Louisiana Medicaid Application for Long-Term Care Services
This form helps applicants determine if they qualify for long-term care services through Louisiana Medicaid. It is designed for those residing or planning to reside in nursing facilities, group homes, developmental centers, or those offered opportunities through HCBS or PACE. Detailed instructions and assistance contacts are provided.
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How do I fill this out?
To begin filling out this application, gather all necessary personal, legal, and medical information. Make sure to use black ink and write clearly. Follow the step-by-step instructions provided on the form.
How to fill out the Louisiana Medicaid Application for Long-Term Care Services?
1
Gather all necessary personal, legal, and medical information.
2
Use black ink and write clearly.
3
Fill out each section according to the instructions provided.
4
If additional space is needed, use a separate sheet of paper or the provided space on page 13.
5
Submit the completed application to the specified Medicaid Application Office.
Who needs the Louisiana Medicaid Application for Long-Term Care Services?
1
Individuals planning to live in a nursing facility or already residing in one need this form to apply for Medicaid long-term care services.
2
Residents of group homes or developmental centers in Louisiana use this form to apply for Medicaid coverage.
3
Applicants offered Home and Community-Based Services (HCBS) need this form to complete their Medicaid application.
4
Elderly individuals participating in the Program of All-Inclusive Care for the Elderly (PACE) use this form to apply for Medicaid services.
5
Individuals with disabilities applying for Intermediate Care Facility for the Intellectually Disabled (ICF/ID) services need this form.
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What are the instructions for submitting this form?
Complete and mail this application to the Medicaid Application Office, 6069 1-49 Service Rd, Suite B, Opelousas, LA 70570 or fax it to 225-389-8019. Make sure to follow all instructions on the form and provide accurate information. Contact a Medicaid representative for any questions or assistance at 1-800-230-0690.
What are the important dates for this form in 2024 and 2025?
Important dates for this form include the annual enrollment period and deadlines for submission to ensure timely processing.
What is the purpose of this form?
The purpose of this form is to determine eligibility for long-term care services through Louisiana Medicaid. Applicants must provide personal, legal, and medical information to assess their qualification for services such as nursing facility care, HCBS, PACE, and other long-term care programs. By completing and submitting this form, individuals can access the necessary support and resources for their long-term care needs.
Tell me about this form and its components and fields line-by-line.
- 1. Applicant's Personal Information: Includes fields for name, social security number, date of birth, gender, marital status, ethnicity, race, mailing and home address, contact information, and residency status.
- 2. Application Assistance: Fields for information about anyone assisting the applicant with the form, including their name, relationship, contact details, and mailing address preference.
- 3. Legal Assistance: Fields for details about any legally appointed representative acting on behalf of the applicant, including their name, type of appointment, relationship, contact details, and mailing address preference.
- 4. Citizenship: Fields for veteran status, U.S. citizenship or national status, alien number, certificate type and number, document type and expiration date, and U.S. residency history since 1996.
- 5. Long-Term Care: Fields to confirm if the applicant plans to enter or currently resides in a long-term care facility, including facility name, entry date, and legal spouse living situation.
- 6. Home and Community-Based Services: Fields for information about HCBS waiver slot offers and the type of waiver the applicant is applying for.
- 7. Disability: Fields to describe any disability the applicant has, its cause, start date, and related medical provider details.
- 8. Health Insurance: Fields for health insurance coverage details, including policy type, policyholder name, insurance company, group/policy number, Medicare claim number, and monthly premium.
What happens if I fail to submit this form?
Failing to submit this form can result in the denial or delay of Medicaid long-term care services. It may impact the applicant's ability to receive necessary support and resources for their care needs.
- Denial of Services: Without submitting the form, the applicant will not be eligible to receive Medicaid long-term care services.
- Delay in Processing: Incomplete or late submissions can lead to delays in the processing of the application, affecting timely access to care.
- Impact on Care Plans: Failure to submit the form may result in disruptions or changes to existing care plans that rely on Medicaid funding.
How do I know when to use this form?
- 1. Nursing Facility Services: For individuals planning to live or currently residing in a nursing facility.
- 2. Group Home Services: For individuals residing in group homes or developmental centers.
- 3. HCBS Waiver Programs: For applicants offered Home and Community-Based Services (HCBS) slots.
- 4. PACE Program: For elderly individuals participating in the Program of All-Inclusive Care for the Elderly (PACE).
- 5. ICF/ID Services: For individuals with intellectual disabilities applying for Intermediate Care Facility (ICF/ID) services.
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