reglab/statecodes huggingface dataset:
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 484.000 - Abortion Clinic Services › Section 484.004 - Provider Certification Requirements

Current through Register 1525, July 5, 2024
(A)
Ambulatory Abortion Clinic
. An ambulatory abortion
			 clinic must be licensed by the Massachusetts Department of Public Health in
			 compliance with the clinic licensure rules and regulations. In order to receive
			 payment from the MassHealth agency, an ambulatory abortion clinic must be
			 enrolled as a participating provider in MassHealth.
(B)
Hospital
. A
			 hospital in which abortions are performed must be licensed by the Massachusetts
			 Department of Public Health in compliance with the hospital licensure rules and
			 regulations. In order to receive payment from the MassHealth agency, a hospital
			 must be enrolled as a participating provider in MassHealth.
(C)
Physician
. The
			 MassHealth agency pays for abortion services rendered by a physician only in
			 accordance with
			 130 CMR
			 433.403 and
			 130 CMR
			 433.404.
(D)
Physician
			 Assistant
. The MassHealth agency pays for abortion services
			 rendered by a physician assistant only in accordance with
			 130 CMR
			 433.434.
(E)
Certified Nurse
			 Practitioner
. The MassHealth agency pays for abortion services
			 rendered by a certified nurse practitioner only in accordance with
			 130 CMR
			 433.433.
(F)
Certified Nurse
			 Midwife
. The MassHealth agency pays for abortion services rendered
			 by a certified nurse midwife only in accordance with
			 130 CMR
			 433.419.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 484.000 - Abortion Clinic Services › Section 484.005 - Reimbursable Abortion-related Services

Current through Register 1525, July 5, 2024
(A)
			 The MassHealth agency will reimburse providers for the following
			 abortion-related services when they are provided in conjunction with a payable
			 abortion procedure:
(1) pre-operative
			 evaluation and examination;
(2)
			 pre-operative counseling;
(3)
			 laboratory services, including pregnancy testing, blood type, and Rh
			 factor;
(4)
			 Rho (D) immune globulin (human);
(5) anesthesia (general or local);
(6) post-operative care;
(7) follow-up; and
(8) advice on contraception or referral to
			 family planning services.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 484.000 - Abortion Clinic Services › Section 484.007 - Out-of-state Abortions

Current through Register 1525, July 5, 2024
(A) A facility
			 located outside of Massachusetts is eligible to receive reimbursement for
			 abortion services provided to Massachusetts recipients only if it is licensed
			 by the governing or licensing agency in its state to perform abortions. An
			 out-of-state facility must obtain a Massachusetts Medical Assistance provider
			 number before it may receive such reimbursement from the MassHealth
			 agency.
(B) The MassHealth agency
			 will pay for a non-emergency abortion performed in an out-of-state facility
			 only if it is a payable abortion and if prior authorization has been requested
			 from and granted by the MassHealth agency.
(1)
			 The recipient or a referral agency may request prior authorization by telephone
			 or in writing. The request should be made to: MassHealth, Prior Authorization
			 Unit, ATTN: Prior Authorization, 100 Hancock Street, 6th Floor, Quincy, MA,
			 02171 (800) 862-8341. The facility may also make the prior authorization
			 request.
(2) If the MassHealth
			 agency grants a prior authorization request, it will issue a prior
			 authorization number directly to the out of-state facility. In order to receive
			 payment for an out-of-state abortion which requires prior authorization, the
			 facility must enter the approved prior authorization number on the claim
			 form.
(3) The MassHealth agency
			 will grant a prior authorization request only when the abortion service needed
			 by the recipient is not available in a Massachusetts facility.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 484.000 - Abortion Clinic Services › Section 484.008 - Reimbursement for Services

Current through Register 1525, July 5, 2024
A provider of abortion services claiming reimbursement from the
				MassHealth agency must bill according to the fee schedule appropriate to its
				provider category.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 484.000 - Abortion Clinic Services › Section 484.009 - Billing

