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Michigan medicaid eligibility income chart

Michigan form medicaid application 2025

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4.8 out of 5

163 votes

The document is an application form for health care coverage specifically designed for patients in nursing facilities, provided by the Michigan Department of Health and Human Services. It outlines the process for applying, eligibility criteria, and the assistance available for completing the application. The form includes sections for personal information, asset declaration, income details, and legal acknowledgments regarding benefits and responsibilities. It emphasizes non-discrimination policies and provides contact information for assistance.

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Click ‘Get Form’ to open the Michigan Form Medicaid Application in our editor.
Begin by entering the Beneficiary Name and Client ID at the top of the form. Ensure all personal information is accurate.
In the 'Assets Declaration' section, provide details about your assets and those of your spouse, if applicable. Check 'Yes' or 'No' for each asset type listed.
Complete the income section by detailing all sources of income for yourself and any household members. Be thorough to ensure eligibility.
Review the affidavit section carefully. Sign and date where indicated, ensuring that two witnesses are present if necessary.
Once completed, save your document and either print it for mailing or submit it electronically through our platform.

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Versions	Form popularity	Fillable & printable
2016	4.8 Satisfied (163 Votes)
2013	4.1 Satisfied (54 Votes)
2011	3.9 Satisfied (55 Votes)

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What documents are needed for Medicaid in Michigan?

Proof of date of birth (e.g., birth certificate) Proof U.S. citizenship or lawful residence (e.g., passport, drivers license, birth certificate, green card, employment authorization card) Proof of all types of income, earned and unearned (e.g., paycheck stubs, retirement benefits, Supplemental Security Income)