Table A. MassHealth State Plan Base Populations (See STC 91 for terminology) Medicaid Mandatory and Optional State Plan Groups (Categorical Eligibility) Federal Poverty Level (FPL) and/or Other Qualifying Criteria Funding Stream Expenditure and Eligibility Group (EG) Reporting MassHealth Program Comments AFDC-Poverty Level infants < Age 1: 0 through 185% XIX Base Families Standard Medicaid Expansion infants < Age 1: 185.1 through 200% Title XIX if insured at the time of application Title XXI if uninsured at the time of application Funded through title XIX if title XXI is exhausted 1902(r)(2) Children 1902(r)(2) XXI RO Standard
AFDC-Poverty Children and Independent Foster Care Adolescents Age 1 - 5: 0 through 133% Age 6 - 17: 0 through 114% Independent Foster Care Adolescents aged out of DCF until the age of 21 without regard to income or assets Former Foster Care Adolescents until the age of 26 without regard to income or assets (effective January 1, 2014) Title XIX Base Families Standard
AFDC-Poverty Level Children Medicaid Expansion Children I Age 6 - 17: 114.1% through 133% Age 18: 0 through 133% Title XIX if insured at the time of application Title XXI if uninsured at the time of application Funded through XIX if title XXI is exhausted Base Families Bas Fam XXI RO Standard 1 Massachusetts includes in the MassHealth demonstration almost all the mandatory and optional populations aged under 65 eligible under the state plan. All Standard and CommonHealth members who have access to qualifying private insurance may receive premium assistance plus wrap-around benefits. The Massachusetts state plan outlines all covered populations not specifically indicated here.
Table A. MassHealth State Plan Base Populations (continued)* Medicaid Mandatory and Optional Plan Groups (Categorical Eligibility) Federal Poverty Level (FPL) and/or Other Qualifying Criteria Funding Stream Expenditure and Eligibility Group (EG) Reporting MassHealth Demonstration Program Comments Medicaid Expansion Children II Ages 1 - 18: 133.1 through 150% XIX if insured at the time of application XXI if uninsured at the time of application Funded through XIX if title XXI is exhausted 1902(r)(2) Children 1902(r)(2) XXI RO Standard Medicaid Expansion Children II (effective January 1, 2014) Ages 19 and 20: 133.1 through 150% Title XIX 1902(r)(2) Children Standard CHIP Unborn Children 0 through 200% Title XXI n/a Standard Pregnant women 0 through 185% Title XIX Base Families Standard Parents and caretaker relatives ages 19 through 64 eligible section 1931 and 0 through 133% Title XIX Base Families Standard
Children eligible under TEFRA section 134, SSA section 1902(e)(3) and 42 U.S.C. 1396a(e)(3) (Kaileigh Mulligan kids) Age 0 – 17 Require hospital or nursing facility level of care Income < or = to $72.81, or deductible $0 through $2,000 in assets XIX Base Disabled Standard Income and assets of their parents are not considered in determination of eligibility Children receiving IV-E adoption assistance Age 0 through 18 Title XIX Base Families Standard Children placed in subsidized adoption under title IV-E of the Social Security Act
Affordable Care Act New Adult Group (effective January 1, 2014) Ages 19 and 20: 0 through 133% Individuals with HIV or breast or cervical cancer: 0 through 133% Individuals receiving services or on a waiting list to receive services through the Department of Mental Health: 0 through 133% Adults ages 21-64: 0 through 133% XIX New Adult Group Standard (Alternative Benefit Plan) CarePlus (Alternative Benefit Plan) Ages 19 and 20 treated as children and entitled to Individuals exempt from mandatory enrollment in an Alternative Benefit Plan may enroll in Standard
