reglab/statecodes huggingface dataset:
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 508.000 - Masshealth: Managed Care Requirements › Section 508.006 - Accountable Care Organizations (ACOs)

Current through Register 1525, July 5, 2024
(A)
Accountable Care Partnership Plans
.
(1)
Enrollment in an Accountable
			 Care Partnership Plan
.
(a)
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 Accountable Care Partnership Plans in the member's service
			 area. The list of Accountable Care Partnership Plans that the MassHealth agency
			 will make available to members will include those Accountable Care Partnership
			 Plans 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.
(b) MassHealth
			 members are assigned to Accountable Care Partnership Plans, may transfer from
			 Accountable Care Partnership Plans, may be disenrolled from Accountable Care
			 Partnership Plans, and may be re-enrolled in Accountable Care Partnership Plans
			 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 508.007 - Integrated Care Organizations

Current through Register 1525, July 5, 2024
(A)
Eligibility
.
(1) In
			 order to be eligible to enroll in an integrated care organization (ICO), a
			 MassHealth member must meet all of the following criteria, and may not be
			 enrolled or concurrently participate in any of the programs or plans listed in
			 130 CMR
			 508.007(F):
(a) be 21 through 64 years of age at the time
			 of enrollment;
(b) be eligible for
			 MassHealth Standard as defined in
			 130 CMR
			 450.105(A):
MassHealth Standard
or MassHealth CommonHealth as defined in
			 130 CMR
			 450.105(E):
MassHealth CommonHealth
;
(c) be enrolled in Medicare Parts A and B, be
			 eligible for Medicare Part D, and have no other health insurance that meets the
			 basic-benefit level as defined in 130 CMR 501.001:
Definition of
			 Terms
; and
(d) live in a
			 designated service area of an ICO.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 508.000 - Masshealth: Managed Care Requirements › Section 508.008 - Senior Care Organizations

Current through Register 1525, July 5, 2024
(A)
Enrollment Requirements
. In order to voluntarily
			 enroll in a senior care organization, a MassHealth Standard member must meet
			 all of the following criteria:
(1) be 65 years
			 of age or older;
(2) live in a
			 designated service area of a senior care organization;
(3) not be diagnosed as having end-stage
			 renal disease;
(4) not be subject
			 to a six-month deductible period under
			 130 CMR
			 520.028:
Eligibility for a
			 Deductible
;
(5) not be a
			 resident of an intermediate care facility for individuals with intellectual
			 disabilities (ICF/ID); and
(6) not
			 be an inpatient in a chronic or rehabilitation hospital.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 508.000 - Masshealth: Managed Care Requirements › Section 508.009 - Behavioral Health Contractor

Current through Register 1525, July 5, 2024
The following applies to MassHealth members who are not in the
				PCC Plan or a Primary Care ACO and who receive behavioral health services
				through MassHealth's behavioral health contractor. (
See
130 CMR
				508.001(E).)
(A)
Nonemergency Behavioral
			 Health Services
. Behavioral health services, except for emergency
			 services and those services not covered under the MassHealth contract with the
			 behavioral health contractor, may be obtained only from a provider that has
			 entered into an agreement with the MassHealth behavioral health contractor. The
			 MassHealth behavioral health contractor is responsible for authorizing or
			 denying those behavioral health services based on the member's medical need for
			 those services.
(B)
Emergency Behavioral Health Services
. Members may
			 obtain emergency behavioral health services from any qualified participating
			 MassHealth provider as well as any provider that has entered into an agreement
			 with the MassHealth behavioral health contractor.
(C)
Copayments
.
			 Members enrolled in the MassHealth behavioral health contractor must make
			 copayments in accordance with the MassHealth behavioral health contractor's
			 MassHealth copayment policy. Those MassHealth behavioral health contractor
			 copayment policies must
(1) be approved by
			 MassHealth;
(2) exclude the persons
			 and services listed in
			 130 CMR
			 506.014:
Copayments Required by
			 MassHealth
and 520.037:
Copayment and Cost Sharing Requirement
			 Exclusions
;
(3) not exceed
			 the MassHealth copayment amounts set forth in
			 130 CMR
			 506.015:
Copayment and Cost Sharing
			 Requirement Exclusions
and 520.038:
Services Subject to
			 Copayments
; and
(4)
			 include the copayment maximums set forth in
			 130 CMR
			 506.018:
Maximum Cost
			 Sharing
and 520.040:
Maximum Cost Sharing
.
			 (
See
also
			 130 CMR
			 450.130:
Copayments Required by the
			 MassHealth Agency
.)
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 508.000 - Masshealth: Managed Care Requirements › Section 508.010 - Right to a Fair Hearing

