Michigan DHS-4574 Medicaid Application: Assets, Look-Back, and Spousal Rules

The Michigan DHS-4574 form is the asset declaration you file with the Michigan Department of Health and Human Services (MDHHS) when applying for Medicaid coverage of nursing facility care. It comes in two versions, asks for a line-by-line inventory of what you (and, if applicable, your spouse) own, and must be signed under penalty of perjury before a caseworker will measure your resources against Michigan’s Medicaid asset limits.

Pick the Right Version First

MDHHS publishes two variants, and using the wrong one can slow your application or cost your spouse protections they’re entitled to.

Both are available as downloadable PDFs on the MDHHS forms page at michigan.gov and in paper form at any county MDHHS office. If you have a spouse who is not entering a facility, use the DHS-4574-B.

Gather These Documents Before You Start

The form itself doesn’t publish a checklist, but every field asks for details you’ll want in front of you:

  • Recent bank and investment statements showing the institution name and address, account number, and balance for each checking, savings, money market, and CD account.
  • Brokerage statements showing current holdings and values for stocks, bonds, and mutual funds.
  • Life insurance policies with the carrier name and policy number. For whole-life and universal-life, note the cash surrender value, which is the figure the caseworker treats as a countable asset.
  • Vehicle titles or registrations showing the owner’s name as it appears on the title, year, make and model, and any balance owed.
  • Deeds, mortgage statements, or tax assessments for any real estate.
  • Records of any gift, sale, or transfer made in the past five years: receipts, closing statements, or anything showing what moved, to whom, and for how much.

Filling Out the Form Section by Section

The top of the form asks for basic identification: your name, Social Security number, date of birth, and the nursing facility where you reside. On the DHS-4574-B, your spouse’s information goes alongside yours in each section.

Financial Accounts and Investments

A checklist of asset categories comes first: checking and savings accounts, certificates of deposit, cash on hand or in a safe deposit box, and savings bonds, stocks, or mutual funds. Check every category that applies, then complete the table below with the owner’s name, type of asset, balance or value, institution’s name and address, and the account or policy number.2Michigan Department of Health and Human Services. DHS-4574-B – Assets Declaration Patient and Spouse Jointly held assets must be listed with every owner identified.

Life insurance has its own checkbox and is reported in the same table. Term policies generally have no cash value and don’t count, but whole-life and universal-life policies carry a cash surrender value the caseworker will evaluate.

Vehicles

The vehicle section covers cars, trucks, boats, campers, motorcycles, RVs, and anything similar. For each one, list the owner as shown on the title or registration, year, make and model, and any amount still owed.1Michigan Department of Health and Human Services. DHS-4574 – Application for Health Care Coverage Patient of Nursing Facility You do not calculate fair market value yourself; the caseworker handles valuation.

Real Property

If you own land or buildings, list the address and the owner’s name. The form itself does not include fields for a legal description, tax-assessed value, or appraisal; the caseworker will request supporting documentation separately if needed to establish value.

Signature

You must sign and date the form to certify everything you reported is true. A false statement or concealment of material facts on a Medicaid application is a felony under Michigan’s Medicaid False Claim Act, punishable by up to four years in prison, a fine of up to $50,000, or both.3Michigan Legislature. Michigan Compiled Laws Act 72 of 1977 – The Medicaid False Claim Act Federal penalties can add fines up to $10,000 and a one-year suspension of benefits.4Michigan Department of Health and Human Services. Reporting Medicaid Beneficiary Fraud

What Counts Against the Asset Limit

The form exists to measure your countable assets against the thresholds in Michigan’s Bridges Eligibility Manual (BEM 400).5Michigan Department of Health and Human Services. Bridges Eligibility Manual 400 – Assets For the Aged and Disabled Medicaid category most commonly tied to this form, the 2026 countable-asset limit is $9,950 for an individual and $14,910 for a married couple. These figures change annually, so confirm the current number with your caseworker.

Not everything you own counts. Michigan excludes:

  • One homestead, including the land it sits on and related buildings on adjoining land, as long as your equity does not exceed the home equity limit (the federal minimum threshold is $752,000 for 2026).6Medicaid.gov. January 2026 SSI and Spousal CIB
  • One motorized vehicle owned by your asset group. If you own more than one, the vehicle with the highest equity value is typically the one excluded.7Michigan Department of Health and Human Services. Bridges Eligibility Manual 400 – Assets
  • Household goods, furniture, clothing, and similar personal belongings.
  • Up to $1,500 per person in clearly designated burial funds, plus accumulated interest.
  • Burial space items such as plots, crypts, and caskets for you, your spouse, and certain family members.
  • Funds in a MiABLE (529A) account, including interest and matching deposits.

