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REV. MAY 8, 2026 NEBRASKA DEPARTMENT OF MEDICAID ELIGIBILITY

HEALTH AND HUMAN SERVICES 477-000-029

Examples- Assessment and Designation of Resources Example 1 Mr. and Mrs. Edwards have been living in their own home. On 10/15/2013 Mr. Edwards enters a nursing home. On 1/20/2014 Mrs. Edwards contacts the Department to request an assessment of their resources. The worker completes Form IM-73 and determines what total countable resources were at the time Mr. Edwards entered the nursing home. The total of all resources owned as of 1/20/2014 is $60,000. The minimum and maximum resource amounts are listed above. Mrs. Edwards provides the worker with verification that total resources owned in 10/2013 were $65,000. The spousal reserved amount is $32,500. On Form IM-73 the Edwards resources as of 10/2013 consisted of: Certificate of Deposit #1 $25,000 Certificate of Deposit #2 $25,000 Stocks ABC Company 100 shares worth $100 per share $10,000 Bond E $ 5,000 TOTAL $65,000 Form IM-73 is completed and signed by both Mr. and Mrs. Edwards, a copy is given to each, and a copy is retained for the Department's record. $32,500 is reserved for the community spouse (Mrs. Edwards). On 5/1/2014 Mrs. Edwards requests an application for ABD for Mr. Edwards, who is still residing in the nursing home. The worker completes Form IM-74. Resources owned at the time of application are $36,500, which include the $32,500 community spouse allowance plus $4,000 for the alternate care spouse. On Form IM-74 the Edwards resources as of 5/1/2014 consist of: Community Spouse Allowance Alternate Care Spouse Certificate #4 $10,000 Savings #6 $4,000 Bond E $ 5,000

Stocks ABC Company 100 shares worth $100 per share $10,000

Savings Account #5 $ 7,500

TOTAL $32,500

Mr. Edwards meets all other eligibility requirements. The ABD application for Mr. Edwards is approved with a medical effective date of 5/1/2014; Mr. Edwards’ nursing home care is paid for 4/1/2014 as are all other medical bills. Notice is sent advising him of the date of eligibility and also notifying him that he has 90 days from the date of the notice to complete the transfers of ownership so that only $4,000 in resources remain in his name. On 6/28/2014, Mrs. Edwards provides the worker with verification that Mr. Edwards’ name has been removed from the CD, bond, stocks, and savings account #5. They put his $4,000 into a new account, savings account #6.