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Is the person applying for Long Term Care Medical Assistance currently in a nursing home?

Yes No

How long is the nursing home resident expected to stay in the nursing home?

30 days or less 90 days or less 91 days or more I don’t know

Has the person applying for Long Term Care Medical Assistance been in a nursing home in the past 3 months?

Yes No

Long Term Care Medical Assistance is for individuals who are currently residing in a nursing home or have resided in a nursing home within the last 3 months. An application for Long Term Care is NOT appropriate at this time.

Is the person applying for Long Term Care Medical Assistance receiving federal Medicare through the Social Security Administration?

Yes No I don’t know

Please enter the nursing home resident’s Medicare Number (The number may be found on the Medicare card as shown below.)

The nursing home resident has federal Medicare but I don’t know the number. The nursing home resident has applied for federal Medicare but has not received approval yet.

Does the person applying for Long Term Care Medical Assistance need help paying for the federal Medicare co-pays?

Yes No I don’t know

Was the person applying for Long Term Care Medical Assistance residing in the hospital for at least 3 days immediately before transferring to the nursing home?

Yes No I don’t know

Is the person applying for Long Term Care Medical Assistance now receiving rehab or skilled services in the nursing home?

Yes No I don’t know

Does the nursing home resident currently receive Maryland Medicaid (Medical Assistance) or is the resident enrolled in a Maryland Medicaid Managed Care Organization (MCO)? Click for Description

Yes No I don’t know

Please enter the nursing home resident’s Medical Assistance Identification Number here (The number can be found on the front of the Medicaid card as shown below.)

The nursing home resident has Medical Assistance but I don’t know the number.

Please enter the nursing home resident’s MCO Identification Number (The number can be found on the front of the MCO card or may be found on the enrollment letter from your MCO.)

The nursing home resident is covered by an MCO but I don’t know the number.

Based on your response, it appears an application is not appropriate at this time. You need to file a LTC MA application immediately preceding the end of your co-pay days.

Based on your responses, it appears a LTC application is not appropriate at this time. If the resident goes home within 100 days, Medicare and Medicaid may already cover the nursing home expenses. The nursing home will submit a request to the Long Term Care Processor.

If the resident remains in the Nursing Home beyond 100 days, a LTC application will need to be filed immediately after 100 days

Based on your responses, it appears a LTC application is not appropriate at this time. The nursing home resident’s expenses may already be partially covered by Medicare. If the resident remains in the Nursing Home beyond 100 days, a LTC application will need to be filed immediately after 100 days.

Based on your responses, it appears a LTC application is not appropriate at this time. The nursing home resident’s expenses may already be covered by Medicare and Medicaid, for the first 100 days. If the resident remains in the Nursing Home beyond 100 days, a LTC application will need to be filed immediately after 100 days.