DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Health Care Access and Accountability
WI Stats. s. 49.455
F-10096 (07/08)
Federal Regulations 100-360
COMMUNITY SPOUSE ASSET SHARE NOTICE
Instructions:
Economic support (ES) worker is to complete this form and provide a copy to the institutionalized spouse,
community spouse and place a copy in the case file.
Institutionalized Spouse Name (Last, First, MI)
Institutionalized Spouse Address (Street, City, State, Zip Code)
Community Spouse Name (Last, First, MI)
Community Spouse Address (Street, City, State, Zip Code)
All assets owned by both the institutional spouse and the community spouse were evaluated to determine the
community spouse asset share. The community spouse asset share plus the Medicaid asset limit for one-
person equals the amount of assets that the institutionalized person and spouse may have and meet the
Medicaid asset eligibility test for the institutionalized person.
For Medicaid eligibility the total assets, which the community spouse and the institutionalized spouse may have
as of the date of entry into the institution or date of initial request for community waivers may not exceed:
................................................................................................................................................$________________
The community spouse asset share may not exceed...........................................................$________________
Your combined countable assets as of __________________ were...................................$________________
(date)
The community spouse asset share is based on the above and is ......................................$________________
You and your spouse may have $________________ in assets and still qualify for Medicaid eligibility as far as
assets are concerned. This figure is arrived at by adding the community spouse’s asset share and the
Medicaid asset limit for one person ($2,000). You and your spouse will still have to meet Medicaid nonfinancial
and income requirements. Retain this notice along with other Medicaid notices you receive from Medicaid,
when the resident becomes eligible.
SIGNATURE – Economic Support Worker
Date Signed
Case Name
Case Number
Agency
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