MassHealth Long-Term Care Application Packet

MASSHEALTH LONG-TERM CARE APPLICATION PACKET — MASSACHUSETTS

TABLE OF CONTENTS

1. Cover Letter to MassHealth Enrollment Center
2. Applicant and Spouse Identification
3. Coverage Type Requested
4. Income Disclosure (Applicant and Community Spouse)
5. Asset Disclosure — 60-Month Look-Back
6. Primary Residence Treatment
7. Transfer Disclosure and Penalty Analysis
8. Spousal Impoverishment Calculations (CSRA / MMMNA)
9. Spend-Down / Medically Needy Election
10. Frail Elder Waiver Request (if community placement)
11. Estate Recovery Acknowledgment
12. Authorized Representative / Designation
13. Verification Checklist
14. Signature Blocks
15. Massachusetts Practice Notes
16. Sources and References

1. COVER LETTER TO MASSHEALTH ENROLLMENT CENTER

Date: [__/__/____]

MassHealth Enrollment Center
Long-Term-Care Unit
P.O. Box 290794
Charlestown, MA 02129-0214
Fax: (617) 887-8799

Re: Application for MassHealth Long-Term-Care Coverage
Applicant: [________________________________]
SSN (last 4): [____]
Date of Birth: [__/__/____]
Facility / Address: [________________________________]

Dear MassHealth Eligibility Worker:

Enclosed please find the SACA-2 Application for Health Coverage for Seniors and People Needing Long-Term-Care Services for the above-named applicant, together with all required verifications. This application requests:

• ☐ MassHealth Standard — Long-Term Care (institutional / nursing facility)
• ☐ MassHealth Standard — Community (HCBS / Frail Elder Waiver)
• ☐ MassHealth CommonHealth
• ☐ Other: [________________________________]

The requested coverage start date is [__/__/____].

Please direct all eligibility correspondence to the authorized representative identified in Section 12.

Respectfully,

[________________________________]

[NAME], [Applicant / Authorized Representative / Counsel]

2. APPLICANT AND SPOUSE IDENTIFICATION

3. COVERAGE TYPE REQUESTED

3.1. The applicant requests MassHealth Standard coverage on the following basis (check one):

• ☐ Aged 65 or older (Elder)
• ☐ Disabled (under SSA criteria — provide award letter or DDU determination)
• ☐ Blind

3.2. Setting of care:

• ☐ Skilled Nursing Facility (SNF) — Name: [________________________________]; Admission date: [__/__/____]
• ☐ Chronic / Long-Term-Care Hospital
• ☐ Community — Frail Elder Waiver (FEW) requested (see Section 10)
• ☐ Community — PACE (Program of All-Inclusive Care for the Elderly)
• ☐ Other HCBS program: [________________________________]

3.3. Has applicant been clinically screened for nursing-facility level of care?

• ☐ Yes — Date of MDS / Comprehensive Data Set assessment: [__/__/____]
• ☐ No — Screening pending

4. INCOME DISCLOSURE (APPLICANT AND COMMUNITY SPOUSE)

4.1. Applicant gross monthly income:

4.2. Community-spouse gross monthly income (if applicable): $[__________]

4.3. Reference standards (verify current values at time of filing):

• 2026 Personal Needs Allowance (institutional): $72.80 / month
• 2026 Medically Needy Income Limit (MNIL): $522 / month (individual); $650 / month (couple)
• Frail Elder Waiver income standard (2026): up to approximately $2,982 / month (300% SSI federal benefit rate)

5. ASSET DISCLOSURE — 60-MONTH LOOK-BACK

5.1. Asset limits (verify at filing):

• Single applicant (LTC): countable assets must be at or below $2,000
• Community-spouse resource allowance (CSRA, 2026): up to $162,660 (federal cap; verify current MA figure)

5.2. Countable assets (provide statements covering the full 60-month look-back where applicable):

5.3. Non-countable / exempt assets (identify and document):

• ☐ Primary residence (subject to equity cap — see Section 6)
• ☐ One vehicle (any value if used by applicant or community spouse)
• ☐ Household goods and personal effects
• ☐ Term life insurance (no cash value)
• ☐ Irrevocable burial contract / burial space
• ☐ Burial account up to $1,500 (less face value of cash-value life insurance)
• ☐ Other: [________________________________]

