reglab/statecodes huggingface dataset:
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 520.000 - MassHealth: Financial Eligibility › Section 520.018 - Transfer of Resources Regardless of Date of Transfer

Current through Register 1525, July 5, 2024
(A) The provisions of
			 42 U.S.C.
			 1396p apply to all transfers of resources. In
			 the event that any portion of
			 130
			 CMR 520.018 and
			 520.019 conflicts with
			 federal law, the federal law supersedes.
(B) The MassHealth agency denies payment for
			 nursing-facility services to an otherwise eligible nursing-facility resident as
			 defined in
			 130
			 CMR 515.001:
Definition of
			 Terms
who transfers or whose spouse transfers countable resources for
			 less than fair-market value during or after the period of time referred to as
			 the look-back period.
(C) The
			 denial of payment for nursing-facility services does not affect the
			 individual's eligibility for other MassHealth benefits.
(D) Circumstances giving rise to
			 disqualifying transfers of resources are also described at
			 130
			 CMR 520.007(J).
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 520.000 - MassHealth: Financial Eligibility › Section 520.019 - Transfer of Resources Occurring on or after August 11, 1993

Current through Register 1525, July 5, 2024
(A)
Payment of Nursing-facility
			 Services
. The MassHealth agency applies the provisions of
			 130
			 CMR 520.018 and
			 520.019 to nursing-facility
			 residents as defined at
			 130
			 CMR 515.001:
Definition of
			 Terms
requesting MassHealth agency payment for nursing-facility
			 services provided in a nursing facility or in any institution for a level of
			 care equivalent to that received in a nursing facility or for home- and
			 community-based services provided in accordance with
			 130
			 CMR 519.007(B):
Home- and Community-based Services Waiver Frail
			 Elder
.
(B)
Look-back Period
. Transfers of resources are subject
			 to a look-back period, beginning on the first date the individual is both a
			 nursing-facility resident and has applied for or is receiving MassHealth
			 Standard.
(1) For transfers occurring before
			 February 8, 2006, this period generally extends back in time for 36
			 months.
(2) For transfers of
			 resources occurring on or after February 8, 2006, the period generally extends
			 back in time for 60 months. The 60-month look-back period will begin to be
			 phased in on February 8, 2009. Beginning on March 8, 2009, applicants will be
			 asked to provide verifications of their assets for the 37 months prior to the
			 application. As each month passes, the look-back period will increase by one
			 month until the full 60 months is reached on February 8, 2011.
(3) For transfers of resources from or into
			 trusts, the look-back period is described in
			 130
			 CMR 520.023(A).
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 520.000 - MassHealth: Financial Eligibility › Section 520.021 - Treatment of Trusts

Current through Register 1525, July 5, 2024
130 CMR 520.021 through
				520.024
				explains how to treat the principal of and payments from a revocable or
				irrevocable trust established by the individual or by the spouse.
				130 CMR 520.024(A)
				 also includes trusts established by other
				than the individual or spouse and trusts whether or not established by will. In
				the event that a portion of 130 CMR 520.021 through
				520.024
				conflicts with federal law, the federal law supersedes.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 520.000 - MassHealth: Financial Eligibility › Section 520.022 - Trusts or Similar Legal Devices Created before August 11, 1993

Current through Register 1525, July 5, 2024
(A)
Revocable Trust
.
			 The assets and income of an individual or spouse in a revocable trust are
			 countable. The fair-market value of the home or former home of the
			 nursing-facility resident or spouse in a revocable trust is a countable asset.
			 Where the home or former home is an asset of the trust, the home or former home
			 is not subject to the exemptions of
			 130 CMR 520.007(G)(2)
			  or
			 520.007(G)(8).
(B)
Medicaid Qualifying
			 Trust
.
(1) A Medicaid qualifying
			 trust is a revocable or irrevocable trust or similar legal device, created or
			 funded by the individual or spouse, other than by a will, under which
(a) the individual is a beneficiary of all or
			 part of the discretionary or required payments or distributions from the trust;
			 and
(b) a trustee or trustees are
			 permitted to exercise any discretion to make payments or distributions to the
			 individual.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 520.000 - MassHealth: Financial Eligibility › Section 520.023 - Trusts or Similar Legal Devices Created on or after August 11, 1993

Current through Register 1525, July 5, 2024
The trust and transfer rules at
				42
				U.S.C. 1396p apply to trusts or similar legal
				devices created on or after August 11, 1993, that are created or funded other
				than by a will. Generally, resources held in a trust are considered available
				if under any circumstances described in the terms of the trust, any of the
				resources can be made available to the individual.
(A)
Look-back Period for
			 Transfers into or from Trusts
.
(1)
Look-back
			 Period
.
(a) For transfers made
			 before February 8, 2006, the look-back period is 36 months for trusts where all
			 or any portion of the income or principal of an irrevocable trust can be paid
			 to or for the benefit of the nursing-facility resident, but is paid instead to
			 someone else.
(b) The look-back
			 period is 60 months
1. for transfers made on
			 or after February 8, 2006, subject to the phase-in described in
			 130 CMR
			 520.019(B)(2), if all or any
			 portion of the income or principal of a trust can be paid to or for the benefit
			 of the nursing-facility resident, but is instead paid to someone
			 else;
2. if payments are made from
			 a revocable trust to other than the nursing-facility resident and are not for
			 the benefit of the nursing-facility resident; or
3. if payments are made into an irrevocable
			 trust where all or a portion of the trust income or principal cannot under any
			 circumstances be paid to or for the benefit of the nursing-facility
			 resident.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 520.000 - MassHealth: Financial Eligibility › Section 520.024 - General Trust Rules

