MASSACHUSETTS TITLE XXI PROGRAM FACT SHEET

Name of Plan:

MassHealth

Date State Plan Submitted:

January 12, 1998 Date State Plan Approved:

May 29, 1998 Date State Plan Effective:

October 1, 1997

Date Amendment #1 Submitted: October 16, 2001 Date Amendment #1 Approved: March 22, 2002 Date Amendment #1 Effective: January 1, 2002

Date Amendment #2 Submitted: June 26, 2002 Date Amendment #2 Approved: September 19, 2002

Date Amendment #3 Submitted: April 8, 2003 Date Amendment #3 Approved June 23, 2003 Date Amendment #3 Effective: March 1, 2003

Date Amendment #4 Submitted: April 24, 2003 Date Amendment #4 Approved September 15, 2003 Date Amendment #4 Effective: November 1, 2002

Date Amendment #5 Submitted: May 2, 2006 Date Amendment #5 Approved July 20, 2006 Date Amendment #5 Effective: July 1, 2006

Background

• On January 12, 1998, Massachusetts submitted its Children’s Health Insurance Program (CHIP) State plan to expand children's access to health coverage by expanding Medicaid eligibility to children in families with incomes up to 150 percent of the Federal Poverty Level (FPL); and, by creating a separate child health program for children in families with incomes between 150 and 200 percent of the FPL. The separate child health program, the Family Assistance Plan, includes both a direct coverage component and a premium assistance program to enable families to participate in their employer-sponsored insurance coverage.

• Effective November 1, 2002, the separate child health program expanded to include coverage for unborn children up 225 percent FPL. The state implemented the program only up to including 200 percent FPL.

• Effective July 1, 2006, Massachusetts expanded eligibility up to 300 percent FPL in their separate child health program.

Amendments

• On October 16, 2001, Massachusetts submitted a CHIP amendment to change the type of health benefits coverage offered for the CHIP premium assistance program from the benchmark of the HMO with the largest insured commercial enrollment to Secretary-approved coverage. This Secretary-approved coverage is the comprehensive coverage approved for children in the State's Medicaid section 1115 demonstration for premium assistance.

• Massachusetts submitted its second amendment on June 28, 2002, to update and amend the CHIP State plan to indicate the State’s compliance with the final SCHIP regulations.

• On April 8, 2003, Massachusetts submitted its third state plan amendment to increase cost sharing in MassHealth. MassHealth Family Assistance premiums increased for families with income from 150 to 200 percent of the FPL from $10 to $12 per child per month with the family maximum increasing from $30 to $36 per month. The State also implemented premiums for children determined presumptively eligible for MassHealth Family Assistance (separate child health program) and for MassHealth CommonHealth (disabled children) enrollees. The monthly premiums for CommonHealth members range from $15 to $35.

• On April 24, 2003, Massachusetts submitted its fourth state plan amendment that expands coverage (MassHealth Healthy Start) to unborn children of pregnant women up to including 225 percent of the Federal Poverty Level (FPL) who are not otherwise eligible for Medicaid. However, the program was only implemented up to including 200 percent FPL.

• On May 2, 2006, Massachusetts submitted its fifth state plan amendment that expands coverage up to and including 300 percent of the Federal Poverty Level (FPL). Children between 200 and 300 percent FPL may be subject to a waiting period of up to six months if they dropped employer-sponsored insurance within the previous six months. Monthly premiums are assessed for this population as follows: 200.1 to 250.0 percent FPL, $20 per child with a $60 family maximum per month; 250.1 to 300.0 percent FPL, $28 per child with an $84 family maximum per month.

Children Covered Under the Program

• The State reported that 200,950 children were ever enrolled in its program during Federal Fiscal Year 2008.

Administration

• The Division of Medical Assistance (DMA) administers the plan.

Health Care Delivery System

• Health care services will be provided through the State’s existing Medicaid managed care delivery network, which consists of: (1) a primary care case management program; (2) Health Maintenance Organizations; and, (3) a mental health and substance abuse managed care contract. Certain services also are provided on a fee-for-service basis and some children receive services through School-Based Health Centers.

• Participants in the Family Assistance premium assistance program obtain services through contractual arrangements with employer-sponsored insurance (ESI) plans.

Benefit Package

• Children enrolled in the State’s CHIP Medicaid expansion program receive the Medicaid benefit package.

• Direct coverage enrollees receive the benchmark benefits coverage (HMO with the largest commercial enrollment in the State).

• Under the premium assistance program, service delivery and access is limited to the terms and contractual arrangements of the family’s ESI, which must meet the basic benefit level as approved by the Secretary under the State’s Medicaid section 1115 demonstration.

• MassHealth Healthy Start enrollees receive the Basic Benefit Level, as approved by the Secretary under the Massachusetts 1115 section Medicaid demonstration project.

Cost Sharing

• Children in families with incomes between 150.1 and 200.0 percent of the FPL covered under the direct coverage option pay a monthly premium of $12 per child, up to a maximum $36 per family. Premiums are charged to children presumptively eligible for the program. No other cost sharing is imposed on these families.

• Family Assistance Expansion (FAEC) families pay monthly premiums as follows: 200.1 to 250.0 percent FPL, $20 per child with a $60 family maximum per month; 250.1 to 300.0 percent FPL, $28 per child with an $84 family maximum per month.

• MassHealth Healthy Start is a program for unborn children of pregnant women that are not eligible for Medicaid with family incomes up to 200.0 percent of the FPL. The following co-pays apply: generic drugs, $3; name brand drugs $4; mental health services directly related to the health of the unborn child (per visit), $2 (0 - 200 percent FPL).

• Premiums and other cost sharing for families with children covered through the premium assistance program vary, depending on the employer’s plan, the employer’s contribution and the family’s income, but total cost sharing will not exceed 5 percent of the family’s income.

• MassHealth CommonHealth is a program for disabled children. The monthly premiums for CommonHealth members range from $15 to $35 based upon family income. CommonHealth members who have family incomes above 150 percent of the FPL are charged $15 per month, and the monthly premiums increase by $5 for each additional 10 percent of the FPL through 200 percent.

Coordination between CHIP and Medicaid

• Massachusetts uses a single application for all MassHealth programs, including those funded under Medicaid and SCHIP, and the DMA evaluates eligibility for all MassHealth programs. Information from the completed application is entered into the State’s automated eligibility system. Using decision trees, the system determines and automatically enrolls the individual in the most comprehensive coverage for which he or she is eligible.

Crowd Out Strategy

• This program builds upon the current Medicaid section 1115 demonstration, which includes provisions to preserve and enhance employer-sponsored insurance (ESI) coverage. Anyone with access to ESI must enroll in ESI, greatly minimizing any possibility of crowd out. The State also offers an incentive payment under the Insurance Partnership to encourage qualified small employers to begin to continue to provide coverage to low-income employees.

• The State monitors the enrollment practices relating to ESI and the direct coverage option. The State is also studying statewide trends in ESI access and employee participation in ESI.

• Children between 200 and 300 percent FPL may be subject to a waiting period of up to six months if they dropped employer-sponsored insurance within the previous six months.

Outreach Activities

• Outreach includes school-based campaigns, community-wide enrollment campaigns, creation and distribution of promotional materials, and funding community-based organizations through mini-grants to assist in enrollment of hard to reach individuals. Activities are also coordinated and initiated with other State agencies. The DMA also developed a multi-media enrollment campaign for targeted underserved populations and to publicize information on how to access MassHealth benefits.

Financial Information

Total FY 2009 CHIP Allotment -- $321,658,700

Enhanced Federal Matching Rate (FY 09) - 65.00%

Date Last Updated: July 29, 2009

MASSACHUSETTS TITLE XXI PROGRAM FACT SHEET

Name of Plan:

MassHealth

Date State Plan Submitted:

January 12, 1998 Date State Plan Approved:

May 29, 1998 Date State Plan Effective:

October 1, 1997

Date Amendment #1 Submitted: October 16, 2001 Date Amendment #1 Approved: March 22, 2002 Date Amendment #1 Effective: January 1, 2002

Date Amendment #2 Submitted: June 26, 2002 Date Amendment #2 Approved: September 19, 2002

Date Amendment #3 Submitted: April 8, 2003 Date Amendment #3 Approved June 23, 2003 Date Amendment #3 Effective: March 1, 2003

Date Amendment #4 Submitted: April 24, 2003 Date Amendment #4 Approved September 15, 2003 Date Amendment #4 Effective: November 1, 2002

Date Amendment #5 Submitted: May 2, 2006 Date Amendment #5 Approved July 20, 2006 Date Amendment #5 Effective: July 1, 2006

Background

• On January 12, 1998, Massachusetts submitted its Children’s Health Insurance Program (CHIP) State plan to expand children's access to health coverage by expanding Medicaid eligibility to children in families with incomes up to 150 percent of the Federal Poverty Level (FPL); and, by creating a separate child health program for children in families with incomes between 150 and 200 percent of the FPL. The separate child health program, the Family Assistance Plan, includes both a direct coverage component and a premium assistance program to enable families to participate in their employer-sponsored insurance coverage.

• Effective November 1, 2002, the separate child health program expanded to include coverage for unborn children up 225 percent FPL. The state implemented the program only up to including 200 percent FPL.

• Effective July 1, 2006, Massachusetts expanded eligibility up to 300 percent FPL in their separate child health program.

Amendments

• On October 16, 2001, Massachusetts submitted a CHIP amendment to change the type of health benefits coverage offered for the CHIP premium assistance program from the benchmark of the HMO with the largest insured commercial enrollment to Secretary-approved coverage. This Secretary-approved coverage is the comprehensive coverage approved for children in the State's Medicaid section 1115 demonstration for premium assistance.

• Massachusetts submitted its second amendment on June 28, 2002, to update and amend the CHIP State plan to indicate the State’s compliance with the final SCHIP regulations.

• On April 8, 2003, Massachusetts submitted its third state plan amendment to increase cost sharing in MassHealth. MassHealth Family Assistance premiums increased for families with income from 150 to 200 percent of the FPL from $10 to $12 per child per month with the family maximum increasing from $30 to $36 per month. The State also implemented premiums for children determined presumptively eligible for MassHealth Family Assistance (separate child health program) and for MassHealth CommonHealth (disabled children) enrollees. The monthly premiums for CommonHealth members range from $15 to $35.

• On April 24, 2003, Massachusetts submitted its fourth state plan amendment that expands coverage (MassHealth Healthy Start) to unborn children of pregnant women up to including 225 percent of the Federal Poverty Level (FPL) who are not otherwise eligible for Medicaid. However, the program was only implemented up to including 200 percent FPL.

• On May 2, 2006, Massachusetts submitted its fifth state plan amendment that expands coverage up to and including 300 percent of the Federal Poverty Level (FPL). Children between 200 and 300 percent FPL may be subject to a waiting period of up to six months if they dropped employer-sponsored insurance within the previous six months. Monthly premiums are assessed for this population as follows: 200.1 to 250.0 percent FPL, $20 per child with a $60 family maximum per month; 250.1 to 300.0 percent FPL, $28 per child with an $84 family maximum per month.

Children Covered Under the Program

• The State reported that 200,950 children were ever enrolled in its program during Federal Fiscal Year 2008.

Administration

• The Division of Medical Assistance (DMA) administers the plan.

Health Care Delivery System

• Health care services will be provided through the State’s existing Medicaid managed care delivery network, which consists of: (1) a primary care case management program; (2) Health Maintenance Organizations; and, (3) a mental health and substance abuse managed care contract. Certain services also are provided on a fee-for-service basis and some children receive services through School-Based Health Centers.

• Participants in the Family Assistance premium assistance program obtain services through contractual arrangements with employer-sponsored insurance (ESI) plans.

Benefit Package

• Children enrolled in the State’s CHIP Medicaid expansion program receive the Medicaid benefit package.

• Direct coverage enrollees receive the benchmark benefits coverage (HMO with the largest commercial enrollment in the State).

• Under the premium assistance program, service delivery and access is limited to the terms and contractual arrangements of the family’s ESI, which must meet the basic benefit level as approved by the Secretary under the State’s Medicaid section 1115 demonstration.

• MassHealth Healthy Start enrollees receive the Basic Benefit Level, as approved by the Secretary under the Massachusetts 1115 section Medicaid demonstration project.

Cost Sharing

• Children in families with incomes between 150.1 and 200.0 percent of the FPL covered under the direct coverage option pay a monthly premium of $12 per child, up to a maximum $36 per family. Premiums are charged to children presumptively eligible for the program. No other cost sharing is imposed on these families.

• Family Assistance Expansion (FAEC) families pay monthly premiums as follows: 200.1 to 250.0 percent FPL, $20 per child with a $60 family maximum per month; 250.1 to 300.0 percent FPL, $28 per child with an $84 family maximum per month.

• MassHealth Healthy Start is a program for unborn children of pregnant women that are not eligible for Medicaid with family incomes up to 200.0 percent of the FPL. The following co-pays apply: generic drugs, $3; name brand drugs $4; mental health services directly related to the health of the unborn child (per visit), $2 (0 - 200 percent FPL).

• Premiums and other cost sharing for families with children covered through the premium assistance program vary, depending on the employer’s plan, the employer’s contribution and the family’s income, but total cost sharing will not exceed 5 percent of the family’s income.

• MassHealth CommonHealth is a program for disabled children. The monthly premiums for CommonHealth members range from $15 to $35 based upon family income. CommonHealth members who have family incomes above 150 percent of the FPL are charged $15 per month, and the monthly premiums increase by $5 for each additional 10 percent of the FPL through 200 percent.

Coordination between CHIP and Medicaid

• Massachusetts uses a single application for all MassHealth programs, including those funded under Medicaid and SCHIP, and the DMA evaluates eligibility for all MassHealth programs. Information from the completed application is entered into the State’s automated eligibility system. Using decision trees, the system determines and automatically enrolls the individual in the most comprehensive coverage for which he or she is eligible.

Crowd Out Strategy

• This program builds upon the current Medicaid section 1115 demonstration, which includes provisions to preserve and enhance employer-sponsored insurance (ESI) coverage. Anyone with access to ESI must enroll in ESI, greatly minimizing any possibility of crowd out. The State also offers an incentive payment under the Insurance Partnership to encourage qualified small employers to begin to continue to provide coverage to low-income employees.

• The State monitors the enrollment practices relating to ESI and the direct coverage option. The State is also studying statewide trends in ESI access and employee participation in ESI.

• Children between 200 and 300 percent FPL may be subject to a waiting period of up to six months if they dropped employer-sponsored insurance within the previous six months.

Outreach Activities

• Outreach includes school-based campaigns, community-wide enrollment campaigns, creation and distribution of promotional materials, and funding community-based organizations through mini-grants to assist in enrollment of hard to reach individuals. Activities are also coordinated and initiated with other State agencies. The DMA also developed a multi-media enrollment campaign for targeted underserved populations and to publicize information on how to access MassHealth benefits.

Financial Information

Total FY 2009 CHIP Allotment -- $321,658,700

Enhanced Federal Matching Rate (FY 09) - 65.00%

Date Last Updated: July 29, 2009

_____________________________________________________________________________

Table of Contents

State/Territory Name: Massachusetts

State Plan Amendment (SPA) #: MA-13-0026

This file contains the following documents in the order listed:

1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages 4) Additional Attachments that are part of the state plan

The complete title XXI state plan for Massachusetts consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: http://medicaid.gov/Medicaid-CHIP-Program-Information/By- Topics/Childrens-Health-Insurance-Program-CHIP/CHIP-State-Program-Information.html

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services (CMs 7500 Security Boulevard, Mail Stop: S2-26-12 CM Ss

Baltimore, Maryland 21244-1850 CENTERS FOR MEDICARE & MEDICAID SERVICES

CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

maf 05 2015 Robin Callahan Deputy Medicaid Director Massachusetts Executive Office of Health and Human Services Office of Medicaid 1 Ashburton Place, 11th floor Boston, MA 02108

Dear Ms. Callahan:

I am pleased to inform you that the Centers for Medicare & Medicaid Services (CMS) has approved Massachusetts Children’s Health Insurance Program (CHIP) State Plan Amendment (SPA), MA-13-0026 submitted on December 30, 2013. This SPA incorporates the MAGI-based eligibility process requirements in accordance with the Affordable Care Act. The effective date of this SPA is October 1, 2013.

The approval of SPA MA-13-0026 includes full approval of your state’s alternative single streamlined paper application. The state is using an interim alternative single streamlined online application and by December 31, 2014, will implement a revised alternative single streamlined online application that addresses CMS concerns outlined in the companion letter issued with this SPA approval.

Enclosed is a copy of the following CS24 state plan pages and attachments to be incorporated within a separate section at the end of Massachusetts approved state plan:

CS24

e Attachment 1 — Statement of use with respect to the alternative single streamlined online application

e Attachment 2 — State of Massachusetts alternative single streamlined paper application

This approval and the attachments supercede the following sections of the current CHIP State Plan:

e Section 4.3: Single Streamlined Application Screen and Enroll Process e Section 4.4: Renewals, Screening by Other Insurance Affordability Programs

Page 2 — Ms. Robin Callahan

The CMS appreciates the significant amount of work your staff dedicated to preparing this State Plan Amendment. Your title XXI project officer is Mr. Martin Burian. He is available to answer questions concerning this amendment and other CHIP-related issues. Mr. Burian’s contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services Mail Stop: S2-01-16

7500 Security Blvd.

Baltimore, MD 21244-1850

Telephone: (410) 786-3246

Facsimile: (410) 786-5882

E-mail: Martin.Burian@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Mr. Burian and to Mr. Richard McGreal, Associate Regional Administrator (ARA) in our Boston Regional Office. Mr. McGreal’s address is:

Mr. Richard McGreal

Office of the Regional Administrator JFK Federal Building, Suite 2325 Boston, MA 02203-0003

If you have additional questions, please contact Barbara K. Richards, Acting Director, Division of State Coverage Programs at 410-786-5920.

