 

Searches to Verify Applicants’ Assets

Page 81 GAO-12-749 Medicaid Long-Term Care

Table 34: Timing of States’ Property Records Searches in Relation to Eligibility 

Determination, by State, 2011

State Point during eligibility determination process

Alabama 

Alaska 

Arizona 

Colorado 

Connecticut 

Delaware 

Georgia 

Hawaii 

Illinois 

Iowa 

Kansas 

Kentucky 

Louisiana 

Maine 

Maryland 

Michigan 

Mississippi 

Missouri 

Montana 

Nevada 

New Hampshire 

New York 

North Carolina 

Ohio 

Oklahoma 

Oregon 

Pennsylvania 

Rhode Island 

South Carolina 

South Dakota 

Texas 

Vermont 

Washington 
Appendix V: States’ Use of Property Records 

Searches to Verify Applicants’ Assets

Page 82 GAO-12-749 Medicaid Long-Term Care

State Point during eligibility determination process

Wisconsin 

Wyoming 

Source: GAO web-based survey administered to state Medicaid officials.

Legend:

 = Generally before eligibility determination.

 = Sometimes before and sometimes after eligibility determination.

 = Generally after eligibility determination.

Note: This table only includes responses from the 35 states that reported conducting property 

searches. The following 16 states reported they did not conduct property searches: Arkansas, 

California, District of Columbia, Florida, Idaho, Indiana, Massachusetts, Minnesota, Nebraska, New 

Jersey, New Mexico, North Dakota, Tennessee, Utah, Virginia, and West Virginia.
Appendix VI: States’ Use of Vehicle Records 

Searches to Verify Applicants’ Assets

Page 83 GAO-12-749 Medicaid Long-Term Care

Table 35: Proportion of Applicants for Which States Conduct Records Searches 

with the Department of Motor Vehicles to Verify Applicants’ Assets, by State, 2011

State Proportion of applicants

Alabama 

Alaskaa 

Arizona 

Arkansas 

California 

Colorado 

Connecticut 

Delaware 

District of Columbia 

Florida 

Georgia 

Hawaii 

Idaho 

Illinois 

Indiana 

Iowa 

Kansas 

Kentucky 

Louisiana 

Maine 

Maryland 

Massachusetts 

Michigana 

Minnesota 

Mississippi 

Missouria 

Montana 

Nebraska 

Nevadaa 

New Hampshire 

New Jersey 

New Mexico 

New York 

North Carolina 

Appendix VI: States’ Use of Vehicle Records 

Searches to Verify Applicants’ Assets
Appendix VI: States’ Use of Vehicle Records 

Searches to Verify Applicants’ Assets

Page 84 GAO-12-749 Medicaid Long-Term Care

State Proportion of applicants

North Dakota 

Ohio 

Oklahoma 

Oregon 

Pennsylvania 

Rhode Islanda 

South Carolina 

South Dakota 

Tennessee 

Texas 

Utah 

Vermonta 

Virginia 

Washington 

West Virginia 

Wisconsin 

Wyoming 

Source: GAO web-based survey administered to state Medicaid officials.

Legend:

 = All applicants.

 = Most (more than half) applicants.

 = Some applicants.

 = No applicants.

a

State reported conducting vehicle searches only if an applicant submitted questionable information.
Appendix VI: States’ Use of Vehicle Records 

Searches to Verify Applicants’ Assets

Page 85 GAO-12-749 Medicaid Long-Term Care

Table 36: Types of Information That Can Be Used to Conduct Vehicle Records Searches, by State, 2011 

State 

Applicant’s 

name

Applicant’s 

driver license 

number

Applicant’s 

license plate 

number

Applicant’s 

Social Security 

number

Vehicle identification 

number

Alaska ●

Colorado — — — — ●

Connecticut ● ●

Delaware ● ● ● ●

Florida ● ● ● ● ●

Kansas ● ● ● ●

Kentucky ● — — — — 

Maine ●

Maryland ● ● ● ●

Michigan ● ● ● ● ●

Missouri ●

Montana ● ● ●

Nebraska ● ● ● ●

Nevada ● ● ● ● ●

New Mexico ● ● ● ● ●

North Carolina ● ● ● ●

North Dakota ●

Ohio ● ● ● ●

Oregon ● ● ● ●

Pennsylvania ● ●

Rhode Island ● ● — — ●

South Carolina ● ● ● — ●

South Dakota ● ● ● ●

Utah ● ● ● ●

Vermont ● ● ● ●

Virginia ● ●

Washington ● ●

West Virginia ● ● ● ●

Wisconsin ● ● ● ● ●

Wyoming ● ● ● ●

Total 29 18 18 12 20

Source: GAO web-based survey administered to state Medicaid officials.
Appendix VI: States’ Use of Vehicle Records 

Searches to Verify Applicants’ Assets

Page 86 GAO-12-749 Medicaid Long-Term Care

Legend:

— = Response not provided.