Current through Register 1525, July 5, 2024
Members are entitled to a fair hearing under
				130 CMR 610.000:
MassHealth: Fair Hearing Rules
to appeal
(A) the MassHealth agency's determination
			 that the MassHealth member is required to enroll with a MassHealth managed care
			 provider under
			 130 CMR
			 508.001;
(B) a determination by the MassHealth
			 behavioral health contractor, by one of the MCOs, Accountable Care Partnership
			 Plans, or SCOs as further described in
			 130 CMR
			 610.032(B), if the member
			 has exhausted all remedies available through the contractor's internal appeals
			 process;
(C) the MassHealth
			 agency's disenrollment of a member under
			 130 CMR
			 508.003(D)(1), (D)(2)(a), or
			 (D)(2)(b), or discharge of a member from a
			 SCO under
			 130 CMR
			 508.008(E); or
(D) the MassHealth agency's determination
			 that the requirements for a member transfer under
			 130 CMR
			 508.003(C)(3)  have not been
			 met.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 508.000 - Masshealth: Managed Care Requirements › Section 508.011 - Timely Notice of Appealable Actions

Current through Register 1525, July 5, 2024
(A)
			 Whenever an MCO, Accountable Care Partnership Plan, SCO, ICO, or the behavioral
			 health contractor reaches a decision that constitutes an appealable action, as
			 described in
			 130 CMR
			 610.032(B), it must send a
			 notice to the member within the following time frames that describes its
			 decision and its internal appeal procedures:
(1) for a standard service authorization
			 decision to deny or provide limited authorization for a requested service, no
			 later than 14 days following receipt of the request for service, unless the
			 time frame is extended up to 14 additional days because the member or a
			 provider requested the extension or the MCO, Accountable Care Partnership Plan,
			 SCO, and ICO, or behavioral health contractor can demonstrate a need for
			 additional information and how the extension is in the member's
			 interest;
(2) for an expedited
			 service decision to deny or provide limited authorization for a requested
			 service, where a provider requests, or an MCO, Accountable Care Partnership
			 Plan, SCO, ICO, or behavioral health contractor determines, that following the
			 standard time frame in 130 CMR 508.011(A) could seriously jeopardize the
			 member's life or health or ability to attain, maintain, or regain maximum
			 function, no later than three business days after receipt of the request for
			 service, unless the time frame is extended up to 14 additional calendar days
			 because the member requested the extension or the MCO, Accountable Care
			 Partnership Plan, SCO, ICO, or behavioral health contractor can demonstrate a
			 need for additional information and how the extension is in the member's
			 interest;
(3) for termination,
			 suspension, or reduction of a previous authorization for a service, at least
			 ten days before the action, except as provided in
			 42 CFR
			 431.213; and
(4) for denial of payment where coverage of
			 the requested service is at issue, on the day of the payment denial, except
			 that no notice is necessary for procedural denials, which include, but are not
			 limited to, the following:
(a) failure to
			 follow the MCO, Accountable Care Partnership Plan, SCO, ICO, or behavioral
			 health contractor's prior authorization procedures;
(b) failure to follow referral rules;
			 and
(c) failure to file a timely
			 claim.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 508.000 - Masshealth: Managed Care Requirements › Section 508.012 - Time Limits for Resolving Internal Appeals

Current through Register 1525, July 5, 2024
(A)
			 MCOs, Accountable Care Partnership Plans, SCOs, ICOs, and the behavioral health
			 contractor must resolve standard internal appeals within 30 days after
			 receiving the appeal, including any extensions pursuant to 130 CMR
			 508.012(C).
(B) Where the provider
			 requests an expedited appeal or the MCO, Accountable Care Partnership Plan,
			 SCO, ICO, or behavioral health contractor determines (for a request from the
			 member) that following the standard time frame could seriously jeopardize the
			 member's life or health or ability to attain, maintain, or regain maximum
			 function, the MCO, Accountable Care Partnership Plan, SCO, ICO, or the
			 behavioral health contractor must resolve the internal appeal on an expedited
			 basis within 72 hours after receiving the appeal, unless the time frames are
			 extended by up to 14 days pursuant to 130 CMR 508.012(C), in which event the
			 MCO, Accountable Care Partnership Plan, SCO, ICO, or behavioral health
			 contractor must resolve the appeal within 17 days after receiving the appeal.
			 If the MCO, Accountable Care Partnership Plan, SCO, ICO, or behavioral health
			 contractor denies a member's request for expedited resolution of an internal
			 appeal, the MCO, Accountable Care Partnership Plan, SCO, ICO, or behavioral
			 health contractor must resolve the appeal in accordance with the time frames in
			 130 CMR 508.012(A) and must make reasonable efforts to give the member prompt,
			 oral notice of the denial and follow up within two calendar days with a written
			 notice. The MCO, Accountable Care Partnership Plan, SCO, ICO, or behavioral
			 health contractor cannot deny a provider's request (on the member's behalf)
			 that an internal appeal be expedited.
(C) MCOs, Accountable Care Partnership Plans,
			 SCOs, ICOs, and the behavioral health contractor may extend the time frame for
			 resolving internal appeals under the following circumstances, provided that, if
			 the MCO, Accountable Care Partnership Plan, SCO, ICO, or the behavioral health
			 contractor extends the time frame, it must give the member written notice of
			 the reason for the extension:
(1) the member
			 requested the extension;
(2) the
			 MCO, Accountable Care Partnership Plan, SCO or the behavioral health contractor
			 showed (to the MassHealth agency's satisfaction) that there is a need for
			 additional information and how the extension is in the member's interest;
			 or
(3) the ICO showed (to the
			 satisfaction of the MassHealth agency and the Centers for Medicare and Medicaid
			 Services (CMS) that there is a need for additional information and how the
			 extension is in the member's interest.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 508.000 - Masshealth: Managed Care Requirements › Section 508.013 - Timely Notice of Internal Appeal Decisions

