Form LTC AC "Long-Term-Care Application Checklist" - Massachusetts

What Is Form LTC AC?

This is a legal form that was released by the Massachusetts MassHealth - a government authority operating within Massachusetts. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2018;
  • The latest edition provided by the Massachusetts MassHealth;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form LTC AC by clicking the link below or browse more documents and templates provided by the Massachusetts Masshealth.

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Download Form LTC AC "Long-Term-Care Application Checklist" - Massachusetts

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Long-Term-Care Application Checklist
Helpful tips for applying for MassHealth Long-Term-Care (LTC) benefits
Verifications to include with this application for you
You must fill out the Application for Health Coverage for Seniors and People
3
and your spouse (if married, even if spouse is not
N/A
Needing Long-Term-Care Services (SACA-2) and the Long-Term-Care
applying, unless noted otherwise):
Supplement. In order to get any benefits you are entitled to as quickly as
possible, you should include any documentation you have that verifies your
Proof of citizenship or immigration status (this is not needed
income, assets, citizenship or immigration status, and other health insurance.
for a non-applying spouse)
Use the following charts as a guide to completing the application. Additional
information may be requested.
Proof of income, before taxes are taken out, for all types of
income received (except for Social Security income for the
applicant)
3
Ensure the following steps have been taken:
N/A
Current bank statement(s) from 60 months prior to admission
date to the present, for all open accounts
“Long-Term Care” is selected on page 1 of the application.
A copy of the deed(s), current tax bill(s), and proof of amount
owed on all property owned, including life estates
All questions are answered “yes” or “no” for you and your
A copy of the first page of all life-insurance policies or a letter
spouse (if married, even if spouse is not applying).
from the insurance company showing the current cash-
surrender value (for all policies except term policies)
Application is signed by you or your Authorized
Current value of any securities (stocks, bonds, or other)
Representative Designee (ARD). Note: if signed by an ARD, the
ARD form must be completed and sent with the application.
A copy of all annuity contracts. For each annuity owned, give
us proof from the annuity company of the full value of the
annuity, less any penalties and fees if it can be cashed in.
Long-Term-Care Supplement completed and signed by you or
Proof of any deposit given to a health-care or residential facility
your Authorized Representative Designee (ARD)
A copy of the registration for all vehicles
(including fair market value at time of admission)
Disability supplement and medical records release forms have
been completed and mailed separately (individuals under the
Proof of any prepaid burial plans, accounts, or trusts
age of 65 only).
All trust documentation (including the trust(s), schedule of
beneficiaries, any deeds, and bank statements that are held by
Submission of Status Change (SC-1) form (to be submitted by
the trust)
nursing facility staff)
Current copy of all health insurance cards and current premiums
Submission of Level of Care (LOC) indicating clinical
Proof of any resource transfers within the last 60 months from
eligibility (to be submitted by nursing facility staff)
the date of application
LTC AC (09/18)
1
Long-Term-Care Application Checklist
Helpful tips for applying for MassHealth Long-Term-Care (LTC) benefits
Verifications to include with this application for you
You must fill out the Application for Health Coverage for Seniors and People
3
and your spouse (if married, even if spouse is not
N/A
Needing Long-Term-Care Services (SACA-2) and the Long-Term-Care
applying, unless noted otherwise):
Supplement. In order to get any benefits you are entitled to as quickly as
possible, you should include any documentation you have that verifies your
Proof of citizenship or immigration status (this is not needed
income, assets, citizenship or immigration status, and other health insurance.
for a non-applying spouse)
Use the following charts as a guide to completing the application. Additional
information may be requested.
Proof of income, before taxes are taken out, for all types of
income received (except for Social Security income for the
applicant)
3
Ensure the following steps have been taken:
N/A
Current bank statement(s) from 60 months prior to admission
date to the present, for all open accounts
“Long-Term Care” is selected on page 1 of the application.
A copy of the deed(s), current tax bill(s), and proof of amount
owed on all property owned, including life estates
All questions are answered “yes” or “no” for you and your
A copy of the first page of all life-insurance policies or a letter
spouse (if married, even if spouse is not applying).
from the insurance company showing the current cash-
surrender value (for all policies except term policies)
Application is signed by you or your Authorized
Current value of any securities (stocks, bonds, or other)
Representative Designee (ARD). Note: if signed by an ARD, the
ARD form must be completed and sent with the application.
A copy of all annuity contracts. For each annuity owned, give
us proof from the annuity company of the full value of the
annuity, less any penalties and fees if it can be cashed in.
Long-Term-Care Supplement completed and signed by you or
Proof of any deposit given to a health-care or residential facility
your Authorized Representative Designee (ARD)
A copy of the registration for all vehicles
(including fair market value at time of admission)
Disability supplement and medical records release forms have
been completed and mailed separately (individuals under the
Proof of any prepaid burial plans, accounts, or trusts
age of 65 only).
All trust documentation (including the trust(s), schedule of
beneficiaries, any deeds, and bank statements that are held by
Submission of Status Change (SC-1) form (to be submitted by
the trust)
nursing facility staff)
Current copy of all health insurance cards and current premiums
Submission of Level of Care (LOC) indicating clinical
Proof of any resource transfers within the last 60 months from
eligibility (to be submitted by nursing facility staff)
the date of application
LTC AC (09/18)
1
Long-Term-Care Application Checklist
IMPORTANT!
Need additional help?
If you are under the age of 65 and are applying for Long-Term-Care benefits,
You can find more information about how to fill out the Application for
you must be determined disabled by Social Security Administration (SSA) or
Health Coverage for Seniors and People Needing Long-Term-Care
MassHealth in order to be eligible. If you are not considered disabled by SSA,
Services (SACA-2) in the first two pages of the application and also on our
you must complete the MassHealth Adult Disability Supplement and Medical
website at www.mass.gov/masshealth. You may also call us at
Records Release form and send it to Disability Evaluation Services at UMass
(800) 841-2900 (TTY: (800) 497-4648) if you need help filling out the senior
Medical. The evaluation process can take up to 90 days for a disability
application or if you have any questions about the application process.
decision to be made. This supplement will not be processed if a MassHealth
application has not been submitted.
Mail completed application and all verifications to:
Application Process
Central Processing Unit (CPU)
P.O. Box 290794
• When we receive the application, we will assign it to a Long-Term-Care
Charlestown, MA 02129-0214
Intake worker at a MassHealth Enrollment Center (MEC).
• Once the worker has reviewed the application, a request for information
Fax completed application and all verifications to:
may be issued for any additional documentation that is still needed in
order to make an eligibility determination. You will have 30 days from
(617) 887-8799
the date of the notice to provide requested information to the intake
worker.
Mail completed disability supplement and medical records release
• MassHealth has 45 days to issue an eligibility determination, except
forms to:
when a disability evaluation is pending.
Disability Evaluation Services
UMASS Medical DES
Your Right to Appeal
P.O. Box 2796
If you disagree with the action taken by MassHealth, you have the right to
Worcester, MA 01613-2796
appeal and ask for a hearing before an impartial hearing officer. You can also
request a hearing if MassHealth did not act on your request in a reasonable
time. The Board of Hearings must receive your completed, signed request
within 30 calendar days from the date you received the notice of our action. If
you did not receive a written notice of the action to be taken, or MassHealth
did not take an action on your application, you must send your request no
later than 120 calendar days from the date the action takes place. Fair
Hearing Request forms are included with any MassHealth decision notice and
can also be found on our website at www.mass.gov/masshealth.
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