How to Complete the Medi-Cal Spousal Impoverishment Form (MC 604 MDV)

The MC 604 MDV form is Maryland’s spousal impoverishment resource assessment, used when one spouse needs Medicaid-funded long-term care and the couple needs to know how much of their combined assets the at-home spouse can keep. Filing it triggers a formal count of everything the couple owned on a specific “snapshot date” and produces a written notice setting the community spouse resource allowance (CSRA). The work is almost entirely about documentation tied to that single date, so gathering records before you touch the form is what keeps the process moving.

The Snapshot Date Sets Every Number on the Form

Every figure you report on the MC 604 MDV must reflect what the couple owned on the snapshot date. Under Maryland regulation, that date is the first day of the first continuous period of institutionalization, defined as 30 consecutive days of care in a nursing facility or other qualifying medical institution.¹ Federal law computes the couple’s resources as of the beginning of that same period.²

If your spouse entered a nursing home on March 3 and stayed at least 30 days, March 3 is the snapshot date. Bank balances, brokerage values, and property appraisals all need to show that date, not the day you fill in the form. If your spouse was transferred from a hospital to the nursing home, the clock may have started at the hospital admission when nursing-level care was provided there. Maryland’s Medical Assistance Manual directs caseworkers to trace back through transfers and prior admissions to find the true start date.³ Nail down this date first. Everything else on the form depends on it.

Who the Form Is For

The assessment applies to married couples where one spouse is an “institutionalized spouse”: an inpatient in a nursing facility or medical institution providing nursing-level care, whose stay exceeds 30 days, married to someone not in a facility.¹ The other partner is the “community spouse,” living at home or in any non-institutional setting.

Either spouse, or a representative, can request the assessment. You do not have to wait until you file a Medicaid application, and nursing homes are required to tell residents and families that the assessment is available at admission.³

Gather These Documents Before You Fill Anything In

The MC 604 MDV asks for a complete inventory of every asset either spouse owned or had an interest in on the snapshot date, with account numbers, institutions, ownership type (solely owned or joint), and values. Working from original statements rather than memory is the difference between one submission and several rounds of corrections.

Bank statements for every checking, savings, money market, and certificate-of-deposit account, showing the balance on or nearest the snapshot date.
Brokerage statements for stocks, bonds, and mutual funds with market values as of the snapshot date; the closest monthly statement is acceptable if that is all you have.
Statements for all retirement accounts, including 401(k)s, IRAs, and pensions, and including any accounts already in payout status. Both spouses’ accounts count.
Life insurance documents showing cash surrender value, not the death benefit, for any whole or universal policies.
Deeds and tax assessments for any land or buildings the couple owns beyond the primary home.
Fair market values for cars, trucks, and recreational vehicles beyond the one exempt vehicle.
Complete trust documents for any trust either spouse created or holds a beneficial interest in, so the agency can decide whether the trust assets are countable.

What Counts and What Doesn’t

Not everything the couple owns goes into the total. Maryland uses the same exclusions as general Medicaid eligibility. The primary home is excluded as long as the community spouse lives in it (or the institutionalized spouse intends to return) and the couple’s home equity stays within the federal limit, which is $1,130,000 in 2026. One vehicle is excluded regardless of value. Personal belongings, household furnishings, and certain prepaid burial funds are also excluded.

Everything else is countable: cash, investments, additional real estate, life insurance cash value, and non-exempt vehicles. Maryland’s regulation is explicit that all non-excludable resources owned by either or both spouses are included.¹ Assets titled solely in the community spouse’s name still get swept into the calculation.

How the Community Spouse Resource Allowance Is Calculated

Once the agency tallies countable resources, it computes the spousal share, which is half of the combined total.² The CSRA is then the greatest of:

The federal minimum, a CPI-adjusted floor of $32,532 for 2026.
The spousal share (half of combined resources), capped at the CPI-adjusted federal maximum of $162,660 for 2026.
A higher amount set by a court order transferring additional resources to the community spouse.
A higher amount awarded at a fair hearing where the community spouse shows the standard allowance will not produce enough income to meet the minimum monthly maintenance needs allowance.

