Page 1 begins. MassHealth Commonwealth of Massachusetts EOHHS www.mass.gov/masshealth Long-Term-Care Supplement If you are applying for MassHealth long-term-care services, please read the MassHealth and You guide carefully before you fill out this supplement (blue form). Then send the supplement to the MassHealth Enrollment Center listed on the letter that came with this supplement. Do you need long-term-care services in a nursing-home type facility? __ yes __ no If yes, you must answer all questions and fill out all sections of this supplement, including page 4. Are you applying for or getting long-term-care services at home under a Home- and Community-Based Services Waiver? __ yes __ no If yes, you only need to fill out the first four blocks under “Applicant/Member Information” on page 1, the “Resource Transfers” section on page 3, and page 4. Please print clearly. Answer all questions and fill out all sections. If you need more space to finish any section, please use a separate sheet of paper (include your name and social security number), and attach it to this supplement. Applicant/Member Information Last name First name MI Social security number Do you have to pay guardianship expenses for a court-appointed guardian? __ yes __ no [GAR/SMN] Living expenses of the spouse and family members living at home Your spouse living at home may be able to keep some of your income. Fill out the following information about your spouse’s current living expenses. If you do not have a spouse, go to the next section (Long-Term-Care Insurance). Send proof of your spouse’s current living expenses. 1. How much does your spouse pay each month for: Rent? Mortgage (principal and interest)? Homeowner’s/tenant’s insurance? Real estate taxes? Required maintenance charge for a condo or co-op? Room and board for assisted living? 2. Does your spouse pay for heat? __ yes __ no 3. Does your spouse pay for utilities? __ yes __ no 4. Is a child, parent, brother, and/or sister living with your spouse? __ yes __ no If yes, fill out this section. If no, go to the next section (Long-Term-Care Insurance). Send proof of their monthly income before deductions. A deduction may be allowed for their maintenance needs. These persons must be related to you or your spouse, and one of you must claim them as dependents on your federal income tax return. Name Social security number Relationship Date of birth Monthly income before deductions Name Social security number Relationship Date of birth Monthly income before deductions Long-Term-Care Insurance [LIN] Do you or your spouse have long-term-care insurance? __ yes __ no If yes, fill out this section. If no, go to the next section (Real Estate). Send a copy of the policy. Company name/Policy number Policyholder name Effective date Premium amount Company name/Policy number Policyholder name Effective date Premium amount Page 2 begins. Real Estate [ATT] The answers to the following questions will be used to decide if: (1) your real estate will be counted as an asset; or (2) a lien will be placed against your real estate. Note: If the equity interest in your principal place of residence is over $802,000, you may be ineligible for payment of long-term-care services, unless certain conditions are met. 1. Do you or your spouse own or have a legal interest in your home, including a life estate? __ yes __ no If yes, fill out the following information and answer questions 2 through 4. If no, answer question 4 only. Name and address of person(s) on ownership papers Description and address of property location Type of ownership (Check one.) __ Individual __ Tenancy in common __ Joint tenancy __ Life estate Fair-market value Name and address of person(s) on ownership papers Description and address of property location Type of ownership (Check one.) __ Individual __ Tenancy in common __ Joint tenancy __ Life estate Fair-market value 2. Do you have a spouse? __ yes __ no If you answered yes: Name Is this person living in your home? __ yes __ no Do you have a permanently and totally disabled or blind child? __ yes __ no If you answered yes: Name Is this person living in your home? __ yes __ no Do you have a child under 21 years of age? If you answered yes: Name Date of birth Is this person living in your home? __ yes __ no Do you have a brother or sister with a legal interest in the home who was living in the home for at least one year immediately before your admission to the medical institution? ? yes ? no If you answered yes: Name Is this person living in your home? __ yes __ no Do you have a son or daughter who has lived in the home for at least the last two years before your admission to the medical institution and has provided care to you that allowed you to live in the home? __ yes __ no If you answered yes: Name Is this person living in your home? __ yes __ no Do you have a dependent relative? __ yes __ no If you answered yes: Name Describe the