Current through Register 1525, July 5, 2024
(A)
			 MCOs, Accountable Care Partnership Plans, SCOs, ICOs, and the behavioral health
			 contractor must provide notice of an internal appeal decision concerning an
			 appealable action, as described in
			 130 CMR
			 610.032(B), within the
			 timeframes described in
			 130 CMR
			 508.012.
(B) Notice from an MCO, an Accountable Care
			 Partnership Plan, a SCO, an ICO, or the behavioral health contractor concerning
			 an internal appeal must be in writing and, for an expedited internal appeal,
			 reasonable efforts must be made to provide oral notice.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 515.000 - Masshealth: General Policies › Section 515.002 - Introduction to MassHealth

Current through Register 1525, July 5, 2024
(A) The MassHealth
			 agency is responsible for the administration and delivery of health-care
			 services to low- and moderate-income individuals and couples.
(B)
								130 CMR
			 515.000 through
			 522.000:
Other
			 Division Programs
provide the MassHealth requirements for persons who
			 are institutionalized, 65 years of age or older, or who would be
			 institutionalized without community-based services in accordance with all
			 applicable laws, including Title XIX of the Social Security Act.
(C)
								130 CMR
			 501.000:
Health Care Reform: MassHealth:
			 General Policies
through 508.000:
Health Care Reform:
			 MassHealth: Managed Care Requirements
provide the MassHealth
			 requirements for children, young adults, parents and caretaker relatives,
			 adults, pregnant women, disabled persons, persons who are HIV positive,
			 individuals with breast or cervical cancer, and certain other individuals or
			 couples who are younger than 65 years old and not institutionalized. These
			 requirements are prescribed in accordance with all applicable laws, including
			 Title XIX and Title XXI of the Social Security Act and MassHealth's 1115
			 Medicaid Research and Demonstration Waiver.
(D) The MassHealth agency will determine
			 eligibility for low-income subsidies under Medicare Part D, as set forth in the
			 Medicare Prescription Drug and Improvement and Modernization Act of 2003 and as
			 described at 20 CFR Part 418.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 515.000 - Masshealth: General Policies › Section 515.003 - MassHealth Coverage Types

Current through Register 1525, July 5, 2024
(A) The
			 MassHealth agency provides access to health care by determining eligibility for
			 the coverage type that provides the most comprehensive benefits for a person
			 who may be eligible. Generally, members are provided services on a
			 fee-for-service basis as defined at
			 130
			 CMR 515.001.
(B) The MassHealth agency offers the
			 following types of coverage: MassHealth Standard, MassHealth Family Assistance,
			 MassHealth Limited, MassHealth Senior Buy-in, and MassHealth Buy-in. The type
			 of coverage for which a person is eligible is based on the person's and the
			 spouse's income and assets, as described in
			 130 CMR
			 519.000:
MassHealth: Coverage Types
and 520.000:
MassHealth: Financial Eligibility
, and
			 immigration status, as described in
			 130 CMR
			 518.000:
MassHealth: Citizenship and
			 Immigration
.
(C) The
			 MassHealth agency may limit the number of people who can be enrolled in
			 MassHealth Family Assistance. When the MassHealth agency imposes such a limit,
			 no new applicants 65 years of age or older who are subject to these limitations
			 will be added to MassHealth Family Assistance, and current MassHealth Family
			 Assistance members who have lost eligibility for more than 30 days for any
			 reason will not be allowed to reenroll until the MassHealth agency is able to
			 reopen enrollment for adults.
(1) Applicants
			 who cannot be enrolled under MassHealth Family Assistance pursuant to
			 130
			 CMR 515.003(C), will be
			 placed on a waiting list when their eligibility has been determined. When the
			 MassHealth agency is able to open enrollment for adult applicants, the
			 applications will be processed in the order they were placed on the waiting
			 list.
(2) Medical coverage for
			 MassHealth Family Assistance for persons enrolled from a waiting list will
			 begin on the date that the application or new determination is processed from
			 the waiting list.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 515.000 - Masshealth: General Policies › Section 515.004 - Administration of MassHealth

