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130 CMR: DIVISION OF MEDICAL ASSISTANCE

Trans. by E.L. 213 Rev. 01/01/14 MASSHEALTH FINANCIAL ELIGIBILITY Chapter 520 Page 520.031

520.031: Notification of Potential Eligibility

(A) The MassHealth agency informs the applicant who has excess monthly income that he or she is currently ineligible for MassHealth Standard, Family Assistance, or Limited but may establish eligibility for a six-month period by meeting the deductible. The MassHealth agency informs the applicant in writing of the following: (1) the deductible amount and the method of calculation; (2) the start and end dates of the deductible period; (3) the procedures for submitting medical bills; (4) his or her responsibility to report all changes in circumstances that may affect eligibility or the deductible amount; and (5) that the bills submitted to meet the deductible are the responsibility of the individual and cannot be submitted for MassHealth agency payment.

(B) A member who has established eligibility based upon meeting a deductible is only eligible for MassHealth Standard, Family Assistance, or Limited until the end of the deductible period. At the end of the deductible period, the MassHealth agency notifies the member in writing of a new deductible period and amount, if the countable-income amount continues to exceed applicable income standards.

520.032: Submission of Bills to Meet the Deductible

(A) Criteria. To establish eligibility by meeting a deductible, the individual must submit verification of medical bills whose total equals or exceeds the deductible and that meet the following criteria. (1) The bill must not be subject to further payment by health insurance or other liable third- party coverage, including the Health Safety Net. (2) The bill must be for an allowable medical or remedial-care expense in accordance with 130 CMR 520.032(B). A remedial-care expense is a nonmedical support service made necessary by the medical condition of the individual or the spouse. (3) The bill must be unpaid and a current liability or, if paid, paid during the current six- month deductible period. (4) Any bill or portion of a bill used to meet a deductible may not be applied to any other deductible period. However, any portion of a bill not used to meet the current deductible may be used in a future deductible period. The MassHealth agency will not pay any bills or portions of bills that are used to meet the deductible. These bills remain the responsibility of the applicant.