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The Alternative Housing Voucher Program (AHVP) provides rental

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AHVP Nursing Home Pilot Pre-Application
The Alternative Housing Voucher Program (AHVP) provides rental
assistance vouchers to low income, non-elderly persons with disabilities.
The voucher provides a subsidy that can be used to rent a private market
apartment anywhere in Massachusetts. AHVP Participants receive one
bedroom vouchers (except for an appropriate reasonable accommodation).
For more information on the Alternative Housing Voucher Program,
including general eligibility requirements you can visit
https://www.mass.gov/service-details/alternative-housing-voucher-
program-ahvp or the CHAMP website,
https://publichousingapplication.ocd.state.ma.us/ .
This pre-application is for a pilot program using 50 AHVP vouchers for
residents of Skilled Nursing (SNF) certified by Medicaid (MassHealth)
who are eligible for AHVP to live in the community. If more than 50
eligible people apply, a lottery will be held to determine who will receive
vouchers. If you are chosen, you may be contacted by MassHealth to
discuss transition options. To be eligible, you must be
- 59 years old or younger
- A person with a disability
- Low-income (as defined at this link: https://www.mass.gov/doc/ahvp-
dmhrsp-income-limits-2021/download . The lowest income limit
across the state is currently $47,150 for a single person)
- Continuously residing in a skilled nursing facility from June 1, 2021
to July 15, 2021
This pre-application does not put you on any waiting lists for standard
AHVP. If you would also like to be added to a standard AHVP waitlist,
you must do that through CHAMP or your local housing authority. If you
pass the pre-screening for this pilot and are chosen, you will then continue
to the standard eligibility screening process for AHVP.
AHVP Nursing Home Pilot Pre-Application
Medicaid defines a skilled nursing facility as “A nursing facility with the
staff and equipment to give skilled nursing care and, in most cases, skilled
rehabilitative services and other related health services” and skilled
nursing care as “care like intravenous injections that can only be given by
a registered nurse or doctor.” You can check if your place of residence is
certified as a skilled nursing facility by going to
https://www.medicare.gov/care-compare/?providerType=NursingHome
and entering the name and location of your residence.
This application can be submitted online until July 15, 2021 at the
following link: https://tinyurl.com/AHVPapp . You may also submit this
application by mail by sending it to the following address:
Stavros, attn: AHVP pilot
210 Old Farm Road
Amherst, MA 01002
If sending by mail, it must be postmarked by July 15, 2021.
After submitting this application, it will be sent to the Center for
Independent Living (CIL) in your area. They will follow up with you to
confirm receipt and possibly request more details, including verification of
your residence in a Skilled Nursing Facility. The following are equally
acceptable forms of verification:
- A verifier fills out and signs the optional “verification” section on the
pre-application. A verifier can be your social worker, case worker,
care manager, nursing home staff, a doctor, RN, or medical
practitioner
- Letter or email from a verifier stating that you reside in a particular
skilled nursing facility
- Signature of CIL employee who has personal knowledge that you are
a nursing home resident (“Personal knowledge” means that they have
first-hand information such as having visited)
- MassHealth statement that establishes residence
AHVP Nursing Home Pilot Pre-Application
This program is an equal housing opportunity. In Massachusetts, it is unlawful for a
housing provider to discriminate against a current or prospective tenant based
on: Race, Color, National Origin, Religion, Sex, Familial Status, Disability, Source
of Income, Sexual Orientation, Gender Identity, Age, Marital Status, Veteran or
Active Military Status, and Genetic Information
AHVP Nursing Home Pilot Pre-Application
FIRST NAME: MIDDLE INITIAL:
LAST NAME:
BIRTHDATE:
E-MAIL ADDRESS: PRONOUNS:
TELEPHONE: VOICE TTY
OTHER PHONE NUMBERS: VOICE TTY
NAME OF SKILLED NURSING FACILITY WHERE YOU RESIDE:
ADDRESS OF FACILITY: CITY/TOWN:
STATE: ZIP CODE:
Is anyone helping prepare this pre-application? Yes No
If Yes: name and contact info of preparer:
PROGRAM QUESTIONS
Are you 59 years old or younger? Yes No
Are you a person with a disability? Yes No Unsure
Do you currently reside in a Skilled Nursing Facility?
Yes No Unsure
If Yes: Admittance Date:
Do you have a disability for which you need an accommodation of an AHVP policy or
procedure, or assistance completing this application? Yes No
If Yes: please enter some additional details, attach additional sheet if necessary:
AHVP Nursing Home Pilot Pre-Application
By my signature, I certify that the information I have given in this pre-
application is true and correct. I understand that any false statement or
misrepresentation may result in the denial of my pre-application. I understand this
pre-application is not an offer of housing. I recognize that this information will be
shared with the Center for Independent Living and MassHealth in my area, and
AHVP Administering Agency as appropriate, and agree they may contact me.
APPLICANT SIGNATURE DATE
PREPARER SIGNATURE (if applicable) DATE
Optional: Verification of residence in a Medicaid or MassHealth
Certified Skilled Nursing Facility (SNF)
You may provide verification of your residence in an SNF by having a
professional fill out and sign this portion of the form, as described on the
front page. You can also attach any other form of acceptable verification
to this pre-application. If you do not include verification with this pre-
application, it will be requested later. Verification documentation must be
received by the application deadline for an application to be considered.
VERIFIER NAME:
PREFERRED CONTACT:
Signatory is: (Check all that apply, include job title or other details if relevant)
Social worker, case worker, or nursing home staff
Doctor, nurse, or other medical provider
CIL Staff
Other:
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AHVP Nursing Home Pilot Pre-Application
Applicant currently resides in an SNF
Applicant does not currently reside in an SNF
I consent to be contacted by CIL staff with any further questions pertaining to
verification of the applicant’s residence
By my signature, I certify that the information I have given in this section of the
pre-application is true and correct. .
VERIFIER SIGNATURE DATE
For CIL Staff use
Date recieved:
Applicant’s residence in an SNF has been verified Not been verified
Eligibility notification date and method:
Name: Date
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Completed 7 July 2021

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