Current through Register 1525, July 5, 2024
(A)
MassHealth
. The MassHealth agency formulates
			 requirements and determines eligibility for all MassHealth coverage
			 types.
(B)
Other
			 Agencies
.
(1)
Department of Transitional Assistance (DTA)
.
(a) The Department of Transitional Assistance
			 administers the Transitional Aid to Families with Dependent Children (TAFDC)
			 Program. Persons who meet the requirements of § 1931 of Title XIX
			 (42 U.S.C. §
											1396u-1) are automatically eligible for
			 MassHealth Standard coverage.
(b)
			 DTA also administers the Emergency Aid to the Elderly, Disabled and Children
			 (EAEDC) Program. MassHealth provides coverage to those persons receiving EAEDC
			 cash assistance as follows:
1. MassHealth
			 Standard: children younger than 19 years old, young adults 19 and 20 years old
			 who are citizens, qualified noncitizens, qualified noncitizens barred, and
			 nonqualified individuals lawfully present, parents and caretakers who are
			 citizens or qualified noncitizens, and elders 65 years of age or older who are
			 citizens or qualified noncitizens;
2. Mass Health Care Plus: adults 21 through
			 64 years of age who are citizens or qualified noncitizens; and
3. MassHealth Family Assistance: children
			 younger than 19 years old, young adults 19 and 20 years of age who are
			 nonqualified persons living under color of law (PRUCOLs), parents and
			 caretakers who are qualified noncitizens barred, nonqualified individuals
			 lawfully present, nonqualified PRUCOLs, adults 21 through 64 years of age, and
			 elders 65 years of age or older who are qualified noncitizens barred,
			 nonqualified individuals lawfully present, and nonqualified PRUCOLs.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 515.000 - Masshealth: General Policies › Section 515.007 - Rights of Applicants and Members

Current through Register 1525, July 5, 2024
The policies of the MassHealth agency are administered in
				accordance with federal and state law. Applicants and members must be informed
				of their rights and responsibilities with respect to MassHealth.
(A)
Right to Nondiscrimination
			 and Equal Treatment
. The MassHealth agency does not discriminate
			 on the basis of race, color, sex, sexual orientation, religion, national
			 origin, disability, or age in admission or access to, or treatment or
			 employment in, its programs or activities. Grievance procedures for resolution
			 of discrimination complaints are administered and applied by the MassHealth
			 agency's Affirmative Action Office.
(B)
Right to
			 Confidentiality
. The confidentiality of information obtained by
			 the MassHealth agency during the MassHealth eligibility process is protected in
			 accordance with federal and state regulations. The use and disclosure of
			 information concerning applicants, members, and legally liable third parties is
			 restricted to purposes directly connected to the administration of MassHealth
			 as governed by state and federal law.
(C)
Right to Timely Provision of
			 Benefits
. Eligible applicants and members have the right to the
			 timely provision of benefits, as defined in
			 130 CMR
			 516.000:
MassHealth: The Eligibility
			 Process
.
(D)
Right to Information
. Persons who inquire about
			 MassHealth, either orally or through a written request, have the right to
			 receive information about medical benefits, coverage type requirements, and
			 their rights and responsibilities as applicants and members of
			 MassHealth.
(E)
Right
			 to Apply
. Any person, individually or through an authorized
			 representative, has the right, and must be afforded the opportunity without
			 delay, to apply for MassHealth.
(F)
Right to Be Assisted by Others
.
(1) The applicant or member has the right to
			 be accompanied by an appeal representative during the appeal process.
(2) An application for MassHealth may be
			 filed by an authorized representative, including on behalf of a deceased
			 person.
(3) An appeal of a
			 MassHealth decision, including one brought on behalf of a deceased person, may
			 be filed by an appeal representative, as defined in
			 130
			 CMR 515.001.
(4) The extent of the authorized
			 representative's and appeal representative's authority to act on behalf of the
			 applicant or member is determined by the applicant or member's delegation of
			 authority, applicable law, or underlying legal document.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 515.000 - Masshealth: General Policies › Section 515.008 - Responsibilities of Applicants and Members

Current through Register 1525, July 5, 2024
(A)
Responsibility to Cooperate
. The applicant or member
			 must cooperate with the MassHealth agency in providing information necessary to
			 establish and maintain eligibility, and must comply with all the rules and
			 regulations of MassHealth, including recovery and obtaining or maintaining
			 other health insurance.
(B)
Responsibility to Report Changes
. The applicant or
			 member must report to the MassHealth agency, within ten days or as soon as
			 possible, changes that may affect eligibility. Such changes include, but are
			 not limited to, income, assets, inheritances, gifts, transfers of and proceeds
			 from the sale of real or personal property, distributions from or transfers
			 into trusts, address, availability of health insurance, immigration status, and
			 third-party liability.
(C)
Cooperation with Quality Control
. The Quality Control
			 Division periodically conducts an independent review of eligibility factors in
			 a sampling of case files. When a case file is selected for review, the member
			 must cooperate with the representative of Quality Control. Cooperation
			 includes, but is not limited to, a personal interview and the furnishing of
			 requested information. If the member does not cooperate, MassHealth benefits
			 may be terminated.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 515.000 - Masshealth: General Policies › Section 515.009 - Referrals to Investigative Units