We look forward to continuing to work with you and your staff.

Sincerely, Eliot Fishman Director Enclosure ce:

Richard McGreal, Associate Regional Administrator, CMS Boston Region I

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services (CMS

7500 Security Boulevard, Mail Stop: S2-26-12 CM Ss (CENTERS FOR MEDICARE & MEDICAID SERVICES

Baltimore, Maryland 21244-1850

Children and Adults Health Programs Group

CENTER FOR MEDICAID & CHIP SERVICES

MAY 05 2014

Robin Callahan

Deputy Medicaid Director

Massachusetts Executive Office of Health and Human Services Office of Medicaid

1 Ashburton Place, 11th floor

Boston, MA 02108

RE: CS24 — Eligibility Process State Plan Amendment (SPA), MA-13-0026 Dear Ms. Callahan:

This letter is being sent as a companion to the Centers for Medicare & Medicaid Services (CMS) approval of state plan amendment (SPA) MA-13-0026, which was submitted to CMS on December 30, 2013. Our review of this submission included a review of the alternative single streamlined online application developed by the state.

Until December 31, 2014, the state is using an interim alternative single streamlined online application. This interim application needs to be revised to reflect the following changes.

Necessary changes Date by which changes will be completed

Questions regarding residency and health December 31, 2014 conditions will only be asked of applicants.

Questions on access to employer-sponsored December 31, 2014 coverage, when needed for APTC eligibility, will ask about the premium amount of the lowest-cost option offered by the employer.

Please submit the revised alternative single streamline online application to CMS for review no later than December 1, 2014, to ensure approval by December 31, 2014.

Page 2 — Ms. Robin Callahan

We continue to be available to provide technical assistance. If you have any questions about your application, please contact Victoria Collins at Victoria.Collins@cms.hhs.gov or (410) 786-2167. We look forward to continuing to work with you and your staff.

Sincerely,

arbara K. Ric Acting Director Division of State Coverage Programs

S

ce: Richard McGreal, Associate Regional Administrator, CMS Boston Region I

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility MA.0696.R00.00 - Oct 01, 2013 Home Logout Finder Save Validate Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Massachusetts State Funds: $ Federal Funds: $ Submitted By: Alison Kirchgasser Last Revision Date: Oct 2, 2014 Submit Date: Dec 30, 2013 Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. MA-13-0026 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 10/01/2013 (mm/dd/yyyy) Federal Statute/Regulation Citation 2102(b)(3) & 2107(e)(1)(O) of the SSA and 42 CFR 457, subpart C Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Character Count:1959 out of 2000 MA, through this amendment, seeks approval for its alternative single streamlined app. for all insurance affordability programs. This application was developed in accordance with section 1413(b)(1) (A) of the ACA. MA continues to make changes to the online app. based on field testing and federal guidance. Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 11/02/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: CMS 179 11/02/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

USE OF THE ALTERNATIVE SINGLE STREAMLINED APPLICATION

O Paper Application Online Application

TRANSMITTAL NUMBER: STATE:

MA-13-0026 Massachusetts

Through December 31, 2014, the state is using an interim alternative single streamlined application. After December 31, 2014, the state will use a revised alternative single streamlined application. The revised application will address the issues outlined in the CMS letter, which was issued with the approval of this state plan amendment, concerning the state’s application. The revised application will be incorporated by reference into the state plan.

cms. CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

2102(b)(3) & 2107(e)(1)(O) of the SSA and 42 CFR 457, subpart C

The CHIP Agency meets all of the requirements of 42 CFR 457, subpart C for application processing, eligibility screening and enrollment.

Application Processing

Indicate which application the agency uses for individuals apply ing for coverage who may be eligible based on the applicable modified adjusted gross income standard:

oO The single, streamlined application developed by the Secretary in accordance with section 1413(b)(1)(A) of the Affordable Care Act.

x An alternative single, streamlined application developed by the state and approved by the Secretary in accordance with < section 1413(b)(1)(B) of the Affordable Care Act.

An alternative application used to apply for multiple human service programs approved by the Secretary, provided that the (] agency makes readily available the single or alternative application used only for insurance affordability programs to individuals seeking assistance only through such programs.

The agency's procedures permit an individual, or authorized person acting on behalf of the individual, to submit an application via the internet website described in CF R 457.340(a), by telephone, via mail, in person and other commonly available electronic means.

The agency accepts applications in the following other electronic means.

Other electronic means:

Name of method Description

Fax Applicants are able to fill out a paper application and fax it to the agency.

Screen and Enroll Process

The CHIP Agency has coordinated eligibility and enrollment screening procedures in place that are applied at time of initial application, periodic redeterminations, and follow-up eligibility determinations. The procedures ensure that only targeted low- income children are provided CHIP coverage and that enrollment is facilitated for applicants found to be potentially eligible for other insurance affordability programs.

&

Procedures include:

SPA# MA-13-0026 Approval Date: MAY 0 3 201s Effective Date: October 1, 2013 Page 1 of 3

CHIP Eligibility

im Screening of application to identify all individuals eligible or potentially eligible for CHIP or other insurance affordability programs; and

ri Income eligibility test, with calculation of household income consistent with 42 CFR 457.315 for individuals identified as potentially eligible for Medicaid or other insurance affordability programs based on household income; and

fa Screening process for individuals who may qualify for Medicaid on a basis other than having household income at or below the applicable MAGI standard, based on information in the single streamlined application.

The CHIP agency has entered into an arrangement with the Exchange to make eligibility determinations for advanced Yes premium tax credits in accordance with section 1943(b)(2) of the SSA.

Redetermination Processing

wl Redeterm inations of eligibility for individuals whose financial eligibility is based on the applicable modified adjusted gross income standard are performed as follows, consistent with 42 CFR 457.343:

[Once every 12 months.

ial Without requiring information from the individual if able to do so based on reliable information contained in the individual's account or other more current information available to the agency.

If the agency cannot determine eligibility solely on the basis of the information available to it, or otherwise needs additional [lf information to complete the redetermination, it provides the individual with a pre-populated renewal form containing the information already available.

Screening by Other Insurance Affordability Programs

The CHIP Agency provides assurance that it has adopted procedures to accept and process electronic accounts of individuals screened as potentially eligible for CHIP by other insurance affordability programs in accordance with the requirements of 42

CFR 457.34 8(b) and to determine eligibility in accordance with 42 CFR 457.340 in the same manner as if the application had been submitted directly to, and processed by the state.

The CHIP Agency elects the option to accept CHIP eligibility decisions made by the Exchange or other agencies administering insurance affordability programs as provided in 42 CFR 457.348 and to furnish CHIP in accordance with requirem ents of 42

CFR 457.340 to the same extent and in the same manner as if the applicant had been determined by the state to be eligible for CHIP.

ba

Pas

Check all types of agencies that apply:

The Exchange

Medicaid

(1 Other agency administering insurance affordability programs

The CHIP Agency has entered into an agreement with agencies administering other insurance affordability programs to fulfill the requirements of 457.348(b) and will provide this agreement to the Secretary upon request.

MAY 05 2014

SPA# MA-13-0026 Approval Date: Effective Date: October 1, 2013 Page 2 of 3

(CMS CHIP Eligibility

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

V.20130709

MAY 05 2016

SPA# MA-13-0026 Approval Date:

Effective Date: October 1, 2013 Page 3 of 3

OFFICIAL

Application for Health Coverage >, and Help Paying Costs Instructions

(elles CONNECTOR

Commonwealth of Massachusetts | EOHHS

Please read these instructions before you fill out the application.

led

Apply faster online! Go to: MAhealthconnector.org, You will get results quickly. You can create a secure online account where you can see copies of notices and get important news fast.

Ld

Please read the attached Member Booklet carefully before you fill out the application. Keep the booklet.

It may answer questions you have later.

Use this application to apply for subsidized health coverage

This is your application for MassHealth, the Children’s Medical Security Plan (CMSP), the Massachusetts Health Connector (Health Connector) plans, and the Health Safety Net (HSN). MassHealth gives health care coverage and helps pay for health insurance premiums for families, children, and individuals. The Massachusetts Health Connector is the state’s marketplace for health and dental insurance. The Health Connector can help you shop for and enroll in insurance plans from leading health insurers in the state. You can also find out through the Health Connector if you are eligible for any programs that help you pay for health insurance premiums and lower your out-of-pocket health care costs. For more information about programs that are available through the Health Connector, see pages 3 and 19-20 in the Member Booklet.

For information about the CMSP or the HSN, see page 18 for CMSP and pages 21-22 for HSN in the Member Booklet.

The kind of health coverage you get depends on your household size, income, and other circumstances. This information helps us make sure everyone gets the best coverage. Fill out all information for each person in your household. After you fill out your application and submit it, we will review it. If you ace eligible, you will get the most complete coverage available.

Who can use this application

This application is for people who need health insurance and/ or help paying for it, and who:

live in Massachusetts, ® are not living in or about to go into a nursing home, and * are under age 65.

This application may also be used by people of any age who are: * parents of children under age 19, adult relatives living with and taking care of children under age 19 when neither parent is living in the home, or ¢ disabled and either: ¢ work 40 or more hours a month or are currently working and have worked at least 240 hours in the

six months immediately before the month of the application, or ° not working (only if under age 65). If this application is not for you, call MassHealth Customer Service at 1-800-841-2900 (TTY: 1-800-497-4648 for people who are deaf, hard of hearing, or speech disabled). ”

Tell us about your household

Tell us about all household members who live with you

and are applying for health coverage. You must answer all questions and fill out all supplements (if applicable) for each household member who is applying.

Do include ° Yourself * Your spouse * Your natural, adoptive, or step children under age 19 * Your unmarried partner if you have children together who are under age 19 * Your unmarried partner’s children who live with you and who are under age 19, if you also include your unmarried partner © Anyone you include on your tax return (even if they do not live with you) * Anyone your unmarried partner included on his or her tax return (even if they do not live with you), if you also include your unmarried partner * Anyone else under age 19 who you live with and take care of

You do not have to include

* Your unmarried partner, unless you have children together

* Your unmarried partner’s children, unless they live with you

* Your parents who you live with and who file their own taxes if they do not claim you as a tax dependent (if you are aged 19 or older)

* Other adult relatives who you do not claim as a tax dependent

© ACA-2 (Rev. 01/14)

Massachusetts

over B

Effective Date: 10/01/2013

OFFICIAL

Filling out the application . Start with yourself, and then add other adults and children. If you have more than four people in your household including yourself, you will need to make copies of the pages for Person 4 before you fill them out, and attach them to the application.

Generally, you do not need to give us the citizenship or immigration statuses, or the social security numbers (SSNs) of household members who are not applying. However, you must give us an SSN or proof that one has been applied for for every household member who is applying, unless one of the following exceptions applies. * -You or any household member has a religious exemption as described in federal law. * You or any household member is eligible only for a nonwork SSN. * You or any household member is not eligible for an SSN. Unless an exception applies, we need SSNs for all persons applying for health coverage. An SSN is optional for persons not applying for health coverage, but giving us an SSN can speed up the application process. We use SSNs to check income and other information to see who is eligible for help with health coverage costs. If someone does not have an SSN or needs help getting one, call the Social Security Administration at 1-800-772-1213 (TTY: 1-800-325-0778 for people who are deaf, hard of hearing, or speech disabled), or go to socialsecurity.gov. Please see the Member Booklet for more information. We keep the information provided to us private, and only use and disclose it in accordance with applicable law. We will try to prove your information and determine eligibility with matches through federal data sources, such as the Social Security Administration (SSA), the Internal Revenue Service (IRS), the Department of Homeland Security (DHS), and state data sources, such as the Department of Revenue (DOR), the Registry of Motor Vehicles (RMV), and other state-run public programs. If we are not able to prove your information or need more information, we will contact you. We may give you provisional coverage for up to 90 days during the time period that we are waiting for proof of information (other than a determination of disability). See the Member Booklet for more information about disability.

Massachusetts

To help us see if you are eligible:

* fill out the application completely,

* besure to tell us in Part 3 about health insurance you may be able to get through your job,

© fill out the parts of Supplement A that apply, if you answer yes to any questions about injury, illness, disability, accommodation, or applying due to an accident or injury caused by someone else; do not leave any answer blank,

° answer all questions in Part 4 and in Supplement C about any health insurance that you may have now, and

© fill out Supplement B, if you or any household member is an American Indian or Alaska Native.

Remember, you must read, sign, and date the Rights and Responsibilities and Signature pages (Part 6, pages 16-18) after you have filled out the application.

When we get the signed and dated application, we will _ review it. If we need more information after we complete the data matches, we will contact you. Once we get all needed information, we will make a decision about your eligibility. We will send you a written notice about this decision. If you need medical care and you pay for it before you get an approval notice from us, you may be able to get a refund from your health care provider for what you paid.

To start filling out this application, go to page 1.

You can submit your application in any of the following ways.

© Sign on to your account at www.MAhealthconnector.org. You can create an online account if you do not already have one. * Send your filled-out, signed application to: Health Insurance Processing Center P.O. Box 4405 Taunton, MA 02780.

© Fax your filled-out, signed application to: 617-887-8770.

* Call MassHealth Customer Service at 1-800-841-2900 (TTY: 1-800-497-4648 for people who are deaf, hard of hearing, or speech disabled).

If you have any questions about this application or the information you need to send, please call MassHealth Customer Service at 1-800-841-2900 (ITY: 1-800-497-4648

for people who are deaf, hard of hearing,

or speech disabled).

Effective Date: 10/01/2013

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Application for Health Coverage oe ; and Help Paying Costs IG CONNECTOR

Commonwealth of Massachusetts | EOHHS

Please print clearly. Be sure to answer all questions. Fill out all parts of the application and all supplements that apply. Ifyou need more space, attach a separate piece of paper to the application. Put Person 1’s name and social security number at the top of any attached paper.

We need one adult in your household to be the contact person for your application (Person 1).

wie Tell us about you (Person 1)—Fill out this part for yourself.

1.Firstname Middle initial +Last name Suffix (ex., Jr.) Relationship to you SELF

2. Home street address Apt.#

City State Zip code 3. Are you homeless? 4, Mailing address (if different from home address)

(Jves [[}No

City State Zip code 5. Telephone number Other telephone number 6. Email address 7. Date of birth (mm/dd/yyyy) 8.Gender 9, Written language choice 10. Spoken language choice

Om CF

We needa social security number for every person applying for health coverage who has one, An SSN is optional for persons not applying for health coverage, but giving us an SSN can speed up the application process. We use SSNs to check income and other information to see who is eligible for help with health coverage costs. If someone needs help getting an SSN, call the Social Security Administration at 1-800-772-1213 (TTY: 1-800-325-0778 for people who are deaf, hard of hearing, or speech disabled), or go to socialsecurity.gov. Please see the application instructions or the Member Booklet for more information.

11. Doyouhave a social security number (SSN)? [_]Yes [_]No If yes, give us the number. - - (Optional, if not applying) ifno, check one of the reasons below. (Applied, but have not received SSN [Religious exemption [_]Only eligible for nonwork SSN {Not eligible to get SSN [_] Eligible for SSN, but have not applied 12. Will you file a federal income tax returnnext year? [_]Yes [_]No (To get a tax credit, you must file taxes for the year you are requesting benefits. You can still apply for health coverage even if you do not file a federal income tax return.) If yes, answer 12.a., 12.b., and 12.c. if no, answer 12.c, 12.a. Will you file jointly with a spouse? [_]Yes [_]No_ ifyes, name of spouse: (lf married, you must file federal taxes jointly for the year you are requesting benefits.) 12.b. Will you claim any dependents on your income tax return? [_]Yes [_]No Ifyes, list name(s) of dependents: 12.c, Will someone else claim you as a dependent on his or her tax return? [Yes [_]No

if yes, name of tax filer: How are you related to the tax filer? 18, Are you pregnant? [_]Yes [_]No 13.a. Ifyes, how many children are you expecting? 13.b. What is the due date? (mm/dd/yyyy) ACA-2 (Rev. 01/14) 1 Please go to the next page. >

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14. Are you applying for health coverage for yourself? [_]Yes [_]No

Ifno, go to Part 2: Tell us about other people in this household on page 3. if yes, answer all questions below for Person 1 (yourself). 15. Are you living in Massachusetts and planning to stay? [__]Yes [_]No 16. Do you live with at least one child under age 19? [Yes [—]No 16.a. tyes, are you the main person taking care of this child? [—]Yes [~]No 17. Are you injait or prison? [_]Yes [_]No lf1no, go to the next question. 17a. Ifyes, are you (Check one,): [1Convicted? What is your expected release date? (mm/dd/yyyy) [Not convicted? (For example: confined only) 18. Did you age out of faster care at the age of 18 or older? [ |Yes [__]No Ifyes, were you enrolled in Medicaid when you aged out of foster care? [ |Ves [Jo

7

“Aging out” means the individual was in the custody of a state child welfare agency in any state or of a tribe in any state when he or she turned 18 years of age, or older if the individual decided to stay in placement after age 18. 19. Are you a U.S. citizen, national, or naturalized U.S. citizen? [__]Yes [_]No If yes, go to Question 20. 19.a.|fno, do you have an eligible immigration status? (See the Member Booklet for more information.) [_]Yes [No [_ |Noresponse ”

Ifno or no response, you may get only one or more of the following: MassHealth Standard (if pregnant), MassHealth Limited, the Children's Medical Security Plan (CMSP), or the Health Safety Net (HSN). Go to Question 20.

