MassHealth for Seniors and Individuals Seeking Long-Term-Care Services (LTC), Webinar: MassHealth for Seniors and Individuals Seeking, MA Health Care Training Forum | 508-856-4306 |, UMass Chan Medical School - Commonwealth Medicine, Application for Health Coverage for Seniors and People Needing Long-Term-Care Services, Massachusetts Legal Assistance Corporation, Explain who can use the Application for Health Coverage for Seniors and People Needing Long-Term-Care Services (SACA-2) and the MassHealth Buy-In for people who are eligible for Medicare, Demonstrate how to complete each section of the SACA-2 application and the MassHealth Buy-In for people who are eligible for Medicare, Identify what documents are required and how to submit them, Discuss best practices for handling SACA-2 applications, Part 2 - Programs for MassHealth Members 65 Years of Age and Older, Part 3 - MassHealth Renewal for Members 65 Years of Age and Older. MassHealth about an upcoming August 31 MassHealth training on the application and renewal process for people age 65 or older or seeking long term care. RE: Updated Application Packet for Seniors and People Needing Long Please list all the immigrations statuses and/or conditions that have applied to you since you entered the U.S. You or any household member is not eligible for an SSN. d.Will you be claimed as a dependent on someone else's federal income tax return for the year for which you are applying? We need one adult in the household to be the contact person for your application. MAGI rules to determine eligibility. Also send proof of all of the following expenses, if applicable, for the last 12 months: mortgage, taxes, utilities (gas/ electric), heat, water/sewer, insurance, condo or co-op fee, repairs and maintenance. If you need more space, attach another sheet of paper. is a collaboration between the Department of Elementary and Secondary Education (DESE) and the Department of Developmental Services (DDS) for DDS-eligible students who are at risk of a future residential placement. Can I edit mass health saca on an iOS device? We're forwarding this announcement from MassHealth & the Connector with links to updated income Tables & Flyers, updated Application Forms and other resources. If you can't find an answer to your question, please contact us. Yes No If Yes, answer all the questions below in Step 2 for Person 1 (yourself). Under MassHealth Publications, click on MassHealth Member Library. Dining Centers, town listing 2021-03, MA SACA-2 You must provide a mailing address. 2015, MA SACA-2 You can also download pages for additional persons at mass.gov/masshealth. Box 290794 Charlestown, MA 02129-0214 This site uses cookies to enhance site navigation and personalize your experience. You must give us an SSN or proof that one has been applied for every household member who is applying, unless one of the following exceptions applies. Enroll in coverage any time of the year if you are applying for dental plans or help paying for health coverage including MassHealth, Children's Medical Security Plan (CMSP), Health Safety Net, or ConnectorCare. Renew your MassHealth coverage | Mass.gov You can also prove identity with a drivers license or some other form of. MassHealth members who received a renewal notice with an eSubmission number may be eligible to fill out and complete their Renewal application online. e. Are you filing taxes separately because you are a victim of domestic abuse or abandonment? Yes No. www.mass.gov/coronavirus-disease-covid-19-and-masshealth, Some MassHealth members may be eligible to enroll in the Program of, Care for the Elderly (PACE), which provides members access to a wide range of medical, social, recreational, and wellness services through a. model. Go to Question 20. a.If Yes, does this person have an immigration document? If you or if you know families and individuals in need of help accessing these federal payments, contact Sarah McKitterick at the Shah Family Foundation, located at. If you need more space, attach another sheet of paper. If Yes, please list the name of the tax filer. 03. See IRS Publication 501 or consult a tax professional for tax filing information. The first step individuals need to take is to apply. Address: W1-S011, Shed No.23, Al Hulaila Industrial Zone-FZ, RAK, UAE. is now open and materials for families are available on the DDS website. a.What type of real estate do you own? Box 290794 Charlestown, MA 02129-0214 Fax: (617) 887-8799 Hand deliver . Find the right form for you and fill it out: Camp Clover Point Camp Counselor Agreement No results. If you need additional services, contact MassHealth at (800) 841-2900. MASSHEALTH and the HEALTH SAFETY NET | Who Can Use This Application, This is your application for health coverage if you live in Massachusetts and are, an individual 65 years of age or older and living at home and, not the parent of a child under 19 years of age who lives with you; or, not an adult relative living with and taking care of a child younger than 19 years of age when neither parent is living in the home; or. We will keep all the information you provide private and secure, as required by law. You or any household member is not eligible for an SSN. Are you living in Massachusetts, and do you either intend to reside here, even if you do not have a fixed address, or have you entered Massachusetts with a job commitment or seeking employment? The Masshealth form is the application for this program, and it can be downloaded from the Masshealth website. Yes