Current through Register 1525, July 5, 2024
Intentional false statements or fraudulent acts made in
				connection with obtaining medical benefits or payments under MassHealth are
				punishable under M.G.L. c. 118E, § 39 by fines, imprisonment, or both. In
				all cases of suspected fraud, MassHealth agency staff will make a referral to
				the Bureau of Special Investigations, or other appropriate
				agencies.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 515.000 - Masshealth: General Policies › Section 515.010 - Recovery of Overpayment of Medical Benefits

Current through Register 1525, July 5, 2024
The MassHealth agency has the right to recover payment of
				medical benefits to which the member was not entitled at the time the benefit
				was received, regardless of who was responsible and whether or not there was
				fraudulent intent. No provision under
				130
				CMR 515.010 will limit the MassHealth
				agency's right to recover overpayments.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 515.000 - Masshealth: General Policies › Section 515.011 - Estate Recovery

Current through Register 1525, July 5, 2024
(A)
Introduction
.
(1) The
			 MassHealth agency will recover the amount of payment for medical benefits
			 correctly paid from the estate of a deceased member. Recovery is limited to
			 payment for all services provided
(a) while
			 the member was 65 years of age or older, except on or after October 1, 1993,
			 while the member was 55 years of age or older; and
(b) on or after March 22, 1991, while the
			 member, regardless of age, was institutionalized, and the MassHealth agency
			 determined that the member could not reasonably be expected to return
			 home.
(c) Effective for dates of
			 death on or after December 31, 2016, MassHealth will offset the estate recovery
			 claim by the total of any premiums paid to the MassHealth agency on behalf of
			 the member when the member was 55 years of age or older.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 515.000 - Masshealth: General Policies › Section 515.012 - Real Estate Liens

Current through Register 1525, July 5, 2024
(A)
Liens
. A real estate lien enables the MassHealth
			 agency to recover the cost of medical benefits paid or to be paid on behalf of
			 a member. Before the death of a member, the MassHealth agency will place a lien
			 against any property in which the member has a legal interest, subject to the
			 following conditions:
(1) per court order or
			 judgment; or
(2) without a court
			 order or judgment, if all of the following requirements are met:
(a) the member is an inpatient receiving
			 long-term or chronic care in a nursing facility or other medical
			 institution;
(b) none of the
			 following relatives lives in the property:
1.
			 a spouse;
2. a child younger than
			 21 years old, or a blind or permanently and totally disabled child;
			 or
3. a sibling who has a legal
			 interest in the property and has been living in the house for at least one year
			 before the member's admission to the medical institution;
(c) the MassHealth agency determines that the
			 member cannot reasonably be expected to be discharged from the medical
			 institution and return home; and
(d) the member has received notice of the
			 MassHealth determination that the above conditions have been met and that a
			 lien will be placed. The notice includes the member's right to a fair
			 hearing.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 515.000 - Masshealth: General Policies › Section 515.013 - Voter Registration

Current through Register 1525, July 5, 2024
(A) Voter
			 registration forms are available through the MassHealth agency to applicants
			 and members who are:
(1) U.S. citizens;
			 and
(2) 18 years of age or older,
			 or who will be 18 years old on or before the date of the next election, in
			 accordance with the National Voter Registration Act of 1993.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 515.000 - Masshealth: General Policies › Section 515.014 - Long-term-care Insurance Minimum Coverage Requirements for MassHealth Exemptions

Current through Register 1525, July 5, 2024
For purposes of the financial eligibility exemption under
				130
				CMR 520.007(G)(8)(d),
				concerning treatment of the former home as an asset, and the exemption under
				130
				CMR 515.011(B)  and
				515.012(C),
				concerning repayment of assistance provided for nursing facility and other
				long-term-care services (hereafter collectively referred to as "MassHealth
				exemptions"), a long-term-care insurance policy must provide certain minimum
				coverage requirements as determined by the Division of Insurance.
(A) Under Division of Insurance regulations
			 at 211 CMR
			 65.09(1)(e)(2), to qualify
			 for the MassHealth exemptions, an individual must be a covered person under an
			 individual, group, or employment-based group policy issued on or after March
			 15, 1999, that meets the individual policy minimum standards of
			 211
			 CMR 65.05:
Minimum Standards for
			 Individual Policies
and all of the following requirements.
(1)
Scope of
			 Benefits
. The policy must cover nursing and custodial care in a
			 nursing facility licensed by the Department of Public Health.
(2)
Daily Dollar
			 Benefits
. The policy must have available benefits of at least $125
			 per coverage day in a nursing facility, except where the actual expense
			 incurred is less, regardless of whether accrued benefits are measured in terms
			 of days or dollar amount.
(3)
Nursing Facility Coverage Days: Lifetime Benefit
			 Period
. The policy must have benefits available sufficient to
			 cover at least 730 days in a nursing facility.
(4)
Elimination
			 Period
. No policy may have an elimination period (days on which
			 services are provided to an insured before the policy begins to pay benefits)
			 longer than 365 days in a nursing facility. The application of more than one
			 elimination period is not allowed, unless the insured has received no benefits
			 for a period of at least 180 consecutive days. In
lieu
of an
			 elimination period, the policy may have a deductible of no more than
			 $54,750.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 515.000 - Masshealth: General Policies › Section 515.015 - Reimbursement of Certain Out-of-Pocket Medical Expenses

