Form DHS-3531 – Fill Out and Use This PDF

Form DHS-3531 is a document that you'll need to complete when applying for payment for long-term care services.

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Form DHS-3531 PDF Details

Form DHS-3531 is used to apply for health care coverage for long-term care (nursing homes or intermediate care facilities) or services to help you stay in your home through the Minnesota Health Care Programs. /p>

Here is some information to help you establish how long it will require to complete Form DHS-3531.

Question	Answer
Form Name	Dhs 3531 Form
Form Length	28 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	7 min
Other names	how to dhs 3531 eng, form dhs 3531 eng, mn dhs 3531, dhs form 3531

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DHS-3531-ENG 5-17

MINNESOTA HEALTH CARE PROGRAMS (MHCP)

Application for Medical Assistance for

Long-Term-Care Services (MA-LTC)

■What is this application for?

Use this application to apply for health care coverage for:

■Long-term care (LTC), such as care in a nursing home or intermediate care facility or nursing-facility level of care in an inpatient hospital

■Services to help you stay in your home or other settings in the community through these home and community-based services (HCBS) waiver programs:

•Brain Injury (BI)

•Community Access for Disability Inclusion (CADI)

•Community Alternative Care (CAC)

•Developmental Disabilities (DD)

•Elderly Waiver (EW)

IMPORTANT: You must have an LTC consultation (LTCC) assessment before our program can pay for LTC in a facility or for additional services to help you stay in your home. The LTCC assessment will help you decide what type of care or additional services you need to stay in your home. Call your county agency as soon as possible to schedule an LTCC assessment. Payment for LTC services can only begin starting the date of the LTCC assessment.

Do not use this application to apply for these things:

■Health care coverage other than LTC described above

■Cash or food and nutrition programs

■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. The phone numbers for county agencies are listed in Attachment C.

■What do I need to do with this form?

1.Read the Notice of Privacy Practices and Notice of Rights and Responsibilities in Attachment A. Tear them off and keep them.

2.Answer all questions on the application. If you need more space, write the number of the question and the answer on a separate piece of paper. Include it with the application.

3.Sign and date the application.

4.Attach proofs.

5.Mail or take the application to your county or tribal agency. The addresses for county agencies are listed in Attachment C.

Send in your application right away even if you do not have all proofs. We will contact you if we need more information.

■Questions?

If you have questions or need help, call your county or tribal agency. The phone numbers for county agencies are listed in Attachment C. If you are 60 years old or older, you can also call the Senior LinkAge Line® at 800-333-2433. If you have a disability, you can also call the Disability Linkage Line® at 866-333-2466.

651-431-2670 or 800-657-3739

ADA1 (9-15)

For accessible formats of this publication or assistance with additional equal access to human services, write to DHS.info@state.mn.us, call 800-657-3739, or use your preferred relay service.

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DHS-3531-ENG

5-17

MINNESOTA HEALTH CARE PROGRAMS (MHCP)

Application for Medical Assistance for Long-Term-Care Services (MA-LTC)

DATE RECEIVED

	Office Use Only
CASE NUMBER	WORKER NUMBER

■Answer all questions the best you can.

■Return the form right away.

■We will contact you if we need more information.

1.Information for the person living in or planning to live in a long-term-care facility or requesting services to help the person live at home or other settings in the community

FIRST NAME

LAST NAME

DATE OF BIRTH


GENDER		MARITAL STATUS
Male	Female	Legally separated			Divorced	Never married	Married	Widowed
Do you have a Social Security number (SSN)?			Yes	No

IF YES, WHAT IS YOUR SSN?

IF NO, HAVE YOU APPLIED FOR AN SSN?

Yes No

IF YOU HAVE NOT APPLIED, WHY NOT? (Choose a reason code from the list on Attachment B)

Do you have a guardian or conservator?	Yes – fill in the following	No

NAME OF GUARDIAN OR CONSERVATOR

CITY

	PHONE NUMBER

STATE	ZIP CODE

Are you a veteran or the spouse of a veteran?

Are you blind, or do you have a physical or mental health condition that limits your ability

Yes

to work or perform daily activities?

Yes

Are you pregnant?

IF YES, HOW MANY BABIES ARE EXPECTED?

DUE DATE (MM/DD/YYYY)

Have you had a long-term-care consultation?