6. PRIMARY RESIDENCE TREATMENT

6.1. Property address: [________________________________]

6.2. Title held by: [________________________________]

6.3. Current fair-market value: $[__________]; outstanding mortgage / lien: $[__________]; net equity: $[__________]

6.4. Home equity cap (institutional applicants). For 2026, MassHealth disregards the principal residence as a countable asset only if equity does not exceed approximately $1,130,000 (verify current federal index). Equity above the cap renders the applicant ineligible for nursing-facility services unless a community spouse, minor child, or blind/disabled child resides in the home.

6.5. Is one of the following individuals living in the home?

• ☐ Community spouse
• ☐ Child under age 21
• ☐ Blind or permanently disabled child of any age
• ☐ Sibling with equity interest who resided in the home for one year before institutionalization
• ☐ Caregiver child who resided in the home for two years before institutionalization and provided care that delayed institutionalization
• ☐ None of the above

6.6. Intent-to-return statement (if applicant in facility): The applicant intends to return to the residence: ☐ Yes ☐ No.

7. TRANSFER DISCLOSURE AND PENALTY ANALYSIS

7.1. Look-back period: 60 months from the date of application (or the later of application date and date applicant is institutionalized and otherwise eligible).

7.2. Disclose every transfer of assets by applicant or spouse (including gifts, sales below fair market value, additions to joint accounts later removed, and trust funding) during the look-back:

7.3. Penalty calculation (illustrative — MA penalty divisor effective Nov. 1, 2025 is $450/day):

• Total disqualifying transfers: $[__________]
• Divided by penalty divisor: $450/day
• Period of ineligibility: [____] days, beginning the date applicant is institutionalized and otherwise eligible (130 CMR 520.019)

7.4. Permitted transfers / exceptions claimed (check all that apply and attach supporting documentation):

• ☐ Transfer to community spouse
• ☐ Transfer to blind or permanently disabled child (or trust solely for benefit of)
• ☐ Transfer of home to caregiver child meeting the two-year care exception
• ☐ Transfer of home to sibling with equity interest meeting the one-year residency exception
• ☐ Transfer to a (d)(4)(A) special-needs trust for an individual under 65 with a disability
• ☐ Transfer to a (d)(4)(C) pooled trust (consider age-65 issues under MA practice)
• ☐ Transfer made for purpose other than to qualify for MassHealth (rebuttal evidence attached)
• ☐ Return of transferred asset (cure)

8. SPOUSAL IMPOVERISHMENT CALCULATIONS (CSRA / MMMNA)

8.1. Snapshot date (first day of first continuous period of institutionalization of 30+ days): [__/__/____]

8.2. Total countable assets owned by either spouse on snapshot date: $[__________]

8.3. Community Spouse Resource Allowance (CSRA): $[__________] (verify current MA cap)

8.4. Applicant's share above CSRA must be spent down or otherwise reduced before eligibility.

8.5. Minimum Monthly Maintenance Needs Allowance (MMMNA) — verify current figure:

• Community-spouse gross monthly income: $[__________]
• MMMNA standard: $[__________] (federal minimum / maximum per 42 U.S.C. § 1396r-5)
• Excess shelter allowance: $[__________]
• Diversion of applicant's income to community spouse: $[__________]/month

8.6. Fair-hearing request to increase CSRA or MMMNA based on exceptional circumstances?

• ☐ Yes — basis: [________________________________]
• ☐ No

9. SPEND-DOWN / MEDICALLY NEEDY ELECTION

9.1. Massachusetts is a medically needy state. Applicants whose income exceeds the categorical limit may qualify by incurring medical expenses sufficient to reduce countable income to the MNIL within a six-month deductible period (130 CMR 506.000).

9.2. Six-month deductible period: from [__/__/____] through [__/__/____]

9.3. Documented incurred medical expenses (attach itemized bills):

9.4. Election: ☐ Apply expenses to current deductible period; ☐ Carry forward.

10. FRAIL ELDER WAIVER REQUEST (IF COMMUNITY PLACEMENT)

10.1. The applicant requests enrollment in the MassHealth Frail Elder Waiver (FEW), a 1915(c) HCBS waiver administered by EOEA / EOHHS for individuals who meet nursing-facility level of care but elect to remain in the community.

