MassHealth Application and Appeal Forms

Senior Medical Benefit Request for Seniors and People Needing Long-Term-Care Services

This is the MassHealth application. Substantial documentation such as bank statements, pension stubs, investment statements, etc. is necessary when submitting the application so careful reading of each section is essential.

 http://www.mass.gov/eohhs/docs/masshealth/membappforms/saca-2-english.pdf

 

Asset Assessment for Potential MassHealth Eligibility

This is not a form that you submit but rather one that a married couple receives.  This asset assessment is automatically generated when a married person who is in a nursing home applies for MassHealth.  It reflects the amount of assets that the community (at-home) spouse is allowed to keep without taking any further action. (Note:  Sometimes, the community spouse can appeal this notice and keep all of the assets, even though the notice appears to indicate that a substantial amount must be spent on the institutionalized spouse’s nursing home care.  For further information, see Protecting Assets and Maximum Income for the Community Spouse When Applying for MassHealth in 2013 to Help Pay for the Unhealthy Spouse’s Nursing Home Bills in Massachusetts )

http://www.mass.gov/eohhs/docs/masshealth/appforms/mh-aa.pdf

 

Proof of U.S. Citizenship/National Status Requirements for MassHealth

Most people do not need to deal with this issue when applying for MassHealth, because seniors and disabled persons who get or can get Medicare or Supplemental Security Income (SSI), or disabled persons who get Social Security Disability (SSDI), do NOT have to give proof of their U.S. citizenship/national status and identity.  Other people do have to prove citizenship, and this document describes what constitutes satisfactory proof of citizenship.

http://www.mass.gov/eohhs/docs/masshealth/memlibrary/mh-us-citizenship-national-status-identity-requirements.pdf

 

Permission to Share Information (PSI)

Submit this form if applicant would like MassHealth to be able to discuss their application or appeal with a third party such as a family member or elder law attorney.  Read it carefully as other support documentation may be necessary in order for the PSI to be valid.

http://www.mass.gov/eohhs/docs/masshealth/privacy/psi.pdf

 

Authorized Representative Designation Form (ARD)

This form designates the person who you choose to act on your behalf and will assist you in applying for MassHealth. Care should be taken to fill out the appropriate sections on page 3 and 4. Other support documentation may be necessary in order for the ARD to be valid.

http://www.mass.gov/eohhs/docs/masshealth/privacy/ard.pdf 

 

MassHealth Adult Disability Supplement

This is an additional form that must be submitted in the MassHealth application process when a Pooled Trust account has been established or when the applicant is claiming a disability.

http://www.mass.gov/eohhs/docs/masshealth/appforms/mads-adult.pdf

 

Senior Guide to Health Care Coverage

A guide to the MassHealth application process for those seeking Long Term Care Benefits and explains who is eligible for MassHealth, Commonwealth Care, and the Health Safety Net and what the income and asset rules are, what medical services you can get under MassHealth, and what your rights and responsibilities are.

http://www.mass.gov/eohhs/docs/masshealth/membappforms/saca-1-english-mb.pdf

 

Financial Information Request

When requesting mandatory prior-year statements from various financial institutions, this form can be utilized so that there is no cost to the applicant.  (Note:  It is often best to have the statements sent directly to you.  Although you can request that the statements be sent directly to MassHealth, you will not know what was received or if anything was even received.  Also, it is not uncommon for a MassHealth eligibility worker to make a request for something that was already submitted to the worker, so it is best to make sure you have copies of everything sent to MassHealth.)

If the application is filed in the Taunton office, use this form:   http://www.mass.gov/eohhs/docs/masshealth/appforms/fir-1-taunton.pdf

If the application is filed in the Chelsea office, use this form:   http://www.mass.gov/eohhs/docs/masshealth/appforms/fir-1-chelsea.pdf

If the application is filed in the Tewksbury office, use this form:   http://www.mass.gov/eohhs/docs/masshealth/appforms/fir-1-tewksbury.pdf

If the application is filed in the Springfield office, use this form:   http://www.mass.gov/eohhs/docs/masshealth/appforms/fir-1-springfield.pdf

 

Notice of Privacy Practices

This notice describes how medical information about the applicant may be used and disclosed by MassHealth, and how one can gain access to this information.

http://www.mass.gov/eohhs/docs/masshealth/privacy/npp-brochure.pdf

 

Fair Hearing Request

This form is used after a MassHealth denial or a stop benefits notice has been received in order to preserve rights and request a Fair Hearing. Care should be taken to submit this request within the requisite time frame, which is often 30 days.  (Note:  Although you have to follow the regulations in order to be eligible for a fair hearing, MassHealth often ignores the regulations when applied to the agency.  For example, while the MassHealth regulations state that the fair hearing must be decided in a very short period of time, usually 45 or 90 days from the time you first request it, it is likely that you will wait an even longer period of time before the fair hearing is even scheduled.)

http://www.mass.gov/eohhs/docs/masshealth/appforms/fair-hearing.pdf

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