Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid 600 Washington Street Boston, MA 02111 www.mass.gov/masshealth Eligibility Operations Memo 09-18 October 15, 2009 TO: MassHealth Eligibility Operations Staff FROM: Russ Kulp, Director, MassHealth Operations RE: Revisions to the MassHealth Lien Forms Introduction MassHealth has made changes to the series of forms relating to liens, the MA-10 through MA-15. Changes were made to the MA-13 and MA-14 to comply with a request made by the Massachusetts Registry of Deeds to provide a uniform space in the upper-right corner for a registry stamp. Other changes include * removing the reference to a social security number; * adding space for the MassHealth identification number; and * updating the text to use “MassHealth” instead of “Medicaid.” Availability of Lien Forms The MA-10, MA-11, MA-12, MA-13, and MA-15 are available to MassHealth Enrollment Center (MEC) staff on the MassHealth Intranet and are fillable online. MEC staff should complete the MA-13 online, print it, sign it, and send it to the Estate Recovery Unit. Because the Release of MassHealth Lien (MA-14) is initiated by the Estate Recovery Unit, it is not available to MEC staff. When completing the MA-10, MA-11, and MA-15, MEC staff should use the MassHealth ID number if one has been issued. If one has not been issued, MEC staff should use the individual’s social security number. Attachments Please find the series of lien forms attached to this memo. * Statement of Intent to Return Home (MA-10-O); * Statement of Expectation to Return Home (MA-11-O); * Notice of Intent to Place a Lien (MA-12-O); * MassHealth Lien (MA-13-O); * Release of MassHealth Lien (MA-14); and * Agreement to Sell Property (MA-15-O). (continued on next page) Questions If you have any questions about this memo, please have your MEC designee contact the Policy Hotline. Commonwealth of Massachusetts Executive Office of Health and Human Services www.mass.gov/masshealth Statement of Intent to Return Home MassHealth Enrollment Center Address: City/Town/Zip: Date: Name: Address: City/Town/Zip: MassHealth ID no.: The Commonwealth of Massachusetts will determine if your home is a countable asset pursuant to MassHealth regulations at 130 CMR 520.007(G). It may be subject to a real estate lien pursuant to regulations at 130 CMR 515.012(A). To view MassHealth regulations, go to www.mass.gov/masshealth. Please complete this form and return it to the MassHealth Enrollment Center at the above address. When did you leave your home? Why did you leave your home? Do you intend to return home? Yes No If you do not intend to return home, when did you make that decision? Note: If this form is being filled out by someone with the legal authority to act on your behalf (such as the parent of an adult disabled child, a spouse, an eligibility representative, or a legal guardian), please give us the following information: Name of person filling out this form (please print) Authority of person filing out this form Eligibility representative: You may choose an eligibility representative to help you apply for or keep MassHealth benefits. You can do this by filling out a MassHealth Eligibility Representative (ERD) Form. To get an ERD Form, call MassHealth Customer Service at 1-800-841-2900 (TTY: 1- 800-497-4648 for people with partial or total hearing loss). Signature of applicant/member Date Signature of guardian/eligibility representative Date MA-10-O (Rev. 10/09) Commonwealth of Massachusetts Executive Office of Health and Human Services www.mass.gov/masshealth Statement of Expectation to Return Home MassHealth Enrollment Center Address: City/Town/Zip: Date: Name: Address: City/Town/Zip: MassHealth ID no.: This form must be completed by a licensed physician and returned to the MassHealth Enrollment Center at the above address. Patient’s name: MassHealth ID no.: Name of nursing facility or other medical institution: Address of nursing facility or other medical institution: Address of former home: Diagnosis: Is it reasonable to expect this patient to return home within six months after the month of admission? Yes No Doctor’s signature Date Doctor’s name (please print) Address ( ) Telephone number MA-11-O (Rev. 10/09) Commonwealth of Massachusetts Executive Office of Health and Human Services www.mass.gov/masshealth Notice of Intent to Place a Lien MassHealth Enrollment Center Address: City/Town/Zip: Date: Name: Address: City/Town/Zip: MassHealth ID no.: The Commonwealth of Massachusetts, pursuant to regulations at 130 CMR 515.012(A), intends to place a lien against all property and rights to all property in ____________________ County, including the property more fully described below. To view MassHealth regulations, go to ww.mass.gov/masshealth. MassHealth regulations authorize the lien placement because: • MassHealth has determined that you cannot reasonably be expected to be discharged from the nursing facility or other medical institution to your home; and • none of the following relatives live in the property: a. a spouse; b. a child under the age of 21, or a blind or permanently and totally disabled child; or c. a sibling who has an equity interest in the property and has been living in the house for at least one year before your admission to the nursing facility or other medical institution. If you are discharged from the nursing facility or other medical institution and return home after the lien is placed, MassHealth will release the lien. If the property is sold during your lifetime, you must repay MassHealth from your share of the proceeds for the cost of all medical services provided on or after April 1, 1995. Repayment for the cost of the nursing facility and other long-term-care services will not be required if you have notified MassHealth that you do not intend to return home and, on the date you entered the nursing