Table A. MassHealth Demonstration Expansion Populations * Groups with a Categorical Link Made Eligible through the Demonstration (“Hypotheticals”) Federal Poverty Level (FPL) and/or Other Qualifying Criteria Funding Stream Expenditure and Eligibility Group (EG) Reporting MassHealth Program Comments Higher income children with disabilities · < Age 1: 200.1 through 300% · Ages 1 - 18: 150.1 through 300% Title XIX if insured at the time of application Title XXI via the separate XXI program if uninsured at the time of application (Funded through title XIX if title XXI is exhausted) CommonHealth CommonHealth XXI CommonHealth The CommonHealth program existed to the separate XXI Children’s Health Insurance Program and was not affected by the maintenance of effort date. The CommonHealth program is contained in the separate XXI state plan and as authorized under this 1115 demonstration. Certain children derive eligibility from both the authority granted under this demonstration and the separate XXI program. Higher income children with disabilities ages 0 through 18 300% Title XIX CommonHealth CommonHealth Sliding scale premium responsibilities for those individuals above 150 percent of the FPL
Table A. MassHealth Demonstration Expansion Populations (See STC 91 for terminology) Populations Made Eligible through the Demonstration Federal Poverty Level (FPL) and other qualifying criteria Funding Stream Expenditure and Eligibility Group (EG) Reporting Massachusetts Program Additional comments Children ages 1 through 18 Children less than age 1 150.1 through 200 Above 200 through 300% (effective January 1, 2014) Above 200 through 300% (effective January 1, 2014) Title XIX if insured at the time of application Title XXI via the separate XXI program if uninsured (Funded through XIX if title XXI is exhausted) e-Family Assistance Fam Assist XXI (if XXI is exhausted) Family Assistance Premium Assistance Direct Coverage The premium assistance payments and FFP will be based on the children’s eligibility. Parents are covered incidental to the child. No additional wrap other than dental is provided to ESI. Effective January 1, 2014, children ages 0 through 18 from 200-300% FPL who are insured at the time of application are eligible under the 1115 demonstration. Children who are uninsured at the time of application derive eligibility from both the authority granted under this demonstration and the XXI program.
Table A. MassHealth Demonstration Expansion Populations (See STC 91 for terminology) Populations Made Eligible through the Demonstration Federal Poverty (FPL) and other qualifying criteria Funding Stream Expenditure and Eligibility Group (EG) Reporting Massachusetts Demonstration Program Additional comments Adults under the age of 65 who are not otherwise eligible for medical assistance who work for a small employer and purchase ESI that meets basic benefit level (BBL) standards 133.1 through 300% XIX SBE Small Business Employee Premium Assistance Individuals must not be eligible for any MassHealth coverage or for APTCs. No additional wraparound benefits are provided. Individuals whose spouse or children are receiving MassHealth premium assistance for a policy that is available to the individual are not entitled to this benefit.
Table A. MassHealth Demonstration Expansion Populations(continued)* Populations Made Eligible through the Demonstration Federal Poverty Level (FPL) and other qualifying criteria Funding Stream Expenditure and Eligibility (EG) Reporting Massachusetts Demonstration Program Additional comments Individuals with HIV not otherwise eligible for medical assistance with income above 133% through 200% FPL. Above 133 to 200% Title XIX e-HIV/FA Family Assistance Premium assistance is offered in lieu of direct coverage when there is access to other insurance. Additional wraparound to private insurance is provided. Individuals who receive Temporary Assistance for Families and Emergency Aid to Elders, Disabled and Children N/A Title XIX MassHealth Expenditures for health care related for individuals receiving Temporary Assistance for Needy Families and Emergency Aid to Elders, Disabled and Children. Individuals in this eligibility group are eligible for MassHealth based on receipt of TANF and/or EAEDC benefits, not an income determination. Provisional Eligibility Self-Attested income level to qualify for other group, pending verification Title XIX Provisional Eligibility MassHealth Expenditures for amounts spent on individuals found not eligible for Medicaid benefits under this authority in accordance with STC 24.
