reglab/statecodes huggingface dataset:
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 504.000 - Health Care Reform: Masshealth: Citizenship And Immigration › Section 504.001 - Introduction

Current through Register 1525, July 5, 2024
Persons applying for or receiving MassHealth must verify their
				citizenship and identity or immigration status. Citizens and nationals who
				receive Supplemental Security Income (SSI), Social Security Disability
				Insurance (SSDI) based upon disability, or Medicare (including those who are
				entitled to Medicare), and children in receipt of either Title IV-B services or
				Title IV-E adoption assistance or foster care payments do not need to submit
				verification. In addition, a child born to a woman who is eligible for
				MassHealth on the date of the child's birth is exempt from providing
				citizenship and identity verification as described in
				130
				CMR
				504.004(E).
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 504.000 - Health Care Reform: Masshealth: Citizenship And Immigration › Section 504.002 - U.S. Citizens

Current through Register 1525, July 5, 2024
A citizen of the United States is
(A) an individual who was born in the United
			 States or its territories, including Puerto Rico, the Virgin Islands, Guam, and
			 the Commonwealth of the Northern Mariana Islands (CNMI), except those born to a
			 foreign diplomat, and who otherwise qualifies for U.S. citizenship under §
			 301
et seq
. of the Immigration and Nationality Act
			 (INA);
(B) an individual born of a
			 parent who is a U.S. citizen or who otherwise qualifies for U.S. citizenship
			 under § 301
et seq
. of the Immigration and Nationality
			 Act;
(C) a naturalized citizen;
			 or
(D) a national (both citizen
			 national and noncitizen national) as defined in 130 CMR 504.002(D)(1) or (2).
(1)
Citizen
			 National
. A citizen national is an individual who otherwise
			 qualifies as a U.S. citizen under § 301
et seq
. of the
			 Immigration and Nationality Act.
(2)
Noncitizen
			 National
. A noncitizen national is an individual who was born in
			 one of the outlying possessions of the United States, including American Samoa
			 and Swain's Island, to a parent who is a noncitizen national.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 504.000 - Health Care Reform: Masshealth: Citizenship And Immigration › Section 504.004 - Verification of U.S. Citizenship and Identity and Immigration Status

Current through Register 1525, July 5, 2024
(A)
U.S. Citizenship and
			 Immigration Status
. MassHealth requires verification of U.S.
			 citizenship or immigration status for all MassHealth applicants, except other
			 noncitizens.
(1) The MassHealth agency will
			 initiate electronic data matches as described in
			 130 CMR
			 502.004:
Matching
			 Information
to attempt to verify U.S. citizenship or immigration
			 status. If electronic data sources are unable to verify U.S. citizenship or
			 immigration status, additional documentation will be required from the
			 individual.
(2) Acceptable proof of
			 U.S. citizenship is described in
			 130
			 CMR 504.005(A)(1) and (2).
			 Individuals who fail to submit proof of U.S. citizenship within 90 days of the
			 MassHealth agency's request will subsequently only be
(a) eligible for Children's Medical Security
			 Plan (CMSP) if they meet the categorical requirements for CMSP described in
			 130 CMR 522.000:
MassHealth: Other Division Programs
; or
(b) eligible for MassHealth Standard for
			 those who are pregnant if they meet the categorical requirements and financial
			 standards described in
			 130 CMR
			 505.002(D):
Eligibility Requirements for Pregnant Women
.
(3) Acceptable proof of
			 immigration status is described in
			 130
			 CMR 504.005(B). Individuals
			 who fail to submit proof of immigration status within 90 days of the MassHealth
			 agency's request will subsequently be
(a)
			 eligible only for MassHealth Limited, if they meet the categorical requirements
			 and financial standards of MassHealth Standard;
(b) eligible for Children's Medical Security
			 Plan (CMSP) if they meet the categorical requirements for CMSP described in
			 130 CMR 522.000:
MassHealth: Other Division Programs
; or
(c) eligible for MassHealth Standard for
			 those who are pregnant if they meet the categorical requirements and financial
			 standards described in
			 130 CMR
			 505.002(D):
Eligibility Requirements for Pregnant Women
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 504.000 - Health Care Reform: Masshealth: Citizenship And Immigration › Section 504.005 - Documents for Verifying U.S. Citizenship and Identity and Immigration Status

Current through Register 1525, July 5, 2024
(A)
Acceptable Proof of U.S.
			 Citizenship and Identity
. Pursuant to
			 130
			 CMR 504.004(B), U.S.
			 citizens must provide proof of both citizenship and identity.
(1)
Acceptable Proof of Both
			 Citizenship and Identity
. The following documents are satisfactory
			 proof of both citizenship and identity:
(a)
			 U.S. passport, including a U.S. Passport Card issued by the Department of
			 State, without regard to any expiration date as long as such passport or Card
			 was issued without limitation;
(b)
			 Certificate of Naturalization;
(c)
			 Certificate of U.S. Citizenship; or
(d) a document issued by a federally
			 recognized Indian tribe, as published in the Federal Register by the Bureau of
			 Indian Affairs within the U.S. Department of the Interior, and identifies the
			 federally recognized Indian tribe that issued the document, identifies the
			 individual by name, and confirms the individual's membership, enrollment, or
			 affiliation with the tribe. These documents include, but are not limited to, a
			 tribal enrollment card, a Certificate of Degree of Indian Blood, a tribal
			 census document, and documents on tribal letterhead, issued under the signature
			 of the appropriate tribal official that meet the requirements of 130 CMR
			 504.005(A)(1)(d).
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 504.000 - Health Care Reform: Masshealth: Citizenship And Immigration › Section 504.006 - Applicable Coverage Types