10.2. Eligibility self-attestation:

• ☐ Age 60 or older
• ☐ Massachusetts resident
• ☐ Meets nursing-facility level of care (Comprehensive Data Set / clinical screen)
• ☐ Lives in a community setting compliant with the CMS Community Rule (not in assisted living, group home, or rest home as primary residence except as permitted)
• ☐ Not enrolled in PACE or another HCBS waiver
• ☐ Income at or below approximately $2,982 / month (2026; verify current 300% SSI standard)
• ☐ Home-equity interest at or below approximately $1,130,000 (2026; verify current cap)

10.3. Local Aging Services Access Point (ASAP) contacted: [____________] on [__/__/____].

10.4. Services requested: [________________________________] (e.g., personal care, homemaker, adult day health, transportation, supportive home care aide, companion, home-delivered meals, environmental accessibility adaptations, personal emergency response system).

11. ESTATE RECOVERY ACKNOWLEDGMENT

11.1. I acknowledge that MassHealth is required by federal law (42 U.S.C. § 1396p(b)) and Massachusetts law (M.G.L. c. 118E § 31; 130 CMR 515.011) to seek recovery from the probate estate of any individual age 55 or older who received MassHealth benefits, including but not limited to long-term-care services.

11.2. I understand that estate recovery may include the value of the primary residence and other probate assets, subject to hardship-waiver standards.

11.3. Signature: [________________________________] Date: [__/__/____]

12. AUTHORIZED REPRESENTATIVE / DESIGNATION

12.1. I, [________________________________], authorize the following individual to act as my MassHealth authorized representative under 130 CMR 515.005 and to receive all notices, request fair hearings, and submit documentation on my behalf:

12.2. Applicant signature: [________________________________] Date: [__/__/____]

13. VERIFICATION CHECKLIST

• ☐ Photo identification (driver's license / state ID / passport)
• ☐ Birth certificate or proof of citizenship / lawful immigration status
• ☐ Social Security card (applicant and spouse)
• ☐ Medicare card / MBI
• ☐ Other health-insurance cards and policy declarations
• ☐ Marriage certificate; divorce / death certificate where applicable
• ☐ 60 months of statements for every bank, brokerage, and retirement account
• ☐ Most recent federal and Massachusetts income-tax returns (3 years)
• ☐ Pension / annuity award letters
• ☐ Social Security / SSDI / SSI award letters
• ☐ Deeds, mortgage statements, real-estate tax bills
• ☐ Vehicle titles and registrations
• ☐ Life-insurance policies (declaration page and cash-value statement)
• ☐ Burial-contract documentation
• ☐ Trust instruments (revocable and irrevocable)
• ☐ Power of attorney; health-care proxy; guardianship / conservatorship orders
• ☐ Documentation of all transfers within the 60-month look-back
• ☐ Caregiver-agreement contract (if claiming caregiver-child exception)
• ☐ DRA-compliant annuity rider (if applicable) naming MassHealth as remainder
• ☐ Clinical screening / level-of-care determination

14. SIGNATURE BLOCKS

I declare under the penalties of perjury that the foregoing information and the contents of the SACA-2 are true, complete, and accurate to the best of my knowledge.

Applicant:

[________________________________]

[APPLICANT NAME]

Date: [__/__/____]

Authorized Representative / Counsel:

[________________________________]

[REPRESENTATIVE NAME]

Title: [________________________________]

Date: [__/__/____]

