DHS-3531-ENG: Minnesota Application for Medical Assistance for Long-Term Care Services (MA-LTC)

Do you have a Social Security number (SSN)? Yes or No. If yes, enter your SSN. If no, have you applied for an SSN? Yes, or No and why not, choosing a reason code from the list on Attachment C.

Do you have a guardian or conservator? Yes or No.

Are you pregnant? Yes, No or N/A. If yes, enter how many babies are expected and the due date (MM/DD/YYYY).

Have you had a long-term-care consultation? Yes, No or Don't know.

Race and Hispanic or Latino ethnicity are optional information: check all that apply.

Are there other family members living with you? Yes - fill in this section, or No.

If you or anyone in your family is an American Indian or Alaska Native, some income and assets might not count toward your eligibility and you might not be required to pay premiums or copays. Do you want to apply for these exceptions? Yes - you need to complete and include Appendix A, or No.

Enter your street address where you are currently living, and a mailing address (if different).

Are you currently in a long-term-care facility? Yes or No.

Are you a U.S. citizen or U.S. national? Yes, or No - fill in this section. What is your current immigration status? Choose a status from List 1 or List 2 on Attachment C and enter it here. If your status is not listed, write it in.

Did you have a different immigration status before your current status (for example refugee or asylee)? Yes or No. If your previous status is not listed on List 1 or List 2 on Attachment C, write it in.

Do you want someone to act on your behalf as an authorized representative? Yes - complete Appendix B, or No.

Do you want help from MA to pay for medical bills from the past three months? Yes - fill in this section, or No. Check all that apply: One month ago, Two months ago, Three months ago. You must provide proof of your medical expenses for each month for which you are requesting coverage.

For savings or checking accounts, you must provide proof of these assets. Proof may be recent account statements or a written statement from your bank showing the current balance or value of accounts. If you are requesting health care coverage for past months, and any of the asset amounts were not the same in the past months, proof of assets may be requested for each month requested.

Are you working, or do you expect to work in the next month? Include temporary and seasonal work. Yes - fill in this section, or No.

You must provide proof of this income. Proof may be paystubs or a written statement of earnings from your employer if you do not have paystubs.

Did you get money this month or do you expect to get money next month from sources other than work? Include Social Security, Spousal support, Unemployment, Interest, Supplemental Security Income (SSI), Workers' compensation, Veterans' benefits, Dividends, Retirement or pension payments, Public assistance payments, Rental income, Trusts, Payments from a contract for deed, Annuities and Any other payments. Yes - fill in this section, or No.

Do you have medical expenses? Include health insurance premiums, pharmacy co-pays, doctor office co-pays and all unpaid medical bills. Yes - fill in this section, or No.

Have you received benefits from a long-term care partnership insurance policy anytime since July 1, 2006? Yes - fill in this section, No or I don't know.

Updates and reminders about your case in the future: by checking here, you consent to receive electronic notifications.

Read the Notice of Privacy Practices and Notice of Rights and Responsibilities (Attachment B) before signing the Signature Page. By signing, you say that you received and reviewed those notices, know that you must report changes to the information listed on this application, and declare under the penalties of perjury that this application has been examined by you and to the best of your knowledge is a true and correct statement of every material point.

The start date for MA can go back up to three months from your application date if you have medical bills from that time and meet the MA requirements.

Submit your completed and signed application and your proofs in one of these three ways: fax your application for faster processing, mail your application, or submit your application in person.

A person convicted of perjury may be sentenced to imprisonment of not more than five years or payment of a fine of not more than $10,000, or both (checked November 1, 2026). There may be other penalties for not telling the truth.

Do not use this application to apply for health care coverage other than LTC, cash or food and nutrition programs, or health care coverage for family members other than the person applying for LTC. Call your county or tribal agency for the correct application for your situation.