Current through Register 1525, July 5, 2024
130 CMR 520.024 applies to trusts whether or not established by
				will and whether or not established by the individual or spouse.
(A)
Irrevocable
			 Trust
.
(1) The assets and income
			 held in an irrevocable trust established by the individual or spouse that the
			 trustee is required to distribute to or for the benefit of the individual are
			 countable.
(2) Payments from the
			 income or principal of an irrevocable trust established by the individual or
			 spouse to or for the benefit of the individual are countable.
(3) The assets and income held in an
			 irrevocable trust established by other than the individual or spouse that the
			 trustee is required to distribute to the individual are countable.
(4) Payments from the income or the principal
			 of an irrevocable trust established by other than the individual or spouse to
			 the individual are countable.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 520.000 - MassHealth: Financial Eligibility › Section 520.026 - Long-term-care General Income Deductions

Current through Register 1525, July 5, 2024
General income deductions must be taken in the following order:
				a personal-needs allowance; a spousal-maintenance-needs allowance; a
				family-maintenance-needs allowance for qualified family members; a
				home-maintenance allowance; and health-care coverage and incurred medical and
				remedial-care expenses. These deductions are used in determining the monthly
				patient-paid amount.
(A)
Personal-needs Allowance
.
(1) The MassHealth agency deducts $72.80 for
			 a long-term-care resident's personal-needs allowance (PNA).
(2) If an individual does not have income
			 totaling the standard, the MassHealth agency will pay the individual an amount
			 up to that standard on a monthly basis.
(3) The PNA for SSI recipients is
			 $72.80.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 520.000 - MassHealth: Financial Eligibility › Section 520.027 - Long-term-care Deductible

Current through Register 1525, July 5, 2024
If after applying the deductions in
				130 CMR
				520.026(A) through (E) the
				long-term-care- facility resident's monthly income exceeds the public rate at
				the long-term-care facility, the MassHealth agency will establish a six-month
				deductible in accordance with
				130 CMR
				520.028 through
				520.035
				and use an income standard of $72.80.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 520.000 - MassHealth: Financial Eligibility › Section 520.028 - Eligibility for a Deductible

Current through Register 1525, July 5, 2024
The following individuals may establish eligibility by meeting
				a deductible:
(A) former SSI
			 recipients who are not eligible under the Pickle Amendment;
(B) community-based individuals whose
			 countable-income amount exceeds the 100% federal poverty level income
			 standards;
(C)
			 long-term-care-facility residents whose income, after general deductions
			 described in
			 130
			 CMR 520.026, exceeds the public rate in a
			 long-term-care facility;
(D)
			 disabled adult children whose incomes exceed the standards set forth in
			 130
			 CMR 519.004(A):
Eligibility Requirements
; and
(E) persons who are eligible for an increased
			 disregard as described at
			 130
			 CMR 520.013(B).
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 520.000 - MassHealth: Financial Eligibility › Section 520.029 - The Deductible Period

Current through Register 1525, July 5, 2024
The deductible period is a six-month period that starts on the
				first day of the month of application or may begin up to three months before
				the first day of the month of application. The applicant is eligible for this
				period of retroactivity only if the applicant incurred medical expenses covered
				by MassHealth and was otherwise eligible.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 520.000 - MassHealth: Financial Eligibility › Section 520.030 - Calculating the Deductible

Current through Register 1525, July 5, 2024
The deductible is determined by multiplying the excess monthly
				income by six. Excess monthly income is the amount by which the applicant's
				countable-income amount as described in
				130
				CMR 520.009 exceeds the MassHealth
				deductible-income standard.
MASSHEALTH DEDUCTIBLE-INCOME
							 STANDARDS
Number of Persons
Monthly-Income Standard for Community
							 Residents
Monthly-Income Standard for
							 Long-term-care-facility Residents
1
$522
$72.80
2
650
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 520.000 - MassHealth: Financial Eligibility › Section 520.031 - Notification of Potential Eligibility

Current through Register 1525, July 5, 2024
(A) The MassHealth
			 agency informs the applicant who has excess monthly income that he or she is
			 currently ineligible for MassHealth Standard, Family Assistance or Limited but
			 may establish eligibility for a six-month period by meeting the deductible. The
			 MassHealth agency informs the applicant in writing of the following:
(1) the deductible amount and the method of
			 calculation;
(2) the start and end
			 dates of the deductible period;
(3)
			 the procedures for submitting medical bills;
(4) his or her responsibility to report all
			 changes in circumstances that may affect eligibility or the deductible amount;
			 and
(5) that the bills submitted to
			 meet the deductible are the responsibility of the individual and cannot be
			 submitted for MassHealth agency payment.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 520.000 - MassHealth: Financial Eligibility › Section 520.032 - Submission of Bills to Meet the Deductible