Current through Register 1525, July 5, 2024
(A) Citizens,
			 qualified noncitizens, and protected noncitizens may receive MassHealth under
			 any coverage type if they meet the eligibility requirements described in
			 130 CMR 505.000:
Health Care Reform: MassHealth: Coverage Types
.
(B) Qualified noncitizens barred and
			 nonqualified individuals lawfully present may receive the following coverage.
(1) MassHealth Standard, if they are younger
			 than 19 years old, young adults 19 and 20 years of age, or people who are
			 pregnant and meet the categorical requirements and financial standards
			 described in
			 130 CMR
			 505.002:
MassHealth
			 Standard
; independent foster care children 18 through 20 years of age,
			 and children younger than 19 years old and young adults 19 and 20 years of age
			 who are receiving EAEDC.
(2)
			 MassHealth CommonHealth, if they are younger than 19 years old and meet the
			 categorical requirements and financial standards as described in
			 130 CMR
			 505.004:
MassHealth
			 CommonHealth
;
(3)
			 MassHealth Family Assistance, if they are children younger than 19 years old,
			 disabled adults 21 through 64 years of age and meet the categorical
			 requirements and financial standards as described in
			 130 CMR
			 505.005:
MassHealth Family
			 Assistance
or adults 21 through 64 years of age who are receiving
			 EAEDC;
(4) MassHealth Limited, if
			 they are adults 21 through 64 years of age and meet the categorical
			 requirements and financial standards as described in
			 130 CMR
			 505.006:
MassHealth Limited
;
			 and
(5) Children's Medical Security
			 Plan, if they are children younger than 19 years old and meet the categorical
			 requirements and financial standards as described in
			 130 CMR
			 522.004:
Children's Medical Security
			 Plan (CMSP)
;
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 505.000 - Health Care Reform: Masshealth: Coverage Types › Section 505.001 - Introduction

Current through Register 1525, July 5, 2024
130 CMR
				505.000 explains the categorical requirements and
				financial standards that must be met to qualify for a MassHealth coverage type.
				The rules of financial responsibility and calculation of financial eligibility
				are detailed in
				130 CMR
				506.000:
Health Care Reform: MassHealth:
				Financial Requirements
.
(A)
			 The MassHealth coverage types are the following:
(1) MassHealth Standard S for people who are
			 pregnant, children, parents and caretaker relatives, young adults, disabled
			 individuals, certain persons who are HIV positive, individuals with breast or
			 cervical cancer, independent foster care adolescents, Department of Mental
			 Health (DMH) members, and medically frail as such term is defined in
			 130
			 CMR 505.008(F);
(2) MassHealth CommonHealth - for disabled
			 adults, disabled young adults, and disabled children who are not eligible for
			 MassHealth Standard;
(3) MassHealth
			 CarePlus - for adults 21 through 64 years old who are not eligible for
			 MassHealth Standard;
(4) MassHealth
			 Family Assistance - for children, young adults, certain noncitizens and persons
			 who are HIV positive who are not eligible for MassHealth Standard, MassHealth
			 CommonHealth, or MassHealth CarePlus;
(5) MassHealth Limited - for certain lawfully
			 present immigrants as described in
			 130
			 CMR 504.003(A):
Lawfully Present Immigrants
, nonqualified PRUCOLs, and other
			 noncitizens as described in
			 130
			 CMR 504.003:
Immigrants
;
			 and
(6) MassHealth Medicare Savings
			 Programs (MSP, also called Senior Buy-in and Buy-in)-for certain Medicare
			 beneficiaries.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 505.000 - Health Care Reform: Masshealth: Coverage Types › Section 505.002 - MassHealth Standard

Current through Register 1525, July 5, 2024
(A)
Overview
.
(1)
									130
			 CMR 505.002 contains the categorical
			 requirements and financial standards for MassHealth Standard serving children,
			 young adults, parents, caretaker relatives, people who are pregnant, disabled
			 individuals, certain individuals with breast or cervical cancer, certain
			 individuals who are HIV positive, independent foster-care adolescents,
			 Department of Mental Health members, and medically frail as such term is
			 defined in
			 130
			 CMR 505.008(F).
(2) Persons who receive Supplemental Security
			 Income (SSI) benefits from the Social Security Administration (SSA) are
			 eligible for MassHealth Standard.
(3) Persons who receive Transitional Aid to
			 Families with Dependent Children (TAFDC) cash assistance from the Department of
			 Transitional Assistance (DTA) are eligible for MassHealth Standard.
(4) Children, young adults, and parents and
			 caretaker relatives who receive Emergency Aid to the Elderly, Disabled and
			 Children (EAEDC) cash assistance are eligible for MassHealth Standard if they
			 meet the citizenship and immigration requirements described at
			 130
			 CMR 504.002:
U.S. Citizens
and 130 CMR
			 504.003(A)(1):
Qualified Noncitizens
, (2):
Qualified Noncitizens
			 Barred
, and (3):
Nonqualified Individuals Lawfully
			 Present
.
(5) Persons who
			 do not otherwise meet the requirements of
			 130
			 CMR 505.002, but who meet the AFDC rules that
			 were in effect on July 16, 1996, are eligible for MassHealth
			 Standard.
(6) Persons eligible for
			 MassHealth Standard coverage are eligible for medical benefits as described at
			 130
			 CMR 450.105(A):
MassHealth Standard
and
			 130 CMR
			 508.000:
MassHealth: Managed Care
			 Requirements
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 505.000 - Health Care Reform: Masshealth: Coverage Types › Section 505.004 - MassHealth CommonHealth