Yes

N/A

Yes

Don't know

What language do you speak most of the time?

Do you need an interpreter?

Yes

RACE (check all that apply)

White

Black or African American

American Indian or Alaska Native

Asian Indian

OPTIONAL

Chinese

Filipino

Japanese

Korean

Vietnamese

Other Asian

Native Hawaiian

Guamanian or Chamorro

INFORMATION

Samoan

Other Pacific Islander

Other:

→

HISPANIC OR LATINO ETHNICITY (check all that apply)

Mexican

Mexican American

Chicano or Chicana

Puerto Rican

Cuban

Other:

Page 1 of 11

2. Are there other family members living with you?	Yes – fill in below	No

Name (First, MI, Last)

Date of birth

(MM/DD/YYYY)

Relationship to you

3.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 No

4. Address and phone number

STREET ADDRESS WHERE YOU ARE CURRENTLY LIVING				CITY			STATE	ZIP CODE		COUNTY

MAILING ADDRESS (if different)				CITY			STATE	ZIP CODE		COUNTY

PHONE NUMBER	Do you plan to make Minnesota your home?				Do you currently have medical benefits from another state?						WHICH STATE?
	Yes	No			Yes – fill in the following				No

Are you currently in a long-term-care facility?			Yes – fill in the following			No

LONG-TERM-CARE FACILITY NAME

DATE MOVED INTO THIS FACILITY (MM/DD/YYYY)

STREET ADDRESS BEFORE MOVING TO THIS FACILITY

CITY

STATE

ZIP CODE

COUNTY

If you have a home, do you plan to return there?	Yes	No

OPTIONAL

INFORMATION

→

What is your living situation? (choose one)

I live in a hospital, nursing home, treatment facility or detox center.

I have my own housing (rent, pay a mortgage or share housing costs with a roommate).

l live with family or friends because of economic hardship.

I live in an emergency shelter.

I live in a service provider’s housing (foster home or group home).

Unknown

I live in a jail, prison or juvenile detention facility.

I live in a hotel or motel.

I decline to answer.

I live in a place not meant for housing (anywhere outside, a vehicle, an abandoned building, a bus or train station, or an airport). In which county do you live?

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DHS-3531-ENG 5-17

5. Are you a U.S. citizen or U.S. national?	Yes	No – fill in below

What is your current immigration status? (Choose a status code from the list on Attachment B, or write in your status below if it is not on the list.)

a. IMMIGRATION DOCUMENT TYPE

b. ALIEN ID NUMBER

c. CARD NUMBER

d. Did you enter the United States before August 22, 1996?

Yes No

e. Have you lived in the United States for five years or more in a qualified status?

(See Attachment B to determine whether you have a qualified status.)

Yes

f. DATE OF ENTRY (MM/DD/YYYY)		g. Do you have a sponsor?		h. Are you, or is your spouse or parent, a veteran or active-duty member of the military?
		Yes	No	Yes	No

i. Do you want help paying for a medical emergency?					j. Are you getting services from the Center for Victims of Torture?
Yes	No				Yes	No

6. Do you want someone to act on your behalf as an authorized representative?

Yes – complete Appendix B

(You can give a trusted person permission to talk about this application with us, see your information and act for you on matters related to this application, including getting information about your application and signing your application on your behalf.)

7. Do you want help from MA to pay for medical bills from the past three months?

(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.)

	Yes – fill in below	No
How many months?
One	Two	Three

You must provide proof of your medical expenses, income and assets in each of the months for which you are requesting coverage.

Refer to the types of proof listed after each of the following questions for examples of acceptable proof for the income and assets you had.

8.How much cash do you or your spouse have on hand, in a safety deposit box, at home and at the facility where you live?

9.Do you or your spouse have savings or checking accounts, money market accounts or certificates of deposit?

Yes – fill in below

Owner name(s)

Type of account

Bank name and address

Account number

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.

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DHS-3531-ENG 5-17

10. Do you or your spouse have stocks, bonds or retirement accounts?	Yes – fill in below	No

Owner name(s)

Type of investment

Company or bank name and address

Account number

You must provide proof of these assets. Proof may be copies of bonds, stock ownership, retirement accounts, or documents showing current loan balance owed against the asset.