The CSRA is the protected bucket the community spouse keeps. The institutionalized spouse may transfer resources up to the CSRA to the community spouse without a transfer penalty.² Everything above the CSRA that belongs to the institutionalized spouse has to be spent down to Maryland’s individual resource limit, typically $2,500, before Medicaid coverage starts.

A quick example. A couple holds $200,000 in combined countable resources on the snapshot date. Half is $100,000, which falls between the 2026 floor and the ceiling, so the community spouse keeps $100,000. The institutionalized spouse must spend the remaining $100,000 down to $2,500 through paying for care, buying exempt items, or other allowable expenses before qualifying for Medicaid.

Where and How to Submit

Two paths exist, and timing decides which one applies.

Before you apply for Medicaid, either spouse can request a standalone assessment through Maryland’s Office of Eligibility Services. The state charges a fee for this because it is done outside the application process.³ The payoff is seeing the numbers before you commit to a full application, which leaves time to plan any spend-down or asset restructuring.

As part of the Medicaid application, a caseworker at your local Department of Social Services performs the assessment inside the eligibility determination at no charge.³ If an earlier Office of Eligibility Services assessment was already done, the local office will pull it by name and Social Security number.

Maryland Medicaid applications can go in online through the myDHR portal, in person at a local Department of Social Services office, or by mailing a paper application from the Maryland Department of Health website to the local office. Attach the completed MC 604 MDV and all supporting financial documentation to whichever method you use.

The Five-Year Look-Back

Maryland examines all asset transfers made during the 60 months before the date the person is both institutionalized and applying for Medical Assistance.⁴ A gift, below-market sale, or other uncompensated transfer in that window can trigger a penalty period during which Medicaid will not pay for nursing home care.

Transfers between spouses are generally not penalized, and the CSRA transfer itself is specifically protected by federal law.² Gifts to children, transfers into irrevocable trusts, and conveyances where the couple received less than fair market value draw scrutiny. Disclose significant transfers on the application. The agency will find them during verification, and undisclosed transfers create far worse problems than disclosed ones.

After You Submit

A caseworker verifies the reported assets against financial records and may contact banks or brokerages directly. Expect at least one request for clarification or a missing statement; it is rare for a first submission to be perfectly complete. Respond quickly, because delays in producing documents extend the processing timeline.

Once verification is finished, the state issues a formal Resource Assessment notice stating the couple’s combined resources on the snapshot date, the spousal share, the CSRA, and how much the institutionalized spouse must spend down before Medicaid coverage begins. COMAR requires the department to provide a copy of the assessment and documentation to each spouse.¹

If You Disagree With the Result

Either spouse can request a fair hearing to challenge the total resource count, the spousal share, or the CSRA amount. Federal law requires a hearing on the community spouse resource allowance within 30 days of the request.² Maryland requires you to file the hearing request within 90 days from the date on the adverse notice.⁵

The most common argument is that the standard CSRA is too low. If the community spouse shows the protected resources will not produce enough income to reach the minimum monthly maintenance needs allowance, the state must raise the CSRA to fill the gap.⁶ Documentation of monthly expenses, especially housing, utilities, and medical bills, is what carries this argument. A court order can also override the standard CSRA when a hearing result is still insufficient.

1
Legal Information Institute. Maryland Code of Regulations 10.09.24.10-1 – Treatment of Income and Resources of Certain Institutionalized Spouses
2
Office of the Law Revision Counsel. 42 USC 1396r-5 – Treatment of Income and Resources for Certain Institutionalized Spouses
3
Maryland Department of Health. Maryland Medical Assistance Manual Section 1000 – Eligibility for Institutionalized Persons
4
Library of Maryland Regulations. COMAR 10.09.24.08-1 – Disposal of Assets for Less Than Fair Market Value
5
Maryland Department of Health. Medicaid Appeal
6
Legal Information Institute. Maryland Code of Regulations 10.09.24.10-1 – Treatment of Income and Resources of Certain Institutionalized Spouses