Commonwealth of Massachusetts
Executive Office of Health and Human Services
Division of Medical Assistance
600 Washington Street
Boston, MA  02111
www.mass.gov/dma	
	MassHealth
	Long-Term-Care Facility Bulletin 81
	October 2002

	TO:	Nursing Facilities, Chronic Disease and Rehabilitation Inpatient Hospitals, Psychiatric Inpatient Hospitals, Psychiatric Inpatient Hospitals Under 21, State School ICFs/MR, and Rest Homes Participating in MassHealth

	FROM:	Wendy E. Warring, Commissioner

	RE:	New and Revised MassHealth Application Packets and Eligibility Review Materials for Seniors and People Needing Long-Term-Care Services

Background	In the Division’s continuing effort to standardize and streamline the MassHealth application and eligibility review process for seniors and persons needing long-term-care services, the Division has developed new and revised MassHealth application packets and eligibility review materials, and related documents that are part of the Division’s consolidated community/long-term care (LTC) application initiative.

	To support this effort, the Division has restructured and simplified the current community and LTC application process.  Previously, the dual application process required one type of application for community-based seniors, including certain persons needing LTC services to live at home, and another type of application for persons who were institutionalized or awaiting LTC placement.  The new consolidated application process enables the entire senior and LTC population, whether living in the community or in a LTC facility, to complete a generic core application with (in most cases) merely the addition of a small supplement for persons needing LTC services.

Following an extensive review of all documents relating to the application and eligibility review process, eligibility documents have been revised, replaced, or obsoleted.  The new documents have been reformatted and carefully designed to capture the most complete information, eliminate redundancy, and enhance readability.

			MassHealth eligibility staff will require applicants or members to 
		provide documentation only when it is inaccessible through sources
		available to the Division.
					
		(continued on reverse side)

				
		
Background		This bulletin introduces and explains the new consolidated 
(cont.)			community/LTC application and eligibility review process, including new 
		and revised forms and notices, and the new “MassHealth and You”
		information guide.

Note:  The procedures addressed in this memo do not apply to persons who are applying for or are enrolled in MassHealth Buy-In for Qualifying Individuals.  These persons will continue to complete the MassHealth Buy-In Application (MHBI-1).

Traditional		The new and revised forms, notices, and procedures discussed in this 
Populations 		bulletin impact the following “Traditional” populations.
1.  Persons aged 65 or older living in the community who:
		are not parents of or “caretaker relatives” (as defined in 130 CMR 515.001) for children under age 19; or
					are not both disabled and working 40 or more hours a month.
2.	Persons living in the community receiving home- and community-based services that are available to members approved under the Kaileigh Mulligan program, the Program of All-Inclusive Care for the Elderly (PACE), or the Home- and Community-Based Services Waiver program (“spousal waiver”).  These programs, described at 130 CMR 519.007, enable certain disabled or elderly individuals who would otherwise be institutionalized to receive certain necessary services while living at home. 
3.	Persons of any age living in or awaiting placement in a LTC facility.

Overview of New	The following is a list of the new and revised forms and notices.  Each is
and Revised 		described briefly.  Attached to this bulletin are two documents:  the 
Forms and Notices	Quick Reference Desk Guide for Use of Traditional Forms, and a list of the new and revised materials, including the obsolete forms that they are replacing.  The Quick Reference Desk Guide for Use of Traditional Forms is a simplified guide that identifies which forms (or combination of forms) to use for applicants and members specific to certain situations.
						
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Overview of New	The MassHealth Application for Seniors and People Needing 
and Revised	Long-Term-Care Services—MHA (08/02)—RED
Forms and Notices		A comprehensive 10-page “core” document for all Traditional
(cont.)		MassHealth applicants.  
•	It collects data needed to determine MassHealth eligibility for both the community and LTC applicant populations.
•	Attached to the front of the MHA is an instruction cover page, which explains how to complete the form, identifies general verifications needed, and provides information about the application process, including instructions for returning the application and any enclosures. 
•	On page one is a “LTC indicator” question, where the applicant may indicate if LTC services are needed or being received.  This question is applicable to both LTC residents and certain community residents needing LTC services to live at home.  If the answer to this “LTC indicator” question is “yes,” and the applicant lives in, is entering, or is awaiting placement in a LTC facility, the LTC Supplement (included in the MHA packet) must also be completed.  If the applicant is 60 years of age or older and has been accepted under the Home- and Community-Based Services Waiver program as needing LTC services at home, the LTC Supplement must also be completed.
•	On page 2 of the MHA, is the Personal-Care Attendant (PCA) Services section.  This section asks about the need for PCA services for individuals aged 65 or older living at home who intend to remain living in the community.  This section collects information needed to determine if the applicant may be subject to the PCA services unearned income-related disregard when determining financial eligibility for MassHealth.  Part III of the “MassHealth and You” Guide should be read before completing this section.  If the applicant answers “yes” to the last three questions in this section, a PCA Supplement (PCA-SUPP) that is enclosed with the MHA must be completed.  
•	The Asset section now includes questions about any deposits that have been made to a health-care or residential facility, such as an assisted-living facility.  It also contains a section, entitled “Vehicles/Mobile Homes” to capture ownership of any mobile home.
				