Current through Register 1525, July 5, 2024
(A)
Overview
.
(1)
									130
			 CMR 505.004 contains the categorical
			 requirements and financial standards for MassHealth CommonHealth coverage
			 available to both disabled children and disabled adults, and to disabled
			 working adults.
(2) Persons
			 eligible for MassHealth CommonHealth coverage are eligible for medical benefits
			 as described in
			 130
			 CMR 450.105(E):
MassHealth CommonHealth
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 505.000 - Health Care Reform: Masshealth: Coverage Types › Section 505.006 - MassHealth Limited

Current through Register 1525, July 5, 2024
(A)
Overview
.
			 130
			 CMR 505.006 contains the categorical
			 requirements and financial standards for MassHealth Limited coverage for
			 children, young adults, and adults 21 through 64 years old who are parents,
			 caretakers, adults, and disabled adults.
(B)
Eligibility
			 Requirements
.
(1) MassHealth
			 Limited is available to the following:
(a)
			 other noncitizens as described in
			 130
			 CMR 504.003(D):
Other Noncitizens
who are
1.
			 children younger than one year old with modified adjusted gross income of the
			 MassHealth MAGI household that is less than or equal to 200% of the federal
			 poverty level (FPL);
2. children one
			 through 18 years old with modified adjusted gross income of the MassHealth MAGI
			 household that is less than or equal to 150% of the FPL;
3. young adults 19 through 20 years old with
			 modified adjusted gross income of the MassHealth MAGI household that is less
			 than or equal to 150 % of the FPL;
4. adults 21 through 64 years old who are
			 parents, caretakers, or adults with modified adjusted gross income of the
			 MassHealth MAGI household that is less than or equal to 133% of the FPL;
			 and
5. disabled adults 21 through
			 64 years old with modified adjusted gross income of the MassHealth Disabled
			 Adult household that is less than or equal to 133% of the FPL;
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 505.000 - Health Care Reform: Masshealth: Coverage Types › Section 505.007 - Medicare Savings Program (MSP, also called Buy-In)

Current through Register 1525, July 5, 2024
Medicare Savings Program coverage is available to Medicare
				beneficiaries in accordance with
				130
				CMR 519.010:
Medicare Savings Program
				(MSP) - for Qualified Medicare Beneficiaries (QMB)
and
				130
				CMR 519.011:
Medicare Savings Program
				(MSP) - Specified Low Income Medicare Beneficiaries and Qualifying
				Individuals
. MassHealth Standard members receive this benefit under
				130
				CMR 505.002(O). MassHealth
				CommonHealth members receive this benefit in accordance with
				130
				CMR
				505.004(L).
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 505.000 - Health Care Reform: Masshealth: Coverage Types › Section 505.008 - MassHealth CarePlus

Current through Register 1525, July 5, 2024
(A)
Overview
.
(1)
									130
			 CMR 505.008 contains the categorical
			 requirements and financial standards for MassHealth CarePlus. This coverage
			 type provides coverage to adults 21 through 64 years of age.
(2) Persons eligible for MassHealth CarePlus
			 Direct Coverage are eligible for medical benefits, as described in
			 130
			 CMR 450.105(B):
MassHealth CarePlus
and
			 130 CMR
			 508.000:
Health Care Reform: MassHealth:
			 Managed Care Requirements
and must meet the following conditions.
(a) The individual is an adult 21 through 64
			 years of age.
(b) The individual is
			 a citizen, as described in
			 130
			 CMR 504.002:
U.S. Citizens
,
			 or a qualified noncitizen, as described in
			 130
			 CMR 504.003(A)(1):
Qualified Noncitizens
.
(c) The individual's modified adjusted gross
			 income of the MassHealth MAGI household is less than or equal to 133% of the
			 federal poverty level.
(d) The
			 individual is ineligible for MassHealth Standard.
(e) The adult complies with
			 130
			 CMR 505.008(C).
(f) The individual is not enrolled in or
			 eligible for Medicare Parts A or B.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 506.000 - Health Care Reform: MassHealth: Financial Requirements › Section 506.001 - Introduction