When in doubt, report the asset and let the caseworker apply the exclusion. Underreporting carries far more risk than overreporting.

The 60-Month Look-Back

Any asset you transferred for less than fair market value during the 60 months before your application date gets reviewed, and MDHHS may impose a penalty period during which Medicaid will not pay for your nursing facility care. The authority for this review is federal.8Office of the Law Revision Counsel. 42 USC 1396p – Liens, Adjustments and Recoveries, and Transfers of Assets

The penalty is calculated by dividing the total uncompensated value of transferred assets by the average monthly private-pay nursing facility cost in Michigan. For 2026, that divisor is $12,216.30.9Michigan Department of Health and Human Services. Bridges Eligibility Manual 405 – MA Divestment A $60,000 gift three years ago would translate to roughly 4.9 months of ineligibility. The penalty period begins on the later of the first day of the month the transfer happened or the date you would otherwise have become eligible for Medicaid long-term care.

Caseworkers routinely pull bank statements and flag unexplained withdrawals. Every large gift, below-market sale, or substantial transfer within the five-year window needs to show up on the form.

Spousal Protections and the DHS-4574-B

When one spouse enters a nursing facility and the other stays home, federal spousal impoverishment rules let the community spouse keep a protected share of the couple’s combined countable assets. The DHS-4574-B exists to capture both spouses’ assets so this calculation can run.

The protected share is called the Community Spouse Resource Allowance (CSRA). The community spouse keeps the greater of the minimum allowance or half the couple’s combined countable assets, up to the maximum. For the period beginning January 1, 2026, the minimum CSRA is $32,532 and the maximum is $162,660. Assets above the protected amount are considered available to pay for the institutionalized spouse’s care.

The community spouse may also be entitled to a Monthly Maintenance Needs Allowance, which redirects part of the institutionalized spouse’s income to help cover household expenses. Because the math involves both spouses’ assets and income, couples with a home, retirement accounts, or other substantial resources often benefit from working with an elder law attorney before filing.

Submitting the Form

Three channels are available:

  • Upload the completed form and supporting documents through the MI Bridges portal at newmibridges.michigan.gov.10MI Bridges. ISD DFAP Upload Documents
  • Hand-deliver it to your local MDHHS county office, which you can locate through the county office directory at michigan.gov.11Michigan Department of Health and Human Services. County Offices
  • Mail the form and copies of supporting records to the county MDHHS office handling your case, keeping copies of everything you send.

If you’re already in a facility, the social worker or admissions coordinator can often help you submit the paperwork or connect you with your assigned caseworker.

What Happens After You File

MDHHS has 45 days to process a healthcare coverage application, extending to 90 days when eligibility involves a disability determination.12MI Bridges. Application Response Timeframe The caseworker reviews what you reported, cross-references electronic databases and banking records, and applies the exclusions and limits from BEM 400.

If anything is missing or unclear, you’ll receive a DHS-3503 Verification Checklist listing what you still need to provide and a deadline.13Michigan Department of Health and Human Services. Bridges Administrative Manual – Application Processing Respond quickly. A missed deadline can produce a denial based on an incomplete file rather than on your actual eligibility. Common follow-up requests include several months of bank statements, proof of vehicle ownership, and documentation of any transfer flagged during the look-back review.

The determination arrives by mail and explains the reasons for approval or denial. If MDHHS denies the application on asset grounds, you have 90 days from the written denial notice to request an administrative hearing, in writing, by phone, or in person at your local MDHHS office.14Michigan Department of Health and Human Services. Medicaid Fair Hearings Rights and Responsibilities Asset-based denials get overturned most often when the caseworker miscategorized an excluded asset as countable, failed to apply the vehicle or homestead exclusion correctly, or did not account for the community spouse’s protected share. If you were already receiving benefits and MDHHS is reducing or terminating coverage, you can request that benefits continue at the current level while the hearing is pending, but that request has to be filed before the reduction’s effective date.