Current through Register 1525, July 5, 2024
(A)
Criteria
. To establish eligibility by meeting a
			 deductible, the individual must submit verification of medical bills whose
			 total equals or exceeds the deductible and that meet the following criteria.
(1) The bill must not be subject to further
			 payment by health insurance or other liable third-party coverage, including the
			 Health Safety Net.
(2) The bill
			 must be for an allowable medical or remedial-care expense in accordance with
			 130
			 CMR 520.032(B). A
			 remedial-care expense is a nonmedical support service made necessary by the
			 medical condition of the individual or the spouse.
(3) The bill must be unpaid and a current
			 liability or, if paid, paid during the current six month deductible
			 period.
(4) Any bill or portion of
			 a bill used to meet a deductible may not be applied to any other deductible
			 period. However, any portion of a bill not used to meet the current deductible
			 may be used in a future deductible period. The MassHealth agency will not pay
			 any bills or portions of bills that are used to meet the deductible. These
			 bills remain the responsibility of the applicant.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 520.000 - MassHealth: Financial Eligibility › Section 520.033 - Verification of Medical Expenses

Current through Register 1525, July 5, 2024
(A) Medical
			 expenses must be verified by a bill or written statement from a health-care
			 provider with the exception of expenses for nonprescription drugs, which must
			 be verified by a receipt from the provider of the drug. Any unpaid bill
			 incurred before the deductible period must be verified by a bill dated within
			 the six-month deductible period.
(B) Verifications must include all of the
			 following information:
(1) the name of the
			 provider;
(2) the type of service
			 provided;
(3) the name of the
			 individual for whom the service was provided;
(4) the amount charged for the service
			 including the current balance; and
(5) the date of service.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 520.000 - MassHealth: Financial Eligibility › Section 520.034 - Interim Changes

Current through Register 1525, July 5, 2024
The applicant or member must notify the MassHealth agency of
				any changes occurring before meeting the deductible or during the deductible
				period. These changes include an increase or decrease in income or an increase
				in assets.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 520.000 - MassHealth: Financial Eligibility › Section 520.035 - Conclusion of the Deductible Process

Current through Register 1525, July 5, 2024
When the total of submitted bills is equal to or greater than
				the deductible and all other eligibility requirements continue to be met, the
				MassHealth agency notifies the applicant that he or she is eligible. The member
				is eligible for payment of all covered medical expenses incurred during that
				deductible period, other than those submitted to meet the deductible, as long
				as the member continues to meet all other eligibility requirements during the
				balance of the deductible period.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 520.000 - MassHealth: Financial Eligibility › Section 520.038 - Services Subject to Copayments

Current through Register 1525, July 5, 2024
MassHealth members are responsible for making the following
				copayments for pharmacy services unless excluded in
				130
				CmR 520.037.
(A) $ 1 for each prescription and refill for
			 each generic drug and over-the-counter drug covered by MassHealth in the
			 following drug classes: antihyperglycemics, antihypertensives, and
			 antihyperlipidemics; and
(B) $3.65
			 for each prescription and refill for all other generic and over-the-counter
			 drugs, and all brand-name drugs covered by MassHealth
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 520.000 - MassHealth: Financial Eligibility › Section 520.039 - Members Unable to Pay Copayment

Current through Register 1525, July 5, 2024
Providers may not refuse services to a member who is unable to
				pay at the time the service is provided. However, the member remains liable to
				the provider for the copayment amount.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 520.000 - MassHealth: Financial Eligibility › Section 520.040 - Maximum Cost Sharing

Current through Register 1525, July 5, 2024
Members are responsible for MassHealth premiums described in
				130
				CMR 506.012 up to a monthly maximum of 3% of
				applicable monthly income, except no such limit applies to Common Health
				members. Each member's monthly premium cap will be calculated using 3% of the
				lowest income in the MassHealth MAGI household or the MassHealth Disabled Adult
				household, as applicable. A further explanation of this calculation is publicly
				available on MassHealth's website.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 520.000 - MassHealth: Financial Eligibility › Section 520.041 - Copayment Waiver during Federal Public Health Emergency Unwind

Current through Register 1525, July 5, 2024
Notwithstanding
				130
				CMR 520.036 through
				520.040, the MassHealth
				agency will require no copayments by its members during the period May 1, 2023
				through March 31, 2024.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 522.000 - Masshealth: Other Division Programs › Section 522.001 - Massachusetts Insurance Connection for Individuals with AIDS or HIV (Closed to New Applicants)

