Long Term Care Program Medical Assistance Application
Instructions:
This is an application for Medical Assistance that will cover some or all of the costs of persons who stay in approved Long Term
Care Facilities, or who want to receive services under the Home and Community Based (HCBS) Waiver Program. The HCBS
Waiver Program includes: Persons Who Are Elderly or Physically Disabled (EPD), and
Persons with Intellectual and/or Developmental Disabilities (IDD).
You, or someone you have chosen to act for you, need to complete this application only if you are about to enter, or are staying
in a Long Term Care Facility, or are applying for the Home and Community Based Waiver Program. If you want EPD services,
you must first contact the DC Office of Aging's Aging and Disabilities Resource Center (ADRC). You can call the ADRC on
(202) 724-5626 on weekdays from 8:00 a.m. to 5:00 p.m.
This is NOT an application for Cash Assistance, Food Stamps or other types of Medical Assistance.
You must be a resident of the District of Columbia or if you just started staying in a Long Term Facility in D.C., you must
plan to remain in D.C. after your discharge from the facility.
You can mail this application to:
Long Term Care Unit
645 H Street N.E. 5th Floor
Washington, D.C. 20002
You can also bring in this application to the 645 H Street, N.E. Service Center. If you mail this application, please enclose a copy
of the following documents:
● Proof of Residency- Mortgage/Rent Statement, utility bill etc., or
Start Of Care Notice from the Long Term Care Facility if you currently stay in a Facility
● Proof of Income for the past 30 days for self and spouse
● Proof of any Assets that you (or spouse) own such as Bank Accounts,
Stocks, Bonds, Life Insurance, Real Property, etc.
● Health Insurance Cards
● Copies of all paid or unpaid Medical expenses for applicant
● Documents of any assets you transferred in the last five (5) years
Upon your request, an assessment of assets can be completed when you provide proof of all of your assets.
(Combined assets for yourself and spouse).
If you have any questions, you can call 202-698-4220. Revised May 2015
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Are you responsible to pay Court Ordered Spousal Support (Alimony)? Ο Yes Ο No
If yes, the amount of monthly support:
If you agreed to transfer a portion of your income to your spouse, you need to tell us how much your income you want to keep and
how much you would like to transfer. Please mark your choice below.
I want to transfer the maximum amount. Ο Yes Ο No If you answered no, tell us how much you want to keep.
I want to keep Ο $70 Ο $100 Ο $125 Ο $150 If you want to keep another amount, record the amount here. $__________
If your spouse qualifies for a Spousal Allowance, would you like to transfer a portion of your income to your spouse?
Ο Yes Ο No
Under Long Term Care rules, you can transfer a portion of your income to your community spouse, if his/her income is below about
$2000 a month, or more when he/she has high shelter costs. The income you can transfer is called a Spousal Allowance.
Current Address or your address prior to entering the Long Term Care Facility:
Do you plan on returning to this
residence upon discharge?
Ο Yes Ο No
Do you plan to stay in the District of Columbia? Ο Yes Ο No
Have you ever received Medicaid in another state? Ο Yes Ο No
If yes, list the state and the date that your Medicaid was terminated.
State: Date Medicaid was terminated:
2. INFORMATION ON SPOUSE: Complete this information even if you are not applying for your spouse.
Name:
Address:
Date of Birth:
Social Security Number:
Name and Address of the Long Term Care Facility:
Date you entered Facility:
1. PERSONAL INFORMATION
Name:
Social Security Number:
Date of Birth:
Sex: Ο Male Ο Female
Marital Status: Ο Single Ο Married
Ο Divorced Ο Widowed Ο Separated
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Person who is working
Employer's Name and Telephone
Number
Amount of earnings
before taxes and
deductions
How often is it received?
(monthly, weekly, every two
weeks, twice a month, etc.)
Earned Income
3. INCOME: List below the types and amounts of unearned income and earnings you and/or your spouse
receive. List the gross amount of income (before taxes and deductions are taken out).
Unearned Income - such as SSI, Social Security Benefits, Pensions and/or Annuities
Type of Unearned Income
Person Receiving Payment
Amount of Payment (before
taxes and deductions)
How often is it received?
(monthly, weekly, every two
weeks, twice a month, etc.)