Current through Register 1525, July 5, 2024
(A) 130 CMR 506.000 describes the rules
			 governing financial eligibility for MassHealth. Financial eligibility includes
			 household composition, countable income, deductibles, calculation of premiums,
			 and copayments for all coverage types described in 130 CMR 505.000:
Coverage Types
.
(B) Financial eligibility for MassHealth
			 Medicare Savings Programs is determined in accordance with
			 130
			 CMR 519.010:
Medicare Savings Program
			 (MSP)
-
Qualified Medicare Beneficiaries (QMB)
,
			 130
			 CMR 519.011:
Medicare Savings Program
			 (MSP)
-
Specified Low Income Medicare Beneficiaries and
			 Qualifying Individuals
, and 130 CMR 520.000:
Financial
			 Eligibility
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 506.000 - Health Care Reform: MassHealth: Financial Requirements › Section 506.002 - Household Composition

Current through Register 1525, July 5, 2024
(A)
Determination of Household Composition
. MassHealth
			 determines household size at the individual member level. MassHealth determines
			 household composition in two ways.
(1)
MassHealth Modified Adjusted Gross Income (MAGI) Household
			 Composition
. MassHealth uses the MassHealth MAGI household
			 composition rules to determine member eligibility for the following benefits:
(a) MassHealth Standard, as described in
			 130
			 CMR 505.002(B), (C), (D), (F), and
			 (G);
(b) MassHealth Common Health, as described in
			 130
			 CMR 505.004(F) and
			 (G);
(c) MassHealth Care Plus, as described in
			 130
			 CMR 505.008:
MassHealth Care
			 Plus
;
(d) MassHealth
			 Family Assistance, as described in
			 130
			 CMR 505.005(B) through
			 (E);
(e) MassHealth Limited, as described in
			 130
			 CMR 505.006:
MassHealth
			 Limited
; and
(f) Children's
			 Medical Security Plan (CMSP), as described in
			 130
			 CMR 522.004:
Children's Medical
			 Security Plan (CMSP)
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 506.000 - Health Care Reform: MassHealth: Financial Requirements › Section 506.003 - Countable Household Income

Current through Register 1525, July 5, 2024
Countable household income includes earned income described in
				130
				CMR 506.003(A)  and unearned
				income described in
				130
				CMR 506.003(B), less
				deductions described in
				130
				CMR 506.003(D).
(A)
Earned Income
.
(1) Earned income is the total amount of
			 taxable compensation received for work or services performed less pretax
			 deductions. Earned income may include wages, salaries, tips, commissions, and
			 bonuses.
(2) Earned taxable income
			 for the self-employed is the total amount of taxable annual income from
			 self-employment after deducting annual business expenses listed or allowable on
			 a U.S. Individual Tax Return. Self-employment income may be a profit or a
			 loss
(3) Earned income from
			 S-Corporations or Partnerships is the total amount of taxable annual profit (or
			 loss) after deducting business expenses listed or allowable on a U.S.
			 Individual Tax Return.
(4) Seasonal
			 income or other reasonably predictable future income is taxable income derived
			 from an income source that may fluctuate during the year. Annual gross taxable
			 income is divided by 12 to obtain a monthly taxable gross income with the
			 following exception: if the applicant or member has a disabling illness or
			 accident during or after the seasonal employment or other reasonably
			 predictable future income period that prevents the person's continued or future
			 employment, only current taxable income will be considered in the eligibility
			 determination.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 506.000 - Health Care Reform: MassHealth: Financial Requirements › Section 506.004 - Noncountable Household Income

Current through Register 1525, July 5, 2024
Because of state or federal law the following types of income
				are noncountable in the determination of eligibility for individuals described
				at 130 CMR 506.002. Changes to
				state or federal law may affect whether the following remains
				noncountable:
(A) TAFDC, EAEDC, or SSI
			 income;
(B) federal veteran
			 benefits that are not taxable in accordance with IRS rules;
(C) income-in-kind;
(D) roomer and boarder income derived from
			 persons residing in the applicant's or member's principal place of
			 residence;
(E) most workers'
			 compensation income;
(F) pretax
			 contributions to salary reduction plans for payment of dependent care,
			 transportation, and certain health expenses within allowable limits;
(G) child support received;
(H) alimony payments under separation or
			 divorce agreements finalized after December 31, 2018, or pre-existing
			 agreements modified after December 31, 2018. For individuals with alimony
			 agreements finalized on or before December 31,2018, alimony continues to be
			 included in the income of the recipient for the duration of the agreement
			 unless or until the agreement is modified;
(I) taxable amounts received as a lump sum,
			 except those sums that are counted in the month received; in the case of
			 lottery or gambling winnings, those sums that are counted in the month or
			 months required under federal law, including the Tax Cut and Jobs Act of 2017,
			 Public Law
			 115-97;
(J) money received for acting as a Parent
			 Mentor as defined under section 1397 mm(f)(5) of chapter 42 of the United
			 States Code of the Social Security Act;
(K) income received by independent
			 foster-care adolescents described at
			 130
			 CMR 505.002(H):
Eligibility Requirements for Former Foster-care
			 Individuals
;
(L) income
			 from children and tax dependents who are not expected to be required to file a
			 tax return under
Internal Revenue Code
, U.S.C. Title 26,
			 § 6012(a)(1) for the taxable year in which eligibility for MassHealth is
			 being determined, whether or not the children or the tax dependents files a tax
			 return; and
(M) any other income
			 that is excluded by federal laws other than the Social Security Act.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 506.000 - Health Care Reform: MassHealth: Financial Requirements › Section 506.005 - Verification of Income