		(continued on reverse side)

Overview of New	The Long-Term-Care Supplement—LTC-SUPP (08/02)—BLUE
and Revised		A form used to collect LTC (nonclinical) eligibility information that is
Forms and Notices			required for applicants and members requesting MassHealth payment
(cont.)			for LTC services who are living in, entering, or awaiting placement in a LTC facility.  It is also required for persons who have been accepted under the Home- and Community-Based Services Waiver program, which enables eligible persons to live at home instead of being institutionalized.  
•	This form collects resource transfer information, including information about deposits made to a health-care or residential facility (such as an assisted-living facility), information for determining the need to place a lien on real estate or count a home as an asset, and information for determining the patient-paid amount (PPA), including the need for the spousal (or dependent) needs allowance.  
•	The LTC-SUPP is also used to indicate if the applicant or member is under any obligation to pay expenses for a court-appointed guardian.  
•	A LTC Supplement must always be linked to a current MHA or MassHealth Eligibility Review for Seniors and Certain People Needing LTC Services (MER) on file.  
•	The IRS Form 4506 (Request for Copy or Transcript of Tax Form) is enclosed with the LTC Supplement, for those who must submit, but do not have, their federal tax returns for the last two years.
The MassHealth Eligibility Review for Seniors and Certain People Needing Long-Term-Care Services—MER (08/02)—GREEN
•	A comprehensive six-page document, similar to the MassHealth Application, except that it is used solely for MassHealth members both in the community and those new to LTC.  
•	It collects and updates member data at annual and interim eligibility reviews, including reviews for members transitioning from Health Care Reform (HCR) or Supplemental Security Income (SSI).  It is used for community members, and for members entering or residing in LTC facilities when MassHealth has not yet determined eligibility under LTC rules.  
•	It includes a PCA section similar to that on the MHA, and a “Vehicles/Mobile Homes” section as on the MHA.  The Asset section also includes questions about deposits made to a health-care or residential facility, such as an assisted-living facility.  
•	Enclosed with the MER are several other forms:  the UNIV-5 (multilingual notice), which notifies members to get the eligibility review materials translated and offers translation assistance, a PCA-SUPP, and the MR-CL, described below.
			The MassHealth Eligibility Review notice—MR-CL (08/02)
•	The cover notice, issued with the MER, with instructions for completing the MER on the reverse side. 
•	It also explains the review process, gives general verifications needed, and the date the completed review and any needed documentation must be returned (“Send Back by” date).
														
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Overview of New	The MassHealth Long-Term-Care Eligibility Review—LTC-ER (08/02)
and Revised		A one-page, two-sided, review form—a mini-version of the MER that 
Forms and Notices			is used for collecting and updating data from the majority of 
(cont.)			MassHealth LTC members.  These MassHealth “ongoing” LTC members have already been approved for MassHealth using LTC rules and are not new to LTC.  
•	The form has been designed specifically to be as simple to understand and complete as possible, while still capturing the information needed to accurately review continuing MassHealth LTC eligibility.  It is used to update information that is subject to change, as well as for annual reviews.  
•	The front of the form is the MassHealth Long-Term-Care Eligibility Review notice—LTC-ER-CL (08/02), the cover notice with instructions. It identifies the member, indicates general verifications needed, and provides the date the completed review and any needed documentation must be returned (“Send Back by” date).  It also tells members that their MassHealth will stop if the LTC-ER is not returned by the indicated due date.  It gives the member an additional 30 days from the date the completed LTC-ER form is received at the MEC to submit any outstanding verifications, provided the completed LTC-ER is received by the due date.
The Long-Term-Care Eligibility Review Reminder notice—
LTC-ER-REM (08/02)
•	Reminder notice used as needed for those who have not responded to the LTC-ER.  The front is the reminder notice indicating MassHealth will stop if the LTC-ER form is not received by the indicated due (“Send Back by”) date.  
•	The reverse is a duplicate LTC-ER form. 
The Long-Term-Care Spousal and Family Supplement—LTC-SFS (08/02)
•	A one-page form used to gather spousal and dependent information to calculate the maintenance needs of the community spouse/dependent(s) in determining the patient-paid amount (PPA) of the institutionalized spouse. 
•	It may be used in conjunction with the LTC-ER as needed.
The MassHealth Return Notice—Trad-Ret (08/02)
•	Used to send an MHA and to return items (such as an LTC Supplement or Disability Supplement) received when no application has been filed or no member is on file.  
•	The individual (potential applicant) is instructed to complete the application and return it along with the returned documents to the MEC identified on the notice.
The MassHealth Information Request—MIR (Rev. 08/02)
	Used to request verifications needed to determine eligibility.
•	The revised MIR identifies whether the request for information is an initial or second request, and indicates if an LTC-SFS is enclosed.
														