19, Ifyes, do you have an immigration document? [~]Yes [_]No

We will try to prove your immigration status. Please list all the immigration statuses and/or conditions that have applied to you since you entered the U.S. (See the Member Booklet for more information about immigration statuses and documents.)

immigration status

Status award date* (mm/dd/yyyy)} Immigration document type Document iD number

* For battered persons, status award date is date petition was approved as properly filed. 19.c. Did you come to live in the U.S. before August 22,1996? [_]Yes [_]No

19.d, Did you use a different name to get your immigration status? [Yes [_|No If yes, what is it? First name Middle name Last name Suffix (ex., Jr)

19.e. Are you an honorably discharged veteran or an active-duty member of the U.S. military? [_]Yes [_]No 19. Are you a spouse or unremarried surviving spouse of an immigrant who is an honorably discharged veteran or an active-duty member ofthe U.S. military? [_]Yes [_]No 19.g. Are you an unmarried dependent child of an immigrant who is an honorably discharged veteran or an active-duty member of the U.S. military? [_]¥es [~]No 20. Do you have an injury, iiness, or disability (including a disabling mental health condition) that has lasted or is expected to last for at least 12 months? (iflegally blind, answer yes.) [_]Yes [_]No If no, go to the next question. If yes, fill out Part A of Supplement A: Illness, Disability, or Accommodation on page 19, 21. Do you need reasonable accommodation(s) because of a disability or injury? [_]¥es [_]No If no, go to the next question. If yes, fill out Part B of Supplement A: Illness, Disability, or Accommodation on page 19. 22. Are you applying because of an accident or injury that someone else might be responsible for? [_]Yes [_}No Ifno, go to the next question. If yes, fill out Part C of Supplement A: {liness, Disability, or Accommodation on page 19.

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23. Do you have breast or cervical cancer? [_]Yes [_]No (Optional) MassHealth has special coverage rules for people who need treatment for breast or cervical cancer, If no, go to the next question. If yes, we will send you a certificate to be filled out by your doctor to prove your breast or cervical cancer diagnosis. Then MassHealth can see if your MassHealth benefits give you the most coverage possible. 24. Are you HIV positive? [es [No (Optional) If you are HIV positive, you may be eligible for additional coverage or benefits. If no, go to the next question. If yes, you will need to give us proof of your HIV-positive status. Then MassHealth can see if your MassHealth benefits give you the most coverage possible. 25. Did you ever get Supplemental Security Income (SSI)? [__|Yes [_]No If no, go to the next question. If yes, answer questions 25.a, and 25.b. 25.a. When did you last get SSI? (mm/yyyy) 25.b. Do you (Please check one.): [_]live alone? [_Jlivewith a spouse? [_Jlive ina rest home? live and share expenses with another or others (not a spouse)? [_]live in an assisted living facility? L live in someone else's home? 26. Check the box below that best describes you. (Optional) [_JAmerican Indian/Alaska Native (Mashpee Wampanoag) [__]American Indian/Alaska Native (Wampanoag Tribe of Gay Head (Aquinnah)) (_JAmerican Indian/Alaska Native (Other Tribal Nation) (Asian [_]Black or African American [_]Hispanic/Latino/Black [_]Hispanic/Latino/White [_]Hispanic/Latino/Other {__|Native Hawaiian or other Pacific Islander [_]White [_]Other 27. Ifyou are an American Indian or Alaska Native, fill out Supplement B: American Indian (Al)/Alaska Native (AN) on page 20. American Indians and Alaska Natives may not have to pay premiums or copayments, and may get special monthly enrollment periods. Go to Part 2 to add other household members, if needed, or go to Part 3: Current Job and Income Information on page 10.

Tell us about other people in this household

Fill out this part for your spouse or partner and children who live with you and/or anyone included on your federal income tax return, if you file one. See the application instructions for more information about who to include. If you do not file an income tax return, remember to add other persons who live with you.

Person 2 Firstname Middle initial ~Last name Suffix (ex.,Jr.) | Relationship to Person 1 2. Home street address Apt. #

City State Zip code 3.1s Person 2 homeless? 4, Mailing address (if different from home address)

Ces [[]No

City State Zip code 5, Telephone number

6. Email address 7.Date of birth (mm/dd/yyyy)| 8. Gender 9, Written language choice —_‘| 10. Spoken language choice

Cm (F We need a social security number for every person applying for health coverage who has one. Please see the application instructions or the Member Booklet for more information. 11. Does Person 2 havea social security number (SSN)? [_]¥es [_]No

Ifyes, give us the number. - - (Optional, if not applying)

If no, check one of the reasons below. [_JApplied, but have not received SSN [Religious exemption [__]Only eligible for nonwork SSN [_JNoteligible to get SSN [__] Eligible for SSN, but have not applied

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12. Will Person 2 file a federal income tax return next year? [_ Yes [_]No

(To get a tax credit, Person 2 must file taxes for the year he or she is requesting benefits, Person 2 can still apply for health coverage even if he or she does not file a federal income tax return.) If yes, answer 12.a., 12.b., and 12.c. If no, answer 12.c,

12.a.Will Person 2 file jointly with a spouse? [_]Yes [_]No Ifyes, name of spouse: _,

(|f married, Person 2 must file federal taxes jointly for the year he or she is requesting benefits.) 12.b, Will Person 2 claim any dependents on his or her income tax return? [_]Yes [_]No

If yes, list name(s) of dependents:

12.c. Will someone else claim Person 2 as a dependent on his or her tax return? [_]Yes [_]No How is Person 2 related to the tax filer?

If yes, name of tax filer:

13. ts Person 2 pregnant? [~ ]Yes [_]No

13.a. If yes, how many children is she expecting?

13.b. What is the due date? (mm/dd/yyyy)

14. Is Person 2 applying for health coverage? [__|Yes [_]No If no, go to Person 3 or Part 3: Current Job and Income Information on page 10. If yes, answer all questions below for Person 2.

15. Is Person 2 living in Massachusetts and planning to stay? [" ]Yes [_]No

16. Does Person 2 live with at least one child under age 19? [_]Yes [_]No

16.a. f yes, is Person 2 the main person taking care of this child? [__]Yes [_]No

17. IsPerson 2 in jail or prison? [_]Yes [_]No

Ifno, go to the next question. T7a. If yes, is Person 2 (Check one.):

[_1Cénvicted? What is his or her expected release date? (mm/dd/yyyy)

[Not convicted? (For example: confined only)

18. Did Person 2 age out of foster care at the age of 18 or older? [_]Yes [_]No

tt yes, was this person enrolled in Medicaid when he or she aged out of foster care? [__]¥es [—]No

“Aging out” means the individual was in the custody of a state child welfare agency in any state or of a tribe in any state when he or she turned 18 years of age, or older if the individual decided to stay in placement after age 18.

19. |s Person 2a US. citizen, national, or naturalized U.S. citizen? [_]Yes [_]No

If yes, go to Question 20.

19.a.If no, does Person 2 have an eligible immigration status? (See the Member Booklet for more information.) [yes [No f No response

[fo or no response, Person 2 may get only one or more of the following: MassHealth Standard (if pregnant), MassHealth Limited, the Children’s Medical Security Plan (CMSP), or the Health Safety Net (HSN). Go to Question 20.

19.b. if yes, does Person 2 have an immigration document? [_]Yes [_]No

We will try to prove Person's 2 immigration status. Please list all the immigration statuses and/or conditions that have applied to Person 2 since he or she entered the U.S. (See the Member Booklet for more information about immigration statuses and documents.)

Immigration status

Status award date* (mm/dd/yyyy)

Immigration document type

Document ID number

* For battered persons, status award date is date petition was approved as properly filed. 19.c. Did Person 2 come to live in the U.S. before August 22, 1996? [__]Yes [_]No

19.d. Did Person 2 use a different name to get his or her immigration status? [__]Yes [_]No !f yes, what Is it?

First name

Middle name

Last name

Suffix (ex., Jr.)

19. Is Person 2 an honorably discharged veteran or an active-duty member of the U.S. military? [_]Yes [_]No

19f.1s Person 2 a spouse or unremarried surviving spouse of an immigrant who is an honorably discharged veteran or an active-duty member ofthe U.S. military? [_]Yes [_]No

ACA-2 (Rev. 01/14)

Massachusetts

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19.g. Is Person 2 an unmarried dependent child of an immigrant who is an honorably discharged veteran or an active-duty member ofthe US. military? [~]Yes [“]No 20. Does Person 2 have an injury, illness, or disability (including a disabling mental health condition) that has lasted or is expected to last for at least 12 months? (If legally blind, answer yes.) [_]Yes [_]No , if no, go to the next question. If yes, fill out Part A of Supplement A: Illness, Disability, or Accommodation on page 19. 21, Does Person 2 need reasonable accommodation(s) because of a disability or injury? [~ ]Yes [__]No if no, go to the next question. ifyes, fill out Part B of Supplement A: {liness, Disability, or Accommodation on page 19. 22. Is Person 2 applying because of an accident or injury that someone else might be responsible for? {_]Yes [_]No If no, go to the next question. If yes, fill out Part C of Supplement A: Illness, Disability, or Accommodation on ipage 19. 23. Does Person 2 have breast or cervical cancer? [Yes [_|No (Optional) MassHealth has special coverage rules for people who need treatment for breast or cervical cancer. [fno, go to the next question. If yes, we will send a certificate to be filled out by Person 2's doctor to prove his or her breast cancer or her cervical cancer diagnosis, Then MassHealth can see if Person 2's MassHealth benefits give him or her the most coverage possible, 24. Is Person 2 HIV positive? [_]Yes [_]No (Optional) If Person 2 is HIV positive, he or she may be eligible for additional coverage or benefits, : Ifo, go to the next question. If yes, Person 2 will need to give us proof of his or her HIV-positive status. Then MassHeaith can see if Person 2's MassHealth benefits give him or her the most coverage possible, 25. Did Person 2 ever get Supplemental Security Income (SSI)? [_]Yes [_]No If no, go to the next question. If yes, answer questions 25.2. and 25.b. 25.a. When did Person 2 last get SSI? (mm/yyyy) 25.b. Does Person 2 (Please check one.): [_]live alone? Tiive with a spouse? [—]liveina rest home? [live and share expenses with another or others (nota spouse)? [_]live in an assisted living facility? [__live in someone else's home? 26. Check the box below that best describes Person 2. (Optional) {_]American Indian/Alaska Native (Mashpee Wampanoag) [_]American Indian/Alaska Native (Wampanoag Tribe of Gay Head (Aquinnah)) {JAmerican Indian/Alaska Native (Other Tribal Nation) [_JAsian [_]Black or African American [_]Hispanic/Latino/Black [_ ]Hispanic/Latino/White [_]Hispanic/Latino/Other [_]Native Hawaiian or other Pacific Islander [_]White [_]Other 27, if Person 2is an American Indian or Alaska Native, fill out Supplement B: American Indian (Al)/Alaska Native (AN) on page 20. American Indians or Alaska Natives may not have to pay premiums or copayments, and may get special monthly enrollment periods. Continue adding other household members, if needed, or go to Part 3: Current Job and Income Information on page 10.

Person 3 L Firstname Middle initial ~Last name Suffix (ex., Jr.) | Relationship to Person 1 2. Home street address Apt# - Relationship to Person 2 City State Zip code 3.[s Person 3 homeless? 4, Mailing address (if different from home address) (ves []No City State Zip code 5. Telephone number 6. Email address 7 Date of birth (mm/dd/yyyy)} 8. Gender 9.Written language choice —_| 10. Spoken language choice

Cm CF

We need a social security number for every person applying for health coverage who has one. Please see the application instructions or the Member Booklet for more information.

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11. Does Person 3 have a social security number (SSN)? [_]Yes [_]No Ifyes, give us the number. - - (Optional, if not applying) {f no, check one of the reasons below. [JApplied, but have not received SSN [__]Religious exemption [_] Only eligible for nonwork SSN (_JNoteligibleto get SSN [7] Eligible for SSN, but have not applied

12. Will Person 3 file a federal income tax return next year? [_]Yes [_]No (To get a tax credit, Person 3 must file taxes for the year he or she is requesting benefits. Person 3 can still apply for health coverage even if he or she does not file a federal income tax return.) If yes, answer 12.a., 12.b., and 12.¢, If no, answer 12.c. 12.a. Will Person 3 file jointly with a spouse? [_]Yes [_]No Ifyes, name of spouse: (If married, Person 3 must file federal taxes jcintly for the year he or she is requesting benefits.) 12.b, Will Person 3 claim any dependents on his or her income tax return? [_]Yes [_]No If yes, list name(s) of dependents: 12.c. Will someone else claim Person 3 as a dependent on his or her tax return? [_]Yes [_]No If yes, name of tax filer: How is Person 3 related to the tax filer? 13. IsPerson 3 pregnant? [_]Yes [_]No 13.a. If yes, how many children is she expecting? 14. Is Person 3 applying for health coverage? [__]Yes [_]No {fno, go to Person 4 or Part 3: Current Job and Income Information on page 10. if yes, answer all questions below for Person 3. 15. Is Person 3 living in Massachusetts and planning to stay? [_]Yes [No 16. Does Person 3 live with at least one child under age 19? [_]¥es [_]No 16.a. Ifyes, is Person 3 the main person taking care of this child? [—]Yes [~]No 17, IsPerson 3 injail or prison? [_]Yes [_]No If no, go to the next question. TZa. If yes, is Person 3 (Check one.): [[1Convicted? What is his or her expected release date? (mm/dd/yyyy) [Not convicted? (For example: confined only) 18. Did Person 3 age out of foster care at the age of 18 or older? [_]Yes |_]No If yes, was this person enrolled in Medicaid when he or she aged out of foster care? [yes O No “Aging out" means the individual was in the custody of a state child welfare agency in any state or of a tribe in any state when he or she turned 18 years of age, or older if the individual decided to stay in placement after age 18. 19, Is Person 3. US. citizen, national, or naturalized U.S. citizen? [_]Yes [_]No If yes, go to Question 20. 19..If no, does Person 3 have an eligible immigration status? (See the Member Booklet for more information.) [__]Yes [_]No [__|No response ifno or no response, Persan 3 may get only one or more of the following: MassHealth Standard (if pregnant), MassHealth Limited, the Children’s Medical Security Plan (CMSP), or the Heaith Safety Net (HSN). Go to Question 20. 19. Ifyes, does Person 3 have an immigration document? [_]Yes [_]No

13.b, What is the due date? (mm/dd/yyyy)

We will try to prove Person's 3 immigration status. Please list all the immigration statuses and/or conditions that have applied to Person 3 since he or she entered the U.S. (See the Member Booklet for more information about immigration statuses and documents.)

Immigration status

Status award date* (mm/dd/yyyy)} Immigration document type Document {D number

* For battered persons, status award date is date petition was approved as properly filed. 19.c. Did Person 3 come to live in the U.S. before August 22, 1996? [_]Yes [_]No

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19.d. Did Person 3 use a different name to get his or her immigration status? [_]Yes [|No If yes, what is it? First name Middle name Last name Suffix (ex., Jr.)

19. s Person 3 an honorably discharged veteran or an active-duty member of the U.S. military? [“]Yes [—]No 19.1s Person 3 a spouse or unremarried surviving spouse of an immigrant who is an honorably discharged veteran or an active-duty member ofthe U.S. military? [_]Yes [~]No 19.g.1s Person 3 an unmarried dependent child of an immigrant who is an honorably discharged veteran or an active-duty member ofthe U.S. military? [“]¥es [_]No 20. Does Person 3 have an injury, illness, or disability (including a disabling mental health condition) that has lasted or is expected to last for at least 12 months? (if legally blind, answer yes.) [~]Yes [~]No If no, go to the next question. If yes, fill out Part A of Supplement A: Illness, Disability, or Accommodation on page 19. 21. Does Person 3 need reasonable accommodation(s) because of a disability or injury? [_]Yes [—]No If no, go to the next question. If yes, fill out Part B of Supplement A: Illness, Disability, or Accommodation on page 19. 22. Is Person 3 applying because of an accident or injury that someone else might be responsible for? [__]Yes [_]No If no, go to the next question. If yes, fill out Part C of Supplement A: Illness, Disability, or Accommodation on page 19. 23. Does Person 3 have breast or cervical cancer? [_]Yes [_]No (Optional) MassHealth has special coverage rules for people who need treatment for breast or cervical cancer. If no, go to the next question. If yes, we will send a certificate to be filled out by Person 3's doctor to prove his or her breast cancer or her cervical cancer diagnosis. Then MassHealth can see if Person 3's MassHealth benefits give him or her the most coverage possible, 24, \s Person 3 HIV positive? [_]Yes [_]No (Optional) It Person 3 is HIV positive, he or she may be eligible for additional coverage or benefits. If no, go to the next question. If yes, Person 3 will need to give us proof of his or her HIV-positive status. Then MassHealth can see if Person 3's MassHealth benefits give him or her the most coverage possible. 25. Did Person 3 ever get Supplemental Security income (SSI)? [__Yes [_]No If no, go to the next question. If yes, answer questions 25.a. and 25.b. 25.a.When did Person 3 last get SSI? (mm/yyyy) 25.b. Does Person 3 (Please check one.): [__ltive alone? [_]live with a spouse? [_Jlivein a rest home? Lllve and share expenses with another or others (not a spouse)? [liive in an assisted living facility? [_]live in someone else's home? 26. Check the box below that best describes Person 3. (Optional) [_JAmerican Indian/Alaska Native (Mashpee Wampanoag) [__]American Indian/Alaska Native (Wampanoag Tribe of Gay Head (Aquinnah)) {_JAmerican Indian/Alaska Native (Other Tribal Nation) {Asian []Black or African American [_]Hispanic/Latino/Black [Thispanic/Latino/White [—]Hispanic/Latino/Other [_|Native Hawaiian or other Pacific islander [_]White [_]Other 27, \f Person 3is an American Indian or Alaska Native, fill out Supplement B: American Indian (Al)/Alaska Native (AN) on page 20. American Indians or Alaska Natives may not have to pay premiums or copayments, and may get special monthly enrollment periods. Continue adding other household members, if needed, or go to Part 3: Current Job and Income Information on page 10.

fyou have more than three people to add, make a copy of Person 4's blank information pages (pages 7-9) before you fill them out.