Current through Register 1525, July 5, 2024
Verification of income is mandatory. Income may be verified
				either through electronic data matches or paper verification.
(A)
Electronic Data
			 Matches
.
(1)
Data
			 Matches
. MassHealth electronically matches with federal and state
			 data sources described in
			 130
			 CMR 502.004:
Matching
			 Information
to verify attested income.
(2)
Reasonable
			 Compatibility
. The income data received through an electronic data
			 match is compared to the attested income amount to determine if the attested
			 amount and the data source amount are reasonably compatible. If these amounts
			 are reasonably compatible, the attested income is considered verified for
			 purposes of an eligibility determination. To be considered reasonably
			 compatible
(a) both the attested income and
			 the income from the data sources must be above the applicable income standard
			 for the individual; or
(b) both the
			 attested income and the income from the data sources must be at or below the
			 applicable income standard for the individual; or
(c) the attested income is at or below the
			 applicable standard and the income from the data sources is above the
			 applicable standard but their difference is 10% or less; or
(d) the attested income is above the
			 applicable standard and the income from the data sources is at or below the
			 applicable standard.
(3)
Self-attested Income
. When self-attested income is
			 reasonably compatible with the electronic data, the income amount used to
			 determine eligibility is the self-attested amount.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 506.000 - Health Care Reform: MassHealth: Financial Requirements › Section 506.006 - Transfer of Income

Current through Register 1525, July 5, 2024
All household members are required to avail themselves of all
				potential income.
(A) If the
			 MassHealth agency determines that income has been transferred for the primary
			 purpose of establishing eligibility for MassHealth, the income is counted as if
			 it were received.
(B) If the
			 MassHealth agency is unable to determine the amount of available income, the
			 family group remains ineligible until such information is made
			 available.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 506.000 - Health Care Reform: MassHealth: Financial Requirements › Section 506.007 - Calculation of Financial Eligibility

Current through Register 1525, July 5, 2024
The rules in
				130
				CMR 506.003 and
				506.004 describing countable
				income and noncountable income apply to both MassHealth MAGI households and
				MassHealth Disabled Adult households.
(A) Financial eligibility for coverage types
			 that are determined using the MassHealth MAGI household rules and the
			 MassHealth Disabled Adult household rules is determined by comparing the sum of
			 all countable income less deductions for the individual's household as
			 described in
			 130
			 CMR 506.002 with the applicable income
			 standard for the specific coverage type.
(1)
			 The MassHealth agency will construct a household as described in
			 130
			 CMR 506.002 for each individual who is
			 applying for or renewing coverage. Different households may exist within a
			 single family, depending on the family members' familial and tax relationships
			 to each other.
(2) Once the
			 individual's household is established, financial eligibility is determined by
			 using the total of all countable monthly income for each person in that
			 individual's MassHealth MAGI or Disabled Adult household. Income of all the
			 household members forms the basis for establishing an individual's eligibility.
(a) A household's countable income is the sum
			 of the MAGI-based income of every individual included in the individual's
			 household with the exception of children and tax dependents who are not
			 expected to be required to file a return as described in
			 42 CFR
			 435.603 and
			 130
			 CMR 506.004(M).
(b) Countable income includes earned income
			 described in
			 130
			 CMR 506.003(A)  and unearned
			 income described in
			 130
			 CMR 506.003(B)  less
			 deductions described in
			 130
			 CMR 506.003(D).
(c) In determining monthly income, the
			 MassHealth agency multiplies average weekly income by 4.333.
(3) Five percentage points of the
			 current federal poverty level (FPL) is subtracted from the applicable household
			 total countable income to determine eligibility of the individual under the
			 coverage type with the highest income standard.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 506.000 - Health Care Reform: MassHealth: Financial Requirements › Section 506.008 - Cost-of-living Adjustment (COLA) Protections

Current through Register 1525, July 5, 2024
Applicants and members whose income increases each January as
				the result of a cost-of-living adjustment (COLA) will have their eligibility
				determined using their social security income just before the COLA, if such
				income can be verified, until the subsequent federal poverty level
				adjustment.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 506.000 - Health Care Reform: MassHealth: Financial Requirements › Section 506.009 - The One-time Deductible

Current through Register 1525, July 5, 2024
(A)
Eligibility Requirements
. Disabled adults described in
			 130
			 CMR 505.004(C)(5)(a)  and
			 disabled young adults described in
			 130
			 CMR 505.004(E)(3)(a)1. may
			 establish eligibility for MassHealth CommonHealth by meeting a one-time-only
			 deductible. Once a deductible has been met, the person may be assessed a
			 premium in accordance with the premium schedule in
			 130
			 CMR 506.011(B)(2). Once the
			 deductible has been met, the person is not required to meet another deductible
			 if there is a lapse in CommonHealth coverage.
(B)
Definition of the
			 Deductible
. The deductible is the total dollar amount of incurred
			 medical expenses that an applicant, whose MassHealth Disabled Adult household
			 income, as described in
			 130
			 CMR 506.003, exceeds 133% of the federal
			 poverty level (FPL), must be responsible for before MassHealth eligibility is
			 established.
(C)
The
			 Deductible Period
. The deductible period is a six-month period
			 beginning on the date established in accordance with
			 130
			 CMR 505.004(M):
Medical Coverage Date
.
(D)
Calculating the
			 Deductible
. The amount of the deductible is determined by
			 comparing the MassHealth Disabled Adult household income as described in
			 130
			 CMR 506.003 to the MassHealth CommonHealth
			 Monthly Deductible Income Standards provided in the following chart and
			 multiplying the difference by six.
THE MASSHEALTH COMMONHEALTH
							 MONTHLY DEDUCTIBLE INCOME STANDARDS
MassHealth Disabled Adult Household
							 Size
Income
							 Standards
542
1
670
2
795
3
911
4
1036
5
1161
6
1286
7
1403
8
1528
9
1653
10
+ 133 for each additional person
(E)
Notification of the Deductible
.
(1) The applicant who has excess monthly
			 income will be informed they are currently ineligible for MassHealth, but may
			 establish eligibility by meeting the deductible. The applicant will be informed
			 in writing of the following:
(a) the
			 deductible amount; and
(b) the
			 start and end dates of the deductible period.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 506.000 - Health Care Reform: MassHealth: Financial Requirements › Section 506.010 - Verification of Medical and Remedial-care Expenses