Page 3
If yes, the Fee Amount:
Telephone Number:
Representative Payee:
Ο Yes Ο No
NAME:
Authorized Representative:
Ο Yes Ο No
NAME:
ADDRESS:
Do you pay a monthly Rep. Payee fee?
Ο Yes Ο No
If yes, the Fee Amount:
Telephone Number:
ADDRESS:
Do you pay a monthly fee?
Ο Yes Ο No
ADDRESS:
Do you pay a monthly Conservator fee?
Ο Yes Ο No
If yes, the Fee Amount:
Telephone Number:
If you checked "yes" please provide the following information.
Conservator:
Ο Yes Ο No
NAME:
5. Legal Representation - Do you have one of the following acting on your behalf? Please answer here.
Ο Yes Ο No
5
4
3
2
1
4. Please list your spouse and any dependent children, dependent parents and dependent siblings that live in your
home.
Last Name
First Name
Middle
Initial
Sex
Date of
Birth
Social Security
Number
Relation
to You
Do you claim
this person as
a dependent on
your tax
return?
Gross
Monthly
Income
Page 4
If you have medical bills for services that you received before the month of this application, we may be able to help you pay some or all of those
bills. If you don't want us to pay those bills, or Medicaid rules do not allow us to pay the bills, we may be able to reduce what you will need to pay
for your long term care services.
You can ask for Medicaid to cover your medical bills for up to three months prior to the month of this application. We call this the retroactive
period. For D.C. Medicaid to pay for those months, you must have lived in D.C., met income requirements, and met the resource limit for
Medicaid of $4,000 for one person, or $6,000 for a couple. If you are eligible for the retroactive period, we will reimburse you for the bills you
already paid for those months. Retroactve Medicaid may cover prior nursing home expenses, but may not cover other long term care services.
If you do not want retroactive benefits, you can ask us to use your unpaid medical bills to reduce the amount that you will need to pay for your
long term care services for this month and future months. You can use any unpaid medical bills no matter how old they are. This includes unpaid
bills for long term care services. If you want us to apply your past bills to your future long term care costs, then you will still be responsible for
paying those past bills.
If a third party insurance, like Medicare or other health insurance paid your medical bill, or if the bill was previously counted for Medicaid
Spenddown eligibility, we cannot use the bill to reduce the amount you will need to pay for yout LTC/HCBS services.
In the boxes on the next page, please let us know if you want Medicaid coverage for the retroactive period, or if you want to use your past medical
bills to reduce the amount you will need to pay for your future long term care services, or to determine your eligibility through Spend-Down, or if
you want us to do a combination of these. For more information, ask your Medicaid worker.
6A. Past Medical Expenses
If your monthly income is more than $2,200, you may be over-income for LTC/HCBS services. Even if your income is over the limit, you may still be able
to get LTC/HCBS Services by showing that you have high medical expenses. This is called Medicaid “Spend-Down.” To get Medicaid under Spend-
Down, you must have a certain amount of medical bills. The total amount of medical bills you need is your “deductible.” When you have enough bills,
including some past bills, you will meet your deductible and you may be eligible under Spend-Down. Medicaid will not pay the bills you count towards your
deductible. After you meet your deductible, Medicaid may pay for your other medical bills. If you are over-income for LTC/HCBS services, you can use
past medical bills to meet your Spend-Down deductible.
Under Spend-Down rules for LTC/HCBS services, you can also qualify based on the cost of the LTC/HCBS Services that you expect to pay during a six
month Spend-Down period. If we approve LTC/HCBS services based on your expected costs, you are still responsible for paying these projected costs.
If we use your projected LTC/HCBS costs to Spend Down to Medicaid, you can still use your past medical bills to reduce the amount you will need to pay
for your LTC/HCBS services. You can use paid and unpaid bills from the current and past three months for Spend Down. You can also use unpaid bills
that are more than three months old, and old bills that were just paid during the past three months. Since Medicaid cannot pay the bills that you use for
Spend Down, it is usually best to use bills that you already paid. If you are found to be over-income and need to use Spend Down to get LTC services, we
will send you a notice telling you the amount of your deductible. If you provide bills with your application that you ask us to use for Spend Down, we will
send you an additioinal notice saying how much you still owe. In the over-income notice we send to you we will ask you if you want us to use your
expected expenses. If you want us to use expected expenses, you will need to sign a statement saying you want to do that and return the signed
statement to us. You can also provide any other bills you want to use.