Person 4 1.Firstname Middle initial ~Last name Suffix (ex.,Jr.) | Relationship to Person 1 2.Home street address Apt. # Relationship to Person 2 City State Zip code Relationship to Person 3 3.[s Person 4 homeless? 4, Malling address (if different from home address) [Yes (-]No

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City : State Zip code 5. Telephone number 6. Email address 7. Date of birth (mm/dd/yyyy)} 8. Gender 9, Written language choice. | 10. Spoken language choice Ou OF

We need a social security number for every person applying for health coverage who has one. Please see the application instructions or the Member Booklet for more information. :

11. Does Person 4 have a social security number (SSN)? [—]Yes [_]No If yes, give us the number. - - (Optional, if not applying) Ino, check one of the reasons below. [_JApplied, but have not received SSN [_]Religious exemption [_] Only eligible for nonwork SSN [_]Noteligible toget SSN [__] Eligible for SSN, but have not applied 12, Will Person 4 file a federal income tax return next year? [_]Yes [_]No (To get a tax credit, Person 4 must file taxes for the year he or she is requesting benefits, Person 4 can still apply for health coverage even if he or she does not file a federal income tax return.) If yes, answer 12.a,, 12.b., and 12.c. if no, answer 12.c, 12.a, Will Person 4 file jointly with a spouse? [~]Yes [_]No Ifyes, name of spouse: (If married, Person 4 must file federal taxes jointly for the year he or she is requesting benefits.) 12.b, Will Person 4 claim any dependents on his or her income tax return? [_]Yes [_]No If yes, list name(s) of dependents:

12.c. Will someone else claim Person 4 as a dependent on his or her tax return? [_]Yes [_]No

Ifyes, name of tax filer: How is Person 4 related to the tax filer? 13. Is Person 4 pregnant? [_]Yes [_]No 13.a. If yes, how many children is she expecting? 13.b. What is the due date? (mm/dd/yyyy)

14. Is Person 4 applying for health coverage? [_]Yes [_]No Ifo, goto Part 3: Current Job and Income Information on page 10. If yes, answer all questions below for Person 4. 15. 1s Person 4 living in Massachusetts and planning to stay? [__]Yes [_]No 16. Does Person 4 live with at least one child under age 19? [_]Yes [_]No 16.a. If yes, is Person 4 the main person taking care of this child? [_]Yes [_]No 17. IsPerson 4 injail or prison? [_]Yes [_]No If no, go to the next question. I7a. Ifyes, is Person 4 (Check one.): [1 Convicted? What is his or her expected release date? (mm/dd/yyyy) [)Not convicted? (For example: confined only) 18. Did Person 4 age out of foster care at the age of 18 or older? [_]Yes [_]No Ifyes, was this person enrolled in Medicaid when he or she aged out of foster care? [" ]Yes [_]No

“Aging out” means the individual was in the custody of a state child welfare agency in any state or of a tribe in any state when he or she turned 18 years of age, or older if the individual decided to stay in placement after age 18. 19, Is Person 4a US. citizen, national, or naturalized US. citizen? {"_]Yes [_]No If yes, go to Question 20. 19.2. If no, does Person 4 have an eligible immigration status? (See the Member Booklet for more information.) [_|Yes [__]No [__]No response

If no or no response, Person 4 may get only one or more of the following: MassHealth Standard (if pregnant), MassHealth Limited, the Children’s Medical Security Plan (CMSP), or the Health Safety Net (HSN).Go to Question 20. -

19.b, Ifyes, does Person 4 have an immigration document? [—]Yes [_]No

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We will try to prove Person's 4 immigration status. Please list all the immigration statuses and/or conditions that have applied to Person 4 since he or she entered the U.S. (See the Member Booklet for mare information about immigration statuses and documents.)

Immigration status

Status award date* (mm/dd/yyyy)| Immigration document type Document ID number

* For battered persons, status award date is date petition was approved as properly fijed. 19.c, Did Person 4 come to live in the U.S. before August 22,1996? [_]Yes [_]No 19.d. Did Person 4 use a different name to get his or her immigration status? [_]Yes []No If yes, what is it?

First name Middle name Last name Suffix (ex., Jr.)

“19. 1s Person 4 an honorably discharged veteran or an active-duty member of the U.S. military? [_]Yes [_]No 19f.Is Person 4a spouse or unremarried surviving spouse of an immigrant who is an honorably discharged veteran or an active-duty member of the U.S. military? [_]¥es [7]No 19.g. Is Person 4 an unmarried dependent child of an immigrant who is an honorably discharged veteran or an active-duty member of the U.S. military? [~]Yes [_]No . 20. Does Person 4 have an injury, iliness, or disability (including a disabling mental health condition) that has lasted or is expected to last for at least 12 months? (Iflegally blind, answer yes.) [__]Yes [_]No If no, go to the next question. If yes, fill out Part A of Supplement A: illness, Disability, or Accommodation on page 19. 21, Does Person 4 need reasonable accommodation(s) because of a disability or injury? [_]Yes [_]No [Fino go to the next question. If yes, fill out Part B of Supplement A: Illness, Disability, or Accommodation on page 19. 22. Is Person 4 applying because of an accident or injury that someone else might be responsible for? [__]Yes [_]No If no, go to the next question. If yes, fill out Part C of Supplement A: Illness, Disability, or Accommodation on page 19. 23. Does Person 4 have breast or cervical cancer? [_]Yes [_]No (Optional) MassHealth has special coverage rules for people who need treatment for breast or cervical cancer. If no, go to the next question. If yes, Person 4 will send a certificate to be filled out by Person 4's doctor to prove his or her breast cancer or her cervical cancer diagnosis. Then MassHealth can see if Person 4's MassHealth benefits give him or her the most coverage possible. 24, Is Person 4 HIV positive? [_]¥es [_]No (Optional) If Person 4 is HIV positive, he or she may be eligible for additional coverage or benefits. Ifno, go to the next question. If yes, Person 4 will need to give us proof of his or her HIV-positive status. Then MassHealth can see if Person 4's MassHealth benefits give him or her the most coverage possible. 25. Did Person 4 ever get Supplemental Security income (SSI)? [__]Yes [_]No If no, go to the next question. If yes, answer questions 25.a, and 25.b, 25.a. When did Person 4 last get SSI? (mm/yyyy) 25.b, Does Person 4 (Please check one.): [_]live alone? [__]livewitha spouse? [_]liveina rest home? [live and share expenses with another or others (not a spouse)? [_]livein an assisted living facility? [live in someone else's home? 26. Check the box below that best describes Person 4. (Optional)

[_JAmerican Indian/Alaska Native (Mashpee Wampanoag) [_]American indian/Alaska Native (Wampanoag Tribe of Gay Head (Aquinnah)) [Jamerican indian/Alaska Native (Other Tribal Nation) [_]Asian [_]Black or African American [_]Hispanic/Latino/Black [_]Hispanic/Latino/White [_]Hispanic/Latino/Other [_]Native Hawaiian or other Pacific Islander [_]White [_]Other

27. If Person 4 is an American Indian or Alaska Native, fill out Supplement B: American Indian (Al)/Alaska Native (AN) on page 20. American Indians or Alaska Natives may not have to pay premiums or copayments, and may get special monthly enrollment periods, Continue adding other household members, if needed, or go to Part 3: Current Job and Income Information on page 10.

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Current Job and Income Information

We use your income to see if you are eligible for health coverage. See the Member Booklet. If you are self-employed, and pay yourself wages, fill out both the Current Job and Self-employed income sections.

About You (Person 1)

1, (Check all that apply.)

[Employed (Go to Current Job 1.) [_]Self-employed (Go to Self-employed income.) [__]Not employed (Go to Money from other sources section.) Current Job 1

2. Employer name

Employer address City State Zip code

Employer telephone Employer tdentification Number (EIN—if you know)

3. Does this job offer health insurance? [_]Yes [_]No

If yes, check one.

[_Ithis job offers health insurance now.

[_IThis job will offer health insurance, starting (mm/dd/yy).

3.a. If this job offers health insurance now or will at a later date, can the health plan cover an employee's spouse or dependent(s)? Lives List the name(s): [No + How much will the employee pay for the lowest-cost individual health plan? $

How often? (Check one.) [_]Weekly [_]Monthly [—}Twice amonth [Yearly

+ {fan employee joins a program to stop smoking or using tobacco, how much money could he or she save on the monthly premium? $ + Does the health insurance plan(s) offered by the employer meet the “minimum value” standard? [_]Yes [_]No

Minimum value means that the health insurance plan pays at least 60% of the total health insurance costs of the average enrollee. (The employer or insurance company will know this information.) 3.b. What health insurance changes will this job make for the next year? (if you know) [This job will stop offering health insurance. [_]This job will start offering health insurance to employees or change the premium for the lowest-cost available plan. «How much will the employee's premiums be (for an individual plan)? $ How often? (Check one.) []Weekly [_]Monthly [_]Twice a month [_]Yearly + Date of change: (mm/dd/yyyy) 3.c._] No health insurance plans offered by the employer will meet the “minimum value” standard. Minimum value means that the health insurance plan pays at least 60% of the total health insurance costs of the average enrollee. (The employer or insurance company will know this information.) 4. Does this employer have 50 or fewer full-time employees? [_]Yes [__]No (If you do not know, answer no to this question.) Ifyes, we may be able to help you pay for your coverage. For more information, see the Member Booklet for description of coverage. 5. Isthis job a sheltered workshop? [__|Yes [_]No 6. How much do you currently earn in gross wages, less pre-tax deductions? $ 6.a. How often are you paid? (Check one.) [_]Weekly [“]Every 2weeks [~]Twice amonth [_]Monthly [_]Yearly 6.b. About how many hours do you work each WEEK? 6.c. When did you begin getting this income? (mm/dd/yyyy) 7. lfyour income from this job changes during the year (such as seasonal or contract employment), check the months you have worked or expect to

work, [Jan (-]feb (]Mar [Apr []May [June [JJuly [lAug []Sept [Joct [JNov [_]Dec

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8.a.(Checkone.) [_]Partnership [_]S-Corporation [_]Self-employed 8.b. Business name:

8.c. What is your expected yearly income from this source, less any business expenses? (Do not include your wages and tips.) $ 8.d. Date you began getting this income (mm/dd/yyyy)

Current Job 2 (If none, go to Money from other sources section.) 9, Employer name

Employer address City State Zip code

Employer telephone Employer Identification Number (EIN—if you know)

10. Does this jab offer health insurance? [_]Yes [_]No Ifyes, check one. [this job offers health insurance now. [1 this job will offer health insurance, starting (mm/dd/yy). 10.a. {this job offers health insurance now or will at a later date, can the health plan cover an employee's spouse or dependent(s)? (Nes List the name(s): [1No + How much will the employee pay for the lowest-cost individual health plan? $ How often? (Check one.) [_]Weekly [_]Monthly [—]Twicea month []Yearly * {fan employee joins a program to stop smoking or using tobacco, how much money could he or she save on the monthly premium? $ * Does the health insurance plan(s) offered by the employer meet the “minimum value” standard? [_]Yes [_]No Minimum value means that the health insurance plan pays at least 60% of the total health insurance costs of the average enrollee. (The employer or insurance company will know this information.) 10.b. What health insurance changes will this job make for the next year? (if you know) [This job will stop offering health insurance, [his job will start offering health insurance to employees or change the premium for the lowest-cost available plan. * Howmuch will the employee's premiums be (for an individual plan)? $ How often? (Check one.) [~]Weekly [_]Monthly [_]Twicea month [Yearly + Dateofchange: (mm/dd/yy) 10.c.[_]No health insurance plans offered by the employer will meet the “minimum value” standard. Minimum value means that the health insurance plan pays at least 60% of the total health insurance costs of the average enrollee, (The employer or insurance company will know this information.) 11. Does this employer have 50 or fewer full-time employees? [__]Yes [—]No (If you do not know, answer no to this question.) Ifyes, we may be able to help you pay for your coverage. For more information, see the Member Booklet for description of coverage. 12. Isthis job a sheltered workshop? [~ ]Yes [_]No 13. How much do you currently earn in gross wages, less pre-tax deductions? $ 13.a.How often are you paid? (Check one.) [_]Weekly [_]Every2weeks [_]Twiceamonth [_|Monthly [_]Yearly 13.b, About how many hours do you work each WEEK? 13.c. When did you begin getting this income? (mm/dd/yyyy)

14. {f your income from this job changes during the year (such as seasonal or contract employment), check the months you have worked or expect to

work. [Jan []feb (JMar [Apr [_JMay (_JJune [_]July [_JAug [Sept [_JOct [[JNov [_]Dec

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Self-employed income

15,a.(Check one.) [_]Partnership [_]S-Corporation [7] Self-employed 15.b, Business name:

15.c. What is your expected yearly income from this source, less any business expenses? (Do not include your wages and tips.) $ 15.d. Date you began getting this income (mm/dd/yyyy)

Money from other sources

16. Do you get money from other sources? [- ]Yes [_]No

Check all of the sources, give the amount, and how often you get it. (You do not need to tell us about child support, nontaxable veterans’ payments, or Supplemental Security Income (SSI).)

[Unemployment $ How often? [ordinary or qualified dividend $ How often? C[Pension $ How often? (Ttusts $ How often? CAnnuity $ How often? Llinterest $ How often? LSocial Security $ How often? [Inet farming/fishing $ How often? (net rental income $ How often? L [Royalty $ How often? (capital gains $ How often? [Alimony received $ How often? (Gambling proceeds $ How often? [Ttax-excludedforeign income $ How often? (Taxable military retirement pay (not paid through the Veterans’ Administration) $ How often?

(Tax refund, credit, or offset of state or local income taxes $ How often?

[_JOther income (Specify:) $ How often?

Deductions allowed on federal tax return All or part of certain expenses can be deducted from income so that you do not pay taxes on them. These amounts are not counted in your income, and may lower the cost of your health coverage. 17. Do you have any of the deductible expenses below? [~]Yes [~]No . If yes, please check all of the types you have, fill in the deductible amount, and how often you have this expense. Do not include an expense that you already claimed under self-employment income above. Lalimony paid $ How often? [JStudent loan interest. $ How often? Other tax deductions (such as business expenses, [RA contributions, contributions to taxable retirement income, deductible part of self- employment tax, educator expenses, health savings account contributions (deduction), moving expenses, penalty on early withdrawal of savings, self-employment health insurance, self-employment retirement plan, and tuition and other school-related costs)

Type: $ How often?

Type: $ How often?

Type: $ How often? Total income (Person 1)

18. Do you expect your total income (including earned income and money from other sources) to be the same next year? [—]Yes [_]No (If you are not sure, answer no to this question.)

If no, what do you expect your total income to be next year? $ (Estimate) Person 2 (Second adult) (Ifyou have income to report for more than two persons, make a copy of pages 12-15 before you fill them out.) Name: :

1. (Check all that apply.) [employed (Go to Current Job 1.) [_] Self-employed (Go to Self-employed income.) [_]Not employed (Go to Money from other sources section.)

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Current Job 4 2. Employer name

Employer address City ‘ State Zip code

Employer telephone Employer Identification Number (EIN—if you know)

3. Does this job offer health insurance? [_]Yes [_]No

ifyes, check one. [_]this job offers health insurance now. [CJ This job will offer health insurance, starting (mm/dd/yy). 3.a. If this job offers health insurance now or will at a later date, can the health plan cover an employee's spouse or dependent(s)? (les List the name(s): (No

+ Howmuch will the employee pay for the lowest-cost individual health plan? $

How often? (Check one.) [_]Weekly [_]Monthly [~}Twicea month [_]Yearly + Ifan employee joins a program to stop smoking or using tobacco, how much money could he or she save on the monthly premium? $ + Does the health insurance plan(s) offered by the employer meet the “minimum value” standard? [_]Yes [_]No

Minimum value means that the health insurance plan pays at least 60% of the total health insurance costs of the average enrollee. (The employer or insurance company will know this information.) 3.b. What health insurance changes will this job make for the next year? (if you know) [this job will stop offering health insurance, [this job will start offering health insurance to employees or change the premium for the lowest-cost available plan. + How much will the employee's premiums be (for an individual plan)? $ How often? (Check one.) []Weekly [~]Monthly [_]Twiceamonth [_ ]Yearly + Date of change: (mm/dd/yy) 3.c.[_]No health insurance plans offered by the employer will meet the “minimum value” standard, Minimum value means that the health insurance plan pays at least 60% of the total health insurance costs of the average enrollee. (The employer or insurance company will know this information.) 4. Does this employer have 50 or fewer full-time employees? [_]Yes [_]No (If you do not know, answer no to this question.) If yes, we may be able to help pay for this coverage. For more information, see the Member Booklet for description of coverage. 5, Isthis job asheltered workshop? [__]Yes [_]No 6. How much does this person currently earn in gross wages, less pre-tax deductions? $ 6.a, How often is this person paid? (Check one.) [~]Weekly [_]Every 2 weeks [_]Twiceamonth [_]Monthly [__]Yearly 6.b, About how many hours does this person work each WEEK? 6.c. When did this person begin getting this income? (mm/dd/yyyy) 7. |fthis person's income from this job changes during the year (such as seasonal or contract employment), check the months this person has worked or expectstowork. [_]Jan [“]feb [(JMar [Apr []May [JJune [_]July [_JAug []Sept [JOct [Nov [_]Dec Self-employed income 8.a.(Checkone,) [_]Partnership [_]S-Corporation [_]Self-employed 8.b. Business name:

8.c, What is this person's expected yearly income from this source, less any business expenses? (Do not include his or her wages and tips.) $

8.. Date this person began getting this income (mm/dd/yyyy)

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Current Job 2 : (If none, go to Money from other sources section.) 9. Employer name

Employer address City : State Zip code

Employer telephone Employer Identification Number (EIN—if you know)