Current through Register 1525, July 5, 2024
(A)
Introduction
. The Massachusetts Insurance Connection
			 (MIC) is a health insurance buy-in program administered by the MassHealth
			 agency for individuals with Acquired Immune Deficiency Syndrome (AIDS) or human
			 immunodeficiency virus (HIV). MIC is closed to new applicants effective January
			 1, 2020. Program participants may continue to receive benefits through MIC for
			 as long as they meet the requirements of 130 CMR 522.001(B).
(B)
Eligibility
			 Requirements
. The MassHealth agency may pay the monthly private
			 and group health insurance premiums of a program participant (and his or her
			 spouse and dependent children, provided that the program participant
(1) was enrolled in the MIC program as of
			 December 31, 2019, and remains continuously enrolled in the MIC program
			 (continuous enrollment ends when a program participant has not been enrolled in
			 the MIC program for six months);
(2) had a health insurance policy (group or
			 private) before becoming eligible for the MIC program (individuals who elect to
			 continue employer-based group health insurance are subject to the provisions of
			 the Omnibus Budget Reconciliation Act of 1990 (OBRA) and the Consolidated
			 Omnibus Budget Reconciliation Act of 1985 (COBRA), P.L. 99-272 ) that
(a) has comprehensive coverage, as determined
			 by the MassHealth agency on an individual basis; and
(b) requires premium payments that do not
			 exceed the average monthly cost incurred by the MassHealth agency for the care
			 of an individual with AIDS or HIV;
(3) has a diagnosis of AIDS or HIV;
(4) applies for and meets the Social Security
			 Administration's definition of disability for AIDS or HIV;
(5) is a resident of Massachusetts;
(6) in conjunction with his or her spouse and
			 dependent children, has a gross annual income that does not exceed 300% of the
			 annualized federal poverty level income standard for a household of that size;
			 and
(7) is not eligible for a
			 MassHealth coverage type that provides or pays for comprehensive
			 benefits.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 522.000 - Masshealth: Other Division Programs › Section 522.002 - Refugee Resettlement Program

Current through Register 1525, July 5, 2024
(A)
Regulatory Authority
. The Refugee Resettlement Program
			 (RRP) is regulated pursuant to Chapter 2 of Title IV of the Immigration and
			 Nationality Act (INA),
			 8
			 U.S.C. 1521
et seq
. and
			 Refugee Medical Assistance (RMA) is provided in accordance with 45 CFR 400
			 Subpart G.
(B)
Overview
.
(1) The RRP
			 was established by the Refugee Act of 1980. The Refugee Act of 1980 authorizes
			 funds for the administration and implementation of social and educational
			 services and employment training and placement, as well as cash assistance and
			 medical assistance to refugees without regard to race, religion, nationality,
			 sex, or political opinion. It is the intent of the Refugee Act of 1980 to
			 promote the resettlement and economic self-sufficiency of refugees within the
			 shortest time frame possible.
(2)
			 The Massachusetts Office for Refugees and Immigrants (ORI) is the state agency
			 responsible for the delivery of services to refugees under the RRP. ORI has
			 entered into an agreement with the MassHealth agency to provide RMA to eligible
			 individuals. Refugee resettlement agencies under contract with ORI make the RRP
			 eligibility determination and assist refugees to submit an application for
			 MassHealth.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 522.000 - Masshealth: Other Division Programs › Section 522.003 - Adoption Assistance and Foster Care Maintenance

Current through Register 1525, July 5, 2024
Any child placed in subsidized adoption or foster care under
				Title IV-E of the Social Security Act is automatically eligible for medical
				assistance provided by the state where the child resides.
(A) Children receiving state-subsidized
			 adoption payments from a state that is a member of the Interstate Compact on
			 Adoption and Medical Assistance (ICAMA) will be eligible for medical assistance
			 provided by the state where the child resides if that state is a member of
			 ICAMA.
(B) Children receiving
			 state-subsidized adoption payments from a state that is not a member of ICAMA,
			 or any child receiving state-subsidized foster-care payments will only be
			 eligible for medical assistance provided by his or her state of
			 origin.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 522.000 - Masshealth: Other Division Programs › Section 522.004 - Children's Medical Security Plan (CMSP)

Current through Register 1525, July 5, 2024
(A)
Regulatory Authority
. The Children's Medical Security
			 Plan (CMSP) is administered pursuant to M.G.L. c. 118E, § 10F.
(B)
Overview
. CMSP
			 provides coverage to uninsured children younger than 19 years old who do not
			 qualify for any other MassHealth coverage type, other than MassHealth Limited,
			 and who do not have physician and hospital health-care coverage. To apply for
			 these benefits, an applicant must submit an application as described in
			 130 CMR
			 502.001:
Medical Benefit Request
			 (MBR)
and 502.002:
Reactivating the Medical Benefit
			 Request
.
(C)
Eligibility Requirements
. Children are eligible for
			 CMSP if they are
(1) a resident of
			 Massachusetts, as defined in
			 130 CMR
			 503.002: Residence Requirements ;
(2) younger than 19 years old;
(3) not otherwise eligible for any other
			 MassHealth coverage type, other than MassHealth Limited. Children who are
			 otherwise eligible and who are not receiving MassHealth coverage as a result of
			 not complying with administrative requirements of MassHealth are not eligible
			 for CMSP. Children who lose eligibility for MassHealth Family Assistance as a
			 result of nonpayment of premiums or as a result of not enrolling in
			 employer-sponsored health insurance through Premium Assistance are not eligible
			 for CMSP; and
(4) uninsured. An
			 applicant or member is uninsured if he or she
(a) does not have insurance that provides
			 physician and hospital health-care coverage;
(b) has insurance that is in an exclusion
			 period; or
(c) had insurance that
			 has expired or has been terminated.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 610.000 - MassHealth: Fair Hearing Rules › Section 610.001 - Purpose