Note: This table only includes responses from the 30 states that reported conducting vehicle 

searches. The following 21 states reported they did not conduct vehicle searches: Alabama, Arizona, 

Arkansas, California, District of Columbia, Georgia, Hawaii, Idaho, Illinois, Indiana, Iowa, Louisiana, 

Massachusetts, Minnesota, Mississippi, New Hampshire, New Jersey, New York, Oklahoma, 

Tennessee, and Texas.
Appendix VI: States’ Use of Vehicle Records 

Searches to Verify Applicants’ Assets

Page 87 GAO-12-749 Medicaid Long-Term Care

Table 37: Timing of States’ Record Searches with the Department of Motor Vehicles 

in Relation to Eligibility Determination, by State, 2011 

State Point during eligibility determination process

Alaska 

Colorado 

Connecticut 

Delaware 

Florida 

Kansas 

Kentucky 

Maine 

Maryland 

Michigan 

Missouri 

Montana 

Nebraska 

Nevada 

New Mexico 

North Carolina 

North Dakota 

Ohio 

Oregon 

Pennsylvania 

Rhode Island 

South Carolina 

South Dakota 

Utah 

Vermont 

Virginia 

Washington 

West Virginia 

Wisconsin 

Wyoming 

Source: GAO web-based survey administered to state Medicaid officials.
Appendix VI: States’ Use of Vehicle Records 

Searches to Verify Applicants’ Assets

Page 88 GAO-12-749 Medicaid Long-Term Care

Legend:

 = Generally before eligibility determination.

 = Sometimes before and sometimes after eligibility determination.

 = Generally after eligibility determination.

Note: This table only includes responses from the 30 states that reported conducting vehicle 

searches. The following 21 states reported they did not conduct vehicle searches: Alabama, Arizona, 

Arkansas, California, District of Columbia, Georgia, Hawaii, Idaho, Illinois, Indiana, Iowa, Louisiana, 

Massachusetts, Minnesota, Mississippi, New Hampshire, New Jersey, New York, Oklahoma, 

Tennessee, and Texas.
Appendix VII: States’ Collection of Third-Party 

Information to Identify Transfers of Assets

Page 89 GAO-12-749 Medicaid Long-Term Care

Table 38: Proportion of Applicants for Which States Take Additional Steps to Obtain 

Information from Third Parties to Identify Assets Transferred for Less Than Fair 

Market Value, by State, 2011

State Proportion of applicants

Alabama 

Alaskaa 

Arizona 

Arkansas 

California 

Colorado 

Connecticut 

Delaware 

District of Columbia 

Florida 

Georgia 

Hawaii 

Idaho 

Illinois 

Indiana — 

Iowa 

Kansas 

Kentuckya,b 

Louisianaa 

Maine 

Marylandb 

Massachusetts 

Michigana 

Minnesota 

Mississippi 

Missouri 

Montanaa 

Nebraska 

Nevadaa 

New Hampshire 

New Jerseya 

New Mexico 

New York 

North Carolina 

Appendix VII: States’ Collection of ThirdParty Information to Identify Transfers of 

Assets 
Appendix VII: States’ Collection of Third-Party 

Information to Identify Transfers of Assets

Page 90 GAO-12-749 Medicaid Long-Term Care

State Proportion of applicants

North Dakota 

Ohio 

Oklahoma 

Oregon 

Pennsylvania 

Rhode Island 

South Carolinab 

South Dakota 

Tennesseea 

Texas 

Utah 

Vermont 

Virginia 

Washington 

West Virginia 

Wisconsina 

Wyominga 

Source: GAO web-based survey administered to state Medicaid officials.

Legend:

 = All applicants.

 = Some applicants.

 = No applicants.