10. Does this job offer health insurance? [__]Yes [_]No Ifyes, check one. LI this job offers health insurance now. [This job will offer health insurance, starting (mm/dd/yyyy). 10.a. If this job offers health insurance now or will at a later date, can the health plan cover an employee's spouse or dependent(s)? Llves List the name(s): [No + How much will the employee pay for the lowest-cost individual health plan? $ How often? (Check one.) [~]Weekly [~]Monthly [—]Twicea month [—]Yearly + Ifan employee joins a program to stop smoking or using tobacco, how much money could he or she save on the monthly premium? $ + Does the health insurance plan(s) offered by the employer meet the “minimum value” standard? Liles ([]No Minimum value means that the health insurance plan pays at least 60% of the total health insurance costs of the average enrollee. (The employer or insurance company will know this information.) 10.b. What health insurance changes will this job make for the next year? (if you know) [_Ithis job will stop offering health insurance. [This job will start offering health insurance to employees or change the premium for the lowest-cost available plan. + How much will the employee's premiums be (for an individual plan)? $ How often? (Check one.) [_]Weekly [~]Monthly [_]Twicea month [_]Yearly + Date of change: (mm/dd/yy) 10.c.[_]No health insurance plans offered by the employer will meet the “minimum value” standard. Minimum value means that the health insurance plan pays at least 60% of the total health insurance costs of the average enrollee. (The employer or insurance company will know this information.) 11. Does this employer have 50 or fewer full-time employees? [_ Yes [_]No (Ifyou do not know, answer no to this question.) If yes, we may be able to help pay for this coverage. For more information, see the Member Booklet for description of coverage. 12, Isthis jab a sheltered workshop? [__]Yes [~]No 13, How much does this person currently earn in gross wages, less pre-tax deductions? $ 13.a. How often is this person paid? (Check one.) [_]Weekly []Every2weeks [_]Twiceamonth [_]Monthly [—]Yearly 13.b, About how many hours does this person work each WEEK? 13.c. When did this person begin getting this income? (mm/dd/yyyy) 14. If this person's income from this job changes during the year (such as seasonal or contract employment), check the months this person has worked or expects towork. [Jan []Feb [_JMar [_JApr (_JMay [June [July [JAug []Sept [Joct [JNov [_]Dec Self-employed Income 15.a.(Check one.) [_]Partnership {7]$-Corporation [_] Self-employed 15.b. Business name: 15.c, What is this person's expected yearly income from this source, less any business expenses? (Do not include his or her wages and tips.) $ 15.d. Date this person began getting this income (mm/dd/yyyy)

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Money from other sources _

16. Does this person get money from other sources? [__]Yes [_]No

Check all of the sources, give the amount, and how often this person gets it. (You do not need to tell us about child support, nontaxable veterans’ payments, or Supplemental Security Income (SSI).)

[Unemployment $ How often? Jordinary or qualified dividend $ How often? [_]Pension $ How often? Ctnusts $ How often? [Annuity $ How often? Cilnterest $ How often? LJSocial Security $ How often? {Net farming/fishing $ How often? [Wnetrentalincome $ How often? loyalty $ How often? LJ Capital gains $ How often? [JAlimony received $ How often? (JGambling proceeds $ How often? [Tiavexcluded foreign income $ How often? [_JTaxable military retirement pay (not paid through the Veterans’ Administration) $ How often?

[Tax refund, credit, or offset of state or local income taxes $ How often?

[other income (Specify:) $ How often?

Deductions allowed on federal tax return

All or part of certain expenses can be deducted from income so that this person does not pay taxes on them. These amounts are not counted in this person's income, and may lower the cost of his or her health coverage.

17. Does this person have any of the deductible expenses below? [" ]Yes [_]No If yes, please check all of the types he or she has, fill in the deductible amount, and how often this person has this expense. Do not include an expense that he or she already claimed under self-employment income above. [Alimony paid $ How often?" [_JStudent loan interest $ How often? [_Jother tax deductions (such as business expenses, IRA contributions, contributions to taxable retirement income, deductible part of self-

employment tax, educator expenses, health savings account contributions (deduction), moving expenses, penalty on early withdrawal of savings, self-employment health insurance, self-employment retirement plan, and tuition and other school-related costs)

Type: $ How often? Type: $ Howoften? Type: $ How often?

Total Income (Person 2)

18, Do you expect Person 2's total income (including earned income and money from other sources) tobe the same next year? [_ Yes [~]No (If you are not sure, answer no to this question.)

Ifno, what do you expect Person 2's total income to be next year? $ (Estimate)

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part 4 [ET Insurance You Have Now

Please answer the questions below about health insurance, and follow the instructions. If you or any household member has enrolled in one of the health insurance plans below, but the benefits have not yet started, check yes to the question. MassHealth may be able to help pay premiums. 1. Doyouor any household member have Medicare? [—]Yes [_]No Ifyes, fill out Part A of Supplement C: Health Insurance on page 21. 2. Doyou or any household member have federal health insurance provided by the U.S. military (Veterans’ Affairs or TRICARE) or other federal coverage? [__]Yes [_]No tyes; fill out Part B of Supplement C: Health Insurance on page 21.

3. Doyou or any household member currently have any other type of health insurance? (This includes insurance through an employer, union, college or university, former employer (COBRA), and coverage bought by you or any household member, or a parent who is not living in the household.) [ves [No .

Ifyes, fill out Part C of Supplement C: Health Insurance on page 21. fyou answered no to all three questions above, go to Part 5: Parental Information.

Parental Information

For all children in the household, please answer the following three questions. - 1. Was any child in the household adopted by a single parent? [_]Yes [_]No ifyes, list child’s(rens’) name(s): 2. Does any child in the household have a parent who has died? [__]Yes [_]No If yes, list child’s(ren's) name(s): 3. Does any child in the household havea parent whois unknown? [_]Yes [_]No If yes, list child’s(ren‘s) name(s): if there are any children in the household who have a noncustodial parent (a parent who does not live with the child) but are not listed above, give us the following information. Child’s(ren's) name(s): We will send a form to the child’s(ren’s) custodial parent to fill out and return to us. This form asks questions about any parents who do not live with the child, Go to Part 6: Rights and Responsibilities and Signature Page.

a'\: teem Rights and Responsibilities and Signature Page On behalf of myself and all persons listed on this application, ! understand, represent, and agree as follows.

1. MassHealth may require eligible persons to enroll in available employer-sponsored health insurance if that insurance meets the criteria for MassHealth payment of premium assistance.

2. Employers of eligible persons may be notified and billed in accordance with state regulations for any services that hospitals or community health centers provide to these persons that are paid for by the Health Safety Net.

3. Health coverage premiums must be paid for all persons listed on this application who are applying. Failure to pay any premium due may result in the State deducting the amount owed from the tax refunds of responsible persons. If any person applying is a certain American Indian or Alaska Native, MassHealth premiums may not have to be paid.

4, MassHealth has the right to pursue and get money from third parties who may be obligated to pay for health services provided to eligible persons enrolled in MassHealth programs. These third parties may include other health insurers, spouses, or parents obligated to pay for medical support, or individuals obligated to pay under accident settlements. Eligible persons must cooperate with MassHealth in establishing third-party support and obtaining third-party payments for themselves and anyone whose rights they can legally assign. Eligible persons may be exempted from this obligation if they believe and tell MassHealth that cooperation could result in harm to them or anyone whose rights they can legally assign.

5, Aparent and/or guardian of minor children must agree to cooperate with state efforts to collect medical support from a noncustodial parent unless they believe and tell MassHealth that cooperation will harm the children or the parent or guardian.

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6. Eligible persons who are injured in an accident, or in some other way, and get money from a third party because of that accident or injury must use that money to repay MassHealth or the Health Safety Net for certain services provided.

7. Eligible persons must tell MassHealth or the Health Safety Net, in writing, within 10 calendar days, or as soon as possible, about any insurance claims or lawsuits filed because of an accident or injury. :

8. The status of this application may be shared with a hospital, community health center, other medical provider, or federal or state agencies when necessary for treatment, payment, operations, or the administration of the programs listed above.

9. Tothe extent permitted by law, MassHealth may place a lien against any real estate owned by eligible persons or in which eligible persons have a legal interest. If property is sold, money from the sale of that property may be required to be used to repay MassHealth for medical services provided.

10. To the extent permitted by law, for any eligible person aged 55 or older, or for any eligible person for whom MassHealth helps pay for care in a nursing home, MassHealth may seek money from the eligible person's estate after death.

11. Eligible persons must tell the health care program(s) in which they enroll about any changes in their or their household's income or employment, household size, health insurance coverage, health insurance premiums, and immigration status, or about changes in any other information on this application and any supplements to it within 10 calendar days of learning of the change. Eligible persons can make changes by calling 1-888-665-9993 (TTY: 1-888-665-9997 for people who are deaf, hard of hearing, or speech disabled). A change in information could affect eligibility for these persons or for persons in their household.*

12. MassHealth, the Massachusetts Health Connector, and the Health Safety Net will obtain from eligible persons’ current and former employers and health insurers all information about health insurance coverage for these persons. This includes, but is not limited to, information about policies, premiums, coinsurance, deductibles, and covered benefits that are, may be, or should have been available to these persons or members of their household.

13. MassHealth, the Massachusetts Health Connector, and the Health Safety Net may get any records or data about persons listed on this application to document medical services claimed or provided to them. We will keep such information private, and only use and disclose it in accordance with applicable law.

14, MassHealth, the Massachusetts Health Connector, and the Health Safety Net may get records or data from federal and state data sources and programs, such as the Social Security Administration, the Internal Revenue Service, the Department of Homeland Security, the Department of Revenue, and the Registry of Motor Vehicles, to prove any information given on this application and any supplements, or other information once an individual becomes amember, and to support continued eligibility. We will keep all records and data provided to us private, and only use and disclose it in accordance with applicable law.

(For renewal of coverage in future years)

15, MassHealth, the Massachusetts Health Connector, and the Health Safety Net will use income data, including information from federal tax returns, to determine eligibility. To make it easier to check income at renewal time, | may authorize MassHealth, the Massachusetts Health Connector, and the Health Safety Net to use data from federal tax returns to redetermine eligibility in future years. MassHealth, the Massachusetts Health Connector, and the Health Safety Net will use this data to the extent | authorize, and will send me a notice, let me make any changes, and allow me to opt out at any time. On behalf of all persons applying for health coverage, I: (Check one.)

(C1 permit use of the data for the next five years; or

[_] permit use of the data for: (Check one.) [Jone year, [—] two years, [] three years, [_] four years [C1 donot permit the use of federal tax data to renew eligibility for help paying for health coverage.

16. MassHealth, the Health Connector, and the Health Safety Net may send notices and share information pertaining to the eligibility, renewal of eligibility or enrollment of persons listed on this application to me and to the other persons listed on this application.

17. Iflam acting on behalf of someone in filling out this application and any supplements, | have filled out and sent the enclosed Authorized Representative Designation Form with this application or have such form on record. | understand that my signature on this application and any supplements as an authorized representative certifies that the information on this application and any supplements, including those submitted with this application as well as any other forms or documents that may be submitted to or required by MassHealth, the Health Connector, the Children’s Medical Security Plan, or the Health Safety Net, is correct and complete to the best of my knowledge.

ACA-2 (Rev. 01/14) 17 Please go to the next page. >

Massachusetts Effective Date: 10/01/2013

OFFICIAL

18. If] think that MassHeatth or the Health Connector has made a mistake in eligibility for me and/or other applicants, | have the right to appeal or file a grievance. If | disagree with the action taken by MassHealth or the Health Connector, | have the right to appeal and ask for a hearing before an impartial hearing officer. | can also ask for a hearing if I did not receive a notice telling me about the action that was taken. To find out how to appeal, please call 1-888-665-9993 (TTY: 1-888-665-9997 for people who are deaf, hard of hearing, or speech disabled). | understand that | may be eligible to continue getting benefits while my appeal is being decided. | may have a lawyer or other person repfesent me, but | may also represent myself. MassHealth or the Health Connector will not pay for anyone to represent me. Additional information about appeals will be provided with any notices | receive, as well as during the appeal process.

19, Under federal law, discrimination is not permitted on the basis of race, color, national origin, sex, age, sexual orientation, gender identity, or disability. 1 can file a complaint of discrimination by going to www.hhs.gov/ocr/oifice/file. *You can also report changes in any of the following ways. + Sign on to your account at www.MAhealthconnector.org. You can create an online account if you do not already have one, + Send the change information to: Health Insurance Processing Center P.O, Box 4405 Taunton, MA 02780.

* Fax the change information to: 617-887-8770.

I certify under the penalties of perjury that:

« — {have read or have had read to me the information on this application, including any supplements and instruction pages, and understand that the Member Booklet contains important information;

— |have permission to submit this application for and receive eligibility enrollment information about all persons listed on this application and as may be allowed by any legal documents | have submitted with this application;

+ — |understand my rights and responsibilities and the rights and responsibilities of all persons for whom | am submitting this application, as explained in the rights and responsibilities before this signature page;

+ — [have told or will tell all persons for whom | am submitting this application about these rights and responsibilities so they also understand their rights and responsibilities;

+ {understand and agree that MassHealth and the Health Connector will treat electronic, faxed, telephonic, or copies of signatures with the same force and effect as an original signature(s);

+ Theinformation | have supplied is correct and complete to the best of my knowledge about myself and other persons for whom! am submitting this application; and

+ — |may be subject to penalties under federal law if | intentionally provide false or untrue information.

xX Signature of Person 1 or authorized representative Print name Date

Designation Form to us for us to process this application.

For certified application counselors, navigators, agents, and brokers only. Fill out this section if you are a certified application counselor, navigator, agent, or broker filling out this application for someone else,

Important: If you are submitting this application as an authorized representative, you must submit an Authorized Representative |

First name, middle initial, last name, suffix

Organization name

Send the filled-out application to: Health Insurance Processing Center

P.O. Box 4405 Taunton, MA 02780 or fax to 617-887-8770.

ACA-2 (Rev. 01/14) 18 Please go to the next page.

Massachusetts Effective Date: 10/01/2013

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SUPPLEMENT A Cement . IHness, Disability, or Accommodation CONNECTOR

PartA Ifyou answered yes to Question 20 in Parts 1 and/or 2 about you or any household member having an injury, illness, or disability that has lasted or may last for at least 12 months, answer the next three questions, 1. Does this person get money from Social Security for a disability? [~ ]Yes [-_]No

Ifyes, name(s): 2. Did this person ever get Supplemental Security Income (SSI)? [_]Yes [_]No

Ifyes, name(s): 3. Isthis person legally blind? [_]Yes [_]No

if yes, name(s): Part B ff you answered yes to Question 21 in Parts 1 and/or 2 about you or any household member needing reasonable accommodation because of a disability or injury, check all that apply below, and list name(s). 1. Condition L[Lowvision—Name(s): (1Blind—-Name(s): [[eat—Name(s): (Mhard othearing—Name(s): [developmentally disabled—Name(s): Lnteltectually disabled—Name(s): [Physically disabled—Name(s): (other (Please explain.)—-Name(s): 2. Accommodation [Tiexttelephone (TTY)—Name(s): Cl Large print publications—Name(s): [american Sign Language interpreter—Name(s): LWideo Relay Service (VRS)—Name(s): [communication Access Real-time Translations (CART)—Name(s): [Publications in Braille—Name(s): (assistive listening device—Name(s): [_JPublications in electronic format—Name(s): L_Jother (Please explain.)—Name(s):

Part C

Ifyou answered yes to Question 22 in Parts 1 and/or 2 about you or any household member applying because of an accident or injury that someone else may be responsible for, answer the next two questions.

1. Did someone else cause this person's injury, illness, or disability, or could someone else's insurance or this person's own insurance, other than health insurance (like homeowner's or auto insurance) cover it? [_]Yes []No

{fyes, name the injured person(s): 2. Has this person filed a lawsuit, a workers’ compensation claim, or an insurance claim for this accident or injury? [_]Yes [_]No Ifyes, name the injured person(s):

ACA-2 (Rev. 01/14) 19 Go back to the application. >

Massachusetts Effective Date: 10/01/2013

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SUPPLEMENT B C mieKT American Indian (Al)/Alaska Native (AN) CONNECTOR

4

Fill out this supplement if you or any household member is an American Indian or Alaska Native,

American Indians and Alaska Natives who enroll in MassHealth can also get services from the Indian Health Services, tribal health programs, or urban Indian health programs.

Ifyou or any household members are American Indians or Alaska Natives, you may not have to pay premiums or copayments, and may get special monthly enrollment periods. To make sure you and your household members get the most help possible, please fill out this supplement.

