The HFS 3654 form in Illinois, formally titled “Additional Financial Information for Long Term Care Applicants,” is issued by the Illinois Department of Healthcare and Family Services and collects the detailed financial information the state needs to decide whether you qualify for Medicaid coverage of nursing home or supportive living care. You file it with the Illinois Department of Human Services as part of your long-term care Medicaid application, along with supporting documents for every asset, account, and transfer you disclose.
Who Has to File HFS 3654
Anyone applying for Illinois Medicaid to pay for care in a nursing home, a supportive living facility, or certain home- and community-based waiver programs has to complete HFS 3654. If the applicant is married, the spouse’s financial information is required too, whether or not the spouse is also applying.
Completing the form is treated as a cooperation requirement. Leaving it blank, refusing to answer sections, or failing to produce the underlying records can result in a denial of the application.1Illinois Department of Human Services. Workers’ Action Guide WAG 01-02-01-a – Special Cooperation Requirements for Long Term Care HFS 3654 is one piece of a two-track application: alongside the DHS financial filing, you also need a needs screening through the Department on Aging or DHS to confirm that you require nursing-facility-level care.2Illinois Department of Healthcare and Family Services. Long Term Care
Financial Records to Gather Before You Start
The form instructs applicants to answer every question completely and accurately. Pull your paperwork together first. You will be asked about:
- Bank and investment accounts, including current statements for checking, savings, certificates of deposit, stocks, bonds, and mutual funds held individually or jointly.
- Annuity contracts, with issuer, value, and beneficiary designations. Illinois requires long-term care applicants to name the state as a remainder beneficiary on annuities.3Illinois Department of Healthcare and Family Services. Highlights of New Eligibility Requirements for Long Term Care
- Promissory notes, loans, and mortgages where you are the lender. The state requires you to directly assign these interests to the state upon your death.3Illinois Department of Healthcare and Family Services. Highlights of New Eligibility Requirements for Long Term Care
- Trust documents for any trust in which you are grantor, beneficiary, or trustee, revocable or irrevocable.
- Real property records — deeds, tax assessments, and mortgage statements — for any real estate beyond your primary residence.
- Life insurance policies, with face value and cash surrender value for each.
- Transfer records for anything you gave away, sold below market value, or otherwise transferred in the five years before the application date.
The form is used both to measure what you have now and to review how you managed assets in the recent past. Incomplete or inaccurate answers carry real weight. False statements on a benefits application are treated as a criminal offense under the Illinois Public Aid Code, and a signed declaration you know to be wrong can rise to perjury.4Illinois General Assembly. 305 ILCS 5 – Illinois Public Aid Code
The Numbers Your Answers Are Measured Against
The financial picture you disclose on HFS 3654 gets compared to Illinois Medicaid’s asset and income thresholds. Knowing those thresholds while you fill out the form helps you see where you stand.
Countable Assets
A single applicant can hold no more than $2,000 in countable assets. A married couple where both spouses are applying can hold up to $3,000 combined.5Illinois General Assembly. 305 ILCS 5/5-2 Countable assets include bank balances, investment accounts, cash surrender value of life insurance above certain thresholds, and most other property that could be converted to cash.
When one spouse needs long-term care and the other stays in the community, the community spouse keeps a protected share of the couple’s combined resources known as the Community Spouse Resource Allowance. For applications received on or after January 1, 2026, the CSRA is up to $143,172.6Illinois Department of Human Services. PM 07-02-22 – Community Spouse Resource Allowance A court order or a successful appeal can raise that figure if the community spouse needs the extra resources to maintain adequate income.
What Is Exempt
Not everything you list on the form counts against the limit:
- Your primary residence, so long as equity does not exceed $730,000 and you, your spouse, or a dependent relative lives there. If you are already in a facility, you must declare an intent to return home.
- One vehicle used for medical appointments, employment, or daily living.
- Personal belongings — clothing, furniture, and household goods.