— = Response not provided.

a

State reported taking additional steps only if it questioned the applicant’s information or had reason 

to believe a transfer may have occurred.

b

State reported taking additional steps only if an applicant reported a transfer.
Appendix VIII: GAO Analysis of Annuity 

Language Contained in States’ Application 

Forms

Page 91 GAO-12-749 Medicaid Long-Term Care

Table 39: Characteristics of Medicaid Long-Term Care Application Forms Related to 

Deficit Reduction Act of 2005 (DRA) Annuity Provisions, by State, 2011

Application form contained language regarding 

requirements to

State 

Disclose interest in an 

annuity

Name the state as a remainder 

beneficiary

Alabama ● ●

Alaska ● ●

Arizona a a

Arkansas b ●

California ●

Colorado ●c

Connecticut ●

Delaware ● ●

District of Columbia

Florida ● ●d

Georgia

Hawaii ● ●

Idaho

Illinois ●

Indiana ●c ●e

Iowa ●c ●f

Kansas ● ●

Kentucky g g

Louisiana ● ●

Maine ● ●

Maryland ● ●

Massachusetts ● ●h

Michigan ●

Minnesota ●

Mississippi ●

Missouri ●

Montana ● ●

Nebraska ● ●

Nevada ●

New Hampshire ● ●

New Jersey ●

New Mexico ●

Appendix VIII: GAO Analysis of Annuity 

Language Contained in States’ Application 

Forms
Appendix VIII: GAO Analysis of Annuity 

Language Contained in States’ Application 

Forms

Page 92 GAO-12-749 Medicaid Long-Term Care

Application form contained language regarding 

requirements to

State 

Disclose interest in an 

annuity

Name the state as a remainder 

beneficiary

New York ● ●

North Carolina ● ●d

North Dakota ●

Ohio ●

Oklahoma ●c

Oregon ● ●

Pennsylvania ●

Rhode Island ● ●

South Carolina ● ●

South Dakota ● ●

Tennessee ● ●

Texas ● ●

Utah ●

Vermont ●

Virginia ● ●

Washington ● ●

West Virginia ●

Wisconsin ● ●i

Wyoming ●

Total 45 27

Source: GAO analysis of state application forms for Medicaid coverage for long-term care.

Notes: Our review was limited to state application forms for Medicaid coverage for long-term care 

provided to us by state officials. Some states might require disclosure of an interest in an annuity and 

include a statement regarding the state becoming a remainder beneficiary through another means, 

such as a form other than the long-term care application form or through an interview conducted as 

part of the application process.

a

State collected information from applicants through an interview rather than a paper application form. 

A state official provided the form eligibility workers use during their interviews with applicants and this 

form contained language regarding requirements to disclose interest in an annuity. It also contained 

language regarding the state becoming a remainder beneficiary, but specified this was for annuities 

purchased on or after July 1, 2006 (rather than the date included in the DRA provision—February 8, 

2006).

b

State’s application form included a statement regarding having to disclose interest in an annuity, but 

the sections of the application form that ask applicants to list their income or resources did not 

mention annuities.

c

State’s application form did not specify that annuities must be disclosed for the applicant’s spouse.

d

State’s application form contained language regarding the state becoming a remainder beneficiary, 

but specified this was for annuities purchased on or after November 1, 2007 (rather than the date 

included in the DRA provision—February 8, 2006).
Appendix VIII: GAO Analysis of Annuity 

Language Contained in States’ Application 

Forms

Page 93 GAO-12-749 Medicaid Long-Term Care

e

State’s application form contained language regarding the state becoming a remainder beneficiary, 

but specified this was for annuities purchased on or after November 1, 2009 (rather than the date 

included in the DRA provision—February 8, 2006).

f

State’s application form contained language regarding the state becoming a remainder beneficiary, 

but did not indicate that this is a requirement.

g

State collected information from applicants through an interview rather than a paper application form.

h

State’s application form specified that the applicant may be required to name the state as a 

remainder beneficiary, and referred the applicant to a booklet for more information.

i

State’s application form contained language regarding the state becoming a remainder beneficiary, 

but specified this was for annuities purchased on or after January 1, 2009 (rather than the date 

included in the DRA provision—February 8, 2006).
Appendix IX: Comments from the Department 

of Health and Human Services

Page 94 GAO-12-749 Medicaid Long-Term Care

Appendix IX: Comments from the 

Department of Health and Human Services
Appendix IX: Comments from the Department 

of Health and Human Services

Page 95 GAO-12-749 Medicaid Long-Term Care
Appendix X: GAO Contact and Staff 

Acknowledgments

Page 96 GAO-12-749 Medicaid Long-Term Care

Carolyn L. Yocom, (202) 512-7114 or yocomc@gao.gov

In addition to the contact named above, Michelle B. Rosenberg, Assistant 

Director; Emily Binek; Julianne Flowers; Kaycee M. Glavich; Shirin 

Hormozi; Emily Loriso; Christina Ritchie; and Phillip J. Stadler made key 

contributions to this report.

Appendix X: GAO Contact and Staff 

Acknowledgments 

GAO Contact

Staff 

Acknowledgments 

(290953)
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