Current through Register 1525, July 5, 2024
(A) Medical or remedial-care 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.
(B) Verifications must include all of the
			 following information:
(1) the type of service
			 provided;
(2) the name of the
			 person for whom the service was provided;
(3) the amount charged for the service
			 including the current balance; and
(4) the date of service.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 506.000 - Health Care Reform: MassHealth: Financial Requirements › Section 506.011 - MassHealth Premiums and the Children's Medical Security Plan (CMSP) Premiums

Current through Register 1525, July 5, 2024
The MassHealth agency may charge a monthly premium to
				MassHealth Standard, CommonHealth or Family Assistance members who have income
				above 150% of the federal poverty level (FPL), as provided in
				130
				CMR 506.011. The MassHealth agency may charge
				a monthly premium to members of the Children's Medical Security Plan (CMSP) who
				have incomes at or above 200% of the FPL. MassHealth and CMSP premiums amounts
				are calculated based on a member's household modified adjusted gross income
				(MAGI) and their household size as described in
				130
				CMR 506.002 and
				130
				CMR 506.003 and the premium billing family
				group (PBFG) rules as described in
				130
				CMR 506.011(A). Certain
				members are exempt from paying premiums, in accordance with
				130
				CMR 506.011(J).
(A)
Premium Billing Family
			 Groups
.
(1) Premium formula
			 calculations for MassHealth and CMSP premiums are based on premium billing
			 family groups (PBFG). A PBFG is comprised of
(a) an individual;
(b) a couple who are two persons married to
			 each other according to the rules of the Commonwealth of Massachusetts and are
			 living together; or
(c) a family
			 who live together and consist of
1. a child or
			 children younger than 19 years old, any of their children, and their
			 parents;
2. siblings younger than
			 19 years old and any of their children who live together, even if no adult
			 parent or caretaker is living in the home; or
3. a child or children younger than 19 years
			 old, any of their children, and their caretaker relative when no parent is
			 living in the home.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 506.000 - Health Care Reform: MassHealth: Financial Requirements › Section 506.012 - Premium Assistance Payments

Current through Register 1525, July 5, 2024
(A)
Coverage Types
. Premium assistance payments are
			 available to MassHealth members who are eligible for the following coverage
			 types:
(1) MassHealth Standard, as described
			 in 130 CMR 505.002:
MassHealth Standard
, with the exception of those individuals
			 described in
			 130
			 CMR
			 505.002(F)(1)(d);
(2) MassHealth Standard for Kaileigh
			 Mulligan, as described in
			 130
			 CMR 519.007:
Individuals Who Would Be
			 Institutionalized
;
(3)
			 MassHealth Common Health, as described in
			 130
			 CMR 505.004:
MassHealth Common
			 Health
;
(4) MassHealth
			 Care Plus, as described in
			 130
			 CMR 505.008:
MassHealth Care
			 Plus
;
(5) MassHealth
			 Family Assistance for HIV-positive adults and HIV-positive young adults, as
			 described in
			 130
			 CMR 505.005(E):
Eligibility Requirements for HIV-positive Individuals Who Are Citizens
			 or Qualified Noncitizens with Modified Adjusted Gross Income of the MassHealth
			 MAGI Household Greater than 133 and Less than or Equal to 200% of the Federal
			 Poverty Level
;
(6)
			 MassHealth Family Assistance for disabled adults whose Disabled Adult
			 MassHealth household income is at or below 100% of the FPL and who are
			 qualified noncitizens barred, nonqualified individuals lawfully present, and
			 nonqualified PRUCOLs, as described in
			 130
			 CMR 505.005(C):
Eligibility Requirements for Children and Young Adults Who Are
			 Nonqualified PRUCOLs with Modified Adjusted Gross Income of the MassHealth MAGI
			 Household at or below 150% of the Federal Poverty Level
;
(7) MassHealth Family Assistance for children
			 younger than 19 years old and young adults 19 through 20 years old whose
			 household MAGI is at or below 150% of the FPL and who are nonqualified PRUCOLs,
			 as described in
			 130
			 CMR 505.005(C):
Eligibility Requirements for Children and Young Adults Who Are
			 Nonqualified PRUCOLs with Modified Adjusted Gross Income of the MassHealth MAGI
			 Household at or below 150% of the Federal Poverty Level
; and
(8) MassHealth Family Assistance for children
			 younger than 19 years old whose household MAGI is between 150% and 300% of the
			 FPL and who are citizens, protected noncitizens, qualified noncitizens barred,
			 nonqualified individuals lawfully present, and nonqualified PRUCOLs, as
			 described in
			 130
			 CMR 505.005(C):
Eligibility Requirements for Children and Young Adults Who Are
			 Nonqualified PRUCOLs with Modified Adjusted Gross Income of the MassHealth MAGI
			 Household at or below 150% of the Federal Poverty Level
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 506.000 - Health Care Reform: MassHealth: Financial Requirements › Section 506.013 - MassHealth Small Business Employee (SBE) Premium Assistance Program

