Form MILTC-64 "Application for Nebraska Medicaid for Aged and Disabled" - Nebraska

What Is Form MILTC-64?

This is a legal form that was released by the Nebraska Department of Health and Human Services - a government authority operating within Nebraska. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2018;
  • The latest edition provided by the Nebraska Department of Health and Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form MILTC-64 by clicking the link below or browse more documents and templates provided by the Nebraska Department of Health and Human Services.

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Download Form MILTC-64 "Application for Nebraska Medicaid for Aged and Disabled" - Nebraska

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Division of Medicaid & Long Term-Care
Application for Nebraska Medicaid for Aged and Disabled
This form is used by:
• Those over age 65
• Those under age 65 who are disabled and/or applying for a disability determination
• Aged, Blind, or Disabled (AABD) applying for a state supplemental grant payment
Complete this form and deliver to the local Department of Health and Human Services office or mail to:
DHHS, Medicaid Eligibility Program
PO Box 2992
Omaha, NE 68103-2992
or Fax the application to: (402) 742-2351
Contact the Department at (855) 632-7633 if assistance is needed in completing this application.
Email Address:
Email:
By checking ‘this box’, I elect to receive notification of my written notices and other correspondence regarding my ben-
efits from DHHS through the email address above. These benefits include; Medicaid, CHIP, SNAP, ADC, LIHEAP, CC Subsidy, AABD
payment and SSAD. I will no longer receive information through the mail. I understand I will receive an email notification of the cor-
respondence, which will provide a link to the DHHS ACCESSNebraska website where I can access the correspondence. I understand
that I must create an authenticated account on the ACCESSNebraska website in order to view my correspondence in Benefit Inquiry.
Text Messaging:
By checking ‘this box’, I agree to receive text messages on the cell phone number above from DHHS
regarding my benefits. These benefits include; Medicaid, CHIP, SNAP, ADC, LIHEAP, CC Subsidy, AABD payment and SSAD. I agree
to contact DHHS if my cell phone number changes or if this number is no longer in my possession. I understand that I can opt out of
this in the future by contacting DHHS. NOTE: Text messaging is currently under development and is targeted to be available in the
near future.
1. If you need us to provide an interpreter, check here:  Which language?
_________________________________________________
2. Do you or anyone in your household need help with any of the following? Please mark all you wish to apply for:
 Medicaid
 Personal Assistance
 Program for All Inclusive Care
 Aged and Disabled Waiver
Services
for Elderly (PACE)
 AABD Grant
3. Complete this section for yourself and everyone who lives with you, even if they are not applying. If you are residing
in a nursing home, boarding home or other group home, list only yourself, and your spouse. Depending on the type of
assistance you have requested, immigration status and Social Security Numbers (SSNs) may be verified.
Attach another sheet if more space is needed.
Is this
Is this
Relationship
Marital
person
Name
Sex
Social
person
to you.
Status &
a U.S.
List yourself First
Birthdate
Age
Male (M)
Security
disabled?
If not related
Effective
Citizen?
Last, First
Female (F)
Number
write "NR"
Date
Yes
No
Yes
No
SELF
4. Household Street Address: (Include Street, City, State, Zip Code)
Telephone Number:
Mailing Address: (If different from Household Street Address)
Other Phone Number:
5. List any previous names used including maiden name:
MILTC-64 12/2018
Page 1
Division of Medicaid & Long Term-Care
Application for Nebraska Medicaid for Aged and Disabled
This form is used by:
• Those over age 65
• Those under age 65 who are disabled and/or applying for a disability determination
• Aged, Blind, or Disabled (AABD) applying for a state supplemental grant payment
Complete this form and deliver to the local Department of Health and Human Services office or mail to:
DHHS, Medicaid Eligibility Program
PO Box 2992
Omaha, NE 68103-2992
or Fax the application to: (402) 742-2351
Contact the Department at (855) 632-7633 if assistance is needed in completing this application.
Email Address:
Email:
By checking ‘this box’, I elect to receive notification of my written notices and other correspondence regarding my ben-
efits from DHHS through the email address above. These benefits include; Medicaid, CHIP, SNAP, ADC, LIHEAP, CC Subsidy, AABD
payment and SSAD. I will no longer receive information through the mail. I understand I will receive an email notification of the cor-
respondence, which will provide a link to the DHHS ACCESSNebraska website where I can access the correspondence. I understand
that I must create an authenticated account on the ACCESSNebraska website in order to view my correspondence in Benefit Inquiry.