Current through Register 1525, July 5, 2024
(A)
Eligibility
			 Requirements
. The following Standard coverage members are entitled
			 to reimbursement for certain medical expenses for which they paid, subject to
			 the provisions of
			 130
			 CMR 515.015:
(1) an individual who
(a) applied for Supplemental Security Income
			 (SSI);
(b) was denied SSI benefits
			 by the Social Security Administration; and
(c) had his or her initial Social Security
			 Administration denial overturned through a reconsideration process,
			 administrative hearing, appeals counsel review, federal court review, or
			 reopening under the Social Security Administration rules on administrative
			 finality; or
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 516.000 - MassHealth: The Eligibility Process › Section 516.001 - Application for Benefits

Current through Register 1525, July 5, 2024
(A)
Filing an Application
.
(1)
Application
. To
			 apply for MassHealth
(a) for an individual
			 living in the community, an individual or his or her authorized representative
			 must file a complete paper Senior Application and all required Supplements or
			 apply in person at a MassHealth Enrollment Center (MEC); or
(b) for an individual in need of
			 long-term-care services in a nursing facility, a person or his or her
			 authorized representative must file a complete paper Senior Application and
			 Supplements or apply in person at a MassHealth Enrollment Center
			 (MEC).
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 516.000 - MassHealth: The Eligibility Process › Section 516.002 - Reactivating the Application

Current through Register 1525, July 5, 2024
The MassHealth agency will reactivate the application after a
				denial of eligibility for failure to provide requested verifications.
(A) If the requested information is received
			 within 30 days of the date of denial, the date of receipt of one or more of the
			 verifications is considered the date of reapplication.
(B) The date of reapplication replaces the
			 date of the denied application. The applicant's earliest date of eligibility
			 for MassHealth is based on the date of reapplication.
(C) If the reapplication is subsequently
			 denied and not appealed, the applicant must submit a new application to pursue
			 eligibility for MassHealth. The earliest date of eligibility for MassHealth is
			 based on the date of the new application.
(D) If the denial is due to excess assets,
			 the date of reapplication is described at
			 130 CMR 520.004:
Asset Reduction
.
(E) A new application is required if a
			 reapplication is not received within 30 days from the date of denial.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 516.000 - MassHealth: The Eligibility Process › Section 516.003 - Verification of Eligibility Factors

Current through Register 1525, July 5, 2024
The MassHealth agency requires verification of eligibility
				factors including income, assets, residency, citizenship, immigration status,
				and identity as described in
				130 CMR 517.000:
MassHealth: Universal Eligibility Requirements
,
				130 CMR 518.000:
MassHealth: Citizenship and Immigration
, and
				130 CMR 520.000:
MassHealth: Financial Eligibility
.
(A)
Information
			 Matches
. The MassHealth agency initiates information matches with
			 federal and state agencies and other informational services, as described at
			 130 CMR
			 516.004, when an application is received in
			 order to verify eligibility.
(B)
Electronic Data Sources
. If electronic data sources
			 are unable to verify or are not reasonably compatible with the attested
			 information, additional documentation will be required from the
			 individual.
(C)
Request
			 for Information Notice
. If additional documentation is required,
			 including corroborative information as described at
			 130 CMR
			 516.001(B), a Request for
			 Information Notice will be sent to the applicant listing all requested
			 verifications and the deadline for submission of the requested
			 verifications.
(D)
Time
			 Standards
. The following time standards apply to the verification
			 of eligibility factors.
(1) The applicant or
			 member has 30 days from the receipt of the Request for Information Notice to
			 provide all requested verifications.
(2) If the applicant or member fails to
			 provide verification of information within 30 days of receipt of the MassHealth
			 agency's request, MassHealth coverage is denied or terminated.
(3) A new application is required if a
			 reapplication is not received within 30 days of the date of denial.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 516.000 - MassHealth: The Eligibility Process › Section 516.004 - Matching Information