AI/AN Person 1 Name: First Middle initial Last Suffix

1. Isthis persona member of a federally recognized tribe? [— ]Yes [_]No {fyes, check the box that applies. [American Indian/Alaska Native (Mashpee Wampanoag) [_]American Indian/Alaska Native (Wampanoag Tribe of Gay Head (Aquinnah)) [JAmerican Indian/Alaska Native (Other Tribal Nation) 2. Did this person ever get a service from the Indian Heaith Service, a tribal health program, or urban Indian health program, or through a referral from one of these programs? [_]Yes [_]No 2.a. Ino, is this person eligible to get services from the Indian Health Service, tribal health programs, or urban Indian health programs, or through a referral from one of these programs? [_]Yes [—]No

3. Certain money received may not be counted for MassHealth. List the combined income from the following sources, if applicable. + Per capita payments from a tribe that come from natural resources, usage rights, leases, or royalties

+ Payments from natural resources, farming, ranching, fishing, leases or royalties from land designated as Indian trust land by the Department of Interior (including reservations and former reservations)

+ — Money from selling things that have cultural significance

$ How often? [_]Weekly [_]Biweekly [—]Monthly [_]Other (Explain) AI/AN Person 2 Name: First Middle initial Last Suffix

1. Isthis persona member of a federally recognized tribe? [_]Ves [_]No fyes, check the box that applies. [_JAmerican Indian/Alaska Native (Mashpee Wampanoag) [_]American Indian/Alaska Native (Wampanoag Tribe of Gay Head (Aquinnah)) [_JAmerican Indian/Alaska Native (Other Tribal Nation) 2. Did this person ever get a service from the Indian Health Service, a tribal health program, or urban Indian health program, or through a referral from one of these programs? [_]Yes [_]No 2.a. Ifno, is this person eligible to get services from the Indian Health Service, tribal health programs, or urban Indian health programs, or through a referral from one of these programs? [_]Yes [_]No

3. Certain money received may not be counted for MassHealth. List the combined income from the following sources, if applicable. + Per capita payments from a tribe that come from natural resources, usage rights, leases, or royalties

» Payments from natural resources, farming, ranching, fishing, leases or royalties from land designated as Indian trust land by the Department of Interior (including reservations and former reservations)

* — Money from selling things that have cultural significance $ How often? [_]Weekly [—]Biweekly [_|Monthly [_]Other (Explain)

ACA-2 (Rev. 01/14) 20 Go back to the application. >

T Massachusetts Effective Date: 10/01/2013

OFFICIAL SUPPLEMENT C Cee

, Health Insurance CONNECTOR Part A: Medicare Fill out this part if any household member answered yes to having Medicare in the health insurance part (Part 4). 1.Name: Medicare claim number: When did coverage start? (mm/dd/yyyy) La. Does this person have a Medicare Part D plan? [_]Yes [_]No If yes, when did coverage start? (mm/dd/yyyy) 1b. Does this person have a Medigap/Medicare supplemental policy? [_]Yes [_]No . If yes, name of coverage plan: When did coverage start? (mm/dd/yyyy) 2. Name: Medicare claim number: When did coverage start? (mm/dd/yyyy) 2.a. Does this person have a Medicare Part D plan? [—]Yes [_}No if yes, when did coverage start? (mm/dd/yyyy) 2.b. Does this person have a Medigap/Medicare supplemental policy? [_]Yes [_]No lf yes, name of coverage plan: When did coverage start? (mm/dd/yyyy) 3. Do any of the persons above want to apply for help paying for the Medicare Part B premiums? [__]Yes [~]No ifyes, name(s):

Part B: Federal health Insurance benefits

Fill out this part ifany household member answered yes in the health insurance part (Part 4) to having federal health insurance provided by the U.S. military (Veterans’ Affairs or TRICARE) or other federal coverage.

Name of insurance plan or policy: Policyholder name:

Names of covered household members:

Claim/policy number: | When did coverage start? (mm/dd/yyyy) Part C: Other health insurance

Fill out this part if any household member answered yes in the health insurance part (Part 4) to having any other type of health insurance. This includes insurance through an employer, union, college or university, former employer (COBRA), and coverage bought by a household member or parent who is not living in the household.

1. Name of insurance plan or policy: Policyholder name: Date of birth: (mm/dd/yyyy)} SSN (if you know):

Names of covered household members:

Policy number: Group number (if you know): When did coverage start? (mm/dd/yy) ACA-2 (Rev. 01/14) al Please go to the next page.

2

Massachusetts Effective Date: 10/01/2013

OFFICIAL

Source: (Check one.)

[_JEmployer-sponsored (give employer name): [_1Union-sponsored (give union name): {_1college/university []COBRA [7]Retiree [_]Coverage provided by someone outside household [_]Other (Please explain.):

Type of coverage this plan provides: (Check all that apply.) [Doctor's visits and hospitalizations [_]Vision coverage [_]Dental coverage [ |Pharmacycoverage [ |Catastrophic only Premium cost: Premium frequency: (Check one.) $ [JWeekly [—]Everytwoweeks [~]Twiceamonth [_]Monthly [~]Quarterly [_]Yearly 2.Name of insurance plan or policy: Policyholder name: Date of birth: (mm/dd/yyyy)| SSN (if you know):

Names of covered household members:

Policy number: Group number (if you know): When did coverage start? (mm/dd/yyyy) Source: (Check one.)

{_JEmployer-sponsored (give employer name); = {JUnion-sponsored (give union name):

[_]College/university [}COBRA [Retiree {_]Coverage provided by someone outside household

[__]Other (Please explain.):

Type of coverage this plan provides: (Check all that apply.)

[Doctor's visits and hospitalizations [_]Vision coverage [—]Dental coverage [_|Pharmacy coverage [_]Catastrophic only Premium cost: Premium frequency: (Check one.) $ (Weekly [JEverytwoweeks [~]Twiceamonth [—]Monthly [Quarterly [_]Yearly

ACA-2 (Rev. 01/14) 22 Go back to the application.

Massachusetts Effective Date: 10/01/2013

OFFICIAL

Authorized Representative PET ; Designation Form Gb CONNECTOR

Commonwealth of Massachusetts ( EOHHS

Note that you don't need to fill out this form if you live in an institution and want copies of eligibility notices sent to you, and to your spouse who still lives at home, We will do that automatically.

You can choose someone to help you.

You may choose an authorized representative to help you get health care coverage through programs offered by MassHealth and the Massachusetts Health Connector. You can do this by filling out this form (the Authorized Representative Designation Form) or a sufficiently similar designation document. You can sign for yourself, and for any of your dependent children under the age of

18 for whom you are the custodial parent. You are not required to have a representative in order to apply for or receive benefits.

Who can help me?

1. An authorized representative can be a friend, family member, relative, or other person or organization of your choosing” who agrees to help you. It is up to you to choose an authorized representative if you want one. Neither MassHealth nor the Massachusetts Health Connector will choose an authorized representative for you. You must designate in writing using this form (fill out Section I, Part A) the person or organization who you want to be your authorized representative. Your authorized representative must also fill out Section 1, Part B.

2. If, because of a mental or physical condition, you cannot designate an authorized representative in writing, a person (not an organization) who is acting responsibly on your behalf can be your authorized representative if that person certifies, by filling out Section 11, that you are not able to provide a written designation, and that he or she is acting responsibly on your behalf.

3. An authorized representative can also be someone who has been appointed by law to act on your behalf. This person must fill out Section III and either you or this person must submit to us, together with this form, a copy of the applicable legal document stating that this person is lawfully representing you.

4, A person appointed by law to act on behalf of the estate of an applicant or member who has died can also serve as an authorized representative by following the instructions above. An authorized representative under Section III may be a legal guardian, conservator, holder of power of attorney, or health care proxy, of, if the applicant or member has died, the estate’s administrator or executor. What this person is authorized to do for you or for the applicant or member's estate will depend on the wording of the legal appointment.

You must provide the authorized representative's date of birth and an e-mail address, if he or she has one, so that we can prove his or her identity and protect your privacy.

What can an authorized representative do? An authorized representative may: ® fill out your application or eligibility review forms; ¢ fill out other MassHealth or Massachusetts Health Connector eligibility or enrollment forms; * give proof of information reported on these forms; ° report changes in income, address, or other circumstances; * get copies of all of your MassHealth and Massachusetts Health Connector eligibility and enrollment notices; and * acton your behalf in all other matters with MassHealth and the Massachusetts Health Connector.

€% ARD (Rev. 01/14) 1 Please go to the next page.

Massachusetts ~~ Effective Date: 10/01/2013

; OFFICIAL

How does an authorized representative designation end? If you decide that you no longer want a Section I or Section II authorized representative, you must notify us at the time you want the designation to end by: * Signing on to your account at www.MAhealthconnector.org to remove yout representative from your case (you can create an

account if you don’t already have one) (effective 1/1/14); * Mailing a letter notifying us that the designation has ended to:

Health Insurance Processing Center P. 0. Box 4405 Taunton, MA 02780;

* Faxing a letter notifying us that the designation has ended to (617) 887-8770; or

* Calling us at 1-800-841-2900 (TTY: 1-800-497-4648 for people who are deaf, hard of hearing, or speech disabled).

If you mail or fax this notice to us, the notice must include your name, address, and date of birth, the name of your authorized representative, a statement that the designation has ended and your signature or, if you cannot provide written notice, the signature of someone acting on your behalf (in the case of a Section II authorized representative only).

In addition, if your authorized representative notifies us that such person or organization is no longer acting on your behalf, we will no longer recognize the person or organization as your authorized representative. ,

A Section Ill authorized representative's designation ends when his or her legal appointment ends. The authorized representative must notify us as instructed above.

In addition, an authorized representative's designation for a minor child ends on the child’s 18" birthday.

How do I submit this form? If you are applying for health benefits, send your filled-out Authorized Representative Designation form to us with your application. If you are already getting benefits, you must submit the form to us at the time you want to designate an authorized representative by: © Signing on to your account at www.MAhealthconnector.org (you can create an account if you don’t already have one)

(effective 1/1/14);

* Mailing your form to:

Health Insurance Processing Center P. 0. Box 4405 Taunton, MA 02780;

Faxing your form to (617) 887-8770, or © Calling us at 1-800-841-2900 (TTY: 1-800-497-4648 for people who are deaf, hard of hearing, or speech disabled).

ARD (Rev. 01/14) 2 Please go to the next page.

Massachusetts Effective Date: 10/01/2013

OFFICIAL

SECTION |: Authorized Representative Designation (if applicant or member is able to sign)

Part A-to be filled out by applicant or member—please print, except for signature. Please note: Your social security number (SSN) is required if one has been issued.

Applicant's/Member's Name:

SSN (ifyou have one): xxx/xx/xxxx Date of birth: (mm/dd/yyyy)

Applicant's/Member’s e-mail address:

| certify that | have chosen the following person or organization to be the authorized representative for myself and any dependent children under the age of 18 for whom | am the custodial parent and that ! understand the duties and responsibilities this person or organization will have (as explained earlier

inthis form). Applicant's/Member's signature: Date: Authorized Representative's Name: Authorized Representative's phone number:

Authorized Representative's Address: (mailing address, city, state, zip)

Part B:—to be fitled out by authorized representative. Please print, except for signature

B1. Complete if authorized representative is a person. (certify that | will at afl times maintain the confidentiality of any information regarding the applicant or member set forth above and, if applicable, the dependent children of such applicant or member, that is provided to me by MassHealth or the Massachusetts Health Connector.

Ifl am also a provider, staff member, or volunteer affiliated with an organization, and am acting in my capacity as a provider, staff member, or volunteer in connection with my designation as an authorized representative, | certify that | will at all times adhere to all applicable state and federal laws and regulations regarding confidentiality of information and conflicts of interest including those set forth at 42 C.F.R. part 431, subpart F, 42 CFR. § 447.10 and 45 C.FR. § 155.260(f).

Authorized Representative's signature: Date:

Authorized Representative's printed name: Authorized Representative's date of birth: (mm/dd/yyyy)

Authorized Representative’s e-mail address:

B2. Complete if authorized representative is an organization. I certify, on behalf of the organization set forth below, that such organization will at all times maintain the confidentiality of any information regarding the applicant or member set forth above and, if applicable, the dependent children of such applicant or member, that is provided to the organization by MassHealth or the Massachusetts Health Connector. |, the provider, staff member, or volunteer of the organization set forth below, completing this form, certify on behalf of myself and on behalf of the organization | represent, that any providers, staff members, or volunteers acting on behalf of the organization in connection with this authorized representative designation will at all times adhere to all applicable state and federal laws and regulations regarding confidentiality of information, and conflicts of interest, including those set forth at 42 C.F.R. part 431, subpart F, 42 C.F.R. § 447.10 and 45 CFR. § 155.260(f),

Authorized Representative's printed name (organization):

Printed name of provider, staff member, or volunteer completing form:

Signature of provider, staff member, or volunteer completing form: Date:

ARD (Rev. 01/14) 3 Please go to the next page.

Massachusetts 3 Effective Date: 10/01/2013

OFFICIAL

SECTION Il: Authorized Representative Designation (if applicant or member cannot provide written designation)

To be filled out by authorized representative. Please print, except for signature, Please provide a separate form for each applicant or member. An organization is not eligible to be an authorized representative under this section. | certify that | know enough about the applicant or member set forth below to take responsibility for the correctness of the statements made on his or her behalf during the eligibility process and in other communications with MassHealth or the Massachusetts Health Connector, that | understand my duties and responsibilities as this person's authorized representative (as explained earlier in this form), and that this person cannot provide written designation. If this person can understand, | have told the person that MassHealth and the Massachusetts Health Connector will send me a copy of all MassHealth and Health Connector eligibility and enraliment notices and this person agrees to this, and | have told this person that he or she may remove or replace me as his or her authorized representative at any time by the methods described earlier in this form. Ifurther certify that | will at all times maintain the confidentiality of any information regarding the applicant or member set forth below, that is provided fo me by MassHealth or the Massachusetts Health Connector. Please note that the applicant's or member's social security number (SSN) is required-if one has been issued.

Applicant's/Member’s Name:

Applicant's/Member's SSN: xxx/xx/xxxx

Applicant's/Member's date of birth: (mm/dd/yyyy)

Authorized Representative's Name:

Authorized Representative’ Address: (mailing address, city, state, zip)

Authorized Representative's phone number:

Authorized Representative's date of birth: (mm/dd/yyyy)

Authorized Representative's e-mail address:

Authorized Representative's signature:

Date:

SECTION Ill: Authorized Representative Designation (appointed by law)

Tobe filled out by an authorized representative appointed by law (as explained earlier on this form). Please print, except for signature, Please submit a copy of the applicable legal document with this form.

| certify that | will at all times maintain the confidentiality of any information regarding the applicant or member as set forth below, that is provided to me by MassHealth or the Massachusetts Health Connector.

Please note that the applicant's or member’s social security number (SSN) is required if one has been issued.

Applicant's/Member's Name:

Applicant's/Member’s SSN: xxx/xx/Xxxx

Applicant's/Member’s date of birth: (mm/dd/yyyy)

Authorized Representative's Name:

Authorized Representative’ Address: (mailing address, city, state, zip)

Authorized Representative's phone number:

Authorized Representative's date of birth: (mm/dd/yyyy)

Authorized Representative's e-mail address:

Authorized Representative's signature:

Date:

ARD (Rev. 01/14)

Massachusetts

Effective Date: 10/01/2013

_____________________________________________________________________________ Table of Contents State/Territory Name: Massachusetts State Plan Amendment (SPA) #: MA-14-0003 This file contains the following documents in the order listed: 1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages

The complete title XXI state plan for Massachusetts consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: http://medicaid.gov/Medicaid-CHIP-Program-Information/By- Topics/Childrens-Health-Insurance-Program-CHIP/CHIP-State-Program-Information.html

DEPARTMENT OF HEALTH & HUMAN SERVICES ae

Centers for Medicare & Medicaid Services Gr Cc M &

7500 Security Boulevard, Mail Stop: S2-01-16 Baltimore, Maryland 21244-1850 CENTERS FOR MEDICARE & MEDICAID SERVICES CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

Robin Callahan DEC 2 2 2014

Deputy Medicaid Director

Massachusetts Executive Office of Health and Human Services Office of Medicaid

1 Ashburton Place, 11" Floor

Boston, MA 02108

Dear Ms. Callahan:

I am pleased to inform you that the Centers for Medicare & Medicaid Services has approved your Children’s Health Insurance Program (CHIP) state plan amendment (SPA) number MA-14-0003, submitted on January 23, 2014, with additional information provided on December 10, 2014. This SPA relates to Modified Adjusted Gross Income (MAGI) Eligibility and has an effective date of January 1, 2014.

The SPA number MA-14-0003 indicates the state’s coverage of children in its title XXI-funded Medicaid program by age group and MAG]I-equivalent income standards. A copy of the approved state plan page (CS3) and an explanatory supporting document are attached, and both should be incorporated into the state’s approved CHIP state plan in a new Section 4.0. These pages supersede the current Medicaid expansion information of the approved CHIP state plan, currently located in Section.6.

Your title XXI project officer is Mr. Martin Burian. He is available to answer questions concerning this amendment. Mr. Burian’s contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services

7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1850

Telephone: (410) 786-3246

Facsimile: (410) 786-5882

E-mail: Martin.Burian@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Mr. Burian and to Mr. Richard McGreal, Associate Regional Administrator in our Boston Regional Office. Mr. McGreal’s address is:

Centers for Medicare & Medicaid Services Division of Medicaid and Children’s Health Operations

Page 2 - Ms. Robin Callahan JFK Federal Building 15 New Sudbury St, Room 2325 Boston, MA 02203-0003 If you have additional questions, please contact Ms. Kelly Whitener, Director, Division of State Coverage Programs, at ( 410) 786-0719. We look forward to continuing to work with you and your staff toward the approval of your remaining MAGI Eligibility SP As. Enclosures cc: Richard McGreal, ARA, CMS Region I Sincerely, Eliot Fishman Director

Children's Health Insurance Program Eligibility

Control Panel

General Information

File Management

Tribal Input

Summary

Children's Health Insurance Program Eligibility: Summary Page

State/Territory Massachusetts

name: Transmittal Number: Please enter the Transmittal Number (TN) in the format ST- YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number

with leading zeros. The dashes must also be entered. |MA-14-0003

Type of SPA: MAGI Eligibility & Methods ¥ XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility

Proposed Effective Date

(ama yyy)

Federal Statute/ Regulation Citation

[42 CFR 457.320(a)(2) and (3)

Federal Budget Impact

This SPA has a budget impact. Total budget impact:

State Funds: $ Federal Funds: ¢

Subject of Amendment

Please provide a brief summary of SPA changes.