Page 5
Do you need retroactive Medicaid coverage for paid or
unpaid medical bills incurred during the past three months,
including nursing home bills? Ο Yes Ο No
Do you have any past paid or unpaid medical bills, not being
used to determine retroactive Medicaid coverage?
(examples include Nursing Home expenses, Prescription
drugs, Dental bills. Home Health Care costs, etc.)
Ο Yes Ο No
If you answered "yes" to either, or both of the above questions, list the type and amount of these past medical bills that may be used to
determine eligiblity for retroactive coverage, to qualify through Spend Down, and/or to calculate your share of the monthly costs for care in a
Long Term Facility.
Type of Medical Service:
Date of Medical Service:
Amount Billed for Medical Service:
Amount Billed for Medical Service:
Type of Medical Service:
Date of Medical Service:
Amount Billed for Medical Service:
Type of Medical Service:
Date of Medical Service:
Amount Billed for Medical Service:
Type of Medical Service:
Date of Medical Service:
Amount Billed for Medical Service:
6B. Listing of Past Medical Expenses
Attach another page if you have additional medical bills.
Type of Medical Service:
Date of Medical Service:
Amount Billed for Medical Service:
Type of Medical Service:
Date of Medical Service:
Amount Billed for Medical Service:
Type of Medical Service:
Date of Medical Service:
Amount Billed for Medical Service:
Type of Medical Service:
Date of Medical Service:
Amount Billed for Medical Service:
Type of Medical Service:
Date of Medical Service:
Page 5a
7. Health Insurance Information
Medicare Information (from your Medicare Card)
Do you have Medicare?
Ο Yes Ο No
Type of Coverage:
Ο Part A Ο Part B
Medicare Claim Number:
Effective Date
Part A:
Part B:
Other Health Insurance
Do you have other health insurance?
Ο Yes Ο No
Amount of Monthly Premium: $
Does your spouse have
Medicare?
Ο Yes Ο No
Type of Coverage:
Ο Part A Ο Part B
Medicare Claim Number:
Effective Date
Part A:
Part B:
Health Insurance Company- Name and Address
Monthly Premium
Policy Number
Type of Coverage
(Medigap, Retiree,
RX, etc.)
Does your spouse have other health
insurance?
Ο Yes Ο No
Amount of Monthly Premium: $
If you or your spouse have other health insurance, including a Medicare supplement policy, please complete the boxes below and attach a
copy (front and back) of the insurance cards.
Spouse
Self
Page 6
Bank or Credit Union Account
$
2nd Bank or Credit Union Account
$
8A. Current Assets
Do you or your spouse currently own any of the following assets? Ο Yes Ο No
If you answered "yes", please list the type and amount of assets you or your spouse currently own.
Asset Type
Value
Asset Type
Value
Do you or your spouse, own any other assets of value? Ο Yes Ο No
Description of Asset:
Asset Value:
8B. Assets when you entered the Long Term Care Facility
Annuity/Trust Funds/Trust
Accounts
$
Cash- Including Cash Surrender
Value of any Life Insurance Policies
$
Certificates of Deposit
$
Boats/Recreational Vehicles/Motor
Homes
$
Stocks/Bonds/Mutual Funds
$
Real Property including your Home
$
Bank or Credit Union Account
$
2nd Bank or Credit Union Account
$
If you have a spouse who lived with you before you entered the Long Term Care Facility, you need to list below the amount
of assets you or your spouse had when you entered the facility. You can skip this section if this situation does not apply
to you.
Asset Type
Value
Asset Type
Value
Certificates of Deposit
$
Boats/Recreational Vehicles/Motor
Homes
$
Stocks/Bonds/Mutual Funds
$
Real Property including your Home
$
Did you or your spouse own any other assets of value? Ο Yes Ο No
Description of Asset:
Asset Value:
Annuity/Trust Funds/Trust
Accounts
$
Cash- Including Cash Surrender
Value of any Life Insurance Policies
$
Page 7
8C. Transfer of Assets
Have you or your spouse given away or transferred anything of value in the last five years? This would include money in bank
accounts, stocks, bonds, real estate or other possessions of value, or creation of an annuity. Ο Yes Ο No
If yes, complete the following:
Date of Transfer:
Amount received for
Asset:
Value of Asset at
Transfer:
Description of Asset:
Who received the
transferred asset?
Amount received for
Asset:
Who received the
transferred asset?