- Irrevocable prepaid burial or funeral contracts. During the retroactive eligibility months, prepaid contracts up to $10,000 and legal fees up to $10,000 also do not count as available resources.3Illinois Department of Healthcare and Family Services. Highlights of New Eligibility Requirements for Long Term Care
- Life insurance policies with a total face value of $1,500 or less.
Income
Illinois uses an income cap set at 300 percent of the Federal Benefit Rate for long-term care Medicaid. If your monthly income runs over that cap, you may still qualify by establishing a Qualified Income Trust, sometimes called a Miller Trust, which holds the excess and directs it toward your care. Your income, minus a personal-needs allowance and a maintenance allowance for a community spouse, goes to the facility, and Medicaid pays the rest.
The Five-Year Lookback
The transfer section of HFS 3654 is where applicants get into the most trouble, so treat it carefully. Federal law lets the state review asset transfers made in the 60 months before your application date for transfers on or after February 8, 2006,7Office of the Law Revision Counsel. 42 USC 1396p and Illinois adopted that window in place of the older three-year rule.3Illinois Department of Healthcare and Family Services. Highlights of New Eligibility Requirements for Long Term Care
If the state finds transfers for less than fair market value within that window — gifting cash to a child, signing over a house — it imposes a penalty period during which Medicaid will not pay for long-term care. The penalty period begins on the date of the transfer or the date you enter a nursing home and are otherwise Medicaid-eligible, whichever is later. Its length equals the total value transferred divided by the average monthly cost of nursing home care in Illinois.
Returning all of the transferred assets eliminates the penalty. Partial returns do not reduce it proportionally. Omitting a transfer that the state later finds through bank records or other verification exposes you both to the transfer penalty and to fraud consequences under the Public Aid Code.4Illinois General Assembly. 305 ILCS 5 – Illinois Public Aid Code
How to Get the Form and Submit It
Download the current HFS 3654 PDF from the Medical Forms page on the Department of Healthcare and Family Services website, under the “Long Term Care” heading.8Illinois Department of Healthcare and Family Services. Medical Forms Print and complete it by hand, or fill in the fields on screen if the PDF allows it, then print. A physical signature is required either way.
Submit the completed HFS 3654 to the Department of Human Services with the rest of your long-term care Medicaid application packet. You can drop it off at your local DHS Family Community Resource Center. In many cases, the nursing home or supportive living facility will coordinate the submission on your behalf as part of admissions.
Attach the supporting documents — bank statements, trust instruments, annuity contracts, deeds, and transfer receipts — that back up every answer on the form. Missing paperwork is the most common reason applications stall. Remember that the DHS filing is only half the process; the needs screening through the Department on Aging or DHS has to be in place before the state can decide eligibility.2Illinois Department of Healthcare and Family Services. Long Term Care
What Happens After You File
A DHS caseworker reviews your HFS 3654 against your supporting documents and state and federal databases. Federal law requires Medicaid applications to be processed within 90 days, and Illinois has struggled to meet that timeline for long-term care cases, which involve more complex financial verification than standard Medicaid claims. Delays past 90 days are not unusual.
The caseworker may contact you or your representative for additional records or to resolve discrepancies. Answer promptly. An unanswered request can lead to a denial for failure to cooperate. If the application is approved, coverage can be retroactive up to three months before the month you applied, provided you met eligibility rules during those months. If it is denied, the notice will state the reason and explain how to request a hearing.
One Thing to Think About Before You Sign
Illinois can seek reimbursement from your estate after your death for the long-term care Medicaid paid on your behalf. Recovery is not pursued when a surviving spouse, a child under 21, or a blind or permanently disabled child is still living, and the state will not recover against the first $25,000 of estate value for anyone who died on or after July 1, 2022.9Illinois Department of Healthcare and Family Services. Guide to the Medicaid Estate Recovery Program How you title property, whether you use payable-on-death designations, and how you structure burial arrangements are decisions worth making before you file HFS 3654, not after, because they shape what the state can recover later.