11.Do you or your spouse own or co-own houses, condominiums, summer or winter homes, cabins, mobile homes, time-shares, rental properties, any real estate, or life estate interests or remainder interests in real property?

Yes – fill in below	No

				Do you or your spouse
Owner name(s)		Type of property	Property address	live here all year?
				Yes	No

				Yes	No

You must provide proof of these assets. Proof may be real property tax statements, warranty deeds, quit claim deeds, life estate or other real property agreements or documents showing the amounts owed against the property.

12.Do you or your spouse own or co-own promissory notes, contracts for deed or other property agreements?

Yes – fill in below

Owner name(s)

Type of asset

You must provide proof of these assets. Proof may be copies of the contract for deed, mortgage, loan contract, or promissory note.

13. Do you or your spouse have any vehicles in your name? Include cars, trucks, vans, motorcycles, motor

homes, campers, boats, snowmobiles, all-terrain vehicles, etc.

Yes – fill in below

Owner name(s)

Type of vehicle

Year, make, model

You must provide proof of these assets. Proof may be copies of your vehicle title.

Page 4 of 11

DHS-3531-ENG 5-17

14. Do you or your spouse have an interest in a trust or annuity?	Yes – fill in below	No

Owner name(s)

Type

You must provide proof of these assets. Proof may be copies of the annuity contract, other documents showing the value of the annuity or copies of the entire trust document.

15. Do you or your spouse have life insurance?		Yes – fill in below	No

Owner name(s)	Policy number	Insurance company name and address

You must provide proof of these assets. Proof may be a copy of your life insurance policy.

16. Do you or your spouse have a prepaid burial account or burial trust? Include revocable and irrevocable accounts, insurance-funded burials, annuity-funded burials, Cremation Society agreements, burial spaces, burial space items and other funds designated for burial.

Yes – fill in below

Owner name(s)

Type of burial asset

Company or bank name and address

You must provide proof of these assets. Proof may be copies of the life insurance policy, burial contracts or other documents showing the current value of the assets.

17.Do you or your spouse have assets currently used for self-employment or in a business in which you or your spouse has an interest?

Yes – fill in below

Owner name(s)

Type of asset

You must provide proof of these assets. Proof may be current tax documents, business ledgers, or account statements.

Page 5 of 11

DHS-3531-ENG 5-17

18. Do you or your spouse own or co-own any other assets you have not listed?

Yes – fill in below

Owner name(s)

Type of asset

You must provide proof of these assets.

19. Do you or your spouse live in a continuing care retirement community?	Yes	No

You must provide proof of these assets. Proof may be a copy of the continuing care retirement contract.

20. Did you or your spouse create a trust in the last 60 months?	Yes – fill in below	No

NAME(S) OF WHO CREATED THE TRUST

DATE CREATED (MM/DD/YYYY)

You must provide proof of these assets. Proof may be copies of the entire trust document.

21.Did you or your spouse buy an annuity, life estate in another person's home, a promissory note, loan or mortgage in the last 60 months?

Yes – fill in below	No

WHAT WAS BOUGHT?

DATE BOUGHT (MM/DD/YYYY)

You must provide proof of these purchases. Proof may be copies of the annuity contract, promissory note, mortgage or loan contract, or life estate, as well as documentation of amounts owed against the property.

22.Did you or your spouse not accept items or income you could have taken, such as an inheritance or a pension, in the last 60 months?

Yes – fill in below	No

	Item(s) you did not take	Value of the item or income	Date happened
	Item(s) you did not take	Value of the item or income	(MM/DD/YYYY)
		$

		$

You must provide proof of this income. Proof may be award letters, copies of checks, tax forms or court orders or other documents.

Page 6 of 11

DHS-3531-ENG 5-17

23. Did you or your spouse sell, trade or give away items or income in the last 60 months?

Yes – fill in below	No

			Sold, traded or		Date	Amount you
Owner name(s)	Item or income	Value	given away?	To whom?	Date	were paid
Owner name(s)	Item or income	Value	given away?	To whom?	(MM/DD/YYYY)	were paid
		$				$

You must provide proof of sale of these items. Proof may be accounts showing income given away in the last 60 months or receipts from sale or trade of assets documenting the amount each asset was sold or traded for.