End of Month Coverage Beneficiaries determined eligible for subsidized Qualified Health Plan (QHP) coverage through the Massachusetts Health Connector but not enrolled in a QHP Ineligible for MassHealth and Eligible for QHP up to 400% FPL Title XIX End of Month Coverage N/A Effective January 1, 2014, expenditures for individuals who would otherwise lose MassHealth coverage because they are eligible for coverage in a QHP, during the period specified in STC 29. Individuals determined presumptively eligible for HIV-Family Assistance or the Breast and Cervical Cancer Demonstration Program under the demonstration by qualified hospitals that elect to do so. HIV-Family Assistance – 133.1 through 200 BCCDT – above 133.1 through 250 Title XIX Presumptively Eligible Family Assistance Standard
Medically Necessary Non- emergency X X X Transport Nurse Midwife Services X X X X Practitioner Services X X X X Orthotic Services X X X X Outpatient Hospital X X X X Outpatient Surgery X X X X Oxygen and Respiratory Therapy Equipment X X X X Personal Care X X Pharmacy X X X X Physician X X X X Podiatry X X X X Private Duty Nursing X X Prosthetics X X X X Rehabilitation X X X X Dialysis Services X X X X Skilled Nursing Facility X X Limited Limited Speech and Hearing Services X X X X Targeted Case Management X X
definition of an Institution for Mental Diseases (IMD). Diversionary services are offered to provide interventions and stabilization to persons experiencing mental health or substance abuse crises in order to divert from acute inpatient hospitalization or to stabilize after discharge. These services do not include residential programs involving long-term residential stays. Any MassHealth member under the demonstration who is enrolled in managed care may be eligible to receive diversionary services. Managed care entities and the Prepaid Inpatient Health Plan (PIHP) for behavioral health services identify appropriate individuals to receive diversionary services. Managed care entities maintain a network of diversionary services and arrange, coordinate, and oversee the provision of medically necessary diversionary services, as described in Table C. Table C. Diversionary Behavioral Health Services Provided Through Managed Care Under the Demonstration Diversionary Behavioral Health Setting Definition of Service Community Crisis Stabilization 24-hour facility Services provided as an alternative to hospitalization, including short- term psychiatric treatment in structured, community-based therapeutic environments. Community Crisis Stabilization provides continuous 24-hour observation and supervision for Covered Individuals who do not require Inpatient Services. Community Support Program (CSP) Non-24-hour facility An array of services delivered by a community-based, mobile, team of professionals and paraprofessionals. These programs provide essential services to Covered Individuals with a long-standing history of a psychiatric or substance use disorder and to their families, or to Covered Individuals who are at varying degrees of increased medical risk, or to children/adolescents who have behavioral health issues challenging their optimal level of functioning in the home/community setting. Services include outreach and supportive services, delivered in a community setting, which will vary with respect to hours, type and intensity of services depending on the changing needs of the Enrollee. multi-
Any individual receiving benefits during the hospital-determined presumptive eligibility period or the time-limited period while MassHealth investigates and verifies access to qualified and cost-effective private health insurance or the time-limited period while the member is enrolling in such insurance; Any individual receiving Limited coverage; Any individual receiving hospice care, or who is terminally ill as documented with a medical prognosis of a life expectancy of 6 months or less; and Any participant in a Home and Community-Based Services Waiver who is not eligible for SSI and for whom MassHealth is not a secondary payer. MassHealth may permit such individuals to enroll in Managed Care, including the option to enroll with the behavioral health contractor for behavioral health services and receive their medical services through FFS. Managed Care Delivery Systems MassHealth’s Managed Care delivery systems include two categories as described (1) PCCM delivery systems (which includes the PCC Plan and Primary Care ACOs); and (2) MCO-based delivery systems (which includes the MassHealth MCOs and Partnership Plans). Table E below provides an overview of these delivery systems. Table E. Overview of Managed Care Delivery Systems Managed Care PCCM delivery systems MCO-based delivery systems PCC Plan Primary