Commonwealth of Massachusetts
Executive Office of Health and Human Services
Office of Medicaid
600 Washington Street
Boston, MA  02111
www.mass.gov/masshealth

	MassHealth
	Acute Inpatient Hospital Bulletin 134
	February 2008

	TO:	Acute Inpatient Hospitals Participating in MassHealth

	FROM:	Tom Dehner, Medicaid Director

	RE:	Revised Medical Benefit Request Form

Background
MassHealth, in conjunction with the Commonwealth Health Insurance Connector 
Authority (the Connector), has revised the Medical Benefit Request (MBR), 
effective January 2008, in an effort to capture applicant information to 
appropriately determine eligibility for Commonwealth Care.

MBR Changes
The MBR contains the following changes.
*	Instruction page: added instructions for completing new health-insurance 
section and information about “out-of-pocket expenses.”
*	HIV Information Section: question moved from page two to page five.
*	Working Section: revised questions determine access to employer-
subsidized health insurance.
*	Nonworking Section:
?	title of section renamed “Nonworking and Students”;
?	added questions to determine potential access to Massachusetts Division of 
Unemployment Assistance Medical Security Program (MSP) and Division of Health 
Care Finance and Policy Qualifying Student Health Insurance Plan (QSHIP); and
?	added additional space for a second applicant to respond to 
questions.
*	Health Insurance Section: 
?	Part A replaces former Supplement A, “Health Insurance 
Questions”; and
?	Part B has two new questions to determine access to the Fishing 
Partnership Health Plan (FPHP) and TRICARE. 
*	Supplements: deleted former Supplement A, “Health Insurance 
Questions,” and reordered the remaining supplements:
?	Supplement A: Injury, Illness, and Disability;
?	Supplement B: Absent Parent; and
?	Supplement C: Immigration.

(continued on next page)

Virtual Gateway (VG) Changes
Effective January 26, 2008, the Virtual Gateway will collect additional 
information from applicants about access to health insurance. These enhancements 
correspond to the changes made to the paper MBR.

Supplies and Use Of New Forms
Supplies of the new MBR are available. Providers can order copies of the MBR through MassHealth Customer Service at 1-800-841-2900 or by e-mailing a request 
to publications@mahealth.net.

When you receive a supply of the revised MBR, please recycle earlier 
versions.

Questions
If you have any questions about the information in this bulletin, please contact 
MassHealth Customer Service at 1-800-841-2900, e-mail your inquiry to 
providersupport@mahealth.net, or fax your inquiry to 617-988-8974.