Current through Register 1525, July 5, 2024
(A)
MassHealth
			 Determinations
.
(1)
									130 CMR 610.000 sets out
			 the process for requesting and participating in a fair hearing that allows
			 dissatisfied applicants, members, or nursing facility residents to have
			 administrative review of certain actions or inactions on the part of the
			 MassHealth agency and of determinations by a MassHealth managed care
			 contractor.
(2) Such actions
			 include, but are not limited to, determinations of eligibility for MassHealth
			 Standard, MassHealth CommonHealth, MassHealth Family Assistance, MassHealth
			 Limited, MassHealth Senior Buy-In, MassHealth Buy-In, MassHealth CarePlus,
			 MassHealth Small Business Employee Premium Assistance, Children's Medical
			 Security Plan, Refugee Resettlement Program, low-income subsidies under
			 Medicare Part D (as set forth in the
Medicare Prescription Drug and
			 Improvement and Modernization Act
of 2003, as described in federal
			 regulations 42 CFR Part 423, Subpart P), and requests for services that require
			 prior authorization.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 610.000 - MassHealth: Fair Hearing Rules › Section 610.002 - Authority

Current through Register 1525, July 5, 2024
The authority for
				130 CMR 610.000 is set out
				in
				42 CFR 431.200
et seq
., M.G.L. c. 30A, c. 118E, §§ 12, 20, 47, and
				48, and
				801
				CMR 1.03(4). Pursuant to
				M.G.L. c. 118E, § 48, the Board of Hearings (BOH) has exclusive
				jurisdiction to hear appeals relating to the programs administered by the
				MassHealth agency; provided, however, that for certain appeals by an integrated
				care organization (ICO) or senior care organization (SCO) enrollee concerning
				covered benefits, the Centers for Medicare & Medicaid Services (CMS)
				Independent Review Entity (IRE) also has jurisdiction. Pursuant to
				42 U.S.C.
				1396r(e)(7) and 42 CFR
				483.204, the BOH has authority to hear appeals of PASRR determinations. BOH has
				authority to hear financial eligibility appeals, clinical eligibility appeals,
				and service plan appeals for the following 1915(c) home- and community-based
				services waivers: Traumatic Brain Injury (TBI), Acquired Brain Injury -
				Nonresidential Habilitation (ABI-N), Acquired Brain Injury - Residential
				Habilitation (ABI-RH), Moving Forward Plan - Community Living (MFP-CL), and
				Moving Forward Plan - Residential Supports (MFP-RS). BOH has authority to hear
				financial eligibility appeals and clinical eligibility appeals of the following
				1915(c) home- and community-based services waiver: Frail Elder. BOH has
				authority to hear the financial eligibility appeals of the following 1915(c)
				home- and community-based services waivers: Young Children with Autism, Persons
				with an Intellectual Disability - Intensive Supports, Persons with an
				Intellectual Disability - Community Living, and Persons with an Intellectual
				Disability - Adult Supports.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 610.000 - MassHealth: Fair Hearing Rules › Section 610.003 - Scope

Current through Register 1525, July 5, 2024
130 CMR 610.000 sets out
				the processes for fair hearing requests and proceedings started by applicants
				or members to review certain actions or inactions by the MassHealth agency or a
				MassHealth managed care contractor relating to programs administered by the
				MassHealth agency, including determinations of eligibility for low-income
				subsidies under Medicare Part D (as set forth in the
Medicare
				Prescription Drug and Improvement and Modernization Act
of 2003, as
				described in federal regulations at 42 CFR Part 423, Subpart P). In addition,
				appeals pursuant to the Executive Office of Elder Affairs Supplementary Rules
				to the Adjudicatory Rules of Practice and Procedures,
				651 CMR 1.00:
Adjudicatory Rules of Practice and Procedure
are governed by
				the procedures set forth in
				130 CMR 610.000. Appeals by
				residents of a nursing facility who are to be discharged or transferred at the
				initiation of the nursing facility, appeals regarding a nursing facility's
				failure to readmit, and appeals pertaining to PASRR determinations are also
				governed by
				130 CMR 610.000.
				Adjudicatory proceedings initiated by MassHealth providers are governed by
				130 CMR
				450.241 through
				450.248
				or, with regard to appeals of erroneously denied claims, by
				130 CMR
				450.323:
Appeals of Erroneously
				Denied or Underpaid Claims
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 610.000 - MassHealth: Fair Hearing Rules › Section 610.011 - The Office of Medicaid Board of Hearings