relationship and the nature of the dependency Is this person living in your home? __ yes __ no 3. Do you intend to return to your home? __ yes __ no 4. Do you or your spouse own or have a legal interest in other real estate not listed in #1 above? __ yes __ no If yes, please describe the property and list its address below. Page 3 begins. Tax Returns [SUP] Did you or your spouse file U.S. income tax returns in the last two years? (Check one.) __ yes, both years __ yes, one of these years __ no, neither year If yes, you must send copies of these returns. If you did not keep copies of one or more of these returns, you must send in a filled-out and signed Form 4506. Form 4506 is included as part of the Long-Term-Care Supplement if you need to use it. Resource Transfers (resources include both income and assets) [SUP] 1. Have you, your spouse, or someone acting on your behalf given a deposit to any health-care or residential facility, like an assisted-living facility, a continuing-care retirement community, or life-care community? __ yes __ no If yes, give us the name and address of the facility, the amount of the deposit, answer the following questions, and send us a copy of the contract you signed with the facility and any documents about this deposit. Name of facility Address of facility Amount a. Does the facility still have the deposit? __ yes __ no b. Did the facility return the deposit? __ yes __ no If yes, give us the name and address of the person who got the deposit from the facility. Name of person Address 2. In the past 60 months: a. Did you, your spouse, or someone on your behalf transfer income or the right to income? __ yes __ no b. Did you, your spouse, or someone on your behalf transfer, change ownership in, give away, or sell any assets, including your home or other real estate? __ yes __ no c. Did you, your spouse, or someone on your behalf change the deed or the ownership of any real estate, including creating a life estate, even if the life estate was purchased in another person’s residence? __ yes __ no d. If you purchased a life estate in another person’s home, did you live in the home for at least one year after you purchased the life estate? __ yes __ no e. Did you, your spouse, or someone on your behalf add another name to the deed of any property you own? __ yes __ no f. Did you, your spouse, or someone on your behalf receive or give anyone a mortgage, loan, or promissory note on any property or other asset? __ yes __ no g. Did you, your spouse, or someone on your behalf purchase or in any way change an annuity? __ yes __ no 3. In the past 60 months, has any property that was available or belonged to you or your spouse been transferred into or out of a trust? __ yes __ no If you answered yes to any of the questions above, you must fill out the following, and send us proof of this information. Description of asset/income Dates of transfer Transferred to whom Relationship to you or your spouse Amount of transfer Description of asset/income Dates of transfer Transferred to whom Relationship to you or your spouse Amount of transfer Description of asset/income Dates of transfer Transferred to whom Relationship to you or your spouse Amount of transfer You must read the next page carefully, and sign and date it. Page 4 begins. I understand that in some cases, MassHealth may place a lien against any real estate that I have a legal interest in. If MassHealth puts a lien against my property and I sell it, I may need to use money I get from the sale of that property to repay MassHealth for medical services that I get. I certify, under penalty of perjury, that the information on this form is correct and complete to the best of my knowledge. I understand that this information will be used to decide if I can get or continue to get MassHealth payment of long-term-care services. I also understand that I must give proof of the information given on this form and report any changes in this information within 10 days of the change. If you are acting on behalf of someone in filling out this form, a MassHealth Eligibility Representative Designation Form must also be filled out and sent back with this form. Your signature on this form as an eligibility representative certifies that the information on this form is correct and complete to the best of your knowledge. Signature of applicant/member or eligibility representative Print name Date Signature of applicant’s/member’s spouse Print name Date If you are already getting health benefits and now need to apply for long-term-care benefits, send your filled-out Long-Term-Care Supplement to MassHealth Enrollment Center P.O. Box 1231 Taunton, MA 02780 If you need to complete this form as part of the application process for MassHealth and long-term-care health benefits in a long-term-care facility, either send this form 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 LTC-SUPP (Rev. 01/13) Document ends.