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16 130 CMR: DIVISION OF MEDICAL ASSISTANCE

Trans. by E.L. 255 Rev. 02/13/26

130 CMR 515.000: MASSHEALTH: GENERAL POLICIES

515.011: Estate Recovery

(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. (2) The estate includes all real and personal property and other assets in the member's probate estate. (3) Notwithstanding 130 CMR 515.011(A)(1) and in accordance with 42 U.S.C. 1396p(b)(B), the MassHealth agency will not recover Medicare cost-sharing benefits described at 42 U.S.C. 1396(a)(10)(E) with dates of payment on or after January 1, 2010, for persons who received such benefits under 130 CMR 505.002: MassHealth Standard, 505.007: Medicare Savings Program (MSP, also called Buy-in), 130 CMR 519.010: Medicare Savings Program (MSP)— Qualified Medicare Beneficiaries (QMBs), or 130 CMR 519.011: Medicare Savings Program (MSP)—Specified Low-income Medicare Beneficiaries (SLMBs) and Qualifying Individuals (QIs). (a) The date of payment for Medicare cost-sharing deductibles, coinsurance, and copayments is the date the MassHealth agency received the claim. (b) The date of payment for premium payments is the date the MassHealth agency paid the premium.

(B) Exceptions (1) Long-term-care Insurance Exception. No recovery for nursing facility or other long-term- care services may be made from the estate of any person who meets the following requirements. (a) The member was institutionalized; and (b) The member notified the MassHealth agency that they had no intent of returning home; and (c) On the date of admission to the long-term-care institution, the member had long-term- care insurance that, when purchased or at any time thereafter, met the requirements of 130 CMR 515.014 and the Division of Insurance regulations at 211 CMR 65.09(1)(e)2. (2) Cost Effectiveness Exception. Effective for dates of death on or after May 14, 2021, in probate estates of members where the probate petition certifies under the penalties of perjury that the total assets in a member’s estate are valued at $25,000 or less, MassHealth has determined that it is not cost effective to pursue recovery. In such estates, MassHealth waives its right to recovery and will not file a claim or otherwise pursue recovery. MassHealth reserves the right to file a claim and recover in such estates if probate filings do not sufficiently identify the value of the estate or if later probate filings or proceedings or investigation identify or establish that the total assets in the estate exceed $25,000.00.