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  • Apply
  • Select
  • Finalize
  • Please Select Yes or No to continue for Long Term Care Services
  • Please select a facility
  • Please Select Yes or No to continue for In-Home Care-Giver
  • Please Select Yes or No to continue for Assisted Care Services
  • Please Select Yes or No to continue for Division of Developmental Disabilities
  • Please Select Yes or No to continue for Hospice Care
  • Please Select Yes or No to continue for HCA request
  • Please Select Yes or No to continue for Unpaid Medical Expenses.
Long Term Care Coverage

If you or someone in your household needs long-term care or Hospice services, please answer the following questions


Someone in my household needs long-term care services because they are currently living in or expect to move to a medical facility, like a nursing home? *


Someone in my household needs an in-home care-giver? *


Someone in my household needs Assisted Living services? *


Someone in my household needs services through the Division of Developmental Disabilities? *


Someone in my household needs Hospice care? *


Do you need a disability determination because of a disabling condition expected to last 12 months or longer or result in death? *

Unpaid Medical Expenses Coverage

Do you or someone in your household have any unpaid medical expenses incurred within three months of this application? *

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