Description of Asset:
Value of Asset at
Transfer:
Amount received for
Asset:
Date of Transfer:
Date of Transfer:
Who received the
transferred asset?
Description of Asset:
Value of Asset at
Transfer:
Attach another page if you transferred additional assets
9. Additional Questions to See How Much You May Need To Pay for Your Care
Do you own or rent a home? Ο Yes Ο No
Do you expect to return to this home within six (6) months? Ο Yes Ο No
Date of Transfer:
Who received the
transferred asset?
Description of Asset:
Value of Asset at
Transfer:
Amount received for
Asset:
Condo/Co-op Maintenance Fees: ________________
Home Association Fees: ________________
If you expect to return, will your spouse or any of your dependents continue to stay in your home? Ο Yes Ο No
If your home will be unoccupied, you may qualify for a Home Maintenance Allowance that will reduce the amount you
have to pay for your Long Term Care costs. If your home will be ocupied by your spouse, his/her Spousal Allowance
may be increased becasue of high shelter expenses. Please list the amount you pay for the following:
Rent/Mortgage: _________________
Home Insurance: ______________
Real Estate Taxes: ____________
Page 8
REPRESENTATIVE SIGNATURE: ______________________
DATE: ____________________
10. Signature
●
By signing below, I give my permission to DHS to get information about me and my spouse. DHS
can get this information from those officials or institutions that have knowledge of my situation. I
give all of these parties my permission to give information about me to DHS. I have reviewed the
information in my application and I believe that all of the information on this entire application is
true and correct. I know if I give false information, I may be breaking the law and I could be at risk
of criminal prosecution and penalties. I know that state and federal officials will check this
information. I agree to help and cooperate with their potential investigations.
●
I understand that the District of Columbia will seek recovery of the bills it pays for me when I am in
a nursing home or other medical institution. This means that the District of Columbia may put a
lien or claim on my property or estate.
●
I have received a copy of my rights and responsibilities. I understand my responsibilities and agree
to cooperate as required.
●
Authorized Representative(s): If the applicant cannot sign this form, you may sign it for them. By
signing, you certify that this person wants to apply for LTC benefits and agrees to the conditions
above.
SIGNATURE: __________________________________
DATE: ____________________
●
I understand that if I, or my spouse, purchased an annuity on or after February 8, 2006, and I receive
long term care services, the District of Columbia must be named a remainder beneficiary of the
annuity.
Page 9
1 Revised May 2015
Notice of Rights and Responsibilities
General Rules
You must give true and complete information. If you lie or give false information, you may lose your
benefits. You could also be fined and go to prison. We may verify your information to make sure it is
correct. We may check on your income, your Social Security information, and your immigration
information. We verify this information through computer matching programs. We may also interview
you and do a home visit.
Your case may be chosen for a Quality Control review. This is a detailed review of all of your
information. It may include some personal interviews and a review of your medical records. By
applying, you agree to cooperate with the state or federal reviewers. If you refuse to cooperate, you
may lose all or part of your benefits. If you are under investigation or are fleeing to avoid the law, we
may share your information with federal and local agencies.
Under federal and District law, you must provide your Social Security Number (if you have one) if you
are in the assistance unit. (See 42 CFR 435.910, 7 CFR 273.6, DC Code §4-204.07, §4-205.05a,
and §4-217.07) Your SSN will be used to verify your identity, prevent receipt of duplicate benefits,
and make required program changes. The DHS computer system uses your SSN to verify your
income by using records from the Internal Revenue Service, the Social Security Administration, and
the DC Child Support Services Division (CSSD).
Medical Assistance Rules
After you apply, you will get a decision about your Medical Assistance within 45 days (or 60 days if
DHS must determine if you are disabled). If you do not get a notice within this period, please call the
DC Medicaid Branch on (202) 698-4220 or the Change Center on (202) 727-5355. To get free legal
help with Medicaid, call Terris, Pravlik, and Millian on (202) 682-0578 or write to them at 1121 12th
Street, NW, Washington, DC 20005. If you get Medical Assistance, then you must recertify each year
when we send you a recertification notice. There is no time limit for getting Medical Assistance.
