Tip for Insurer-specific

A Partnership policy provides dollar-for-dollar Medicaid asset protection — every dollar the policy pays out protects that amount of your assets if you later apply for Medicaid

Tip for Insurer-specific

Partnership policies must meet specific requirements (inflation protection, specific benefit triggers) to qualify for Medicaid asset disregard

Tip for Insurer-specific

The asset protection applies in ANY state that has a Partnership program (all states except a few have adopted the program)

Long-Term Caremoderate

LTC Partnership Policy Application

Insurer-specific · Private LTC insurance carriers (partnership states)

Application for a qualified state LTC partnership insurance policy. Allows the policyholder to protect assets equal to benefits received when applying for Medicaid. Available in most states.

Form Details

Total fields: 55
Auto-fillable: 30 (55%)
Time without BeneFill: 45 minutes
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Time saved: 33 minutes
Filled by: patient
Frequency: one time
State-specific: Yes — form may vary by state

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Where to Submit This Form

📬

File a claim with your Long-Term Care Partnership insurance carrier

🏢

Call the LTC insurance carrier's claims department

Number listed on your policy or insurance card.

Filing Deadline

File a claim as soon as LTC services begin. Most policies have a waiting/elimination period (typically 30-90 days) before benefits start.

Required Attachments

📎 Completed claim form from the insurance carrier
📎 Physician's statement or plan of care documenting the need for LTC services
📎 Documentation of benefit triggers (typically inability to perform 2+ ADLs or cognitive impairment)
📎 Bills or invoices from LTC providers
📎 Assessment by the insurance carrier's care coordinator (typically arranged by the carrier)

Processing Time

Initial claim review: 30-60 days. Benefits begin after the elimination period is satisfied. Ongoing claims are reviewed periodically.

What Happens Next

If the claim is approved, the carrier pays LTC benefits according to the policy terms (daily/monthly benefit, benefit period, inflation protection). After benefits are exhausted, the dollar-for-dollar asset disregard protects that amount from Medicaid spend-down.

Tips for This Form

✓ A Partnership policy provides dollar-for-dollar Medicaid asset protection — every dollar the policy pays out protects that amount of your assets if you later apply for Medicaid
✓ Partnership policies must meet specific requirements (inflation protection, specific benefit triggers) to qualify for Medicaid asset disregard
✓ The asset protection applies in ANY state that has a Partnership program (all states except a few have adopted the program)
✓ File your claim promptly and track the elimination period — benefits start the day after the elimination period is satisfied

More Long-Term Care Forms

MDS 3.0 (Minimum Data Set)

MDS 3.0 · CMS

Standardized health status screening and assessment tool required for all residents of Medicare/Medicaid-certified nursing facilities. Used for care planning and Medicare payment calculation. Must be completed within 14 days of admission and periodically thereafter.

PASRR Level 1 Screening

State-specific · CMS / State Medicaid agencies

Federally mandated preadmission screening for all individuals entering Medicaid-certified nursing facilities to identify those with mental illness, intellectual disability, or related conditions who may need specialized services.

PASRR Level 2 Evaluation

State-specific · State mental health / developmental disability agencies

Comprehensive evaluation for individuals identified in Level 1 screening. Determines if nursing facility placement is appropriate and what specialized services are needed.

Long-Term Care Medicaid Application

State-specific · State Medicaid agencies

Application for Medicaid coverage of nursing facility care. Includes detailed financial disclosure of income, assets, and transfers. A five-year look-back period for asset transfers applies.

Asset Transfer / Look-Back Documentation

State-specific · State Medicaid agencies

Documentation of all asset transfers in the 60 months (5 years) before Medicaid application. Uncompensated transfers may result in a penalty period of Medicaid ineligibility.

Spousal Impoverishment Protection Forms

State-specific · State Medicaid agencies

Documentation establishing the Community Spouse Resource Allowance (CSRA) and Monthly Maintenance Needs Allowance (MMNA) protecting the non-institutionalized spouse's assets and income.

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Disclaimer: BeneFill™ provides form-filling assistance and informational guidance only. It is not affiliated with, endorsed by, or sponsored by the Private LTC insurance carriers (partnership states) or any government agency. The information provided is for general informational purposes and does not constitute legal, medical, financial, or tax advice. Always verify form requirements and submission details directly with the issuing agency.