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23 130 CMR: DIVISION OF MEDICAL ASSISTANCE

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

130 CMR 515.000: MASSHEALTH: GENERAL POLICIES

(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.

(B) All policies issued prior to March 15, 1999, need only comply with the minimum standards of 211 CMR 65.05: Minimum Standards for Individual Policies, and the limitations and exclusion provision of 211 CMR 65.06: Mandatory Benefit Offers for Individual Policies, which were effective from April 1, 1989, through September 2, 1999.

(C) Exception. No recovery for nursing facility or other long-term-care services may be made under 130 CMR 515.012(B) if the member (1) was institutionalized; (2) notified the MassHealth agency that they had no intention of returning home; and (3) on the date of admission to a long-term-care institution, 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.

515.015: Reimbursement of Certain Out-of-pocket Medical Expenses

(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 (SSA); and (c) had their initial SSA denial overturned through a reconsideration process, administrative hearing, appeals counsel review, federal court review, or reopening under the SSA rules on administrative finality; or (2) an individual who (a) applied for MassHealth; (b) was denied MassHealth; and (c) had their initial denial overturned by a subsequent decision, MassHealth, the fair hearing process, or the judicial review process.