Please rate Mass Health Review Form 09-22
Annuities purchased and/or other annuity transactions on or after February 8, 2006, may make you ineligible for payment of long-term-care services, unless certain conditions are met.
Annuity change: if you answered yes to the question about purchasing or changing an annuity since your last review, you must send us proof of this information.
Health insurance: you must submit a copy of your current premium bill.
Spouse: send proof of your spouse's monthly living expenses, and gross monthly income.
Separate sheet: if you need more space to finish a section, use a separate sheet of paper (include your name and MassHealth ID number), and attach it to this form.
| Question | Answer |
|---|---|
| Form Name | LTC-ER |
| Form Length | 5 pages |
| Fillable? | Yes |
| Fillable fields | 122 |
| Avg. time to fill out | 21 min |
| Edition | 09/22 |
| Other names | LTC-ER, MassHealth long-term-care eligibility review, MassHealth eligibility review form |
| Official source | LTC-ER (Rev 09/22), Commonwealth of Massachusetts EOHHS |
Mass Health Review Form isn’t the one you’re looking for?
Please rate Mass Health Review Form 09-22