Current through Register 1525, July 5, 2024
The Office of Medicaid Board of Hearings (BOH) is responsible
				for administering the fair hearing process in accordance with
				130 CMR
				610.000, holding hearings, and rendering decisions. At
				the MassHealth agency's discretion, BOH also conducts adjudicatory proceedings
				governing providers pursuant to
				130
				CMR 450.241 through
				450.248, and
				130
				CMR 450.323:
Appeals of Erroneously
				Denied or Underpaid Claims
. BOH is administered by a Director who is
				appointed by the Medicaid Director, and who is responsible for ensuring that
				the fair hearing process and decisions comply with the requirements of
				130 CMR
				610.000.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 610.000 - MassHealth: Fair Hearing Rules › Section 610.012 - General Description of the Fair Hearing Process

Current through Register 1525, July 5, 2024
(A) The fair hearing process is an
			 administrative, adjudicatory proceeding where dissatisfied applicants, members,
			 and nursing facility residents can, upon written request, obtain an
			 administrative determination of the appropriateness of
(1) certain actions or inactions by the
			 MassHealth agency;
(2) certain
			 actions or inactions by a managed care contractor;
(3) actions to recover payment for benefits
			 to which the member was not entitled at the time the benefit was
			 received;
(4) alleged coercive or
			 otherwise improper conduct by a MassHealth agency employee;
(5) a notice of intent or failure to give
			 notice of intent by a nursing facility to discharge, transfer, or readmit a
			 resident; or
(6) a PASRR
			 determination.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 610.000 - MassHealth: Fair Hearing Rules › Section 610.013 - Methods for Conducting a Fair Hearing

Current through Register 1525, July 5, 2024
(A)
			 A fair hearing may be conducted
(1)
			 face-to-face, whether in person or by video conferencing; or
(2) telephonically, if the party appearing
			 telephonically agrees to such an appearance and notifies the BOH in advance of
			 hearing of such a request.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 610.000 - MassHealth: Fair Hearing Rules › Section 610.014 - Compilation of Fair Hearing Decisions

Current through Register 1525, July 5, 2024
BOH compiles and maintains fair hearing decisions. Copies of
				decisions are available to the public at BOH after deletion of personal data,
				including the appellant's name and address, in order to protect the
				confidentiality of personal information. To view fair hearing decisions, an
				appointment must be made with the BOH in advance. Requests for appointments
				shall be addressed as expeditiously as possible.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 610.000 - MassHealth: Fair Hearing Rules › Section 610.016 - Appeal Representative

Current through Register 1525, July 5, 2024
(A) An appellant
			 has the right to be represented at his or her own expense by an appeal
			 representative as defined in
			 130
			 CMR 610.004. If the person filing the appeal
			 is not the appellant, all documentation required to demonstrate that the person
			 requesting the appeal is an appeal representative in accordance with
			 130
			 CMR 610.004 must be submitted either at the
			 time the hearing is requested or before the hearing is scheduled. The
			 MassHealth agency must provide copies of all documents related to the fair
			 hearing process to the appellant and to the appeal representative, if any. An
			 appeal representative may exercise on the appellant's behalf any of the
			 appellant's rights under
			 130 CMR
			 610.000.
(B) If a timely request for a hearing is
			 filed but the applicant or member has died prior to the filing, BOH must be
			 informed of the death of the applicant or member at the time of a request for a
			 hearing by the person filing the appeal. In addition, the filing of the appeal
			 on behalf of such a deceased individual must be accompanied by one of the
			 following:
(1)
(a) written proof that the person filing the
			 appeal is a personal representative of the applicant's or member's estate with
			 a current and valid appointment from a court of proper jurisdiction;
			 or
(b) if there is no such personal
			 representative, then written proof of a currently pending petition, docketed in
			 a court of proper jurisdiction, which seeks the appointment of such a personal
			 representative. In addition, the person filing the appeal must notify BOH in
			 writing of the status of the pending petition every 30 days and, once a
			 personal representative with a current and valid appointment has been
			 established, the personal representative must submit written proof of such
			 authority and a desire to pursue the appeal to BOH, within ten days of the
			 appointment.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 610.000 - MassHealth: Fair Hearing Rules › Section 610.017 - Reasonable Accommodations

Current through Register 1525, July 5, 2024
BOH provides reasonable accommodations in accordance with the
Americans with Disability Act
(ADA) to appellants who request
				such accommodations. BOH informs appellants of the availability of this
				service. In addition, BOH will provide telephonic or, at its option, other
				interpreter services for an appellant whose English proficiency is limited,
				unless such appellant provides his or her own interpreter or such appellant
				knowingly and voluntarily signs a waiver of such services.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 610.000 - MassHealth: Fair Hearing Rules › Section 610.018 - Appeal Process for Enrollees in an Integrated Care Organization

Current through Register 1525, July 5, 2024
The Duals Demonstration Program uses a coordinated appeals
				process that provides enrollees with access to both the MassHealth and Medicare
				appeals processes. If the ICO internal appeals process denies a member's
				requested covered benefits in whole or in part, the member may appeal to either
				IRE, BOH, or both, as described in 130CMR 610.018(A) through (C).
(A) If the member's appeal is denied in whole
			 or in part, the ICO must automatically forward an external appeal about
			 Medicare services to the IRE. The member may simultaneously appeal the ICO
			 decision to the BOH.
(B) Services
			 that are not covered by Medicare fee-for-service may only be appealed to the
			 BOH. The ICO must notify the member if the service is not covered by Medicare
			 and that the member has the right to appeal to the BOH.
(C) If the BOH or the IRE decides in the
			 member's favor, the ICO must provide or arrange for the service in dispute as
			 expeditiously as the member's health condition requires, but no later than 72
			 hours from the date the ICO receives the notice of the BOH or the IRE
			 decision.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 610.000 - MassHealth: Fair Hearing Rules › Section 610.026 - Adequate Notice Requirements

