Commonwealth of Massachusetts
Executive Office of Health and Human Services
Office of Medicaid
600 Washington Street
Boston, MA  02111
www.mass.gov/masshealth
	MassHealth
	Community Health Center Bulletin 65
	May 2010

	TO:	Community Health Centers Participating in MassHealth

	FROM:	Terence G. Dougherty, Medicaid Director

	RE:	Revised Medical Benefit Request Form

Background
MassHealth has revised the Medical Benefit Request (MBR) form to capture 
applicant information needed to determine eligibility for MassHealth, 
Commonwealth Care, and Health Safety Net benefits. As a result of the changes to 
the MBR, MA21, the Virtual Gateway Common Intake Application, and MassHealth 
notices have also been revised.

MBR Changes
The revised MBR contains the following changes:
*	Working section: The questions were revised to include applicants’ 
responses about employment in the last 12 months (formerly in the “Not Working 
or College Student” section).
*	Not Working or College Student section: This section has been removed. The 
questions have been relocated to other sections of the application.
*	Nonworking Income section: This section has been revised to capture 
information about income from unemployment compensation (formerly in the “Not 
Working or College Student” section). In addition, a new question has been added 
to capture information about rental income.
*	College Students section: This new section captures information related to 
the availability of health insurance due to enrollment in a college or 
university (formerly in the “Not Working or College Student” section).
*	Health Insurance — Part B: Subsidized Health Insurance section: New 
questions have been added to capture details about the uniformed services.
*	Injury, Illness, or Disability section: This section has been revised, 
removing the second and third questions and inserting a new question about 
accident or injury.
*	Supplement A — Accident or Injury section: This section has been 
reformatted.
*	Obsolete Question: The question “Is your spouse working more than 
100 hours a month?” has been removed from the MBR. MA21 will determine this by 
looking at family group relationships and EIN information.

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Supplies
To order supplies of the revised MBR (dated 03/10), call 1-800-841-2900 or 
e-mail your request to publications@mahealth.net.

Please continue to use the previous version of the MBR until your supply 
is exhausted.

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.