Skip to content subnavigation

Questions? | Policy Manual | Training Information

The DHS-3531 can be used to request both MA and MA payment of LTC services. This application asks questions specific to MA-LTC and allows for detailed responses to those questions.

This form does not inquire about other household members. You must follow up with the applicant, or ask at the interview, to determine a client’s household size. You will see soon how this information is used in relation to MA-LTC determination.

Ideally, all people requesting MA and payment of LTC services would use this form however you cannot require this form if another type of application is received.

The DHS-3543 is a supplemental form used for current basic MA enrollees (or an enrollee of any MHCP, such as MSP only) who report they are moving to an LTCF or indicate they want to receive services through a waiver program. The form provides the additional information needed to determine MA-LTC eligibility when basic MA has been approved prior to the need for LTC services. It will also be used to request LTC services if there is a gap of more than one calendar month of LTC services and basic MA has remained open.

Note: If the enrollee has families with children and adult basis, the DHS-3543A is used.

If an enrollee in the New Eligibility System requests payment of LTC services, the DHS-3543A provides the additional information needed to determine MA-LTC eligibility. There is no asset test for these persons and they are not subject to asset assessment, but LTC factors must still be determined.

If a DHS-3876 is received, you must request that the client complete, sign and return the DHS-3543 before eligibility for MA payment of LTC services can be determined.

If a person completes, signs and returns a DHS-6696 or has applied online through the MNsure website, and the DHS-6696A has been received with a request for MA and MA-LTC, use the information provided to make the LTC determination. Follow the non-MAGI referral process in ONEsoure to gather information. If the person is eligible with a families with children or adult basis, collect information using the DHS-3543A.

Renewal forms, including the Renewal for People Receiving Long-Term Care Services (DHS-2128) and the Minnesota Health Care Programs Renewal (DHS-3418) may also be used as a request for MA-LTC for an MA enrollee when the request is being made at the time completion of the renewal is required. If the MA enrollee is requesting MA-LTC at a time other than at the renewal, the DHS-3543 or the DHS-3543A must be provided. More information about renewal forms used for MA-LTC enrollees can be found in the Eligibility Policy Manual.