No Please select No if this person will be released in the next 60 days. You can submit your application in any of the following ways. We use SSNs to check income and other information to see who is eligible for help with health coverage costs. If you are a new user, click Start Free Trial and establish a profile. See page 10 of the Senior Guide for more information. If Yes: Type ____________________ Amount $ _________ Month Received __________________ Year received _______, 28.Will you receive income during the next calendar year as a one-time only payment? If you pay for certain things that can be deducted on a federal income tax return, telling us about them could make the cost of health coverage a little lower. both you and your spouse are applying for health coverage; there are no children under 19 years of age living with you; and, one spouse is 65 years of age or older and the other spouse is under 65 years of age. Is the tax filer married, filing a joint return? ii APPLICATION INSTRUCTIONS HOW TO APPLY Please identify which program each household member . are not otherwise eligible for MassHealth; do not have access to an affordable health plan that meets the minimum value requirement.*. If you are 65 years or older or you are any age and receive long-term care services and have not previously completed the Application for Health Care Coverage for Seniors and People Needing Long-Term Care Services (SACA), you may need to submit this different application to renew your MassHealth coverage. This person will only need to include him- or herself and any dependents on this application. English. ); in an acute hospital waiting for placement in a long-term- care facility; or. offered by MassHealth Applications to become a MassHealth member Get the applications you need to become a new MassHealth member, including applications for seniors and long-term-care. Video instructions and help with filling out and completing We've got more versions of the masshealth application form. If No or no response, you may get only one or more of the following: MassHealth Standard (if pregnant), MassHealth Limited, the Childrens Medical Security Plan (CMSP), or the Health Safety Net (HSN). Have you filed a lawsuit, a workers' compensation claim, or an insurance claim for this accident or injury? You can easily create your eSignature with pdfFiller and then eSign your s masshealth from directly from your inbox with the help of pdfFillers add-on for Gmail. HOW TO APPLY Please identify which program each household member is applying for on page 1 of the application. To obtain a copy of this application, call us at. 06/16 WHAT YOU NEED WHEN YOU APPLY The following MUST be sent with the application when applying for MassHealth the Health Safety Net and the Massachusetts Health Connector SOCIAL SECURITY NUMBER SSN PROOF OF CITIZENSHIP/NATIONAL STATUS You must give us an SSN or proof that one has been applied for for every Edit your masshealth application 2018 form form online. Be sure to answer all questions. MassHealth members 65 and older and those who receive a SACA renewal will now have the option to upload their renewal for health coverage from a web portal. Mail or fax your filled-out, signed application to MassHealth Enrollment Center Central Processing Unit P.O. Fill out all parts of the application, along with all supplements that apply. This person will claim a personal exemption deduction on his or her federal income tax return for any individual listed on this application as a dependent who is enrolled in coverage through the Massachusetts Health Connector and whose premium for coverage is paid in whole or in part by advance payments. Is your name on this application the same as your name on your social security card? Yes No If No, what name did this person use? Yes No, 19.If this person is a noncitizen, does he or she have an eligible immigration status? First, middle, last, and suffix, c.Did this person arrive in the U.S. after August 22, 1996? Did this person use the same name on this application to get his or her immigration status? Handling documents with our feature-rich and intuitive PDF editor is easy. The application has a versatile toolbar that will enable you to edit PDF forms. They are available for download and print at: The March 2022, as well as the July 2021 version of the ACA-3 and SACA-2 applications, will be accepted through December 31, 2022. A clinical screening will be completed by an ASAP RN and if eligible the screening determination is mailed to MassHealth along with the completed SACA application. You will only need to include yourself and any dependents on this application. _______. If No, check one of the following reasons. If you need more space, attach a separate piece of paper to the application. SACA-2 (Rev. Application for Health Coverage for Seniors and People Needing Long-Term-Care Services HOW TO APPLY Please identify which program each household member is applying for on page 1 of the application* You can submit your application in any of the following ways. You must check Yes to question 7 to be eligible for ConnectorCare or APTCs to help pay for your health insurance. By adding the solution to your Chrome browser, you can use pdfFiller to eSign documents and enjoy all of the features of the PDF editor in one place. Choose one or more document status and type from the list on page 28. Please list all the immigrations statuses and/or conditions that have applied to this person since he or she entered the U.S. List