MassHealth and You Guide - Mass.Gov

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8 How and where to apply Generally, referrals are made by the person’s medical provider. MassHealth applicants and members may apply for the PACE program. Call the MassHealth Enrollment Center at 1-800-408-1253 (TTY: 1-800-231-5698 for people who are deaf, hard of hearing, or speech disabled) for a Senior Medical Benefit Request, and for more information about this program. Home- and Community-Based Services Waiver What it is and whom it is for Allows certain frail people (aged 60 or older) to live at home and get MassHealth Standard, including a wide range of medical and personal-care services at home (like homemaker, nonmedical transportation, and social-day care) Allows the person needing the at-home services, if married and living with his or her spouse, to have MassHealth eligibility determined without counting the income and assets of the other spouse (Also, see “How We Count Transfers of Income, Assets, and the Home” on page 12.) Requires the need for a level of care* equal to that provided in a nursing facility * An agency of the Massachusetts Executive Office of Elder Affairs (EOEA) that covers your local area reviews your medical need for long-term-care services for MassHealth. How and where to apply Generally, referrals are made by the person’s medical provider or by a case manager. OR Call a MassHealth Enrollment Center at 1-888-665-9993 (TTY: 1-888-665-9997 for people who are deaf, hard of hearing, or speech disabled) for a Senior Medical Benefit Request, and for more information about this program. Applying for MassHealth, Commonwealth Care, or the Health Safety Net How to apply 1. Fill out the Senior Medical Benefit Request (orange form). Note: If you are applying for MassHealth through the Kaileigh Mulligan or PACE programs, you do not have to fill out Supplement A: LTC Questions. If you are applying for MassHealth through the Home- and Community-Based Services Waiver, you only need to fill out the “Resource Transfers” section of Supplement A on page 13. 2. Send us the filled-out and signed application with proof of: your monthly income before taxes and deductions (like a copy of your pension stub or award letter). You do not need to send us proof of your social security or SSI income. If employed, send proof of your monthly employment income before taxes and deductions, such as two recent pay stubs or a U.S. tax return. If selfemployed, send a U.S. tax return, or if no U.S. tax return has been filed, you may submit an Accounting of Business Income and Expenses sheet for the last 12 months signed by an accountant (or you, if no accountant was used). Current business records showing other relevant documents may be submitted as acceptable proof of self-employment; the current value of your assets (like copies of your current bank statements**); and your U.S. citizenship/national status and identity. (See pages 28-29 for complete information about acceptable proofs.) See page 3 for information about immigration status and eligibility for benefits. 3. Give us a social security number (SSN) or proof that you have applied for an SSN for you (and your spouse) if applying for MassHealth or Commonwealth Care. However, you do not need to give us an SSN or proof you have applied for an SSN to get MassHealth Limited or the Health Safety Net.
4. After you have filled out the Senior Medical Benefit Request (SMBR) and any needed supplements, either send your filled-out Senior Medical Benefit Request to MassHealth Enrollment Center Central Processing Unit P.O. Box 290794 Charlestown, MA 02129-0214 or hand deliver it to MassHealth Enrollment Center Central Processing Unit Schrafft’s Center 529 Main Street, Suite 1M Charlestown, MA 02129. ** Under Chapter 125 of the Acts: An Act Relative to Exempting Seniors from Certain Bank Fees, financial institutions cannot charge seniors for copies of bank or other financial records if MassHealth is asking for the information. You must be a resident of Massachusetts to get any kind of MassHealth coverage. This means you actually live in Massachusetts and are not temporarily visiting here. Where to call 1. Call MassHealth Customer Service at 1-800-841-2900 (TTY: 1-800-497-4648 for people who are deaf, hard of hearing, or speech disabled) if you need a Senior Medical Benefit Request, a MassHealth and You guide in another language, or interpreter services. 2. Call a MassHealth Enrollment Center at 1-888-665-9993 (TTY: 1-888-665-9997 for people who are deaf, hard of hearing, or speech disabled): if you need help filling out the SMBR; or if you have any questions about the application process. Commonwealth of Massachusetts EOHHS www.mass.gov/masshealth SMBR (Rev. 01/13) Senior Medical Benefit Request for Seniors and People Needing Long-Term-Care Services For office use only Date received: This is an application for MassHealth, Commonwealth Care, and the Health Safety Net. You do not have to be a U.S. citizen/national to get these benefits. Please print clearly. Please answer all questions and fill out all sections and any supplements that apply to you. If you need more space to finish any section on this form, please use a separate sheet of paper (include your name and social security number), and attach it to this form. You MUST answer ALL three questions in the following section. Are you or your spouse applying for: 1. MassHealth or the Health Safety Net while still living at home, in a rest home, in an assisted-living facility, a continuing-care retirement community, or a life-care community? You yes no Your spouse yes no 2. MassHealth while still living at home or in one of the living situations described in question #1 above AND also either applying for or getting services under a Home- and Community-Based Services Waiver, PACE (Program of All-Inclusive Care for the Elderly), or SCO (Senior Care Options)? You yes no Your spouse yes no 3. MassHealth because you are living in a medical institution, like a nursing home or chronic hospital? You yes no Your spouse yes no If you are applying for or getting long-term-care services at home under a Home- and Community-Based Services Waiver, or in a nursing home or chronic hospital, you must also fill out all or part of the blue sheet (Supplement A: Long-Term-Care Questions) at the end of this application. Head of Household/Applicant Last name First name MI Street address City State Zip Mailing address (if different from street address or if living in a shelter) homeless City State Zip Marital status single married separated widowed divorced Is this person a U.S. citizen/national? yes no Gender M F Social security number* Date of birth / / Race (optional) Ethnicity (optional) Spoken language choice Written language choice E-mail Telephone numbers Home: ( ) Cell: ( ) Work: ( ) Name and address of hospital, nursing facility, or other institution (if applicable) Date of admission / / Were you placed here by another state? yes no If yes, what state? Spouse Information Last name First name MI Social security number* Is this person applying? yes no If yes, is this person a U.S. citizen/national? yes no Date of birth / / Gender M F Race (optional) Ethnicity (optional) Spoken language choice Written language choice Address, if different from head of household Is this a hospital, nursing facility, or other institution? yes no * Not required if applying for MassHealth Limited or the Health Safety Net. 1 Please go to the next page HOH HOH PART I 9
Page 1 and 2: A guide for seniors and for persons
Page 3 and 4: Introduction MassHealth and Commonw
Page 5 and 6: What qualified aliens and aliens wi
Page 7 and 8: Countable Assets Countable assets i
Page 9: Persons Living at Home Needing Long
Page 13 and 14: Noncountable Assets Noncountable as
Page 15 and 16: maximum amount can be higher as a r
Page 17 and 18: What must I do if MassHealth agrees
Page 19 and 20: Nursing-Facility Care If you need s
Page 21 and 22: Get MassHealth Card? Yes. You must
Page 23 and 24: Information about Getting Medical S
Page 25 and 26: We will use your social security nu
Page 27 and 28: An eligibility representative can b
Page 29 and 30: Topic Call For applicants and membe
Page 31 and 32: **Affidavits (written statements) o
Page 33 and 34: Massachusetts Immigrant and Refugee
Page 36: Important! If you need an interpret

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