Current through Register 1525, July 5, 2024
Refer to
				130 CMR 450.000:
Administrative and Billing Regulations
for billing regulations
				applicable to all providers. Providers of abortion services must bill the
				MassHealth agency on the appropriate claim form, in accordance with the billing
				instructions.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 485.000 - Sterilization And Hysterectomy Services › Section 485.401 - Introduction

Current through Register 1525, July 5, 2024
130 CMR 485.000 applies to
				sterilization procedures for which sterilization clinics may claim payment
				under MassHealth.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 485.000 - Sterilization And Hysterectomy Services › Section 485.402 - Definitions

Current through Register 1525, July 5, 2024
The following terms used in
				130 CMR 485.000 have the
				meanings given in 130 CMR 485.402 unless the context clearly requires a
				different meaning.
Institutionalized Individual
- an
				individual who is
(1) involuntarily confined or detained, under a civil or
				criminal statute in a correctional or rehabilitative facility, including a
				psychiatric hospital or other facility for the care and treatment of mental
				illness; or
(2) confined, under a voluntary commitment, in a psychiatric
				hospital or other facility for the care and treatment of mental illness.
Mentally Incompetent Individual
- an
				individual who has been declared mentally incompetent by a federal, state, or
				local court of competent jurisdiction for any purpose, unless the individual
				has been declared competent for purposes that include the ability to consent to
				sterilization.
Sterilization
- any medical procedure,
				treatment, or operation for the purpose of rendering an individual permanently
				incapable of reproducing.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 485.000 - Sterilization And Hysterectomy Services › Section 485.403 - Eligible Members

Current through Register 1525, July 5, 2024
(A)
(1)
MassHealth
			 Members
. The MassHealth agency pays for sterilization clinic
			 services only when provided to eligible MassHealth members, subject to the
			 restrictions and limitations described in the MassHealth regulations.
			 130 CMR 450.105:
Coverage Types
specifically states, for each MassHealth
			 coverage type, which services are covered and which members are eligible to
			 receive those services.
(2)
Recipients of the Emergency Aid to the Elderly, Disabled and
			 Children Program
. For information on covered services for
			 recipients of the Emergency Aid to the Elderly, Disabled and Children Program,
see
130 CMR
			 450.106:
Emergency Aid to the
			 Elderly, Disabled and Children Program
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 485.000 - Sterilization And Hysterectomy Services › Section 485.404 - Provider Eligibility

Current through Register 1525, July 5, 2024
Payment for the services described in
				130 CMR 485.000 is made
				only to sterilization clinics that are participating in MassHealth as of the
				date of service. The eligibility requirements for sterilization clinics are as
				follows.
(A)
In
			 State
. A sterilization clinic located in Massachusetts is eligible
			 to participate in MassHealth only if it is licensed as a clinic by the
			 Massachusetts Department of Public Health.
(B)
Out of State
. A
			 sterilization clinic located outside of Massachusetts is eligible to
			 participate in MassHealth only if it meets the licensing requirements in its
			 state, participates in that state's Medicaid program (or equivalent), and meets
			 the requirements specified in
			 130 CMR 485.405
			 through
			 485.413.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 485.000 - Sterilization And Hysterectomy Services › Section 485.405 - Covered Services

Current through Register 1525, July 5, 2024
The MassHealth agency pays for sterilization services provided
				to a member only if all of the following conditions are met.
(A) The member has voluntarily given informed
			 consent for the sterilization procedure in the manner and at the time described
			 in
			 130 CMR
			 485.409 and such consent is documented in the
			 manner described in
			 130 CMR
			 485.410.
(B) The member is at least 18 years of age at
			 the time consent is obtained.
(C)
			 The member is not a mentally incompetent individual or an institutionalized
			 individual.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 485.000 - Sterilization And Hysterectomy Services › Section 485.406 - Assurance of Member Rights

Current through Register 1525, July 5, 2024
No provider may use any form of coercion in the provision of
				sterilization services. Neither the MassHealth agency nor any provider, nor any
				agent or employee of a provider, may mislead any member into believing that a
				decision to have or not have a sterilization will adversely affect the member's
				entitlement to benefits or services for which the member would otherwise be
				eligible. The MassHealth agency has strict requirements for confidentiality of
				member records for sterilization services as well as for all other medical
				services payable under MassHealth.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 485.000 - Sterilization And Hysterectomy Services › Section 485.407 - Retroactive Eligibility

