Asset Assessment for potential MassHealth eligibility Commonwealth of Massachusetts EOHHS www.mass.gov/masshealth Date: You asked MassHealth to determine the amount of your assets. This assessment is important in deciding if you might be eligible for MassHealth long-term-care benefits. To help us determine your assets, you must list on the attached form all assets owned by you and your spouse as of the date you or your spouse were admitted to the nursing facility or medical institution. You must also give MassHealth proof of all assets listed. According to MassHealth regulations, the spouse who is living at home may keep up to $___________ in assets when the spouse who is living in a nursing facility or medical institution applies for MassHealth. This asset amount may be increased due to certain circumstances, which will be explained in your asset assessment notice. This amount may also change due to federal cost-of-living changes. Please answer all questions and fill out all sections on the attached form. Each section has a list of information that you must give to MassHealth so we can decide the value of each asset. If you need more space, use a separate sheet of paper, and attach it to the form. Once you fill out this form and send us proof of your assets, MassHealth will decide what assets the spouse who is living at home can keep. We will send you this decision in writing. If you decide to apply for MassHealth, you must give MassHealth proof of all assets that are available to you and your spouse as of the date of application for MassHealth. You must also give MassHealth proof of all resources (income and assets) transferred generally within the last 36 months. If you want someone to act on your behalf as your eligibility representative, use the enclosed MassHealth Eligibility Representative Designation Form to tell us. If you have any questions about this form, please contact a MassHealth Enrollment Center at 1-888-665-9993 (TTY: 1-888-665-9997 for people with partial or total hearing loss). MH/AA (Rev. 07/04) For office use only Date received: Asset Assessment for potential MassHealth eligibility Commonwealth of Massachusetts EOHHS www.mass.gov/masshealth Please print clearly. Answer all questions and fill out all sections. If you need more space to finish any section on this form, please use a separate sheet of paper, and attach it to this form. Spouse in Nursing Facility or Medical Institution Last name First name MI Social security number Date of birth Sex M F Name of facility Date admitted Telephone number ( ) Street address City State Zip Spouse at Home Last name First name MI Social security number Date of birth Sex M F Street address City State Zip Telephone number Assets Fill out the following sections by listing all information about assets owned by you and/or your spouse as of the date of admission to the nursing facility or medical institution. Bank Accounts/Pension Funds Do you or your spouse have any bank accounts or certificates of deposit, including checking, savings, personal-needs accounts (PNAs), credit union, NOW, and money-market accounts, any retirement accounts, including individual retirement accounts (IRAs), Keogh accounts, pension funds, and/or other bank accounts? yes no If no, go to the next section (Life Insurance). If yes, fill out this section. Send a copy of your bank passbook or bank statement that shows each account balance as of the date of admission to the nursing facility or medical institution. Name(s) on account Name/address of bank or credit union Account number Account type Balance Name(s) on account Name/address of bank or credit union Account number Account type Balance Name(s) on account Name/address of bank or credit union Account number Account type Balance MH/AA (Rev. 07/04) 1. Please go to the next page. Assets (cont.) Life Insurance Do you or your spouse have any life insurance? yes no If no, go to the next section (Trusts). If yes, fill out this section. Send a copy of each life-insurance policy and/or a written statement from the insurance company showing the face value and the cash-surrender value of each policy as of the date of admission to the nursing facility or medical institution. Name of insured Name of insurance company Face value $ Cash-surrender value $ Name of insured Name of insurance company Face value $ Cash-surrender value $ Name of insured Name of insurance company Face value $ Cash-surrender value $ Trusts Are you or your spouse the grantor, trustee, or beneficiary of any trust(s)? yes no If no, go to the next section (Stocks/Bonds/Other). If yes, fill out this section. Send a copy of the trust document and trust accounting, Schedule A, and/or other documentation about the assets and income of each trust as of the date of admission to the nursing facility or medical institution. Name of trust Grantor(s) Trustee(s) Beneficiaries Trust principal Trust income $ $ $ $ $ $ Stocks/Bonds/Other Do you or your spouse own any stocks, bonds, savings bonds, securities, mutual funds, annuities, assets held in safe-deposit boxes, or cash not in the bank? yes no If no, go to the next section (Vehicles/Mobile Homes). If yes, fill out this section. Send a quote from your stockbroker or bank or investment firm for securities, stocks, mutual funds, etc., to prove the value of the asset as of the date of admission to the nursing facility or medical institution. You Your spouse Company Value Company Value Stocks $ $ Bonds $ $ Savings bonds $ $ Mutual funds $ $ Securities $ $ Other $ $ 2. Please go to the next page. Assets (cont.) Vehicles/Mobile Homes Do you or your spouse own any vehicles, including cars, vans, trucks, recreational vehicles, mobile homes, and boats? yes no If no, go to the next section (Real Estate). If yes, fill out this section. Send a copy of your payment book or finance company’s statement and a written statement from a licensed vehicle dealer about the fair-market value of the vehicle and amount owed as of the date of admission to the nursing facility or medical institution. Name of owner Year/Make/Model Fair-market value Amount owed $ $ $ $ $ $ Real Estate Do you or your spouse own individually or jointly (with any other person or entity), or have a legal interest in any real estate, for example: vacation property, rental property, time sharing, vacant lots, and other property (include all property located in and outside of Massachusetts)? yes no If no, go to the next section (Health-Care/Residential Facility Deposits). If yes, fill out this section. Send a copy of your current tax bill and deed for each property listed. Name(s) on ownership papers (deed) Description/Location Market value $ $ $ Health-Care/Residential Facility Deposits 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? yes no If no, go to the next page. If yes, give us the name and address of the facility, the amount of the deposit, and the date it was given to the facility. Send a copy of the facility’s documents about this deposit. Name of facility Address of facility Amount Date $ / / 3. You must read the next page carefully and sign. Signature I certify that I have read or had read to me the asset assessment form and cover letter. I further certify under penalty of perjury that the information given on this assessment form is correct and complete to the best of my knowledge. If you are acting on behalf of someone in filling out this asset assessment, the enclosed MassHealth Eligibility Representative Designation Form must also be filled out and sent back with this assessment. Your signature on this assessment as an eligibility representative certifies that the information on this asset assessment is correct and complete to the best of your knowledge. Signature of spouse in nursing facility or medical institution or eligibility representative Date Signature of spouse living at home or eligibility representative Date Once you have filled out and signed this form, send it to the one MassHealth Enrollment Center (MEC) listed below that is closest to where you live. Revere MEC 300 Ocean Avenue Suite 4000 Revere, MA 02151 Taunton MEC 21 Spring Street Suite 4 Taunton, MA 02780 Springfield MEC 333 Bridge Street Springfield, MA 01103 Tewksbury MEC 367 East Street Tewksbury, MA 01876 If you have any questions about this form, call a MassHealth Enrollment Center at 1-888-665-9993 (TTY: 1-888-665-9997 for people with partial or total hearing loss). 4. Additional Information This page is for your comments and additional information. 5.