Care ACOs (previously “Model B ACOs”) MassHealth MCOs Partnership (previously “Model A ACOs”) Non- Pilot ACO Pilot Non- ACO MCO- Administered ACOs (previously “Model C ACOs”) PCCM delivery systems: The PCC Plan. The PCC Plan is a managed care option operated by MassHealth. Members enrolled in the PCC Plan are also enrolled in a single Behavioral Health Program (BHP) contractor, which is a Prepaid Inpatient Health Plan (PIHP), for behavioral health coverage. Members enrolled in the PCC Plan access other services from MassHealth’s FFS network, subject to PCC referral and other utilization management requirements. Each member enrolled in the PCC Plan is assigned to a designated primary care provider (a “Primary Care Clinician,” or “PCC”) from among the PCC Plan’s available PCCs, who provides primary care case management. A member’s PCC provides most primary and preventive care and is responsible for providing referrals for most specialty services and for otherwise coordinating the member’s services. PCC Plan members may receive family planning services from any
F. Delivery System and Coverage for MassHealth Demonstration Programs Coverage Type Delivery System Type Mandatory Voluntary FFS Only Start Date of Coverage**** Standard/Standard ABP Individuals with no party liability (TPL) Managed Care (PCC Plan, MCO, or Accountable Care) X 10 days prior to date of application Adults with TPL Receive wrap benefits via FFS x 10 days to date of application Children with TPL Receive benefits FFS except for behavioral health via mandatory enrollment in BHP PIHP x x 10 days prior to date of application Individuals with qualifying ESI or SHIP Premium assistance with wrap x 10 days prior to date of application
Coverage Type Delivery System Type Mandatory Voluntary FFS Only Date of Coverage**** Kaileigh Mulligan eligible children and children receiving title IV-E adoption assistance Behavioral health is typically provided via BHP PIHP, although a FFS alternative must be available; all other services are offered via Managed Care or FFS. x Kaileigh Mulligan - may be retroactive to first day of third month before month of application, if covered medical services were received during such period, and the applicant would have been eligible at the time services were provided.” Title IV-E adoption assistance - start date of adoption Medically complex children in the care/custody of the DCF Special Kids Special Care MCO x Start date of state custody Children in the care/custody of the DCF or DYS, including medically complex children in the care/custody of the DCF All services are offered via Managed Care or FFS, with the exception of behavioral health which is provided via mandatory enrollment in BHP PIHP unless the child enrolls in an MCO or Accountable Care Partnership Plan x x x Start date of state custody
Coverage Type Delivery System Type Mandatory Voluntary FFS Only Date of Coverage**** in which case, behavioral health is provided through the MCO or Accountable Care Partnership Plan Provisionally eligible pregnant women and children, for an up to 90-day period, before self- attested family income is verified FFS x 10 days prior to date of application if citizenship/immigration status is verified Individuals in the Breast and Cervical Cancer Treatment Program Managed Care X 10 days prior to date of application CommonHealth* Individuals with no TPL Managed Care ** X 10 days to date of application Adults with TPL Receive wrap benefits via FFS x 10 days prior to date of application
Coverage Type Delivery System Type Mandatory Voluntary FFS Only Start Date of Coverage**** Children with TPL Receive benefits FFS except for behavioral health via mandatory enrollment in BHP PIHP x x 10 days to date of application Individuals with qualifying ESI or SHIP Premium assistance with wrap x 10 days prior to date of application Family Assistance for HIV/AIDS* Individuals with no TPL Managed Care ** X 10 days prior to date of application Individuals with TPL Receive wrap benefits via FFS x 10 days prior to date of application
Coverage Type Delivery System Type Mandatory Voluntary FFS Only Start Date of Coverage**** Individuals with qualifying ESI or SHIP Premium assistance with wrap x 10 days prior to date of application Family Assistance for Children*** Individuals with no TPL Managed Care ** X 10 days prior to date of application Individuals with qualifying ESI or SHIP Premium assistance with wrap x 10 days prior to date of application CarePlus Individuals with no TPL Managed Care X 10 days prior to date of application Individuals with TPL Receive wrap benefits via FFS X 10 days prior to date of application Individuals with qualifying ESI or SHIP Premium assistance with wrap X 10 days to date of application