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8 130 CMR: DIVISION OF MEDICAL ASSISTANCE

Trans. by E.L. 258 Rev. 02/13/26

130 CMR 519.000: MASSHEALTH: COVERAGE TYPES

(a) A child 12 months of age or older must have global developmental skills (as defined in 130 CMR 515.001: Definition of Terms) not exceeding those of a 12-month-old child as indicated by a developmental assessment performed by the child's physician or by another certified professional. In addition, the child's developmental skills level must not be expected to improve. (b) A child younger than 12 months old must have global developmental skills significantly below an age-appropriate level and such skills must not be expected to progress at an age-appropriate rate as indicated by a developmental assessment performed by the child's physician or by another certified professional. (c) Regardless of age, the child must also require all of the following: 1. direct administration of at least two discrete skilled nursing services on a daily basis, each of which requires complex nursing procedures as described at 130 CMR 519.007(A)(3); 2. direct management of the child's medical care provided by a physician or directly by someone who is under the supervision of a physician on a monthly basis; 3. assistance in one or more ADLs beyond what is required at an age-appropriate activity level; and 4. any combination of skilled therapeutic services (physical therapy, occupational therapy, or speech and language therapy) provided directly by or under the supervision of a licensed therapist at least five times a week. (5) Premium Assistance for Standard Kaileigh Mulligan. Individuals eligible for MassHealth Standard in 130 CMR 519.007(A) may be eligible for premium assistance if they meet the requirements described in 130 CMR 505.002(N): Access to Employer-sponsored Insurance and Premium Assistance Investigations for Individuals Who Are Eligible for MassHealth Standard and 506.012: Premium Assistance Payments.

(B) Home- and Community-based Services Waiver—Frail Elder (1) Clinical and Age Requirements. The Home- and Community-based Services Waiver allows an applicant or member who is certified by the MassHealth agency or its agent to be in need of nursing-facility services to receive certain waiver services at home if they (a) are 60 years of age or older and, if younger than 65 years old, are permanently and totally disabled in accordance with Title XVI standards; and (b) would be institutionalized in a nursing facility, unless they receive one or more of the services administered by the Executive Office of Aging and Independence under the Home- and Community-based Services Waiver—Frail Elder authorized under § 1915(c) of the Social Security Act. (2) Eligibility Requirements. In determining eligibility for MassHealth Standard and for waiver services, the MassHealth agency determines income eligibility based solely on the applicant’s or member’s income regardless of their marital status. The applicant or member must (a) meet the requirements of 130 CMR 519.007(B)(1)(a) and (b);