Current through Register 1525, July 5, 2024
The MassHealth agency initiates information matches with other
				agencies and information sources when an application is received in order to
				update or verify eligibility. These agencies and information sources may
				include, but are not limited to, the following agencies: Federal Data Services
				Hub, the Department of Unemployment Assistance, Department of Public Health's
				Bureau of Vital Statistics, Department of Industrial Accidents, Department of
				Veterans' Services, Department of Revenue, Bureau of Special Investigations,
				Social Security Administration, Systematic Alien Verification for Entitlements,
				Department of Transitional Assistance, health insurance carriers, and banks and
				other financial institutions.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 516.000 - MassHealth: The Eligibility Process › Section 516.005 - Time Standards for Eligibility Determination

Current through Register 1525, July 5, 2024
(A)
			 For applicants who do not apply on the basis of a disability, a determination
			 of eligibility must be made within 45 days from the date of receipt of the
			 completed application. All requested information must be received within 30
			 days of the date of request.
(B)
			 For applicants who apply for MassHealth on the basis of a disability, a
			 determination of eligibility must be made within 90 days from the date of
			 receipt of the completed application, including a disability supplement, if
			 required.
(C) If the MassHealth
			 agency determines that unusual circumstances exist, the timeframes for
			 determining eligibility are extended. Unusual circumstances include delay
			 caused by the applicant, by an examining physician, or by other events beyond
			 the control of the MassHealth agency.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 516.000 - MassHealth: The Eligibility Process › Section 516.006 - Coverage Date

Current through Register 1525, July 5, 2024
(A)
Start Date of Coverage
.
(1) For individuals applying for coverage,
			 the date of coverage for MassHealth is determined by the coverage type for
			 which the applicant may be eligible.
			 130
			 CMR 519.000:
MassHealth: Coverage
			 Types
describes the rules for establishing this date.
(2) The begin date of MassHealth Standard,
			 Family Assistance, or Limited coverage may be retroactive to the first day of
			 the third calendar month before the month of application, if covered medical
			 services were received during such period, and the applicant or member would
			 have been eligible at the time services were provided. If more than one
			 application has been submitted and not denied, the begin date will be based on
			 the earliest application that is approved. Retroactive eligibility does not
			 apply to services rendered under a home-and community-based services waiver
			 provided under section 1915(c) of the Social Security Act.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 516.000 - MassHealth: The Eligibility Process › Section 516.007 - Continuing Eligibility

Current through Register 1525, July 5, 2024
(A)
Annual Renewals
. The MassHealth agency reviews
			 eligibility once every 12 months. Eligibility may also be reviewed as a result
			 of a member's changes in circumstances or a change in MassHealth eligibility
			 rules, or as a result of a member's failure to provide verification within
			 requested time frames. The MassHealth agency updates eligibility based on
			 information received as the result of such review. The MassHealth agency
			 reviews eligibility
(1) by information
			 matching with other agencies, health insurance carriers, and information
			 sources;
(2) through a written
			 update of the member's circumstances on a prescribed form;
(3) through an update of the member's
			 circumstances, in person; or
(4)
			 based on information in the member's case file.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 516.000 - MassHealth: The Eligibility Process › Section 516.008 - Notice

Current through Register 1525, July 5, 2024
(A) The MassHealth agency provides all
			 applicants and members a written notice of the eligibility determination for
			 MassHealth. The notice contains an eligibility decision for each member who has
			 requested MassHealth, and either provides information so the applicant or
			 member can determine the reason for any adverse decision or directs the
			 applicant or member to such information.
(B) The MassHealth agency also provides to
			 members notice of any changes in coverage type or patient-paid amount, or loss
			 of coverage.
(C) In addition to
			 sending notices to applicants and members, such written notices are provided to
			 the authorized representative, the institution, if authorized by the applicant
			 or member, as well as to the community spouse, as defined at
			 130 CMR
			 520.016(B)(1)(c):
Right to Appeal
. This may include, in the case of death, the
			 executor, administrator, or legal representative of the deceased individual's
			 estate.
(D) All notices provide
			 information about the right of the applicant or member to a fair hearing, with
			 the exception of asset assessments described at
			 130 CMR 520.016:
Long-term Care: Treatment of Assets
and notices about federal
			 or state law requiring an automatic change adversely affecting some or all
			 members as described in
			 42 CFR
			 431.220(b). Information
			 about the appeal process is found at
			 130 CMR 610.000:
MassHealth: Fair Hearing Rules
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 516.000 - MassHealth: The Eligibility Process › Section 516.010 - Issuance of a MassHealth Card

Current through Register 1525, July 5, 2024
(A) The
			 MassHealth agency issues a MassHealth card to new members, with the exception
			 of those who receive MassHealth Buy-in coverage.
(B) A temporary card may be issued to a
			 member if there is an immediate need.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 517.000 - MassHealth: Universal Eligibility Requirements › Section 517.001 - Universal Eligibility Requirements

Current through Register 1525, July 5, 2024
All MassHealth applicants and members must meet the
				requirements of
				130 CMR 517.000 as a
				condition of eligibility.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 517.000 - MassHealth: Universal Eligibility Requirements › Section 517.002 - Residence Requirements