Text Messaging:
By checking ‘this box’, I agree to receive text messages on the cell phone number above from DHHS
regarding my benefits. These benefits include; Medicaid, CHIP, SNAP, ADC, LIHEAP, CC Subsidy, AABD payment and SSAD. I agree
to contact DHHS if my cell phone number changes or if this number is no longer in my possession. I understand that I can opt out of
this in the future by contacting DHHS. NOTE: Text messaging is currently under development and is targeted to be available in the
near future.
1. If you need us to provide an interpreter, check here:  Which language?
_________________________________________________
2. Do you or anyone in your household need help with any of the following? Please mark all you wish to apply for:
 Medicaid
 Personal Assistance
 Program for All Inclusive Care
 Aged and Disabled Waiver
Services
for Elderly (PACE)
 AABD Grant
3. Complete this section for yourself and everyone who lives with you, even if they are not applying. If you are residing
in a nursing home, boarding home or other group home, list only yourself, and your spouse. Depending on the type of
assistance you have requested, immigration status and Social Security Numbers (SSNs) may be verified.
Attach another sheet if more space is needed.
Is this
Is this
Relationship
Marital
person
Name
Sex
Social
person
to you.
Status &
a U.S.
List yourself First
Birthdate
Age
Male (M)
Security
disabled?
If not related
Effective
Citizen?
Last, First
Female (F)
Number
write "NR"
Date
Yes
No
Yes
No
SELF
4. Household Street Address: (Include Street, City, State, Zip Code)
Telephone Number:
Mailing Address: (If different from Household Street Address)
Other Phone Number:
5. List any previous names used including maiden name:
MILTC-64 12/2018
Page 1
6. Please mark your living arrangement:
 Live in a house - rent/own/mortgage
 Center for Developmentally Disabled
 Rent an apartment, duplex, triplex
 Assisted Living
 Rent a room
 Nursing home
 Board and room situation
 Drug abuse or alcohol treatment center
 Adult Family Home
 Other ___________________________________________________
7. Mark Yes or No and the amount your household is currently billed for each of the following:
Answer Yes or No
Who pays this bill?
How often
Expense
Amount
for each line
(List names of anyone who helps pay this bill)
paid?
a. Rent
 Yes
 No
b. Mortgage
 Yes
 No
c. Lot Rent
 Yes
 No
d. Property taxes on home
 Yes
 No
(if not included in mortgage)
e. Homeowners insurance
 Yes
 No
(if not included in mortgage)
f. Condominium/
 Yes
 No
Association fees
g. Other:
 Yes
 No
__________________________
______________________________________
8. OPTIONAL: Indicate the race and ethnic category of the head of household. Title VI of the Civil Rights Act of 1964
allows us to ask for this information. This information will not be used in determining eligibility for assistance. If you
do not provide this information, it will not affect your application. We ask for the information to assure that benefits are
distributed without regard to race, color, ethnicity, or national origin.
RACE: Select all that apply:
 American Indian or Alaska Native
 Asian
 Black or African American
 Native Hawaiian or Other Pacific Islander
 White
 Other __________________________________________
ETHNIC CATEGORY: Are you Hispanic or Latino?
 Yes
 No
9. Do you or anyone in your household owe medical bills from the past three months?
 Yes
 No
If yes, give us the following information:
Name
Date of Service
Name
Date of Service
10. Does anyone in your household have Medicare coverage?
 Yes
 No
If yes, complete the following:
Person's Name
Medicare Claim #
Person's Name
Medicare Claim #
MILTC-64 (48103) 12/15
Page 2
11. Is anyone in your household covered by personal or employer-provided health insurance, Public Health Service,
TRI-CARE, CHAMPUS, VA, Medical Coverage as a retirement benefit, or Medicare Supplement?
 Yes
 No
If yes, complete the following:
Names of Insured Persons
Insurance Company
Policy/Group
Cost Per
and Policy Holder
Name, Address, Phone Number
Number
Month
A. INCOME
12. Do you or does anyone in your household work? Work includes employment and self-employment. Self-employment
could be farming, odd jobs, providing child care, housekeeping, etc.
Does any Adult or Child
If Yes,
Employer Name or
Gross Amount:
How often
Hourly
Currently Receive any
Yes
No
Who is it?
Income Source:
Paid?
Rate:
(before deductions)
Money from:
Salaries, Wages, Tips,
Business Name:
Commissions, etc.,
(Provide pay stubs for
Address:
each adult)
Date Started:
Salaries, Wages, Tips,
Business Name:
Commissions, etc.,
(Provide pay stubs for
Address:
each adult)
Date Started:
Self-Employment
Business Name:
Income (Include your
most recent Federal
Address:
Tax Return with 1040
and all schedules)
Date Started:
NOTE: You are allowed to claim certain costs of doing business (expenses) to apply against your self-employment
income. These costs can be obtained from tax returns or self-employment ledgers. DHHS will explain which of these
documents (tax returns or ledgers) you will need to provide to identify the allowable costs of doing business.
