Filling Out and Submitting the MAP-115: Kentucky Medicaid Waiver Application

The MAP-115 is a one-page participant authorization form used in Kentucky’s Medicaid waiver application process. It collects only the participant’s name and signature (and an authorized representative’s information, if one is signing) and gives the Commonwealth permission to share the medical information needed to process waiver enrollment.1Cabinet for Health and Family Services. MAP-115 Application Intake – Participant Authorization It is not the Medicaid application itself. It is the consent document that travels with your waiver application after you have already applied for Medicaid through kynect.2Kentucky Health Benefit Exchange. How to Apply for Waiver Services

What the MAP-115 Asks You to Fill In

The form is shorter than most people expect. One page, two sections:1Cabinet for Health and Family Services. MAP-115 Application Intake – Participant Authorization

  • Participant section: first name, middle initial, last name, and signature.
  • Authorized Representative section: a checkbox asking whether a representative is applying on the individual’s behalf, plus that representative’s name and signature if the box is checked.

By signing, the participant acknowledges three things: that medical information will be shared with the Commonwealth and its contract employees for purposes of the Medicaid Waiver Program, that the information provided is correct, and that the Application Initiator has authority to apply on the person’s behalf.1Cabinet for Health and Family Services. MAP-115 Application Intake – Participant Authorization

Nothing else is on the form. No income figures, no assets, no Social Security number, no medical history. Those details live in the separate Medicaid application through kynect and in the clinical assessment forms that accompany the waiver packet.

If the Participant Cannot Sign

If the participant cannot sign because of disability or age, the authorized representative signs in the designated section instead. Check the representative box, print the representative’s name, and sign there.1Cabinet for Health and Family Services. MAP-115 Application Intake – Participant Authorization

Where the MAP-115 Fits in the Waiver Process

Kentucky splits waiver enrollment into two steps, and the MAP-115 belongs to the second one.

Step 1: Apply for Waiver-Supportive Medicaid

Before waiver services can be authorized, you have to be enrolled in the Medicaid category that pays for long-term care. That application is submitted through kynect and does not involve the MAP-115. There are three ways to file:2Kentucky Health Benefit Exchange. How to Apply for Waiver Services

  • Online at kynect.ky.gov, using the purple “Benefits” icon and “Apply for All Programs.”
  • By phone to the Department for Community Based Services (DCBS) at (855) 306-8959.
  • In person at a local DCBS office.

Paper applications sent by mail are not accepted for waiver-supportive Medicaid.2Kentucky Health Benefit Exchange. How to Apply for Waiver Services A kynector can help for free.3kynect Benefits. Kentucky Medicaid and KCHIP

Step 2: Apply for Waiver Services and Sign the MAP-115

Once the Medicaid application is in process or approved, you apply separately for the specific waiver program, again through the “Apply for All Programs” path on kynect.2Kentucky Health Benefit Exchange. How to Apply for Waiver Services The MAP-115 is completed at this stage. Under 907 KAR 1:595, the applicant or an authorized representative must complete and upload the MAP-115 into the Medicaid Waiver Management Application (MWMA), together with a MAP-116 Service Plan – Participant Authorization.4Kentucky Legislative Research Commission. Kentucky Administrative Regulations Title 907 Chapter 1 Regulation 595

How the MAP-115 Gets Submitted

You do not upload the MAP-115 yourself. The MWMA is a state system that only HCBS waiver case managers, waiver providers, and PACE organizations can access directly. In practice you fill out and sign the form, then hand it to your assigned case manager or provider, who uploads it into MWMA on your behalf. All new waiver applications, level-of-care requests, and plan-of-care requests go through MWMA; paper and verbal submissions are no longer accepted.5Cabinet for Health and Family Services. Kentucky Medicaid Waiver Management Application

If a waiver program has a waiting list, the MAP-115 and the rest of the enrollment paperwork are typically finalized when a slot opens and the state contacts you. Approval for Medicaid on its own does not guarantee an immediate waiver slot.

Other Forms in the Packet

The MAP-115 is one piece of a larger set of documents. Depending on the waiver, you should also expect:

  • MAP-116 (Service Plan – Participant Authorization): completed and uploaded into MWMA before or at the time the person-centered service plan is submitted.4Kentucky Legislative Research Commission. Kentucky Administrative Regulations Title 907 Chapter 1 Regulation 595
  • MAP-10 (Waiver Services Physician’s Recommendation): a physician’s statement supporting the need for waiver services.
  • MAP-350 (Long-Term Care Facilities and HCB Program Certification Form): signed by the participant or legal representative at application and at each recertification.4Kentucky Legislative Research Commission. Kentucky Administrative Regulations Title 907 Chapter 1 Regulation 595
  • MAP-351 (Medicaid Waiver Assessment): the formal assessment used to confirm the applicant meets the waiver’s level-of-care requirement.

Each waiver requires proof that the applicant would otherwise need institutional care. The physician’s recommendation on the MAP-10 and the assessment on the MAP-351 feed that determination alongside the MAP-115 authorization. Your case manager coordinates the physician evaluations and assessments and tells you which forms apply to your specific program.

Which Waivers Use the MAP-115

Kentucky operates several home and community-based services (HCBS) waivers under Section 1915(c) of the Social Security Act, and all of them use the MAP-115 as part of enrollment. Each targets a different population and level of care:6Medicaid.gov. Kentucky Waiver Factsheet

  • Home and Community Based (HCB) Waiver: individuals with physical or other disabilities ages 0–64, and people 65 or older who meet a nursing facility level of care.
  • Supports for Community Living (SCL) Waiver: individuals age 3 or older with intellectual or developmental disabilities who meet an ICF/IID level of care.
  • Michelle P. Waiver: individuals age 18 or older with brain injuries who meet a nursing facility level of care.
  • Acquired Brain Injury (ABI) Waiver and ABI Long-Term Care Waiver: adults age 18 or older with brain injuries who meet a nursing facility level of care.
  • Model Waiver II: technology-dependent individuals of any age who meet a nursing facility level of care.
  • CHILD Waiver: individuals from birth through age 21 with autism, developmental or intellectual disabilities, or serious emotional disturbance who meet a hospital or ICF/IID level of care.

The MAP-115 itself does not change between waivers. What differs is the level-of-care standard applied through the accompanying physician and assessment forms.

Getting a Blank Copy

The current MAP-115 is published by the Cabinet for Health and Family Services and available as a PDF on the state’s Medicaid forms page.1Cabinet for Health and Family Services. MAP-115 Application Intake – Participant Authorization If a case manager or waiver provider is already working with you, they will usually bring the form to you along with the rest of the packet, so you may never need to download it yourself.