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


MassHealth 
Nursing Facility Bulletin 117 
January 2000 

TO: Nursing Facilities Participating in MassHealth 

FROM: Mark E. Reynolds, Acting Commissioner 

RE: Changes in the Long Term Care Assessment Form 

Background 

In accordance with 130 CMR 456.409, individuals must meet certain 
clinical criteria to be eligible for MassHealth payment of nursing facility 
services. The determination of clinical eligibility is based upon the Long 
Term Care Assessment Form. The Division or its agent determines 
clinical eligibility when the individual is applying for MassHealth and in 
any of the circumstances described in 130 CMR 456.407(A). 

Revisions to the Long Term Care Assessment Form

The Division has revised the Long Term Care Assessment Form. It is now 
called the MassHealth Long Term Care Assessment Form. As of 
March 1, 2000, the Division or its agent will accept only the MassHealth 
Long Term Care Assessment Form. Nursing facilities must now complete 
the form and submit it along with copies of the most recent 
comprehensive Minimum Data Set (MDS) 2.0 and the current quarterly 
MDS for the determination of the applicant’s or member’s clinical 
eligibility. 

Completing the MassHealth Long Term Care Assessment Form

Nursing facilities must complete the MassHealth Long Term Care 
Assessment Form following the instructions on the back of the form. 
Submit the completed form together with copies of the comprehensive 
and quarterly MDS forms to the appropriate Aging Services Access Point 
(ASAP). 

Obtaining the MassHealth Long Term Care Assessment Form

A copy of the MassHealth Long Term Care Assessment Form is attached. 
You may photocopy the form as needed. To obtain supplies of the form, 
mail or fax a written request to the following address or fax number. 

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




MassHealth 
Nursing Facility Bulletin117 
January 2000 
Page 2 

Questions

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