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Overview of New	The PCA Supplement—PCA-SUPP (08/02)—GOLD
and Revised		This one-page, two-sided form is intended solely for the Traditional Forms and Notices			population who are aged 65 or older and living in the community.  
(cont.)			These individuals have completed the PCA section on page 2 of the MHA or the MER, and by answering “yes” to the last three questions of the PCA section, they have indicated the need for PCA services because of a claimed permanent or chronic disability.  
•	This form allows the individual to identify specific barriers to daily living activities, which may warrant the services of a PCA.  This form is used in conjunction with the MHA or MER in determining financial eligibility.
			MassHealth and You:  A Guide for seniors, and for persons of 
			any age needing LTC services—MH + You Guide (08/02)
				Combined applicant and member guide for both community and LTC 
					populations.  The Guide is intended to provide only general information for applicants and members, and is not designed to include complete information about MassHealth eligibility rules and regulations.  It is formatted into four sections, and includes “sidebar” boxes to provide or highlight certain information.  The Division’s website and MassHealth regulation cites are provided for reference.
					Part I:  Applying for MassHealth—for Seniors Living at Home:  addresses eligibility rules and the application process for persons 65 years of age and older living in the community who generally do not have LTC services needs.
					Part II:  Applying for MassHealth—for Persons Needing LTC Services, Even If Living at Home:  addresses eligibility rules and the application process for persons living in, entering, or awaiting placement in a LTC facility.  It also addresses special program rules for the Kaileigh Mulligan program, the PACE program, and the Home- and Community-Based Services Waiver program.  These special programs allow individuals to receive certain services that enable them to live in the community instead of being institutionalized.
					Part III:  Special Income Eligibility Rules under MassHealth Standard for Persons 65 and Older needing PCA Services to Live at Home:  addresses the unearned income-related disregard requirements for persons aged 65 or older living at home needing PCA services.
					Part IV:  Important Information You Should Know about MassHealth:  addresses a variety of MassHealth eligibility issues, and provides an explanation of the MassHealth coverage types, benefits provided under MassHealth, and referral information.
•	The MassHealth and You Guide is available only in English at present.  You will be notified when the Guide is available in other languages.
														
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Overview of New			The MassHealth Asset Assessment for potential MassHealth 
and Revised			eligibility—MH/AA (Rev. 08/02)—ORANGE
Forms and Notices				Revised slightly, and the cover letter is now attached to the form. 
(cont.)				This form is used to gather information for an assessment of the value
of a married couple’s combined assets when one member of the couple is a resident of a LTC facility and does not wish to apply for MassHealth at the time of the assessment.
The Primary Language Identification Form—PLIF-MEC (07/02)
	Notifies applicants of translation and interpreter assistance through MassHealth, and allows the applicant to indicate if he or she needs a “MassHealth and You” Guide in one of the other eight languages. 

MassHealth		The new Traditional MassHealth Application packet contains:
Application				The MassHealth Application (MHA) including instructions
Packet for				The Long-Term-Care Supplement (LTC-SUPP) with enclosed IRS
Traditional					tax form 4506
Populations				The Personal-Care Attendant Supplement (PCA-SUPP)
•	The MassHealth and You Guide (MH + You Guide)
•	The Primary Language Identification Form for MECs (PLIF-MEC)
•	A Voter Registration Form

Returning the		MassHealth applications are returned to one of the four MassHealth 
Completed		Enrollment Centers in accordance with procedures listed in Appendix
Application to the		B in your provider manual.  Appendix B may also be found at the
Division		Division’s website.

New Asset		The MHA, MER, and LTC Supplement now include new asset questions 
Questions 	about any deposits made to a health-care or residential facility, such as
(“Deposits Made 	an assisted-living facility, by the applicant or member, or by someone
to a Health-Care	acting on behalf of the applicant or member.  These questions have been
Facility”)	added to obtain a more accurate determination of the value of an applicant’s or member’s assets.  For LTC cases, these questions will also help to identify possible transfers of assets.