Current through Register 1525, July 5, 2024
The MassHealth agency does not pay for a sterilization
				performed during the period of a member's retroactive eligibility unless all
				conditions for payment listed in
				130 CMR 485.405
				are met.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 485.000 - Sterilization And Hysterectomy Services › Section 485.409 - Informed Consent Requirements

Current through Register 1525, July 5, 2024
A member's consent for sterilization will be considered
				informed and voluntary only if such consent is obtained in accordance with the
				requirements specified in 130 CMR 485.409(A) and (B), and such consent is
				documented as specified in
				130 CMR
				485.410.
(A) The person who obtains consent
			 (physician, nurse, or counselor, for example) must orally provide all of the
			 following information and advice to the member requesting sterilization:
(1) advice that the individual is free to
			 withhold or withdraw consent to the procedure at any time before the
			 sterilization without affecting the right to future care or treatment and
			 without loss of any federal- or state-funded program benefits to which the
			 individual might be otherwise entitled;
(2) a description of available alternative
			 methods of family planning and birth control;
(3) advice that the sterilization procedure
			 is considered irreversible;
(4) a
			 thorough explanation of the specific sterilization procedure to be
			 performed;
(5) a full description
			 of the discomforts and risks that may accompany or follow the procedure,
			 including an explanation of the type and possible effects of any anesthetic to
			 be used;
(6) a full description of
			 the benefits or advantages the member may expect as a result of the
			 sterilization; and
(7) advice that
			 the sterilization will not be performed for at least 30 days, except under the
			 circumstances specified in
			 130 CMR
			 485.410(A).
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 485.000 - Sterilization And Hysterectomy Services › Section 485.410 - When Informed Consent Must Be Obtained

Current through Register 1525, July 5, 2024
(A)
			 A member's consent for sterilization will be considered informed and voluntary
			 only if such consent is obtained at least 30 days, but not more than 180 days,
			 before the date of the sterilization procedure, except in the case of premature
			 delivery or emergency abdominal surgery. A member may consent to be sterilized
			 at the time of a premature delivery or emergency abdominal surgery if at least
			 72 hours have passed since the member gave informed consent for the
			 sterilization in the manner specified in
			 130 CMR
			 485.409. In the case of premature delivery,
			 the informed consent must have been given at least 30 days before the expected
			 date of delivery.
(B) A member's
			 consent for sterilization will not be considered informed or voluntary if such
			 consent is obtained or given while the member requesting sterilization is:
(1) in labor or childbirth;
(2) seeking to obtain or obtaining an
			 abortion; or
(3) under the
			 influence of alcohol or other substances that affect the individual's state of
			 awareness.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 485.000 - Sterilization And Hysterectomy Services › Section 485.411 - Consent Form Requirements

Current through Register 1525, July 5, 2024
Informed consent for sterilization must be documented by the
				completion of the MassHealth agency's Consent for Sterilization form in
				accordance with the following requirements. (Instructions for obtaining the
				Consent for Sterilization forms are located in Subchapter 5 of the
Sterilization Clinic Manual
.)
(A)
Required Consent
			 Form
.
(1) One of the following
			 Consent for Sterilization forms must be used:
(a) CS-18 - for members 18 through 20 years
			 of age; or
(b) CS-21 - for members
			 21 years of age or older.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 485.000 - Sterilization And Hysterectomy Services › Section 485.412 - Maximum Allowable Fees

Current through Register 1525, July 5, 2024
The MassHealth agency pays sterilization clinics according to
				the rates and regulations established by the Executive Office of Health and
				Human Services (EOHHS) at
				101 CMR 313.00:
Abortion and Sterilization Services Provided by Freestanding
				Clinics
. Payments are subject to the conditions, exclusions, and
				limitations set forth in
				130 CMR 485.000 and
				450.000:
Administrative and Billing Regulations
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 485.000 - Sterilization And Hysterectomy Services › Section 485.413 - Recordkeeping Requirements

