[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-305331-105":53,"doc-detail-305331-en":127},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":120,"head_meta":122,"extra_data":124,"updated_unix":126},105,"en","retroactive-medicaid-application-for-institutional-care-application-form","Retroactive Medicaid Application for Institutional Care - Application Form","","Retroactive Medicaid coverage is requested to pay medical bills incurred in a Nursing Facility, Skilled Nursing Facility, or Intermediate Care Facility for individuals with developmental disabilities during the three months before filing a Long Term Care Medicaid application. The form determines eligibility for retroactive Long Term Care Medicaid and requires the applicant to meet all requirements within the retroactive period. It provides submission methods, collects applicant and residence history, citizenship/immigration status, resource and income history, and requires signatures plus notices about rights and responsibilities.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/retroactive-medicaid-application-for-institutional-care-application-form/305331/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/retroactive-medicaid-application-for-institutional-care-application-form/305331.png","ImageObject",442,249,{"name":88,"@type":89},"\tJames","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-12","2026-09-19",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",9,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"Who should complete this retroactive Medicaid application form?","Question",{"text":109,"@type":110},"Individuals seeking retroactive Medicaid coverage to pay for medical bills received in a nursing facility, skilled nursing facility, or intermediate care facility for the developmentally disabled during the three months before filing a Long Term Care Medicaid application should complete it.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"How do applicants submit the retroactive Medicaid coverage application?",{"text":114,"@type":110},"Submissions can be made by mail, email, upload through Quickbase, fax, or drop-off at one of the listed service centers in Washington, DC.",{"name":116,"@type":107,"acceptedAnswer":117},"What information is required about residence, citizenship, and eligibility status?",{"text":118,"@type":110},"The form asks whether the applicant lived in D.C. throughout the three retroactive months, whether U.S. citizenship/eligible immigration status differed during that period, and when any changes occurred, with reference to Attachment B for eligible immigration status categories.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},305331,1790236789,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":136,"language":137,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":138,"faqs":139,"seo_title":140,"seo_description":61,"update_tm":141,"read_time":76},2336474466412,"https://ap-avatar.wpscdn.com/davatar_155a257f0dc6eb9ab79c44ca47cae57d","Retroactive Medicaid Application for Institutional Care  \nIf you are requesting retroactive Medicaid coverage to pay for medical bills that you received in a Nursing Facility, Skilled Nursing Facility, or Intermediate Care Facility for the Developmentally Disabled 3 months prior to filing your Medicaid Long Term Care Application (retroactive months), please complete, sign and return this application form. This form will be used to determine if you qualify for retroactive Medicaid coverage. You must meet all eligibility requirements for Long Term Care Medicaid coverage during the retroactive period to qualify for Long Term Care Retroactive Medicaid coverage.  \nHow to Submit this Retroactive Medicaid Coverage Application  \nMail: Department of Human Services  \nCase Records Management Unit  \n441 4th Street, NW, Suite 1C-15  \nWashington, DC 20001  \nEmail: [esanursing.home@dc.gov](esanursing.home@dc.gov)  \nYou may upload this application through Quickbase  \nFax: (202) 535-1122  \nDrop Off: You may drop off the completed and signed form at any of the below service centers.  \nH Street Service Center  \n609 H Street, NE  \nWashington, DC 20002  \nFort Davis Service Center  \n3851 Alabama Avenue, SE Washington, DC 20020  \nCongress Heights Service Center  \n4001 South Capitol Street, SW Washington, DC 20032  \nAnacostia Service Center  \n2100 Martin Luther King Avenue, SE Washington, DC 20020  \nTaylor Street Service Center  \n1207 Taylor Street, NW Washington, DC 20011  \n\n| | Applicant Information |\n| --- | --- |\n\nTell Us About Yourself  \nYour Name (first, middle, last)  \nWe will use this information to contact you, if needed.  \n\n| Social Security Number or DC Medicaid Number |  | Date of Birth (mm/dd/yyyy) |\n| --- | --- | --- |\n| City | State | ZIP code |\n\nPhone number (if you have one)  Email address (if you have one)    Are you applying for retroactive coverage for yourself? Yes 􀂅 No 􀂅  \n\n| | Residence History |\n| --- | --- |\n\nDid you live in D.C. throughout the entire three retroactive months? Yes 􀂅 No 􀂅  \nIf no, please tell us which months you did not live in D.C., the state where you were living, and which month you moved into the District.  \nAt any time during the three retroactive months, was your U.S. citizenship/eligible immigration status different from your status at the time you applied for LTC Medicaid? Yes 􀂅 No 􀂅  \nIf yes, please tell us when your citizenship/eligible immigration status changed and you became a U.S. citizen or met one of the eligible immigration status categories.  \n\n| | Citizenship/Eligible Immigration Status* Information |\n| --- | --- |\n\n*Please see Attachment B for more information on what is an eligible immigration status for Medicaid.  \n\n| | Resource History |\n| --- | --- |\n\nAt any time during the three retroactive months, did you or your spouse have resources different in type or value from the resources  \nyou had at the time you applied for LTC Medicaid? Yes 􀂅 No 􀂅  \nDid you and your spouse own the same resources such as cars, home, insurance policies and bank accounts in the three retroactive months as you owned at the time you applied for LTC Medicaid? Yes 􀂅 No 􀂅  \nIf your resources were different please explain below.  \n5  Income History   \nAt any time during the three retroactive months, did you or your spouse have income different from the income you had at the time you applied for LTC Medicaid? Yes 􀂅 No 􀂅  \nIf yes, tell us whose (yours or your spouse’s) income changed and what the gross income was for each of the three retroactive months for which coverage is requested.  \nName (first and last) Month Before LTC Application Two Months Before LTC Application Three Months Before LTC Application    $   $   $   \nName (first and last) Month Before LTC Application Two Months Before LTC Application Three Months Before LTC Application    $   $   $   \nName (first and last) Month Before LTC Application Two Months Before LTC Application Three Months Before LTC Application    $   $   $   \n\n| | Signature |\n| --- | --","cbCaiiObIp7vGxNR","https://ap.wps.com/l/cbCaiiObIp7vGxNR","pdf",256977,7,"English","# How to Submit this Retroactive Medicaid Coverage Application\n# Applicant Information\n# Residence History\n# Citizenship/Eligible Immigration Status Information\n# Resource History\n# Income History\n# Signature\n# Notice of Rights and Responsibilities\n## General Rules","[{\"question\":\"Who should complete this retroactive Medicaid application form?\",\"answer\":\"Individuals seeking retroactive Medicaid coverage to pay for medical bills received in a nursing facility, skilled nursing facility, or intermediate care facility for the developmentally disabled during the three months before filing a Long Term Care Medicaid application should complete it.\"},{\"question\":\"How do applicants submit the retroactive Medicaid coverage application?\",\"answer\":\"Submissions can be made by mail, email, upload through Quickbase, fax, or drop-off at one of the listed service centers in Washington, DC.\"},{\"question\":\"What information is required about residence, citizenship, and eligibility status?\",\"answer\":\"The form asks whether the applicant lived in D.C. throughout the three retroactive months, whether U.S. citizenship/eligible immigration status differed during that period, and when any changes occurred, with reference to Attachment B for eligible immigration status categories.\"}]","Retroactive Medicaid Application for Institutional Care - Application Form | PDF",1789823846]