Current through Register 1525, July 5, 2024
(A) A
			 notice concerning an intended appealable action must be timely as stated in
			 130 CMR 610.015 and
			 adequate in that it must be in writing and contain
(1) a statement of the intended
			 action;
(2) the reasons for the
			 intended action;
(3) a citation to
			 the regulations supporting such action;
(4) an explanation of the right to request a
			 fair hearing; and
(5) the
			 circumstances under which assistance is continued if a hearing is
			 requested.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 610.000 - MassHealth: Fair Hearing Rules › Section 610.027 - Timely Notice Exceptions

Current through Register 1525, July 5, 2024
The MassHealth agency need not send a timely notice, as defined
				at
				130 CMR
				610.015(A), but must send an
				adequate notice, as defined in
				130 CMR
				610.026, no later than the date of an
				appealable action when
(A) the
			 MassHealth agency receives a clear written statement signed by the member that
(1) the member no longer wishes to receive
			 assistance; or
(2) gives
			 information that requires termination or reduction of services and indicates
			 that termination or reduction of services must be the result of supplying that
			 information;
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 610.000 - MassHealth: Fair Hearing Rules › Section 610.028 - Notice Requirements Regarding Actions Initiated by a Nursing Facility

Current through Register 1525, July 5, 2024
(A) A resident may be transferred or
			 discharged from a nursing facility only when:
(1) the transfer or discharge is necessary
			 for the resident's welfare and the resident's needs cannot be met in the
			 nursing facility;
(2) the transfer
			 or discharge is appropriate because the resident's health has improved
			 sufficiently so that the resident no longer needs the services provided by the
			 nursing facility;
(3) the safety of
			 individuals in the nursing facility is endangered;
(4) the health of individuals in the nursing
			 facility would otherwise be endangered;
(5) the resident has failed, after reasonable
			 and appropriate notice, to pay for (or failed to have the MassHealth agency or
			 Medicare pay for) a stay at the nursing facility; or
(6) the nursing facility ceases to
			 operate.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 610.000 - MassHealth: Fair Hearing Rules › Section 610.029 - Time Frames for Notices Issued by Nursing Facilities

Current through Register 1525, July 5, 2024
(A) The notice of discharge or transfer
			 required under
			 130
			 CMR 610.028 must be made by the nursing
			 facility at least 30 days before the date the resident is to be discharged or
			 transferred, except as provided for under 130 CMR 610.029(B) and (C).
(B) In
lieu
of the
			 30-day-notice requirement set forth in 130 CMR 610.029(A), the notice of
			 discharge or transfer required under
			 130
			 CMR 610.028 must be made as soon as
			 practicable before the discharge or transfer in any of the following
			 circumstances, which are considered to be emergency discharges or emergency
			 transfers.
(1) The health or safety of
			 individuals in the nursing facility would be endangered and this is documented
			 in the resident's record by a physician.
(2) The resident's health improves
			 sufficiently to allow a more immediate transfer or discharge and the resident's
			 attending physician documents this in the resident's record.
(3) An immediate transfer or discharge is
			 required by the resident's urgent medical needs and this is documented in the
			 medical record by the resident's attending physician.
(4) The resident has not lived in the nursing
			 facility for 30 days immediately before receipt of the notice.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 610.000 - MassHealth: Fair Hearing Rules › Section 610.030 - Stay of a Transfer or Discharge from a Nursing Facility Pending Appeal

Current through Register 1525, July 5, 2024
(A) If a request for a hearing regarding a
			 discharge or transfer from a nursing facility is received by BOH during the
			 notice period described in
			 130 CMR
			 610.015(B)(3), the nursing
			 facility must stay the planned discharge or transfer until 30 days after the
			 decision is rendered. While this stay is in effect, the resident must not be
			 transferred or discharged from the nursing facility.
(B) If a hearing is requested, in accordance
			 with
			 130 CMR
			 610.015(B)(4), and the
			 request is received before the discharge or transfer, then the nursing facility
			 must stay the planned transfer or discharge until five days after the hearing
			 decision.
(C) If the request for a
			 hearing, in accordance with
			 130 CMR
			 610.015(B)(4), is received
			 within the applicable time frame, but after the transfer, the nursing facility
			 must, upon receipt of the appeal decision favorable to the resident, promptly
			 readmit the resident to the next available bed in the facility.
(D) In the case of a transfer or discharge
			 that is the result of a nursing facility's failure to readmit a resident
			 following hospitalization or other medical leave of absence, if the request for
			 a hearing is received within the applicable time period, in accordance with
			 130 CMR
			 610.015(B)(5), the nursing
			 facility must, upon receipt of the appeal decision favorable to the resident,
			 promptly readmit the resident to the next available bed.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 610.000 - MassHealth: Fair Hearing Rules › Section 610.031 - Notification of the Right to Request a Hearing