Character Count:450 out of 2000 This SPA confirms XXI Medicaid Expansion income eligibility. Authority for XXI claiming is through our 1115 demonstration “

Waiver as well as the Title XXI State Plan. Note that the Title XT income standards listed in the SPA are for children who are v faninsured at time of application. Children at these income

Signature of State Agency Official

Submitted By: Alison Kirchgasser

Last Revision Dec 11, 2014 Date: Submit Date: Jan 23, 2014

BACK CONTINUE _)

coms CHIP Eligibility |

State Name:|Massachusetts | OMB Control Number: 0938-1148

Transmittal Number: MA - 14 - 0003 Expiration date: 10/31/2014 Eligibility for Medicaid Expansion Program _

'CS3

42 CFR 457.320(a)(2) and (3)

Income eligibility for children under the Medicaid Expansion is determined in accordance with the following income standards: There should be no overlaps or gaps for the ages entered.

Age and Household Income Ranges

From Age To Age Above (% FPL) Up to & including (% FPL) +) \0 1 185 200 x +1 6 133 150 x + I\\6 18 114 150 xX */\18 19 0 150 x

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB contro! number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response. including the time to review instructions. search existing data resources. gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS. 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore. Maryland 21244-1850.

V.20140415

DEC 2 2 2014

SPA# MA-14-0003 Approval Date: Effective Date: January 1, 2014

Page | of 1

Title XXI Claiming for Medicaid Expansion; Pre-CHIP Medicaid Upper Income Limit

TRANSMITTAL NUMBER: STATE:

CHIP SPA MA-14-0003 Massachusetts

The age and income levels at which CMS authorizes Massachusetts to begin claiming enhanced match from the state’s title XXI allotment for Medicaid expenditures are based on the historical operation of the Medicaid program in Massachusetts, including the MassHealth section 1115 demonstration, as of March 31, 1997.

DEC 2 2 2014

SPA# MA-14-0003 Approval Date:, Effective Date: January 1, 2014

_____________________________________________________________________________ Table of Contents State/Territory Name: Massachusetts State Plan Amendment (SPA) #: MA-14-0005 This file contains the following documents in the order listed: 1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages The complete title XXI state plan for Massachusetts consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: http://medicaid.gov/Medicaid-CHIP-Program-Information/By- Topics/Childrens-Health-Insurance-Program-CHIP/CHIP-State-Program-Information.html

DEPARTMENT OF HEALTH & HUMAN SERVICES aa Centers for Medicare & Medicaid Services CC.

7500 Security Boulevard, Mail Stop: $2-26-12 Cc M Baltimore, Maryland 21244-1850 NTER FOR MEDICAID & club seen

CENTER FOR MEDICAID & CHIP SERVICES Children and Adults Health Programs Group

APR 15 2014

Robin Callahan

Deputy Medicaid Director

Massachusetts Executive Office of Health and Human Services Office of Medicaid

1 Ashburton Place, 11th floor

Boston, MA 02108

Dear Ms. Callahan:

Iam pleased to inform you that the Centers for Medicare & Medicaid Services (CMS) has approved your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) number MA-14-0005 submitted on February 11, 2014, and related to Modified Adjusted Gross Income (MAGI) Eligibility with an effective date of January 1, 2014.

The SPA number MA-14-0005 describes the state’s plan to provide coverage to children who would otherwise be subject to section 2101(f) of the Affordable Care Act, as specified in the state’s submission of page CS14. Under the Massachusetts 1115 demonstration waiver (“MassHealth”), prior to January 1, 2014, the state used gross income to determine eligibility for all children in Medicaid and CHIP. These income limits were not converted to MAGI standards, and as a result, the state expects that no children in the state will lose Medicaid eligibility due to the elimination of income disregards. A copy of the approved CS14 is attached, and should be incorporated within a separate subsection under section 4.1 of Massachusetts’ approved CHIP state plan.

Your title XXI project officer is Mr. Martin Burian. He is available to answer questions concerning this amendment and other CHIP-related issues. Mr. Burian’s contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services Mail Stop: S2-01-16

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-3246

Facsimile: (410) 786-5882

E-mail: Martin.Burian@cms.hhs.gov

j j' Page 2 - Ms. Robin Callahan Official communications regarding program matters should be sent simultaneously to Mr. Burian and to Mr. Richard McGreal, Associate Regional Administrator (ARA) in our Boston Regional Office. Mr. McGreal's address is: Centers for Medicare & Medicaid Services Division of Medicaid and Children's Health Operations JFK Federal Building 15 New Sudbury Street, Room 2325 Boston, MA 02203-0003 Congratulations on the approval. We look forward to continuing to work with you and your staff toward the approval of your remaining MAGI Eligibility SP As. If you have additional questions, please contact Ms. Barbara K. Richards, Acting Director, Division of State Coverage Programs at ( 410) 786-5920. Enclosure cc: Sincerely, Eliot Fishman Director Mr. Richard McGreal, ARA, CMS Region I, Boston

Control Panel

General Information

File Management

Tribal Input

Summary

Children's Health Insurance

Program Eligibility

Children's Health Insurance Program Eligibility: Summary Page

State/Territory Massachusetts

name: Transmittal Number: Please enter the Transmittal Number (TN) in the format ST- YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number

with leading zeros. The dashes must also be entered. |MA-14-0005

Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion “| Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date

(nm/aa/yyyy)

Federal Statute/ Regulation Citation

[Section 2101(f) of the ACA and 42 CFR 457 310(d)

Federal Budget Impact

This SPA has a budget impact. Total budget impact:

State Funds: $ Federal Funds: $

Subject of Amendment

Please provide a brief summary of SPA changes.

Character Count: 657 out of 2000 [This SPA confirms that no children in Massachusetts will lose Medicaid eligibility due to the elimination of income A

disregards. Prior to January 1, 2014, the state under its 1115 Demonstration Waiver used gross income to determine eligibility for all children in Medicaid and CHIP groups. When converted to

Please provide a brief summary of SPA changes.

Character Count: 657 out of 2000 [This 5PA confirms that no children in Massachusetts will lose Medicaid eligibility due to the elimination of income a

disregards. Prior to January 1, 2014, the state under its 1115 Demonstration Waiver used gross income to determine eligibility for all children in Medicaid and CHIP groups. When converted to

Signature of State Agency Official

Submitted By: Alison Kirchgasser

Last Revision Feb 11, 2014 Date:

Submit Date: Feb 11, 2014

ccmMs. CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

Section 2101(f) of the ACA and 42 CFR 457.310(d)

[if] Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards The CHIP agency provides coverage for this group of children as follows:

Cc The state has received approval from CMS to maintain Medicaid eligibility for children who would otherwise be subject to Section 2101(f) such that no child in the state will be subject to this provision.

The state assures that separate CHIP coverage will be provided for children ineligible for Medicaid due to the elimination of income disregards in accordance with 42 CFR 457.310(d). Coverage for this population will cease when the last child protected

* from loss of Medicaid coverage as a result of the elimination of income disregards has been afforded 12 months of coverage ina separate CHIP (expected to be no later than April 1, 2016 ).

Describe the methodology used by the state to identify and enroll children in a separate CHIP who are subject to the protection afforded by Section 2101(f) of the Affordable Care Act:

The state has demonstrated and CMS has agreed that all children qualifying for section 210 1(f) protection will qualify for the state’s existing separate CHIP.

The state will enroll all children in a separate CHIP who lose Medicaid eligibility because of an increase in family income at their first renewal applying MAGI methods.

The state will enroll children in a separate CHIP whose family income falls above the converted MAGI Medicaid FPL but at or below the following percentage of FPL. The state has demonstrated and CMS has agreed that all or almost all the children who would have maintained Medicaid eligibility if former disregards were applied will be within this income range and therefore covered in the separate CHIP.

% FPL.

The state will enroll children in a separate CHIP who are found to be ineligible for Medicaid based on MAGI but whose family income has not increased since the child’s last determination of Medicaid eligibility or who would have remained eligible for Medicaid (based on the 2013 Medicaid income standard) if the value of their 2013 disregards had been applied to the family income as determined by MAGI methodology.

@ Other.

ction 2101(f) and enroll such children in a separate CHIP based on the following OMS.

The state will identify children protected by S methodology and procedures as approved by

'y for all children in Medicaid and CHIP groups. When converted to MAGI standards, the income limits for children in Medicaid and CHIP did not change. Given this. no children in the state will lose Medicaid eligibility due to the elimination of income disregards.

Prior to January 1. 2014, Massachusetts under its 1115 Demonstration Waiver used gross income to determine eligibility

Describe the benefits provided to this population:

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(cms. CHIP Eligibility

C This population will be provided the same benefits as are provided to children in the state’s Medicaid program. C This population will be provided the same benefits as are provided to children in the state's separate CHIP.

© Other (consistent with Section 2103 of the SSA and 42 CFR 457 Subpart D).

Describe premiums and cost sharing required of this population:

C Cost sharing is the same as for children in the Medicaid program.

C Premiums and cost sharing are the same as for targeted low-income children in the state's separate CHIP.

C No premiums, copayments, deductibles. coinsurance or other cost sharing is required.

C Other premiums and/or cost-sharing requirements (consistent with Section 2103(e) of the SSA and 42 CFR 457 Subpart E).

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer. Mail Stop C4-26-05. Baltimore. Maryland 21244-1850.

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_____________________________________________________________________________ Table of Contents State/Territory Name: Massachusetts State Plan Amendment (SPA) #: MA-14-0006 This file contains the following documents in the order listed: 1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages The complete title XXI state plan for Massachusetts consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: http://medicaid.gov/Medicaid-CHIP-Program-Information/By- Topics/Childrens-Health-Insurance-Program-CHIP/CHIP-State-Program-Information.html

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop: 52-01-16 Baltimore, Maryland 21244-1850 Children and Adults Health Programs Group SEP 2 2 2014 Robin Callahan Deputy Medicaid Director Massachusetts Executive Office of Health and Human Services Office of Medicaid 1 Ashburton Place, 11th Floor Boston, MA 02108 Dear Ms. Callahan: CENTERS FOR MEDICARE & MEDICAID SEIIVICES CENTER FOR MEDICI\ID & CHIP SERVICES I am pleased to inform you that the Centers for Medicare & Medicaid Services has approved your Children's Health Insurance Program (CHIP) state plan amendment (SP A) number MA-14-0006, submitted on March 28, 2014, with additional information provided on September 17, 2014. This SPA relates to Modified Adjusted Gross Income (MAGI) Eligibility and has an effective date of January 1, 2014. The SPA number MA-14-0006 is approved to clarify the state's non-financial eligibility policies on residency, citizenship, social security numbers, substitution of coverage, non-payment of premiums and presumptive eligibility. Copies of the approved state plan pages are attached, and these approved pages supersede sections of Massachusetts' current state plan as detailed below: New State Plan Page Impact on Current State Plan Section CS17: Non-Financial Eligibility Residency Section 4.1.5 CS18: Non-Financial Eligibility- Citizenship Section 4.1.0; 4.1-LR; 4.1.1-LR CS 19: Non-Financial Eligibility - Social Security Section 4.1.9.l Number CS20: Non-Financial Eligibility Substitution of Section 4.4.4 Coverage CS21: Non-Financial Eligibility- Non-Payment of Section 8.7 Premiums CS28: General Eligibility - Presumptive Eligibility Section 4.3.2 for Children Your title XXI project officer is Mr. Martin Burian. He is available to answer questions concerning this amendment. Mr. Burian's contact information is as follows: Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services 7500 Security Boulevard, Mail Stop S2-01-I6 Baltimore, MD 21244-1850

Page 2 - Ms. Robin Callahan Telephone: (410) 786-3246 Facsimile: ( 410) 786-5882 E-mail: Martin.Burian@cms.hhs.gov Official communications regarding program matters should be sent simultaneously to Mr. Burian and to Mr. Richard McGreal, Associate Regional Administrator in our Boston Regional Office. Mr. McGreal's address is: Centers for Medicare & Medicaid Services Division of Medicaid and Children's Health Operations j JFK Federal Building 15 New Sudbury St, Room 2325 Boston, MA 02203-0003 If you have additional questions, please contact Ms. Kelly Whitener, Director, Division of State Coverage Programs, at (410) 786-0719. We look forward to continuing to work with you and your staff toward the approval of your remaining MAGI Eligibility SPAs. Enclosures cc: Richard McGreal, ARA, CMS Region I Sincerely, Eliot Fishman Director

Control Panel

General Information

File Management Tribal Input

Summary

Children's Health Insurance Program Eligibility

Children's Health Insurance Program Eligibility: Summary Page

State/Territory Massachusetts

name: Transmittal Number: Please enter the Transmittal Number (TN) in the format ST- YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number

with leading zeros. The dashes must also be entered. |MA-14-0006

Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing ¥ Non-Financial Eligibility

“ Non-Financial Eligibility

Proposed Effective Date

(nm/a/ yyy)

Federal Statute/ Regulation Citation

[42 CFR 457.320, 42 CFR 457.340(b), Sections 2105(c)(9) and 2107(e)(1)(J) of the SSA an

Federal Budget Impact

“ This SPA has a budget impact. Total budget impact:

State Funds: $

Federal Funds: $ Please attach a revised CHIP budget.

Document

Subject of Amendment

Please provide a brief summary of SPA changes.

Character Count: 682 out of 2000 This amendment codifies the states policies related to non- financial eligibility, including requirements related to “~ residency, presumptive eligibility for unborn children determined by qualified hospitals, social-security number, v citizenship and substitution of coverage, and non-payment of

Signature of State Agency Official

Submitted By: Alison Kirchgasser

Last Revision Sep 23, 2014 Date:

Submit Date: Mar 28, 2014

CHIP Eligibility

OMB Control Number: 0938-1148 10/31/2014

42 CFR 457.320

Residency ,

The CHIP Agency provides CHIP to otherwise eligible residents of the state, including residents who are absent from the state under certain conditions.

A child is considered to be a resident of the state under the following conditions:

im A non-institutionalized child, if capable of indicating intent and who is emancipated or married, if the child is living in the state and:

1. Intends to reside in the state, including without a fixed address, or

2. Has entered the state with a job commitment or seeking employment, whether or not currently employed. [m] A non-institutionalized child not described above and a child who is not a ward of the state:

1. Residing in the state, with or without a fixed address, or

2. The state of residency of the parent or caretaker, in accordance with 42 CFR.435.403(h)(1), with whom the individual resides.

wi An institutionalized child, who is not a ward of the state, if the state is the state of residence of the child's custodial parent or caretaker at the time of placement, or

[i] A child who is a ward of the state regardless of where the child lives, or

A child physically located in the state when there is a dispute with one or more states as to the child's actual state of fl residence.

If the state covers pregnant women, a pregnant woman is considered to be a resident under the following conditions: {m] A non-institutionalized pregnant woman who is living in the state and: 1, Intends to reside in the state, including without a fixed address, or if incapable of indicating intent, is living in the state, or 2. Entered with a job commitment or seeking employment, whether or not currently employed.

rH An institutionalized pregnant woman placed in an out-of-state-institution, as defined in 42 CFR 435.1010. including foster care homes, by an agency of the state, or

iw An institutionalized pregnant woman residing in an in-state-institution, as defined in 42 CFR 435.1010, whether or not the individual established residency in the state prior to entering the institution, or

rl A pregnant woman physically located in the state when there is a dispute with one or more states as to the pregnant woman's actual state of residence.

The state has in place related to the residency of children and pregnant women (if covered by the state):

SPA# MA-14-0006 Approval Date: Effective Date: January 1, 2014

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CHIP Eligibility

One or more interstate agreement(s). No

A policy related to individuals in the state only for educational purposes. No

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

SEP 2 2 2014

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Page 2 of 2

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

sts

Sections 2105(c)(9) and 2107(e)(1)(J) of the SSA and 42 CFR 457.320(b)(6), (c) and (d)

Citizenship 4 The CHIP Agency provides CHIP eligibility to otherwise eligible citizens and nationals of the United States and certain non-citizens, including the time period during which they are provided with reasonable opportunity to submit verification of their citizenship, national status or satisfactory immigration status.

[m] The CHIP Agency provides eligibility under the Plan to otherwise eligible individuals:

Who are citizens or nationals of the United States; or

Who are qualified non-citizens as defined in section 431 of the Personal Responsibility and Work Opportunity Reconciliation

Act (PRWORA) (8 U.S.C. §1641), or whose eligibility is required by section 402(b) of PRWORA (8 U.S.C. §1612(b)) and is not prohibited by section 403 of PRWORA (8 U.S.C. §1613); or

Who have declared themselves to be citizens or nationals of the United States, or an individual having satisfactory immigration status, during a reasonable opportunity period pending verification of their citizenship, nationality, or satisfactory immigration status consistent with requirements of 1903(x), 1137(d), and 1902(ee) of the Act, and 42 CFR 435.406, 407, 956 and 457.380.

The reasonable opportunity period begins on and extends 90 days from the date the notice of reasonable opportunity is received by the individual.

The agency provides for an extension of the reasonable opportunity period if the individual is making a good faith effort

to resolve any inconsistencies or obtain any necessary documentation, or the agency needs more time to complete the

Yes verification process.

The agency begins to furnish benefits to otherwise eligible individuals during the reasonable opportunity period on a date : te . «aes Yes earlier than the date the notice is received by the individual.

The date benefits are furnished is: @ The date of application containing the declaration of citizenship or immigration status. C The date the reasonable opportunity notice is sent.

C Other date, as described:

The CHIP Agency elects the option to provide CHIP coverage to otherwise eligible children up to age 19, lawfully residing Yes in the United States, as provided in Section 2107(e)(1)(J) of the SSA (Section 214 of CHIPRA 2009, P.L. 111-3). "

Otherwise eligible children means children meeting the eligibility requirements of targeted low-income children with the exception of non-citizen status.

The CHIP Agency provides assurance that lawfully residing children are also covered under the state's Medicaid program.