Current through Register 1525, July 5, 2024
(A)
Introduction
.
			 130 CMR 506.013 describes the rules and requirements for the Small Business
			 Employee (SBE) Premium Assistance Program eligibility and the payment
			 calculation for individuals who are eligible for this program, as described at
			 130 CMR
			 505.009:
MassHealth Small Business
			 Employee Premium Assistance.
(B)
Premium Assistance
			 Eligibility Criteria
. MassHealth provides a premium assistance
			 payment to eligible individuals as described at
			 130 CMR
			 505.009:
MassHealth Small Business
			 Employee Premium Assistance
if such individuals have access to an
			 employer-sponsored health insurance (ESI) that meets all of the following
			 criteria.
(1) The ESI meets the Basic Benefit
			 Level (BBL), as described at
			 130 CMR
			 501.001:
Definition of
			 Terms.
(2) The ESI policy
			 holder is in the premium billing family group (PBFG).
(3) At least one person covered by the ESI
			 policy is eligible for MassHealth SBE Premium Assistance benefits, as described
			 in
			 130 CMR
			 505.009:
MassHealth Small Business
			 Employee Premium Assistance.
(4) The ESI is from an employer that offers
			 an individual health-insurance plan to the employee for which the employee
			 contribution costs more than the Health Connector affordability schedule as
			 defined in
			 956 CMR
			 6.05:
Determining
			 Affordability
but less than 9.5% of the MassHealth MAGI
			 income.
(5) The ESI does not cover
			 any individuals who are eligible for or receiving a MassHealth premium
			 assistance payment as described in
			 130 CMR
			 506.012.
(6) Effective January 1, 2015, the ESI is a
			 small-group health insurance plan purchased by the individual's employer
			 through the Health Connector.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 506.000 - Health Care Reform: MassHealth: Financial Requirements › Section 506.016 - 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 506.015.
(A) $ 1 for each prescription and refill for
			 each generic drug and over-the-counter drug covered by the MassHealth agency 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 the MassHealth agency.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 506.000 - Health Care Reform: MassHealth: Financial Requirements › Section 506.017 - 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 506.000 - Health Care Reform: MassHealth: Financial Requirements › Section 506.018 - Maximum Cost Sharing

Current through Register 1525, July 5, 2024
Members are responsible for the 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 506.000 - Health Care Reform: MassHealth: Financial Requirements › Section 506.019 - Copayment Waiver During Federal Public Health Emergency Unwind

Current through Register 1525, July 5, 2024
Notwithstanding
				130
				CMR 506.015 through
				506.018, 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 508.000 - Masshealth: Managed Care Requirements › Section 508.001 - MassHealth Member Participation in Managed Care

Current through Register 1525, July 5, 2024
(A)
Mandatory Enrollment with a
			 MassHealth Managed Care Provider
. MassHealth members who are
			 younger than 65 years old must enroll in a MassHealth managed care provider
			 available for their coverage type. Members described in 130 CMR 508.001(B) or
			 who are excluded from participation in a MassHealth managed care provider
			 pursuant to
			 130
			 CMR 508.002(A)  are not
			 required to enroll with a MassHealth managed care provider.
(B)
Voluntary Enrollment in a
			 MassHealth Managed Care Provider
. The following MassHealth members
			 who are younger than 65 years old may, but are not required to, enroll with a
			 MassHealth managed care provider available for their coverage type:
(1) MassHealth members who are receiving
			 services from DCF or DYS;
(2)
			 MassHealth members who are enrolled in the Kaileigh Mulligan Program, described
			 in
			 130 CMR
			 519.007(A):
The
			 Kaileigh Mulligan Program
. Such members may choose to receive all
			 services on a fee-for-service basis;
(3) MassHealth members who are enrolled in a
			 home- and community-based services waiver. Such members may choose to receive
			 all services on a fee-for-service basis; or (4) MassHealth members who are
			 receiving Title IV-E adoption assistance as described at
			 130 CMR
			 522.003:
Adoption Assistance and
			 Foster Care Maintenance
. Such members may choose to receive all
			 services on a fee-for-service basis.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 508.000 - Masshealth: Managed Care Requirements › Section 508.002 - MassHealth Members Excluded from Participation in Managed Care