13. Has anyone in the household left employment in the last 90 days?
 Yes
 No
If yes, complete the following:
Date of Change
Reason Job
Name
Employer Information
(month, day, year)
Ended
Name:
 Laid Off
 Quit
 On Strike
Address:
 Resigned
 Terminated
Name:
 Laid Off
 Quit
 On Strike
Address:
 Resigned
 Terminated
MILTC-64 (48103) 12/15
Page 3
B. OTHER INCOME
14. Have you or anyone in your household applied for or is anyone in your household receiving other income that is not
from working?
 Yes
 No
If yes, give us the following information:
• Write the monthly amount received and who receives it below.
• If anyone has applied to receive these benefits, but does not receive them yet, write "Applied" on the line.
• If left blank, no amount is listed or "Applied" is not written in, this means no one receives nor plans to receive
this income.
Attach another sheet of paper if more space is needed.
SSI $
Civil Service $
______________________________________________________________
_____________________________________________________
Social Security $
Interest/Dividend $
________________________________________________
_______________________________________________
Pension/Retirement $
Railroad Retirement $
__________________________________________
____________________________________________
Veterans Benefits $
Military Allotment $
_____________________________________________
_______________________________________________
Cash Assistance Payments $
Rental Income $
_________________________________
__________________________________________________
Workers' Compensation $
Claims/Disability $
_____________________________________
________________________________________________
Unemployment Compensation $
Insurance/Accident Settlement $
______________________________
_______________________________
Child Support/Alimony $
Child Support/Alimony $
________________________________________
_________________________________________
Farm Income $
Striker Income $
___________________________________________________
__________________________________________________
Annuities $
Life Estates $
________________________________________________________
______________________________________________________
Trusts/Inheritances $
Partnerships/Corporations $
____________________________________________
____________________________________
Native American Benefits $
Prizes/Awards/Winnings/Lottery $
_____________________________________
_____________________________
Gifts/Money from Relatives or Friends $
Contributions $
_____________________
____________________________________________________
15. Do you or anyone living in your household have any of the following resources? This includes resources on which
your name or any household member's name appears as an owner.
Answer Yes or No for each line:
Type of
Answer yes
Amount
Owned by
Account
Where
Resources
or no
Number
Located
a. Cash
1.
1.
1.
 Yes
 No
2.
2.
2.
b. Checking
1.
1.
1.
 Yes
 No
2.
2.
2.
c. Savings
1.
1.
1.
 Yes
 No
2.
2.
2.
d. Real Estate/Real
1.
1.
1.
 Yes
 No
Property/Farm Land
2.
2.
2.
e. Trusts
1.
1.
1.
 Yes
 No
2.
2.
2.
f. Life Insurance
1.
1.
1.
 Yes
 No
2.
2.
2.
i. Burial Funds/
1.
1.
1.
 Yes
 No
Trusts/Burial Spaces
2.
2.
2.
j. Nursing Home
1.
1.
1.
 Yes
 No
Account
2.
2.
2.
MILTC-64 (48103) 12/15
Page 4
16. Do you or or anyone living in your household have any of the following resources? This includes resources on which
your name or any household member's name appears as an owner.
 Yes
 No
If yes, write the value on the line provided.
$
401K
$
IRA
_____________________________________
_____________________________________
$
Annuities
$
Keogh
_____________________________________
_____________________________________
$
Certificates of Deposit
$
Machinery
_____________________________________
_____________________________________
$
Credit Union Accounts
$
Savings Bonds
_____________________________________
_____________________________________
$
Crops/Livestock
$
Stocks/Investments
_____________________________________
_____________________________________
$
Other:
_____________________________________
_________________
17. Does your name or any household member's name appear on the title of any licensed or unlicensed vehicles
(include cars, trucks, motorcycles, ATVs, boats, RVs, snowmobiles, trailers, aircraft, etc.)?
 Yes
 No
If yes, give us the following information:
Owner
Type of Vehicle
Model
Year
Value
Amount Owed
$
$
$
$
18. Have you or anyone in your household sold, traded or given away anything of substantial value within the past
60 months (5 years)?
 Yes
 No
If yes, give us the following information:
Type of Vehicle
When
Value
Owner
$
MILTC-64 (48103) 12/15
Page 5