Current through Register 1525, July 5, 2024
(A) Payment for any
			 service listed in
			 130 CMR 485.000 is
			 conditioned upon its full and complete documentation in the member's medical
			 record. he sterilization clinic must maintain a record of all medical services
			 provided to a member for at least six years following the date of service. See
			 also the requirement contained in
			 130 CMR
			 485.411(C)(2).
(B) The medical record must contain, but is
			 not limited to, the following information:
(1) the member's name, address, telephone
			 number, date of birth, and MassHealth identification number;
(2) the date of service;
(3) the name, title, and signature of the
			 person performing the service;
(4)
			 the type of visit;
(5) medical
			 history and history update;
(6)
			 pertinent findings on examination;
(7) laboratory tests and results;
(8) abnormal findings and follow-up
			 treatment;
(9) drugs administered
			 or prescribed, including strength, dosage, route, regimen, and number of
			 refills;
(10) drugs dispensed,
			 including strength, dosage, route, regimen, and number of units;
(11) the contraceptive method used and any
			 special instructions;
(12) a
			 summary of counseling; and
(13)
			 plans for follow-up.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 501.000 - Health Care Reform: MassHealth: General Policies › Section 501.002 - Introduction to MassHealth

Current through Register 1525, July 5, 2024
(A) The MassHealth
			 agency is responsible for the administration and delivery of MassHealth
			 services to eligible low- and moderate-income individuals, couples, and
			 families.
(B)
								130 CMR
			 501.000 through
			 508.000 provide the
			 MassHealth requirements for children, young adults, parents and caretaker
			 relatives, adults, people who are pregnant, 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.
(C)
								130 CMR
			 515.000:
MassHealth: General Policies
through
			 130 CMR
			 522.000:
MassHealth: 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.
(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 in federal regulations at 20 CFR Part 418.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 501.000 - Health Care Reform: MassHealth: General Policies › Section 501.003 - 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 an
			 individual who may be eligible.
(B)
			 MassHealth offers several coverage types: Standard, CommonHealth, CarePlus,
			 Family Assistance, and Limited. The coverage type for which a person is
			 eligible is determined based on the individual's income and circumstances, as
			 described in
			 130 CMR
			 503.000 through
			 505.000, and immigration
			 status, as described in
			 130 CMR
			 504.000:
Health Care Reform: 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 adult applicants (21 years of
			 age or older) subject to these limitations will be added to MassHealth Family
			 Assistance, and current adult members in these coverage types 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 in
			 MassHealth Family Assistance.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 501.000 - Health Care Reform: MassHealth: General Policies › Section 501.004 - 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 section 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, and parents and caretakers who are
			 citizens or qualified noncitizens;
2. MassHealth CarePlus: 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, and adults 21 through 64 years old 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 501.000 - Health Care Reform: MassHealth: General Policies › Section 501.005 - Individuals and Families Eligible for or Receiving Medical Assistance on June 30, 1997

Current through Register 1525, July 5, 2024
(A)
Members Who Were Not Subject to a Deductible
.
(1) Individuals and families (including
			 caretaker relatives) who were receiving Medical Assistance on June 30, 1997,
			 and whose family group gross income on June 30, 1997, exceeded MassHealth
			 eligibility standards will be provided MassHealth Standard coverage for one
			 year after the date of MassHealth implementation, except in the following
			 circumstances:
(a) the individual or family no
			 longer lives in Massachusetts;
(b)
			 the individual enters an institution;
(c) the individual turns 65 years
			 old;
(d) the individual or all
			 members of the family are deceased; or
(e) the individual or family is no longer
			 categorically eligible.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 501.000 - Health Care Reform: MassHealth: General Policies › Section 501.006 - Children Receiving Benefits under the Children's Medical Security Plan on August 3, 1998

