Medicaid Forms

Application for Home and Community-Based Services waiver providing personal care, respite, home modifications, and therapies as an alternative to institutional care. Waitlists are common.

Application for Emergency Medical Assistance for individuals meeting all Medicaid requirements except citizenship/immigration status. Must have received emergency services.

Federal marketplace application that also screens for Medicaid/CHIP eligibility and refers to state agencies when the applicant qualifies.

Application for children with severe disabilities to qualify for Medicaid based solely on the child's income/resources. No enrollment cap or waitlist. Requires medical Level of Care determination.

Clinical assessment determining whether an individual meets the institutional level of care required for HCBS waiver enrollment. Criteria vary by state.

Unified application for Medicaid, CHIP, and Marketplace coverage under ACA. Uses MAGI for financial eligibility. Available online, by mail, phone, or in person.

Request for a state fair hearing when Medicaid eligibility is denied, benefits are reduced, or a managed care plan denies services. Benefits may continue if filed timely.

Comprehensive assessment of long-term services and supports needs including ADL/IADL functioning, cognitive status, and caregiver availability. Determines service authorization levels.

Form to select or change a Medicaid managed care organization. In mandatory managed care states, failure to choose results in auto-assignment.

Internal grievance or appeal form for Medicaid managed care plan members to challenge service denials or quality-of-care issues.

Authorization request for Medicaid-funded personal care services including bathing, dressing, meal preparation, and medication management in the home.

Annual renewal verifying continued Medicaid eligibility. Includes income, expenses, and household composition. Failure to complete results in disenrollment.

Documents medical expenses applied toward meeting the spend-down amount. Once the difference between income and the medically needy income level is met, Medicaid covers remaining expenses.

Temporary Medicaid coverage granted by qualified entities (hospitals, clinics) based on preliminary income assessment. Covers services until full application is processed.

Application for Medicare Savings Programs (QMB, SLMB, QI) that help pay Medicare premiums, deductibles, and copays for low-income Medicare beneficiaries.

Application for coverage under Section 1115 demonstration waivers that allow states to test new approaches such as community engagement requirements or substance use treatment.