facility or other medical institution, have a long-term-care insurance policy that meets certain minimum coverage requirements. All other costs will be recovered. For more information about the exception for individuals with long-term-care insurance, see MassHealth regulations at 130 CMR 515.012(C) and 515.014. Any remaining proceeds you get from the sale will be used in determining your continued eligibility. Repayment of the cost of medical services may be deferred while any of the following relatives are still lawfully living in the property: • a sibling who has been residing in the property for at least one year immediately prior to your admission to the nursing facility or other medical institution; or • a son or daughter who: a. has been living in the property for at least two years immediately before your being admitted to the nursing facility or other medical institution; b. establishes to the satisfaction of MassHealth that he or she provided care that permitted you to live at home during the two-year period before institutionalization; and c. has lived lawfully in the property on a continual basis while you have been in the nursing facility or other medical institution. Whether or not a lien is placed, MassHealth may have the right to recover the amount of payment for medical benefits from your probate estate after your death. Recovery is limited to payment for all services that were provided • on or after March 22, 1991, regardless of your age, if you were institutionalized and MassHealth determined that you could not reasonably be expected to return home; • on or after October 1, 1993, if you were aged 55 through 64; or • while you were aged 65 or older. If you disagree with MassHealth’s intention to place a lien, you have the right to a fair hearing. For information about appeal rights, see the other side of this form. Eligibility worker: Telephone number: ( ) MA-12-O (Rev. 10/09) HOW TO ASK FOR A FAIR HEARING Your Right to Appeal: If you disagree with the action by MassHealth, you have the right to appeal and ask for a fair hearing before an impartial hearing officer. The Board of Hearings must get your fair hearing request form no later than 30 calendar days from the date you got MassHealth's official written notice telling you of the action to be taken. If you want to ask for a fair hearing because MassHealth did not take action on your application or on your request for service, MassHealth did not send you a written notice of the action to be taken, or a MassHealth employee's behavior toward you was coercive or improper, the Board of Hearings must get your fair hearing request form no later than 120 calendar days from the date of your application or your request for service, MassHealth's action, or the MassHealth employee's improper behavior. How to Appeal: To ask for a fair hearing, fill out the fair hearing request form (be sure to fill out Section II-Reason for Appeal) and send one copy with a copy of the MassHealth official written notice to: Board of Hearings, Office of Medicaid, 2 Boylston Street, Boston, MA 02116 or fax them to 617-210-5820. Please keep one copy of the fair hearing request form for your information. If You Are Now Getting MassHealth: If the Board of Hearings gets your fair hearing request form before the date the action is taken or, if later, within 10 calendar days of the mailing date of MassHealth's written notice to you, you will keep getting MassHealth until a decision is made on your appeal. If you get MassHealth during your appeal, and then lose your appeal, you may have to pay MassHealth back for the cost of MassHealth benefits that you got during this time period. If you do not want to keep getting MassHealth during your appeal, please check Box A in Section III on the fair hearing request form. If you do not get MassHealth during your appeal, and then you win your appeal, MassHealth will restore your MassHealth benefits. Date of Fair Hearing: At least 10 calendar days before the fair hearing, the Board of Hearings will send you a notice telling you the date, time, and place of the hearing. This will give you time to get ready for the hearing. If you want to have a fair hearing scheduled as soon as possible, check Box B in Section III on the fair hearing request form for an expedited hearing. If you have good cause for not being able to come to the hearing, or if you need a telephone hearing, you must call the Board of Hearings at 617-210-5800 or 1-800- 655-0338 before the hearing date. If you do not reschedule or appear on time at the hearing without documented good cause, your appeal will be dismissed. Your Right to Be Helped at the Hearing: At the hearing, you may represent yourself or be represented by a lawyer or other representative at your own expense. You may contact a local legal service or community agency to get advice or representation at no cost. To get information about legal service or community agencies, call the MassHealth Customer Service Center at 1-800-841- 2900 (TTY: 1-800-497-4648 for people with partial or total hearing loss). If You Need an Interpreter or an Assistive Device: If you do not understand English and/or are hearing or sight impaired, the Board of Hearings will provide an interpreter and/or assistive device for you at the hearing. Please check either Box C or D, or both, in Section III on the fair hearing request form if you need an interpreter or assistive device, or call the Board of Hearings at 617-210-5800 or 1-800-655-0338 at least five business days before the hearing. Your Right to Review Your Case File: You and/or your representative can review your MassHealth case file before the hearing. To do this, call a MassHealth Enrollment Center at 1-888-665-9993 (TTY: 1-888-665-9997 for people with partial or total hearing loss) before the fair hearing. Your MassHealth case file is not kept at the Board