Current through Register 1525, July 5, 2024
(A)
MassHealth Managed Care
			 Provider
. The following MassHealth members are excluded from
			 participation with a MassHealth managed care provider:
(1) a member who has Medicare;
(2) a member who has access to other health
			 insurance that meets the basic-benefit level as defined in 130 CMR 501.001:
Definition of Terms
;
(3) a member who is 65 years of age or older.
			 Such member may voluntarily enroll in a senior care organization (SCO) in
			 accordance with the requirements at
			 130 CMR
			 508.008(A);
(4) a member in a nursing facility, chronic
			 disease or rehabilitation hospital, intermediate care facility for individuals
			 with intellectual disabilities (ICF/ID), or a state psychiatric hospital for
			 other than a short-term rehabilitative stay;
(5) a member who is eligible solely for
(a) MassHealth Limited; or
(b) Children's Medical Security Plan
			 (CMSP);
(6) a member who
			 is receiving medical services through the Emergency Aid to the Elderly,
			 Disabled and Children (EAEDC) Program pursuant to 130 CMR 450.106:
Emergency Aid to the Elderly, Disabled and Children
			 Program
;
(7) a member who
			 is receiving hospice care through MassHealth on a fee-for-service basis, or who
			 is terminally ill as documented by a medical prognosis of a life expectancy of
			 six months or less; and
(8) a
			 member who has presumptive eligibility.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 508.000 - Masshealth: Managed Care Requirements › Section 508.003 - Enrollment with a MassHealth Managed Care Provider

Current through Register 1525, July 5, 2024
(A)
Member
			 Selection
.
(1) In accordance with
			 130 CMR
			 508.004 through
			 508.006,
			 members required or permitted to select a MassHealth managed care provider may
			 select any MassHealth managed care provider from the MassHealth agency's list
			 of MassHealth managed care providers for the member's coverage type in the
			 member's service area, if the provider is able to accept new members.
(2) A member who seeks to enroll with a
			 managed care provider outside of the member's service area must submit a
			 request in writing to the MassHealth agency on forms provided by the MassHealth
			 agency. The MassHealth agency may grant such a request if the out-of-area
			 MassHealth managed care provider is in a service area contiguous to the
			 member's service area and the MassHealth agency determines that:
(a) The out-of-area MassHealth managed care
			 provider is in a service area contiguous to the member's service area;
			 and
(b) The MassHealth agency
			 determines either of the following:
1. the
			 member seeks a specific provider who is in the network of the out-of-area
			 MassHealth managed care provider, such requested provider is not in the network
			 of a MassHealth managed care provider in the member's service area, and the
			 travel time or distance to such requested provider is equal to or less than the
			 travel time to, as determined by the MassHealth agency, a comparable provider
			 in the network of a MassHealth managed care provider in the member's service
			 area; or
2. the medical benefit of
			 receiving care from a MassHealth managed care provider in the member's service
			 area is substantially outweighed, as determined by the MassHealth agency, by
			 the medical benefit of receiving care from the out-of-area MassHealth managed
			 care provider requested by the member.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 508.000 - Masshealth: Managed Care Requirements › Section 508.004 - Managed Care Organizations (MCOs)

Current through Register 1525, July 5, 2024
(A)
Enrollment in an MCO
.
(1)
Selection
			 Procedure
. When a member becomes eligible for managed care, the
			 MassHealth agency notifies the member of the member's obligation to select a
			 MassHealth managed care provider within the time period specified by the
			 MassHealth agency. The MassHealth agency makes available to the member a list
			 of the MCOs in the member's service area. The list of MCOs that the MassHealth
			 agency will make available to members will include those MCOs that contract
			 with the MassHealth agency to serve the coverage type for which the member is
			 eligible and provide services within the member's service area. The member's
			 service area is determined by the MassHealth agency based on zip codes or
			 geographic area. Service area listings may be obtained from the MassHealth
			 agency.
(2) MassHealth members
			 assigned to MCOs, may transfer from MCOs, may be disenrolled from MCOs, and may
			 be re-enrolled in MCOs as described in
			 130 CMR
			 508.003(B)  through
			 130 CMR
			 508.003(E).
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 508.000 - Masshealth: Managed Care Requirements › Section 508.005 - MassHealth Primary Care Clinician Plan (PCC Plan)

Current through Register 1525, July 5, 2024
(A)
Enrollment in the PCC
			 Plan
.
(1)
Selection
			 Procedure
. When a member becomes eligible for managed care, the
			 MassHealth agency notifies the member of the member's obligation to select a
			 MassHealth managed care provider within the time period specified by the
			 MassHealth agency. To enroll in the PCC Plan, the member must select the PCC
			 Plan and an available primary care clinician (PCC). The MassHealth agency makes
			 available to the member a list of the PCCs in the member's service area. The
			 member's service area is determined by the MassHealth agency based on zip codes
			 or geographic area. Service area listings may be obtained from the MassHealth
			 agency. The list of PCCs that the MassHealth agency will make available to
			 members may include those approved as a PCC by MassHealth in accordance with
			 130 CMR
			 450.118:
Primary Care Clinician (PCC)
			 Plan
and who practices within the member's service area.
(2) MassHealth members assigned to the PCC
			 Plan, may transfer from the PCC Plan, may be disenrolled from a PCC's panel,
			 and may be re-enrolled in the PCC Plan as described in
			 130 CMR
			 508.003(B)  through
			 130 CMR
			 508.003(E).