Commonwealth of Massachusetts 
Executive Office of Health and Human Services 
Division of Medical Assistance 
600 Washington Street
Boston, MA 02111


MassHealth 
Community Health Center Bulletin 45 
October 2000 

TO: Community Health Centers Participating in MassHealth 

FROM: Wendy E. Warring, Commissioner 

RE: Revised Medical Benefit Request 

Revised Medical Benefit Request

The Division has revised the Medical Benefit Request (MBR), which is the form 
that is used by people under age 65 who do not live in a long-termcare facility 
to apply for MassHealth and the Children’s Medical Security Plan. The MBR is 
also used by people aged 65 and older who are parents or caretaker relatives of 
children under age 19, and by disabled persons who are aged 65 or older and work 
40 or more hours a month. 

Expanded Definition of Family Group

In addition to making several language and formatting changes to the MBR, the 
Division has expanded its definition of family group. A family group can be 
parents, stepparents, or adoptive parents of any age and any of their children 
under age 19 who are all living together. If no parents are living at home, a 
family group may be siblings under age 19, or children under age 19 and an adult 
related by blood, adoption, or marriage, or a spouse or former spouse of one of 
those relatives who are all living together. A family group can also be an 
individual or a married couple who are living together with no children under 
the age of 19. If more than one family group lives in the home, each family 
group must fill out a separate application.
 
Obtaining Supplies

To get a supply of the revised MBR (MBR-1), send a written request or a fax to 
the following address. 

MassHealth 
ATTN: Forms Distribution 
P.O. Box 9101 
Somerville, MA 02145 
Fax: (617) 576-4087 

continued on back 




MassHealth 
Community Health Center Bulletin 45 
October 2000 
Page 2 

Obtaining Supplies
(cont.)

Each MBR is enclosed in a clear plastic bag with: 

· a MassHealth booklet; 
· a fact sheet that explains CMSP; 
· a Primary Language Declaration Form; and 
· a voter registration form. 

As soon as you get a supply of the revised MBR, you should discard any 
remaining supplies of the previous version (dated 3/98). 

Please Note: The MBR is also available in Spanish. The current version 
is dated 3/98, and includes an insert dated 8/00 to bring the packet up to 
date with current policy. If you currently have a supply of Spanish MBRs 
without inserts, please request a supply of inserts to complete them. 

Other Applications for MassHealth 

People who are aged 65 or older (who are not caretaker relatives or 
disabled persons working 40 or more hours a month) and persons of any 
age who live in a long-term-care facility must use a different form to apply 
for MassHealth. Please refer these potential applicants to a MassHealth 
Enrollment Center at 1-888-665-9993 (TTY: 1-888-665-9997 for the deaf 
and hard of hearing). 

Questions

If you have any questions about this bulletin, please call the MassHealth 
Provider Services Department at (617) 628-4141 or 1-800-325-5231.