of Hearings. Your Right to Ask to Subpoena Witnesses, and Your Right to Question: You or your Representative may write to the Board of Hearings to ask that witnesses or documents be subpoenaed to the hearing. You or your representative may present evidence and cross-examine witnesses at the hearing. The hearing officer will make a decision based on all evidence presented at the fair hearing. NONDISCRIMINATION NOTICE FOR APPLICANTS AND MEMBERS: Under federal and state law, MassHealth does not discriminate on the basis of race, color, sex, sexual orientation, national origin, religion, creed, age, health status, or handicap. FAIR HEARING REQUEST FORM FILL OUT ALL SECTIONS THAT APPLY. PRINT CLEARLY. SECTION I: Applicant/Member Information Name of Applicant or Member: Address: Telephone No.: ( ) MassHealth I.D. or Social Security Number: Cardholder's Name on MassHealth card (if different): SECTION II: Reason for Appeal I, , want a fair hearing because: Signature: Date: SECTION III: Appeal Information (Check the boxes that apply to you.) A. I do not want to keep getting MassHealth during the appeal process. B. I want an expedited hearing. C. I need an interpreter (what language?: ) to be provided by the Board of Hearings. D. I need an assistive device to be provided by the Board of Hearings. (Describe what type of assistive device you need. For example: American Sign Language): SECTION IV: Appeal Representative, if any My appeal representative is: Title: Address: Telephone No.: ( ) FHR-1 (Rev. 02/06) MassHealth Lien The Commonwealth of Massachusetts, pursuant to M.G.L. c. 118E, § 34 and MassHealth regulations at 130 CMR 515.012(A), hereby asserts a lien for the cost of medical assistance paid or to be paid against all property and rights to all property in ____________________ County, including the property more fully described below. To view MassHealth regulations, go to www.mass.gov/masshealth. Ownership Member’s last name: First name: MI: MassHealth ID no.: Location Street address: City/Town: Zip code: County: District: Registration/Recording Information Book: Page: OR Certificate number/Document number: Return to: Estate Recovery Unit P.O. Box 15205 Worcester, MA 01615-0205 1-800-754-1864 Signature Printed name MassHealth Enrollment Center (City/Town only) Date MA-13-O (Rev. 10/09) Commonwealth of Massachusetts Executive Office of Health and Human Services www.mass.gov/masshealth Release of MassHealth Lien The Commonwealth of Massachusetts hereby releases a lien, dated , that it had asserted (or that had been asserted by the former Department of Public Welfare, now known as the Department of Transitional Assistance) pursuant to M.G.L. c. 118E § 34 and MassHealth regulations at 130 CMR 515.012(A) for the cost of medical assistance paid or to be paid against all property and rights to all property described below. To view MassHealth regulations, go to www.mass.gov/masshealth. Ownership Member’s last name: First name: MI: MassHealth ID no.: Location Street address: City/Town: Zip code: County: District: Registration Deed Book: Page: OR Certificate number/Document number: Lien Book: Page: OR Certificate number/Document number: Signature Printed name Estate Recovery Unit P.O. Box 15205 Worcester, MA 01615-0205 1-800-754-1864 Date MA-14 (Rev. 10/09) Commonwealth of Massachusetts Executive Office of Health and Human Services www.mass.gov/masshealth Agreement to Sell Property MassHealth Enrollment Center Address: City/Town/Zip: Date: Name: Address: City/Town/Zip: MassHealth ID no.: The Commonwealth of Massachusetts has determined that pursuant to MassHealth regulations at 130 CMR 520.007(G), the equity value of your real estate at is a countable asset in determining your eligibility for MassHealth. To view MassHealth regulations, go to www.mass.gov/masshealth. We will exempt this property for up to nine months if you agree to • take action to sell the property for no less than fair-market value or otherwise liquidate the equity value in the property to pay for your medical care; • provide evidence, upon request from MassHealth, that you are trying to sell at no less than fair-market value, or liquidate the equity in the property to pay for your medical care; • provide to MassHealth, on request, information on any offer you have received, including the date of the offer, the amount of the offer, and the identity of any real-estate agent conveying the offer; • accept any offer of at least fair-market value; and • notify MassHealth, within 10 days, of any sale or refinancing of the property. To qualify for this exemption, you must sign and return this form to the MassHealth Enrollment Center listed above within 30 days. If you have any questions, call your eligibility worker. MassHealth may extend the nine-month exemption period if, at the end of the nine-month period, you • provide evidence that you have been unable to sell the property at fair-market value; • provide information on each offer you have received and the reason for not accepting it; and • continue to make good-faith efforts to sell the property in accordance with 130 CMR 520.007(G)(4). Eligibility worker: Telephone number: ( ) Signature of Applicant or Eligibility Representative I hereby agree to dispose of real estate owned by me in accordance with the terms described above. I understand that my eligibility for MassHealth will terminate when one of the following occurs: • I sell the property for less than fair-market value; • I reject an offer of at least fair-market value; • I fail to verify that I am trying to sell the property for fair-market value; or • after nine months and after verifying a good-faith effort to sell at fair- market value, I reject a reasonable offer that is equal to at least two-thirds of the fair-market value. Signature of applicant Date Signature of eligibility representative Date MA-15-O (Rev. 10/09)