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Appendix A-15 Revised 07/01/2017 RESOURCE ASSESSMENT NOTICE _______________________________________ Institutional Spouse ___________________ _______________________________________ Community Spouse ___________________ _______________________________________ Date _______________________________ Based on your request for an assessment of resources owned by the couple named above, the Division of Medicaid has determined that the institutional spouse:  would be eligible for Medicaid based on resources, see below for details.  would not be eligible for Medicaid based on resources, see below for details. Resources that are countable in determining Medicaid resource eligibility are as follows: Countable Resource Type Owner(s) of Resource Resource Value

Total Countable Resources of the Couple:

$_________________ Community Spouse (CS) Share: based on federal maximum

$ ________________ Institutional Spouse (IS) Share: based on individual limit

$ ________________ Excess Resources that would be available to the IS

$ ________________ This is an assessment only. Transferring ownership of resources between spouses may be required to arrange spousal shares allowed. In order for the Division of Medicaid to provide an official Medicaid eligibility decision, a full Medicaid application must be filed for long term care Medicaid. Medicaid Specialist ____________________________ Phone # __________________________