Estate Recovery: The District will seek recovery for the bills we pay for you if you are in a nursing
home or other medical institution. Also, if you are age 55 or older, the District will seek recovery for
services that you get. This means that we may put a lien or claim on your property or estate. This
does not apply to any Qualified Medicare Beneficiary (QMB) benefits you get. Effective January 1,
2010, Section 115 of the Medicare Improvement for Patients and Provider Act (MIPPA) prohibits
states from recovering Medicaid payments for Medicare cost sharing expenses made on behalf of
Qualified Medicare Beneficiaries. The District cannot seek recovery of payments for Medicare cost
sharing.If you have questions, call (202) 698-2000.
Lawsuits: If you sue or enter into settlement negotiations with a third party for a medical claim or
injury, you must provide written notice of the action (either by personal service or certified mail) within
20 calendar days to the Medical Assistance Administration, Third Party Liability Section, 441 4
th
Street, NW, Suite 1000-South, Washington, DC 20001. If you have questions, call (202) 698-2000.
Recertification
We will send you a recertification notice in the mail. You will need to work with your Waiver services
case manager, or nursing facility, to get the information you need to give us to continue getting your
Medical Assistance. Please contact them right away to make sure that you can complete your
recertification on time. If you do not recertify, then you will lose your benefits. Also, please let us
know if you move. Just call (202) 727-5355 to report your new address.
2 Revised May 2015
Reporting Changes
You must report changes in your income, Medicare status, marital or institutional status, who lives
with you, or if you move from D.C. You may want to report a change of District address, changes in
your shelter costs and changes in medical expenses. To report a change, call (202) 727-5355. You
must call us by the 10th day of the month after the change. You may also call the LTC unit at (202)
698-4220 to report changes that will affect what you need to pay for your Long Term Care services.
Confidentiality
By applying, you give DHS permission to talk with your employer, your landlord, your nursing facility,
your bank, your doctor, and other people who have information about you. You also give these
people your permission to give information about you to DHS. In addition, you also give DHS
permission to look at your motor vehicle records, wage data, tax information, and other government
records. Of course, DHS keeps all of your information confidential. DHS does not release your
records without your permission (except when required by law).
Equality and Non-Discrimination
In accordance with Federal law and U.S. Department of Health and Human Services (HHS) policy,
this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or
disability. To file a complaint of discrimination, write HHS, Director, Office for Civil Rights, Room 506-
F, 200 Independence Ave., SW, Washington, DC 20201 or call (202) 619-0403 (voice) or (202) 619-
3257 (TDD). HHS is an equal opportunity provider and employer.
In accordance with the DC Human Rights Act of 1977, as amended, DC Official Code § 2-1401.01 et
seq., (Act) the District of Columbia does not discriminate on the basis of actual or perceived: race,
color, religion, national origin, sex (gender or sexual harassment), age, marital status, personal
appearance, sexual orientation, gender identity or expression, familial status, family responsibilities,
matriculation, political affiliation, genetic information, disability, source of income, status as a victim of
an intra-family offense, and place of residence or business. Sexual harassment is a form of sex
discrimination, which is prohibited by the Act. In addition, harassment based on any of the above
protected categories is prohibited by the Act. Discrimination in violation of the Act will not be
tolerated. Violators will be subject to disciplinary action. Complaints of possible violations of this law
may be filed with the Government of the District of Columbia, Office of Human Rights, 441 4
th
Street
NW, Suite 570-North, Washington, DC 20001. Telephone: (202) 727-4559. Fax: (202) 727-9589.
Fair Hearings
If you think that DHS has made a mistake, then you can get a Fair Hearing. Call 202-698-4650 to
find out more. You can also call (202) 727-8280. At a Fair Hearing, you can ask someone else to
speak for you. This could be an attorney, a friend, a relative, or someone else. You can also bring
witnesses. We will pay for transportation to the Fair Hearing for you and your witnesses. We may
also pay for some of your other costs. You can also get free legal help for a Fair Hearing. Call one of
the agencies above to talk to a lawyer or counselor.
Free Legal Help
Neighborhood Legal Services Legal Counsel for the Elderly University Legal Services
4609 Polk St., NE (for persons age 60 or older) 220 I Street, NE, Suite 130
(for Ward 7 only) 601 E Street, NW (202) 547-0198
680 Rhode Island Ave., NE (202)434-2120
2811 Pennsylvania Ave, SE Legal Aid Society
(for Ward 8 only) 666 11
th
Street, NW, Suite 800
(202) 832-6577 (202) 628-1161