Current through Register 1525, July 5, 2024
(A)
Eligibility
.
(1)
			 Children who were receiving benefits under the Children's Medical Security Plan
			 on August 3, 1998, as well as any siblings in their family, will be treated as
			 a protected status group under MassHealth if they
(a) have submitted a complete application
			 (formerly known as Medical Benefit Request) as defined in
			 130
			 CMR 502.001:
Application for
			 Benefits
by March 31, 1999;
(b) meet the eligibility requirements of
			 MassHealth; and
(c) have an income
			 less than or equal to 200% of the FPL.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 501.000 - Health Care Reform: MassHealth: General Policies › Section 501.009 - 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 complies with
			 applicable federal civil rights laws and does not discriminate on the basis of
			 race, color, national origin, age, disability, religion, creed, sexual
			 orientation, or sex (including gender identity and gender stereotyping). A
			 compliance coordinator is designated to administer grievance procedures for
			 discrimination complaints.
(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 with 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
			 502.000:
Health Care Reform: 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 any individual of their choice and the right to be
			 represented by an appeal representative as defined in
			 130
			 CMR 610.004:
Definitions
during the appeal process.
(2) An
			 application for MassHealth may be filed by an authorized representative as
			 described in the definition of authorized representative in
			 130
			 CMR 501.001.
(3) An appeal of a MassHealth decision,
			 including one brought on behalf of a deceased person, may be filed by an appeal
			 representative if such appeal representative meets the requirements in
			 130
			 CMR 610.016:
Appeal
			 Representative
.
(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 501.000 - Health Care Reform: MassHealth: General Policies › Section 501.010 - 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
			 available health insurance. The MassHealth agency may request corroborative
			 information necessary to maintain eligibility, including obtaining or
			 maintaining available health insurance. The applicant or member must supply
			 such information within 30 days of the receipt of the agency's request. If the
			 member does not cooperate, MassHealth benefits may be terminated.
(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, the
			 availability of health insurance, 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 501.000 - Health Care Reform: MassHealth: General Policies › Section 501.011 - 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 501.000 - Health Care Reform: MassHealth: General Policies › Section 501.012 - Recovery of Overpayment of Medical Benefits

Current through Register 1525, July 5, 2024
The MassHealth agency has the right to recover payment for
				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 501.012 will limit the MassHealth
				agency's right to recover overpayments.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 501.000 - Health Care Reform: MassHealth: General Policies › Section 501.013 - 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 501.000 - Health Care Reform: MassHealth: General Policies › Section 501.014 - 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 501.000 - Health Care Reform: MassHealth: General Policies › Section 501.015 - Reimbursement of Certain Out-of-pocket Medical Expenses

Current through Register 1525, July 5, 2024
(A)
Eligibility
			 Requirements
. The following persons will be entitled to
			 reimbursement for certain medical expenses for which they paid, subject to the
			 provisions of
			 130
			 CMR 501.015.
(1) A member who
(a) applied for SSI;
(b) was denied SSI benefits by the Social
			 Security Administration; and
(c)
			 had their 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.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 502.000 - Health Care Reform: MassHealth: Eligibility Process › Section 502.001 - Application for Benefits

Current through Register 1525, July 5, 2024
(A)
Filing an Application
. To apply for MassHealth, an
			 individual or their authorized representative must file an application online
			 at
www.MAHealthConnector.org
,
			 complete a paper application, complete a telephone application, or apply in
			 person at a MassHealth Enrollment Center (MEC).
(1)
Date of
			 Application
.
(a) The date of
			 application for an online, telephonic, or in-person application is the date the
			 application is submitted to the MassHealth agency.
(b) The date of application for a paper
			 application that is either mailed or faxed is the date the application is
			 received by the MassHealth agency.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 502.000 - Health Care Reform: MassHealth: Eligibility Process › Section 502.002 - Reactivating the Application

Current through Register 1525, July 5, 2024
If all required information is received by the MassHealth
				agency after the period described in
				130
				CMR 502.001(D), or after a
				denial of eligibility, the MassHealth agency reactivates the application and
				considers it submitted as of the date the information is received, and the
				medical coverage date is established in accordance with
				130
				CMR 502.006. A new application must be
				completed if all required information is not received within one year of
				receipt of the previous application.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 502.000 - Health Care Reform: MassHealth: Eligibility Process › Section 502.003 - Verification of Eligibility Factors