Current through Register 1525, July 5, 2024
(A) Upon being notified of any appealable
			 action, the applicant or member will be informed in writing of his or her right
			 to a hearing, of the method by which a hearing may be requested, and of the
			 right to use an appeal representative (
see
130 CMR
			 610.016 ).
(B) If an applicant or member indicates
			 disagreement with an appealable action, the acting entity will provide the
			 applicant or member with an appeal form and, if requested, help complete the
			 form. The MassHealth agency may not restrict the applicant's or member's
			 freedom to request a fair hearing.
(C) If there is an individual or organization
			 that provides free legal representation, the person requesting a hearing will
			 be informed of the availability of that service.
(D) At the time that a nursing facility
			 notifies a resident that he or she is to be discharged or transferred, the
			 nursing facility must inform the resident that he or she has the right to
			 request a hearing before the MassHealth agency.
(E) At the time that DMH or DDS notifies an
			 individual of the individual's PASRR determination, the acting entity must
			 inform the individual that he or she has the right to request a hearing before
			 BOH.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 610.000 - MassHealth: Fair Hearing Rules › Section 610.032 - Grounds for Appeal

Current through Register 1525, July 5, 2024
(A) Applicants and
			 members have a right to request a fair hearing for any of the following
			 reasons:
(1) denial of an application or
			 request for assistance, or the right to apply or reapply for such
			 assistance;
(2) the failure of the
			 MassHealth agency to give timely notice of action on an application for
			 assistance in accordance with the requirements of M.G.L. c. 118E, §
			 21;
(3) any MassHealth agency
			 action to suspend, reduce, terminate, or restrict a member's
			 assistance;
(4) MassHealth agency
			 actions to recover payments for benefits to which the member was not entitled
			 at the time the benefit was received;
(5) individual MassHealth agency
			 determinations regarding scope and amount of assistance (including, but not
			 limited to, level-of-care determinations);
(6) coercive or otherwise improper conduct as
			 defined in
			 130 CMR
			 610.033 on the part of any MassHealth agency
			 employee directly involved in the applicant's or member's case;
(7) any condition of eligibility imposed by
			 the MassHealth agency for assistance or receipt of assistance that is not
			 authorized by federal or state law or regulations;
(8) the failure of the MassHealth agency to
			 act upon a request for assistance within the time limits required by MassHealth
			 regulations;
(9) the MassHealth
			 agency's determination that the member is subject to the provisions of
			 130 CMR 508.000:
MassHealth: Managed Care Requirements
;
(10) the MassHealth agency's denial of an
			 out-of-area provider under
			 130 CMR
			 508.003(A)(2);
(11) the MassHealth agency's disenrollment of
			 a member from a managed care provider under
			 130 CMR
			 508.003:
Enrollment with a MassHealth
			 Managed Care Provider
;
(12) the MassHealth agency's denial of a
			 member's request to transfer out of the member's MCO, ACPP, or Primary Care ACO
			 under
			 130 CMR
			 508.003:
Enrollment with a MassHealth
			 Managed Care Provider
;
(13) the MassHealth agency's determination to
			 enroll a member in the Controlled Substance Management Program under the
			 provisions of
			 130 CMR
			 406.442:
Controlled Substance
			 Management Program
; and
(14) the MassHealth agency's determination of
			 eligibility for low-income subsidies under Medicare Part D, as set forth in the
			 Medicare Prescription Drug and Improvement and Modernization Act of 2003 as
			 described in federal regulations at 42 CFR Part 423, Subpart P.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 610.000 - MassHealth: Fair Hearing Rules › Section 610.033 - Coercive or Otherwise Improper Conduct

Current through Register 1525, July 5, 2024
(A)
Definitions
.
(1)
			 Coercive conduct means knowingly compelling an applicant, member, or former
			 member by force, threat, intimidation, or other abuse of position to take
			 action that is injurious to his or her best interest and that he or she would
			 not otherwise have done.
(2)
			 Improper conduct means reckless and unreasonable abuse of authority that
			 interferes with the applicant's, member's, or former member's exercise of
			 rights under MassHealth.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 610.000 - MassHealth: Fair Hearing Rules › Section 610.034 - Request for a Fair Hearing

Current through Register 1525, July 5, 2024
(A) A request for a
			 fair hearing is defined as a written statement by the appellant that asks for
			 administrative review of an appealable action. The request for a fair hearing
			 must be received by BOH within the time limits set forth in
			 130 CMR
			 610.015.
(B) Any request for a fair hearing that cites
			 coercive or otherwise improper conduct on the part of a MassHealth agency
			 employee must state the name of the employee and the place, date, and nature of
			 the incident or incidents. If the request lacks the information required by 130
			 CMR 610.034, BOH will notify the appellant of the requirement. If the appellant
			 then fails to provide the information within ten days, the appeal will be
			 dismissed.