24. Are you working, or do you expect to work in the next month? Include temporary and seasonal work.

	Yes – fill in below	No

EMPLOYER NAME					START DATE (MM/DD/YYYY)

Is this job seasonal?			Has this job ended?		IF YES, END DATE (MM/DD/YYYY)
Yes	No		Yes	No

Wages and tips before taxes (Choose one and fill in the dollar amount and your hours per week.)

Hourly	$	per hour	Hours per week:
Weekly	$		Hours per week:
Every two weeks	$		Hours per week:
Twice a month	$		Hours per week:
Monthly	$		Hours per week:
Yearly	$		Hours per week:

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.

25. Are you self-employed, or do you expect to be self-employed next month?

Yes – fill in below

TYPE OF WORK

MONTHLY INCOME

MONTHLY EXPENSES

START DATE (MM/DD/YYYY)

You must provide proof of this income. Proof may be most recent income tax returns and all related schedules or business records if taxes are not filed.

Page 7 of 11

DHS-3531-ENG 5-17

26. 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		■ Any other payments
Yes – fill in below	No

Type of income		Amount		How often received?			Has this income ended?
		$				Yes	No	IF YES, END DATE (MM/DD/YYYY)
						Yes	No

		$				Yes	No	IF YES, END DATE (MM/DD/YYYY)
						Yes	No

		$				Yes	No	IF YES, END DATE (MM/DD/YYYY)
						Yes	No

		$				Yes	No	IF YES, END DATE (MM/DD/YYYY)
						Yes	No

You must provide proof of this income. Proof may be award letters, copies of checks, tax forms, court orders, or other documents.

27. Expenses

If you are blind or have a disability, do you have work expenses?			IF YES, TYPE OF EXPENSE(S)		MONTHLY AMOUNT
Yes	No	Not applicable			$

If you have a legal guardian or conservator, do you pay a fee?			IF YES, FEE PAID
Yes	No	Not applicable	$

Do you have court-ordered child or medical support payments taken from your income?				IF YES, AMOUNT PER MONTH
Yes	No			$


Do you have court-ordered spousal maintenance payments taken from your income?				IF YES, AMOUNT PER MONTH
Yes	No			$

You must provide proof of these expenses. Proof may be court orders or paystubs.

28.Do you have medical expenses? Include health insurance premiums, pharmacy co-pays, doctor office co-pays and all unpaid medical bills.

Yes – fill in below

LIST EACH MEDICAL EXPENSE

You must provide proof of these expenses. Proof may be receipts of pharmacy co-pays, unpaid medical bills, or notices of health insurance premiums.

Page 8 of 11

DHS-3531-ENG 5-17

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Complete the minnesota eng payment PDF and enter the details for each and every area:

Fill in the FIRST NAME, LAST NAME, DATE OF BIRTH, GENDER, MARITAL STATUS, Male, Female, Legally separated, Divorced, Never married, Married, Widowed, Do you have a Social Security, Yes, and IF YES WHAT IS YOUR SSN areas with any information that are asked by the program.

It is necessary to put down some information within the space OPTIONAL INFORMATION, White Chinese Vietnamese Samoan, Black or African American Filipino, American Indian or Alaska Native, Asian Indian Korean Guamanian or, HISPANIC OR LATINO ETHNICITY check, Mexican, Mexican American, Chicano or Chicana, Puerto Rican, Cuban, Other, and Page of.

You will have to identify the rights and obligations of each party in field Are there other family members, Yes fill in below, Name First MI Last, Date of birth MMDDYYYY, Relationship to you, If you or anyone in your family, assets might not count toward your, Yes you need to complete and, Address and phone number, STREET ADDRESS WHERE YOU ARE, CITY, STATE, ZIP CODE, and COUNTY.

Terminate by looking at all these fields and filling them in as required: MAILING ADDRESS if different, CITY, STATE, ZIP CODE, COUNTY, PHONE NUMBER, Do you plan to make Minnesota your, Do you currently have medical, WHICH STATE, Yes, Yes fill in the following, Are you currently in a, Yes fill in the following, LONGTERMCARE FACILITY NAME, and DATE MOVED INTO THIS FACILITY.

Step 3: As you pick the Done button, the completed document is easily transferable to any kind of of your devices. Or alternatively, you can easily send it via mail.

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