Current through Register 1525, July 5, 2024
The MassHealth agency requires verification of eligibility
				factors including income, residency, citizenship, immigration status, and
				identity as described in
				130 CMR
				503.000:
Health Care Reform: MassHealth:
				Universal Eligibility Requirements
,
				130 CMR
				504.000:
Health Care Reform: MassHealth:
				Citizenship and Immigration
, and
				130 CMR
				506.000:
Health Care Reform: MassHealth:
				Financial Requirements
.
(A)
Information Matches
. The MassHealth agency initiates
			 information matches with other agencies and information sources as described at
			 130
			 CMR 502.004 in the following order, when an
			 application is received in order to verify eligibility:
(1) the Federal Data Hub, which matches with
			 the Social Security Administration, the Department of Homeland Security, and
			 the Internal Revenue Service; and
(2) other federal and state agencies and
			 other informational services.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 502.000 - Health Care Reform: MassHealth: Eligibility Process › Section 502.004 - Matching Information

Current through Register 1525, July 5, 2024
The MassHealth agency may initiate information matches with
				other agencies and information sources when an application is received, at
				annual renewal, and periodically, in order to update or verify eligibility.
				These agencies and information sources may include, but are not limited to, the
				following: the 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, and health insurance carriers.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 502.000 - Health Care Reform: MassHealth: Eligibility Process › Section 502.005 - Time Standards for an Eligibility Determination

Current through Register 1525, July 5, 2024
(A) For applicants who do not apply on the
			 basis of a disability, the MassHealth agency makes an eligibility determination
(1) within 60 days from the date of receipt
			 of the complete application if the applicant is potentially eligible for
			 MassHealth Family Assistance; or
(2) within 45 days from the date of receipt
			 of the complete application for all other nondisabled
			 applicants.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 502.000 - Health Care Reform: MassHealth: Eligibility Process › Section 502.007 - 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 change 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 a 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, by telephone, or on the MAHealthConnector.org account;
			 or
(4) based on information in the
			 member's case file.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 502.000 - Health Care Reform: MassHealth: Eligibility Process › Section 502.008 - 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
			 members a notice, in accordance with
			 130
			 CMR 610.015:
Time Limits
, of
			 any loss of coverage, or any changes in coverage type, premium, or premium
			 assistance payments.
(C) The
			 notices described in
			 130
			 CMR 502.008(A) and (B)
			 provide information about the applicant's and member's right to a fair hearing,
			 with the exception of notices about hospital-determined presumptive
			 eligibility, as described in
			 130
			 CMR 502.003(H), 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 502.000 - Health Care Reform: MassHealth: Eligibility Process › Section 502.010 - 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 premium assistance under MassHealth Small Business
			 Employee Premium Assistance as described in
			 130
			 CMR 505.009:
MassHealth Small
			 Business Employee Premium Assistance
.
(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 503.000 - Health Care Reform: MassHealth: Universal Eligibility Requirements › Section 503.001 - Universal Eligibility Requirements

Current through Register 1525, July 5, 2024
MassHealth applicants and members must meet all of the
				requirements of
				130 CMR 503.000 as a
				condition of eligibility.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 503.000 - Health Care Reform: MassHealth: Universal Eligibility Requirements › Section 503.002 - 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 503.000 - Health Care Reform: MassHealth: Universal Eligibility Requirements › Section 503.003 - 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 an SSN, except as provided in 130 CMR
			 503.003(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 from any applicant who
(a) attests to a religious exemption as
			 described in federal law;
(b) is
			 only eligible for a non-work SSN;
(c) is not eligible to receive a
			 SSN.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 503.000 - Health Care Reform: MassHealth: Universal Eligibility Requirements › Section 503.004 - Assignment of Rights to Medical Support and Third-party Payments