15. MASSACHUSETTS PRACTICE NOTES

• 209(b) state. Massachusetts is one of a minority of states that elected the Section 209(b) option under 42 U.S.C. § 1396a(f), permitting more restrictive eligibility methodologies than SSI for the aged, blind, and disabled. Massachusetts pairs this with a medically needy spend-down pathway (130 CMR 506.000), so a Qualified Income Trust (Miller Trust) is generally not used.
• Application form. Use SACA-2 for new applications; SACA-2-ERV for renewals. The form may be mailed to the MassHealth Enrollment Center, Long-Term-Care Unit, P.O. Box 290794, Charlestown, MA 02129-0214; faxed to (617) 887-8799; or filed online via the MassHealth long-term-care portal.
• Look-back and penalty divisor. The look-back is 60 months. Effective November 1, 2025, the daily penalty divisor is $450. The divisor changes annually each November — confirm at filing.
• Asset limit. $2,000 for a single LTC applicant. The community-spouse resource allowance follows the federal cap (approximately $162,660 in 2026; verify current MA figure).
• Personal Needs Allowance. $72.80 / month for institutional residents (2026; verify current).
• Home-equity cap. Approximately $1,130,000 (2026; verify current federal index under 42 U.S.C. § 1396p(f)).
• Frail Elder Waiver. A 1915(c) HCBS waiver for adults 60+ who meet NF level of care. Apply through the local Aging Services Access Point (ASAP).
• Estate recovery. Mandatory for benefits paid to recipients age 55+. Massachusetts limits recovery to probate estate (not enhanced/expanded recovery), but the primary residence is reachable through probate. Plan accordingly using life estates, enhanced life estates ("Lady Bird" deeds are not used in MA), or irrevocable income-only trusts (with caution under 130 CMR 520.023).
• Fair hearings. A denial, termination, or reduction notice may be appealed to the Board of Hearings under 130 CMR 610.000. Request hearing within thirty (30) days of notice (sixty (60) days in some circumstances) — verify the applicable deadline on the notice.
• Annuity rules. DRA-compliant immediate, non-assignable, actuarially sound annuities can convert countable assets to an income stream, but Massachusetts must be named as the primary remainder beneficiary up to the amount of benefits paid (42 U.S.C. § 1396p(c)(1)(F)).
• Caregiver-child and sibling exceptions. Strictly construed. Document caregiving services with contemporaneous logs, medical records, and corroborating affidavits.
• Common pitfalls. Joint-account "convenience" arrangements, undocumented loans to family members, gifts to grandchildren for tuition, and undisclosed life-insurance cash value are the most frequent sources of denial or penalty.

16. SOURCES AND REFERENCES

• Mass.gov — Program financial guidelines for certain MassHealth applicants and members: https://www.mass.gov/info-details/program-financial-guidelines-for-certain-masshealth-applicants-and-members
• Mass.gov — Applications to become a MassHealth member (SACA-2): https://www.mass.gov/lists/applications-to-become-a-masshealth-member
• Mass.gov — Frail Elder Waiver (FEW): https://www.mass.gov/frail-elder-waiver-few
• Mass.gov — Standard Payments to Nursing Facilities (101 CMR 206.00, eff. Oct. 1, 2025): https://www.mass.gov/regulations/101-CMR-20600-standard-payments-to-nursing-facilities
• 130 CMR 515.000 et seq. — MassHealth General Policies: https://www.mass.gov/regulations/130-CMR-515000-masshealth-general-policies
• 130 CMR 519.000 — MassHealth Coverage Types: https://www.mass.gov/regulations/130-CMR-519000-masshealth-coverage-types
• 130 CMR 520.000 — MassHealth Financial Eligibility: https://www.mass.gov/regulations/130-CMR-520000-masshealth-financial-eligibility
• M.G.L. c. 118E (Division of Medical Assistance / MassHealth): https://malegislature.gov/Laws/GeneralLaws/PartI/TitleXVII/Chapter118E
• 42 U.S.C. § 1396p (Transfer of assets, estate recovery): https://www.ssa.gov/OP_Home/ssact/title19/1917.htm
• 42 U.S.C. § 1396r-5 (Spousal impoverishment): https://www.ssa.gov/OP_Home/ssact/title19/1924.htm
• CMS — Section 209(b) States Implementation Guide: https://www.medicaid.gov/resources-for-states/downloads/macpro-ig-more-restrictive-requirements-1902f-209bstates.pdf
• MassHealth Customer Service: (800) 841-2900; TDD/TTY: 711

Disclaimer: This template is provided for informational purposes only and does not constitute legal or tax advice. MassHealth long-term care eligibility involves complex federal and state rules. An attorney licensed in Massachusetts must review and customize this packet before filing. Verify all figures, citations, and program rules at the time of submission.