Effective Date		The new application and eligibility review process (including the use of 
for Use of the 		the new and revised forms and notices) were effective August 1, 2002.
New and Revised				Once the new and revised materials are available, any supply of
Traditional Forms					obsolete Traditional materials should be recycled.
•	To ease the transition, MECs will accept and process completed obsolete forms received on or after August 1, 2002, through December 31, 2002.  These include the UNIV-1 or MA/LTC-1 (or
		MA-3RD, if any).

						

Ordering Supplies		Order supplies of the above forms by submitting a written request to the 
		following address.

			MassHealth
			Attention:  Forms Distribution
			P.O. Box 9101
			Somerville, MA  02145
			Fax:  703-917-4937

Questions	If you have any questions about the information in this bulletin, please contact the MassHealth Provider Services Department at 617-628-4141 or 1-800-325-5231.

QUICK REFERENCE DESK GUIDE FOR USE OF TRADITIONAL FORMS

Applicant:  Living in	Applicant Completes Form(s)	
•	Community

•	Community (Spousal Waiver)

•	Long-Term Care	•	MHA

•	MHA and LTC-SUPP

•	MHA and LTC-SUPP	

Member:  Current Situation	Member:  New Situation	Member Completes Form(s)	
HCR (MA21)	•	Turns 65—Community

•	Enters Long-Term-Care Facility

•	Kaileigh Mulligan eligibility or PACE enrollee

•	Spousal Waiver (person may also be a PACE enrollee)	•	MER

•	MER and LTC-SUPP

•	MER

•	MER and LTC- SUPP	
SSI (MAOA)	•	In Community (includes PACE)

•	In Community (includes Spousal Waiver)

•	In LTC	•	MER

•	MER and LTC-SUPP

•	MER and LTC- SUPP	
Traditional (Community)	•	Reviews and changes

•	Enters LTC	•	MER

•	MER and LTC-SUPP	
Traditional (LTC)	•	Reviews and changes

•	Person goes into Community (65 or older)

•	Person goes into Community (under 65) 	•	LTC-ER (with LTC-SFS, if deemed necessary by worker)

•	MER*

•	ERV-5* [review eligibility under HCR rules]	
*If SSI was closed and member has RSDI income, remember to check for PICKLE and DAC eligibility.

LIST OF NEW AND REVISED TRADITIONAL FORMS
(and the obsolete forms they are replacing)

New and Revised Forms	Replaces Obsolete Forms	
MHA (08/02)—MassHealth Application for Seniors and People Needing LTC Services (with attached instructions cover sheet)	MA/LTC-1 (Rev. 06/97)
UNIV-1 (7/95)
UNIV-2 (Rev. 06/97)
AS-1 (06/97)
MEC-Cover (Rev. 06/00)	
LTC-SUPP (08/02)—Long-Term-Care Supplement	MA/LTC-1 (Rev. 06/97)	
MER (08/02)—MassHealth Eligibility Review for Seniors and Certain People Needing LTC Services and MR-CL (08/02)—cover letter and instructions	MA-3RD
MA-3RDC
MA-3RD/MAOA-D/S (all Rev. 02/95)
SSI-MAOA DMARDT57	
LTC-ER (0/02) and LTC-ER-CL (08/02)—MassHealth LTC Eligibility Review form and cover notice	MA/LTC-RD (11/91)	
LTC-SFS (08/02)—LTC Spousal and Family Supplement	MA/LTC-RD/SUPP (11/91)	
LTC-ER (08/02) and LTC-ER-REM (08/02)—MassHealth LTC Eligibility Review form and Reminder notice	None	
MIR-R, MIR-S, MIR-TA, and MIR-TE (Rev. 08/02)—MassHealth Information Request (one for each MEC)	MIR-R (Rev. 06/00)
MIR-S, MIR-TA, and MIR-TE (all 03/00)	
Trad-Ret (08/02)—MassHealth Return Notice	None	
PCA-SUPP (08/02)—Personal-Care Attendant Supplement	None	
MH/AA (08/02)—Asset Assessment for potential MassHealth eligibility (Rev. 08/02)	MH/AA (03/00)
MH/AA-C (03/00)	
MH + YOU Guide (08/02)—MassHealth and You—A Guide for seniors, and for persons of any age needing long-term-care services	UNIV-3 (Rev. 06/97)
AMH (Rev. 06/97)	

Trad-List (10/02)