Current through Register 1525, July 5, 2024
(A) Every legally able applicant or member
			 must assign to the MassHealth agency his or her rights to medical support and
			 third-party payments for medical benefits provided under Mass-Health as well as
			 the rights of applicants or members for whom he or she can legally assign
			 medical support and third-party payments.
(B) The applicant or member must fully
			 cooperate with the MassHealth agency in
(1)
			 establishing paternity;
(2)
			 obtaining any medical support and payments; and
(3) identifying and providing information to
			 assist the MassHealth agency in pursuing third parties, including a
			 noncustodial parent, who may be legally obligated to pay for care and services
			 for the applicant or member, or person on whose behalf benefits are requested,
			 unless the applicant or member has grounds to waive cooperation as described in
			 130 CMR
			 503.005 or
			 505.002(D):
Eligibility Requirements for Pregnant
			 Women
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 503.000 - Health Care Reform: MassHealth: Universal Eligibility Requirements › Section 503.005 - Waiver of Cooperation for Good Cause

Current through Register 1525, July 5, 2024
(A)
			 Good cause is established if
(1) the
			 MassHealth agency finds that cooperation is against the best interest of the
			 child with respect to the obligation to establish paternity of a child born out
			 of wedlock, obtain medical-care support and payments, or identify or provide
			 information to assist the MassHealth agency in pursuing a liable third party
			 for a child for whom the applicant or member can legally assign rights;
			 or
(2) the MassHealth agency finds
			 that cooperation is not in the best interest of the applicant or member or the
			 person for whom the benefit is being requested or furnished because it is
			 anticipated that cooperation will result in reprisal against, and cause serious
			 physical or emotional harm to the applicant or member or another person with
			 respect to the obligation to cooperate in all cases not covered by 130 CMR
			 503.005(A)(1).
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 503.000 - Health Care Reform: MassHealth: Universal Eligibility Requirements › Section 503.006 - Assignment for Third-party Recoveries

Current through Register 1525, July 5, 2024
As a condition of eligibility, an applicant or member must
				inform the MassHealth agency when any such individual is involved in an
				accident, or suffers from an illness or injury, or other loss that has resulted
				or may result in a lawsuit or insurance claim. The applicant or member
				must
(A) file an insurance claim for
			 compensation, if available; and
(B)
			 agree to comply with all requirements of M.G.L. c. 118E, § 22 including,
			 but not limited to
(1) assigning to the
			 MassHealth agency or its agent the right to recover an amount equal to the
			 MassHealth benefits provided from the proceeds of any claim or other proceeding
			 against a third party;
(2)
			 providing information about the claim or any other proceeding and cooperating
			 fully with the MassHealth agency or its agent, unless the MassHealth agency
			 determines that cooperation would not be in the best interests of, or would
			 result in serious physical or emotional harm to, the applicant or member, in
			 accordance with
			 130 CMR
			 503.005;
(3) notifying the MassHealth agency in
			 writing within ten days of filing any claim, civil action, or other proceeding;
			 and
(4) repaying and cooperating
			 fully with the MassHealth agency or its agent to ensure the member's legal
			 representative repays the MassHealth agency from the money received from a
			 third party for all MassHealth benefits provided on or after the date of the
			 accident or other incident; provided that if the member is involved in an
			 accident or other incident after becoming MassHealth eligible, repayment will
			 be limited to MassHealth benefits provided as a result of the accident or
			 incident.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 503.000 - Health Care Reform: MassHealth: Universal Eligibility Requirements › Section 503.007 - Potential Sources of Health Care

Current through Register 1525, July 5, 2024
The MassHealth agency is the payer of last resort and pays for
				health care and related services only when no other source of payment is
				available, except as otherwise required by federal law.
(A)
Health
			 Insurance
. Every applicant and member must obtain and maintain
			 available health insurance in accordance with
			 130 CMR 505.000:
Health Care Reform: MassHealth: Coverage Types
. Failure to do
			 so may result in loss or denial of eligibility unless the applicant or member
			 is
(1) receiving MassHealth Standard or
			 MassHealth CommonHealth; and
(2)
			 younger than 21 years old or pregnant.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 503.000 - Health Care Reform: MassHealth: Universal Eligibility Requirements › Section 503.008 - 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 130 CMR 503.008 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.