name(s) and date(s) of birth of dependents. MassHealth will check if anyone applying for health coverage on this application is eligible for MassHealth or the HSN. If you are interested, check the box on page 1 then read and sign the SNAP rights and responsibilities on pages 17-23. Once we get what we need, we will make a decision about your eligibility and send you a written notice. Contract Process, Copyright ESWA 2020. Giving us an SSN can speed up the application process. Will this person be claimed as a dependent on someone else's federal income tax return for the year for which this person is applying? Living in Massachusetts. On August 26, 2022, MassHealth senior members and their authorized representatives (ARD) now have the option to submit the SACA renewal electronically. It may help us to process this application faster if you include a copy of your immigration document with the application. Frail Elder Waiver (FEW) - ESWA - ESWAESWA For more information please contact ESWAs Information & Referral Unit at 508-756-1545, or irinfo@eswa.org, The Agency and its programs receive funds administered through the Massachusetts Executive Office of Elder Affairs; and federal financial support under the Older Americans Act provided by the Central Massachusetts Agency on Aging. Statement I filed a federal income tax return with the Internal Revenue Service (IRS) for every year that I received an Advance Premium Tax Credit (APTC). To use our professional PDF editor, follow these steps: Set up an account. Share your form with others Send saca 2 masshealth form via email, link, or fax. PDF Application for Health Coverage for Seniors and People Needing Long Enrolled in a Home Care Program through an ASAP and receiving at least one waiver approved service per month. b.Do you plan to file a joint federal tax return with your spouse for the tax year for which you are applying? The new form, called "Masshealth Eligibility Review Form", is now available on the Masshealth website. b.On average, how much net income (profits after business expenses are paid) will you get from this self-employment each month, or, how much will you lose from this self-employment each month? Certified Application Counselors must fill out a Certified Application Counselor Designation Form if they have not done so already. Go to Step 2 Person 2 to add another household member, if needed. How is this person related to the tax filer? Now more than ever, it is important to get money for the families who need it. If applying for the FEW for enrollment in the Program for all-Inclusive Care for Elders (PACE) or a Senior Care Options (SCO) contact that agency for the FEW. Yes No If No, go to the next question. The National Health Law Program about a lawsuit filed in federal district court in Connecticut challenging the legality of a federal Medicaid rule narrowing the scope of the moratorium on Medicaid termination during the pandemic (MassHealthimplemented this problematic federal rule in July 2021), and. MTF Office508-856-4306 phonemtf@umassmed.edu. You can now submit this application online! Yes No. You can also download, print, or export forms to your preferred cloud storage service. The Trump Administration issued an interim final rule in November 2020, at the time of the Presidential election. PDF MassHealth Updates revised 7.22 $, Capital gains: On average, how much net income or loss will you get from this capital gain each month? Yes No. Masshealth Form Fill Out Printable PDF Forms Online No street address. Apply for MassHealth coverage for seniors and people of any age who This application is available in Spanish. Please complete this question to help us meet your language and cultural needs. Mail or fax your filled-out, signed application to MassHealth Enrollment Center Central Processing Unit P.O. Put Person 1s name and social security number at the top of any attached paper. Mail or fax your filled-out, signed application to MassHealth Enrollment CenterPO Box 290794Charlestown, MA 02129-0214 Fax: (617) 887-8799 Under MassHealth Publications, click on MassHealth Member Library. Note: Right now, members can only submit their Renewal application online. _____, b.Were you getting health care through a state Medicaid program? Worcester Memory Cafe The Official Website of the Massachusetts Health Care Training Forum, On August 26, 2022, MassHealth senior members and their authorized representatives (ARD) now have the option to submit the SACA renewal electronically. Explain who can use the Application for Health Coverage for Seniors and People Needing Long-Te r m-Care Services (SACA-2) and the Medicare Savings Program (MassHealth Buy-In) Applications Describe eligibility requirements Demonstrate how to complete each section of the SACA-2 and MassHealth Buy-In application If Yes, who? APPLICATION FOR HEALTH COVERAGE FOR SENIORS AND PEOPLE NEEDING LONG-TERM-CARE SERVICES SACA-2 Rev. An SSN is optional for persons not applying for health coverage, but giving us an SSN can speed up the application process. 15.DISABILITY Answer this question if you are under age 65 or age 65 or older and working. Updates from MassHealth and Other Resources - Mass Legal Services 2.The statement is true for all people listed in the household. Then check yes below the statement if: 1.You have received an APTC or ConnectorCare in the past, and. It asks the Court to invalidate the rule and, in the meantime, to restore benefits to persons wrongfully terminated from Medicaid during the public health emergency.