MassHealth Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid www.mass.gov/masshealth MassHealth Community Health Center Bulletin 68 November 2011 TO: Community Health Centers Participating in MassHealth FROM: Julian J. Harris, M.D., Medicaid Director RE: Revisions to the Medical Benefit Request, the Senior Medical Benefit Request, Other Forms, and the Virtual Gateway Background MassHealth has revised the Medical Benefit Request (MBR), the Senior Medical Benefit Request (SMBR), and other related forms to clarify policy and capture applicant information to appropriately determine eligibility for individuals who are visitors to Massachusetts. In addition, there are changes to clarify current policy and to the format of the forms. As a result, MA21, the Virtual Gateway (VG) Common Application, and MassHealth notices have been revised. These changes are effective October 1, 2011. Changes to the MBR, SMBR, and the VG Revisions common to the MBR and the SMBR * Visitor section: This section was removed and was replaced with a new section about residency. * Residency section: A new section was added to determine whether individuals who are applying for benefits are residents of Massachusetts and if they intend to remain in the state. * Health Insurance You Have Now and Subsidized Health Insurance You May Be Eligible For sections: All references to the Fishing Partnership Health Plan (FPHP) were removed. o In Part A – Health Insurance You Have Now: The FPHP was removed as an insurance-type option. o In Part B – Subsidized Insurance You May Be Eligible For: The question about income from the commercial fishing industry was removed. * Signature page: Language was added to ensure that the individuals signing the application are aware that the signature certifies the correctness of not only the application and the supplements submitted in conjunction with the application, but also the correctness of any other documents and forms that are submitted or required by MassHealth. Revisions unique to the MBR * Instructions – first page: There are minor formatting changes and (cont.) grammatical corrections. * Instructions – second page: A reference to the FPHP was removed. * American Indian/Native American section: The section was relocated and both the statement and the question were updated. * Supplement B: Absent Parent Questions and Assignment of Rights: The language in the third line of instructions at the top of the first page was updated to include specific instructions to sign Part E (signature section). In addition, the language in Part E was revised. Revisions unique to the SMBR * Instructions – second page: The mailing addresses have been changed to advise applicants where to submit an application. The addresses are based on the type of benefits requested. o Applications for benefits for those living in the community (including those applying for waiver benefits, such as Frail Elder, Kaleigh Mulligan, and PACE) should be mailed to the Central Processing Unit (CPU) in Charlestown. o Applications for long-term-care services in long-term-care facilities should be mailed to the MassHealth Enrollment Center (MEC) that is closest to where the facility is located. * American Indian/Alaska Native section: This section was added to the application. Virtual Gateway Revisions The Virtual Gateway has been updated to include all of the changes and additions for the MBR and the SMBR (with the exception of mailing addresses for individuals who need long-term-care services in a longterm- care facility). Related Forms Absent-Parent Questions and Assignment of Rights (AP-1) This stand-alone form has been updated with the same changes as the Supplement B: Absent-Parent Questions and Assignment of Rights in the MBR. Long-Term-Care Supplement (LTC-SUPP) This stand-alone form has been updated to include the mailing addresses that mimic the mailing addresses located on the instruction pages of the SMBR. Eligibility Representative Designation Form (ERD) * What an eligibility representative does section: The reference to the Uncompensated Care Pool (former name of the Health Safety Net) was removed. * Where to send the form section: This form has been updated to include the various mailing addresses. MassHealth Buy-In application and instructions (MHBI-1 and MHBI-2) This application has been updated to include a different mailing address (CPU in Charlestown). Annual Review Forms (ERVs and MERs) The eligibility review forms are being revised to add the absent parent changes (ERVs) and the updated signature page information (ERVs and MERs). Residency Information The residency question asks individuals if they are residents of Massachusetts and if they intend to remain in the state. It will be used to identify those individuals who may be eligible for benefits and those who do not meet the criteria. This information must be completed on all applications before MassHealth can process the application. Proof of Residency If there is any question of residency, such as conflicting or contradictory information about the applicant’s declared place of residence, MassHealth may ask the applicant to provide proof of residency. If proof of residency is required, MassHealth will send a request for information (verification) notice. The applicant will have 60 days (if under age 65) or 30 days (if aged 65 or older) to submit the documentation. The notice will identify the types of documents that can be submitted to prove Massachusetts residency. The acceptable documentation includes the following. * For adults o lease or mortgage statement; o city or town real-estate tax bill; o rent receipt; o current utility bill; o statement from a shelter; or o notarized affidavit supporting residency * For children o school records; o nursery-school or day-care records; or o notarized affidavit supporting residency Suspected Fraud If an individual who is helping an applicant complete an application suspects that the applicant is providing fraudulent information, the assisting individual should process the application and then report the suspected fraud to MassHealth by calling the MassHealth Fraud Hotline at 1-877-4FRAUD-0 (1-877-437-2830). The assisting individual should provide any information that would help MassHealth investigate the issue, such as the applicant’s name, address, date of birth, social security number (if available), the reason for the suspected fraud, and the application information (such as the date submitted or the application number). Changes about American Indians and Alaska Natives American Indians and Alaska Natives who are eligible for or who have ever received an item or service furnished by the Indian Health Service, and Alaska Natives an Indian tribe, a tribal organization, or an urban Indian organization, or from a non-Indian health-care provider through a referral from an Indian health-care provider are exempt from paying copayments and premiums as MassHealth members. This update eliminates the portion of the question that asked only for those American Indians and Alaska Natives under age 19. The policy now applies to all American Indians and Alaska Natives regardless of age. Supplies and Use of Outdated Forms Supplies of the revised forms are now available. To order supplies, call 1-800- 841-2900 or e-mail your request to publications@mahealth.net. MassHealth will continue to accept the previous version of these forms until supplies are exhausted. MassHealth will convert the “visitor” responses to the new “residency” responses based on how the applicant answers the “visitor” questions. 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.