Current through Register 1525, July 5, 2024
As a condition of eligibility, an applicant or member must be a
				resident of the Commonwealth of Massachusetts.
(A) Unless otherwise specified
(1) individuals 21 years of age or older are
			 residents of the Commonwealth if they are living in the Commonwealth and either
(a) intend to reside in the Commonwealth,
			 with or without a fixed address; or
(b) have entered the Commonwealth with a job
			 commitment or are seeking employment, whether or not they are currently
			 employed; or
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 517.000 - MassHealth: Universal Eligibility Requirements › Section 517.003 - Residence of Institutionalized Individuals

Current through Register 1525, July 5, 2024
(A)
Placement by a Public Agency
. An individual who has
			 been placed in an institution or a foster care home in another state by a
			 public agency of the Commonwealth shall be considered a resident of the
			 Commonwealth. An individual placed in an institution or a foster care home in
			 the Commonwealth by a public agency of another state shall be considered a
			 resident of that state and not of the Commonwealth. If an individual who has
			 been placed in an institution leaves the institution and is competent at the
			 time of leaving, the individual is a resident of the Commonwealth if he or she
			 is physically located in the Commonwealth.
(B)
Other Institutionalized
			 Individuals
. Unless otherwise specified, residency for an
			 institutionalized individual who has not been placed in the institution by a
			 public agency is determined as follows.
(1)
			 If the individual is younger than 21 years old, is not married, and is not
			 emancipated, or is 21 years of age or older and became incapable of indicating
			 intent before 21 years old, the individual is a resident of the Commonwealth if
(a) the residence of the parent, parents, or
			 legal guardian at the time of placement is the Commonwealth, regardless of the
			 physical location of the individual;
(b) the current residence of the parent,
			 parents, or legal guardian who filed the application is the Commonwealth, and
			 the individual is institutionalized in the Commonwealth;
(c) in the case of an individual 21 years of
			 age or older who became incapable of indicating intent before 21 years old, the
			 current residence of a parent who filed the application is the Commonwealth,
			 regardless of the physical location of the individual, if the parents reside in
			 separate states; or
(d) the current
			 residence of the person or party filing the application is the Commonwealth,
			 the individual is institutionalized in the Commonwealth, and the individual has
			 been abandoned by his or her parents and does not have a legal
			 guardian.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 517.000 - MassHealth: Universal Eligibility Requirements › Section 517.005 - Persons Institutionalized for Mental Disease

Current through Register 1525, July 5, 2024
(A) Individuals younger than 18 years old and
			 those 65 years of age or older, who are patients in a public or private
			 institution for mental disease, may be eligible for MassHealth.
(B) Individuals who reach the age of 18 while
			 they are patients in an institution for mental disease may be eligible for
			 MassHealth until they reach age 22, provided they are disabled in accordance
			 with Title XVI requirements.
(C)
			 Individuals between 18 and 65 years of age who are patients in public or
			 private institutions for mental disease are not eligible for MassHealth, except
			 as provided in 130 CMR 517.005(B). Such individuals may establish eligibility
			 for MassHealth when entering an acute hospital from a public or private
			 institution for mental disease if otherwise categorically and financially
			 eligible.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 517.000 - MassHealth: Universal Eligibility Requirements › Section 517.006 - Social Security Number (SSN)

Current through Register 1525, July 5, 2024
(A)
Requirements
.
(1)
Condition of Eligibility
. As a condition of
			 eligibility for MassHealth, all persons applying in the household must furnish
			 a SSN or proof of application for a SSN, except as provided in 130 CMR
			 517.006(A)(1). The applicant is notified of the obligation to apply for a SSN
			 for any person applying in the household. The MassHealth agency does not
			 require a SSN or proof of application for a SSN for any applicant who
(a) attests to a religious exemption as
			 described in federal law;
(b) is
			 only eligible for a non-work SSN; or
(c) is not eligible to receive a
			 SSN.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 517.000 - MassHealth: Universal Eligibility Requirements › Section 517.007 - Utilization of Potential Benefits

Current through Register 1525, July 5, 2024
(A) An
			 applicant or member must take all necessary steps to obtain benefits to which
			 he or she is legally entitled, or for which he or she may be eligible, unless
			 he or she can show that doing so would put the applicant, member, or any of the
			 applicant's or member's family members in harm by supplying information to the
			 policyholder in cases where there is demonstrated necessity for restricting
			 such access. Benefits under this provision include, but are not limited to,
(1) Social Security benefits;
(2) Railroad Retirement benefits;
(3) federal Veterans' Administration
			 benefits, including payment provided by the Veterans' Administration to
			 purchase Aid and Attendance;
(4)
			 civil service annuities;
(5)
			 unemployment compensation;
(6)
			 workers' compensation;
(7) state
			 retirement benefits; and
(8) any
			 benefits to which the applicant or member is legally entitled and any share in
			 any estate to which the applicant or member is entitled. Members are not
			 required to maintain a health plan if its cost causes financial hardship to the
			 member.