SPA# MA-14-0006 Approval Date: Effective Date: January 1, 2014

CHIP Eligibility

The CHIP Agency elects the option to provide CHIP coverage to otherwise eligible pregnant women, lawfully residing in the United States, as provided in Section 214 of CHIPRA 2009, P.L. 111-3. The state may not select this option unless the state also elects to cover lawfully residing children. A state may not select this option unless the state also covers Targeted Low- Income Pregnant Women. ,

rl An individual is considered to be lawfully residing in the United States if he or she is lawfully present and meets state residency requirements. ;

[Ml] An individual is considered to be lawfully present in the United States if he or she is:

1. A qualified non-citizen as defined in 8 U.S.C. 1641(b) and (c);

2. A non-citizen in a valid nonimmigrant status, as defined in 8 U.S.C. 1101(a)(15) or otherwise under the immigration laws (as defined in 8 U.S.C. 1101(a)(17));

3. A non-citizen who has been paroled into the United States in accordance with 8 U.S.C.1182(d)(5) for less than 1 year, except for an individual paroled for prosecution, for deferred inspection or pending removal proceedings;

4. A non-citizen who belongs to one of the following classes: (i) Granted temporary resident status in accordance with 8 U.S.C.1160 or 1255a, respectively;

(ii) Granted Temporary Protected Status (TPS) in accordance with 8 U.S.C. §1254a, and individuals with pending applications for TPS who have been granted employment authorization;

(iii) Granted employment authorization under 8 CFR 274a.12(c);

(iv) Family Unity beneficiaries in accordance with section 301 of Pub. L. 101-649,'as amended;

(v) Under Deferred Enforced Departure (DED) in accordance with a decision made by the President; (vi) Granted Deferred Action status;

(vii) Granted an administrative stay of removal under 8 CFR 241;

(viii) Beneficiary of approved visa petition who has a pending application for adjustment of status;

5. Is an individual with a pending application for asylum under 8 U.S.C. 1158, or for withholding of removal under 8 U.S.C.1231,or under the Convention Against Torture, who:

(i) Has been granted employment authorization; or

(ii) Is under the age of 14 and has had an application pending for at least 180 days; 6. Has been granted withholding of removal under the Convention Against Torture; 7. Is a child who has a pending application for Special Immigrant Juvenile status as described in 8 U.S.C.1 101(a)(27)(J); 8. Is lawfully present in American Samoa under the immigration laws of American Samoa; or

9. Is a victim of severe trafficking in persons, in accordance with the Victims of Trafficking and Violence Protection Act of 2000, Pub. L. 106-386, as amended (22 U.S.C. 7105(b)).

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10. Exception: An individual with deferred action under the Department of Homeland Security's deferred action for the childhood arrivals process, as described in the Secretary of Homeland Security's June 15, 2012 memorandum, shall not be considered to be lawfully present with respect to any of the above categories in paragraphs (1) through (9) of this definition. :

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information‘unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mai] Stop C4-26-05, Baltimore, Maryland 21244-1850.

SEP 2 2 2014

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CHIP Eligibility

OMB Control Number: 0938-1148

42 CFR 457.340(b)

Social Security Number ,

Asa condition of eligibility, the CHIP Agency must require individuals who have a social security number or are eligible for one as

determined by the Social Security Administration, to furnish their social security number, or numbers if they have more than one number.

The CHIP Agency requires individuals, as a condition of eligibility, to furnish their social security number(s), with the following exceptions:

Individuals refusing to obtain a social security number (SSN) because of well established religious objections, or Individuals who are not eligible for an SSN, or

Individuals who are issued an SSN only for a valid non-work purpose.

im The CHIP Agency assists individuals, who are required to provide their SSN, to apply for or obtain an SSN from the Social Security Administration if the individual does not have or forgot their SSN.

[™] The CHIP Agency informs individuals required to provide their SSN: By what statutory authority the number is solicited; and

How the state will use the SSN.

The CHIP Agency provides assurance that it will verify each SSN furnished by an applicant or beneficiary with the Social Security Administration, not deny or delay services to an otherwise eligible applicant pending issuance or verification of the individual's SSN by the Social Security Administration and that the state's utilization of the SSNs is consistent with sections 205

and 1137 of the Social Security Act and the Privacy Act of 1974.

The state may request non-applicant household members to voluntarily provide their SSN, if the state meets the requirements below.

The state requests non-applicant household members to voluntarily provide their es SSN. °

When requesting an SSN for non-applicant household members, the state assures that:

ia At the time such SSN is requested, the state informs the non-applicant that this information is voluntary and provides information regarding how the SSN will be used; and

im The state only uses the SSN for determination of eligibility for CHIP or other insurance affordability programs, or for a purpose directly connected with the administration of the state plan.

PRA Disclosure Statement

SEP 2 2 2014

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CHIP Eligibility

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

SEP 2 2 2014

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CHIP Eligibility

OMB Control Number: 0938-1148 10/31/2014

457.310(b)(2) and (b)(3), 457.320(a)(9) and 2110(b)(1)(C) of the SSA

Substitution of Coverage

The CHIP Agency provides assurance that it has methods and policies in place to prevent the substitution of group health coverage or other commercial health insurance with public funded coverage. These policies include:

[lJ Substitution of coverage prevention strategy:

Name of policy Description

Monitoring health insurance status at | For all applicants, the Commonwealth performs a time of application health insurance investigation and matching, accessing a comprehensive database. An investigation and matching is performed with all members of the household and their employers to determine if the member is enrolled in employer-sponsored insurance (ESI) that meets a basic benefit level and cost- effectiveness test (“qualifying insurance”). Targeted, more in-depth, investigations are also performed when individuals report on their application that their employer offers health insurance or if the individuals report that they work more than 138 hours per month (approximately 30+ hours per week) to determine if they have access to qualifying ESI but has not yet enrolled. If so, MassHealth will instruct the individuals and their family to enroll. Massachusetts passed legislation that allows for MassHealth members to enroll outside employers’ open- enrollment periods, treating a request by MassHealth for enrollment as a qualifying event.

Mandatory employer sponsored health | Enrollment in ESI is mandatory for all MassHealth- insurance enrollment and premium eligible populations with confirmed access to assistance for such ESI qualifying insurance. If MassHealth-qualifying ES] is available, applicants may receive premium assistance, but may not receive direct coverage. MassHealth does not allow members to opt out of qualifying ESI in order to obtain direct public coverage.

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Monitoring substitution of coverage MH’s premium assistance (PA) program will prevent families from dropping their private health insurance coverage. MH covers children with family incomes at or below 300% FPL through PA if they have access to insurance that is qualifying or through direct coverage if they do not have access to such insurance. Thus, there will be no financial incentive for families to drop private coverage to enroll in MH.

To discourage families from dropping their private coverage prior to applying, MH emphasizes in its marketing and outreach materials the availability of PA benefits for insured families. Additionally, when the family applies for MH benefits, MH uses the information included on the Medical Benefit Request (MBR) to complete an intensive health insurance investigation. Through the health insurance investigation, MH will be able to ensure that all applicants who have qualifying private health insurance and ail applicants with access to qualifying ESI participate in private coverage.

MH continuously monitors the effectiveness of these policies. MH monitors members to determine: how many of those members are required to enroll in ESI; how many had no access to ESI; and how many had access to ESI but were enrolled in direct coverage because the ESI did not meet the minimum requirements as qualifying insurance.

The Commonwealth measures the overall changes in the employer-sponsored insurance market through employer surveys. Through these surveys, MH is able to monitor changes both in the overall ESI market and within the large and small group markets. These employer statistics may be used to determine whether changes in the MH Family Assistance population are due to specific employer benefit changes or larger trends in the Commonwealth.

MassHealth regularly examines movement between direct coverage and PA within the caseload to measure substitution and determine if current crowd-out prevention strategies are effective.

A waiting period during which an individual is ineligible due to having dropped group health coverage. fo | (J If the state covers pregnant women, the waiting period does not apply to pregnant women. If the state elects to offer dental only supplemental coverage, the following assurances apply:

oO The other coverage exclusion does not apply to children who are otherwise eligible for dental only supplemental coverage as provided in section 2110(b)(5) of the SSA.

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CHIP Eligibility

MERTON MAONC AEE A SEDC OPCS

(] The waiting period does not apply to children eligible for dental only supplemental coverage.

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer. Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

V.20130718

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CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

42 CFR 457.570

Non-Payment of Premiums ;

Does the state impose premiums or enrollment fees? Yes Can non-payment of premiums or enrollment fees result in loss of CHIP eligibility? Yes Does the state have a premium lock out period? Yes

Please describe the lock-out period:

The lockout period begins on the date a member is terminated for non-payment of premiums (which is sixty days after the date on the bill) and ends on the date when the member’s coverage can next begin as described below.

What is the length of the time premium lock-out period? Select a length of time:

C One month

C Two months

@ 90 days

( Other (not to exceed 90 days)

Are there exceptions to the required lock-out period? Yes

Individual's income decreased to a level where no premium is required or within Medicaid standards

Other financial hardship

Describe:

The individual has shown to the satisfaction of the Medicaid agency that at the time the premium was incurred or when the individual is seeking to reactivate benefits that the individual had an undue financial hardship or if the Medicaid agency determines that the requirement to pay a premium results in an undue financial hardship for an individual the agency may waive or reduce premium balances.

Other Describe : + The individual pays all delinquent amounts that have been billed + The individual establishes a payment plan and agrees to pay the current xX "| premium being assessed and the payment-plan-arrangement amount SPA# MA-14-0006 Approval Date: Effective Date: January 1, 2014

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CHIP Eligibility

The individual is currently eligible for a MassHealth coverage type that equires a premium payment but they have a delinquent balance from thei previous Children’s Medical Security Plan coverage.

The state assures that: .

It does not require the collection of past due premiums or enrollment fees as a condition of eligibility for enrollment once the lock-out period has expired; and

It provides enrollees with an opportunity for an impartial review to address disenrollment from the progtam in accordance with section 457.1130(a)(3); and .

The child will be reenrolled in CHIP during the lock-out period upon payment of past due premiums or enrollment fees.

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

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SPA# MA-14-0006 Approval Date: Effective Date: January 1, 2014

Page 2 of 2

CEMs CHIP Eligibility

OMB Control Number: 0938-1148

Expiration date: 10/3

1/2014

Separate Child Health Insurance Program oe as General Eligibility - Presumptive Eligibility for Children.

CS28

42 CFR 457.355 and 435.1102, 2107(e)(1)(L) and 1920A of the SSA

The CHIP Agency covers children when determined presumptively eligible by a qualified entity. |Yes

[iM] Describe the population of children to whom presumptive eligibility applies:

Unborn children of pregnant women with incomes at or below 200% FPL who are not otherwise eligible for MassHealth Standard.

[i] Describe the duration of the presumptive eligibility period and any limitations:

Presumptive eligibility will be determined by qualified hospitals eligible to make hospital presumptive eligibility (HPE) determinations under the state Medicaid program. The HPE period lasts from the time of the presumptive eligibility

the state Medicaid agency can make a final determination. An individual is eligible for one presumptive eligibility period within a twelve-month period, starting with the effective date of the initial presumptive eligibility period.

determination until the end of the following month, or if an individual submits a full application within that time period, until

[Mi] Describe the application process and eligibility determination factors used:

Certified Application Councilors (CACs) at hospitals qualified to make presumptive eligibility determinations will assist individuals with the HPE determination.

The presumptive eligibility determination is based on self-attested information of the following factors: the individual's

household size and income: state residency; and citizenship or immigration status.

categorical or non-financial eligibility for the group for which the individual’s presumptive eligibility is being determined:

[M] The CHIP Agency uses qualified entities, as defined in section 1920A. to determine eligibility presumptively for children.

Separate Child Health Insurance Program ee S30 General Eligibility - List of Qualified Entities : :

A qualified entity is an entity that is determined by the agency to be capable of making presumptive eligibility determinations based on an individual’s household income and other requirements. and that meets at least one of the following requirements. Select the types of entities used to determine presumptive eligibility:

Furnishes health care items and services covered under the approved plan and is eligible to receive 0 payments under the approved plan

Is authorized to determine a child’s eligibility to participate in a Head Start program under the Head Start Oo Act

Is authorized to determine a child's eligibility to receive child care services for which financial assistance Oo is provided under the Child Care and Development Block Grant Act of 1990

Is authorized to determine a child’s eligibility to receive assistance under the Special Supplemental Food O Program for Women, Infants, and Children (WIC) under section 17 of the Child Nutrition Act of 1966

SEP 2 2 2014

SPA# MA-14-0006 Approval Date: Effective Date: January 1

, 2014

Page | of 2

CccoMs CHIP Eligibility

oO Is authorized to determine a child’s eligibility under the Medicaid state plan or for child health assistance under the Children’s Health Insurance Program (CHIP)

oO Is an elementary or secondary school. as defined in section 14101 of the Elementary and Secondary Education Act of 1965 (20 U.S.C. 8801)

[J Is an elementary or secondary school operated or supported by the Bureau of Indian Affairs (] Isa state or Tribal child support enforcement agency under title IV-D of the Act

oO Is an organization that provides emergency food and shelter under a grat under the Stewart B. McKinney Homeless Assistance Act

oO Is a state or Tribal office or entity involved in enrollment in the program under Medicaid, CHIP. or title IV-A of the Act

Is an organization that determines eligibility for any assistance or benefits provided under any program of

oO public or assisted housing that receives Federal funds. including the program under section 8 or any other section of the United States Housing Act of 1937 (42 U.S.C. 1437) or under the Native American Housing Assistance and Self Determination Act of 1996 (25 U.S.C. 4101 et seq.)

Any other entity the state so deems, as approved by the Secretary

Name of entity Description Qualified Hospitals A qualified hospital that has elected to make + hospital presumptive eligibility determinations X under 42 CFR 435.1110

The CHIP Agency assures that it has communicated the requirements for qualified entities. at 1920A(b)(3) of the Act, and provided adequate training to the entities and organizations involved. A copy of the training materials has been included.

An attachment is submitted.

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed. and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer. Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

V.20130709

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SPA# MA-14-0006 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

_____________________________________________________________________________ Table of Contents State/Territory Name: Massachusetts State Plan Amendment (SPA) #: MA-14-0013 This file contains the following documents in the order listed: 1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages

The complete title XXI state plan for Massachusetts consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: http://medicaid.gov/Medicaid-CHIP-Program-Information/By- Topics/Childrens-Health-Insurance-Program-CHIP/CHIP-State-Program-Information.html

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop: S2-01-16 Baltimore, Maryland 21244-1850 Children and Adults Health Programs Group SEP 2 2 2014 Robin Callahan Deputy Medicaid Director Massachusetts Executive Office of Health and Human Services Office of Medicaid 1 Ashburton Place, 11th Floor Boston, MA 02108 Dear Ms. Callahan: CMS CENTERS FOR MEDICARE & MEDICAID SERVICES CENTER FOR MEDICAID & CHIP SERVICES I am pleased to inform you that the Centers for Medicare & Medicaid Services has approved your Children's Health Insurance Program (CHIP) state plan amendment (SPA) number MA-14-0013, submitted on March 28, 2014, with additional information provided on September 17, 2014. This SPA relates to Modified Adjusted Gross Income (MAGI) Eligibility and has an effective date of January 1, 2014. In SPA number MA-14-0013, page CS15 provides assurance that the state will apply methodologies based on MAGI for all separate CHIP covered groups, using the approved MAGI conversion plan income thresholds. The state indicates on page CS7 that it will cover targeted low-income children, and indicates on page CS9 that it will cover children from conception to birth when the mother is not eligible for Medicaid. A copy of the approved CS 15 is attached and supersedes the language on income counting in Section 4.1.3 of the state's currently approved CHIP state plan. The CS15 page should be incorporated within a separate subsection under Section 4.3 of the current CHIP state plan. A copy of the approved CS7 and CS9 are attached and together supersede the current Geographic Area and Age sections as well as the income standards in the Income section, which are Sections 4.1.1, 4.1.2 and 4.1.3, respectively, of the current CHIP state plan. Your title XXI project officer is Mr. Martin Burian. He is available to answer questions concerning this amendment. Mr. Burian' s contact information is as follows: Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services 7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1850 Telephone: ( 410) 786-3246 Facsimile: (410) 786-5882 E-mail: Martin.Burian@cms.hhs.gov

Page 2 - Ms. Robin Callahan Official communications regarding program matters should be sent simultaneously to Mr. Burian and to Mr. Richard McGreal, Associate Regional Administrator in our Boston Regional Office. Mr. McGreal's address is: Centers for Medicare & Medicaid Services Division of Medicaid and Children's Health Operations JFK Federal Building 15 New Sudbury St, Room 2325 Boston, MA 02203-0003 If you have additional questions, please contact Ms. Kelly Whitener\ Director, Division of State Coverage Programs, at (410) 786-0719. We look forward to continuing to work with you and your staff toward the approval of your remaining MAGI Eligibility SP As. Enclosures cc: Richard McGreal, ARA, CMS Region I Sincerely, Eliot Fishman Director

Children's Health Insurance Program Eligibility

Control Panel

General Information

File Management

Tribal Input

Summary

Children's Health Insurance Program Eligibility: Summary Page

State/Territory Massachusetts

name: Transmittal Number: Please enter the Transmittal Number (TN) in the format ST- YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number

with leading zeros. The dashes must also be entered. |MA-14-0013

Type of SPA: ¥ MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility

Proposed Effective Date

(nm/de/ yyy)

Federal Statute/ Regulation Citation

[2402(b)(1)(B)(v) of the SSA; 42 CFR 457.310, 315, 320457.310(d), 42 CFR 457.10, Sectio

Federal Budget Impact

This SPA has a budget impact. Total budget impact:

State Funds: $ Federal Funds: $

Subject of Amendment

Please provide a brief summary of SPA changes.

Character Count:312 out of 2000 This amendment defines the CHIP MAGI eligibility and methods. Note that for the Conception to Birth SPA we are discontinuing the Healthy Start program that is currently authorized under the CHIP unborn child option and instead will be providing these pregnant women the full set of MassHealth Standard benefits.

Signature of State Agency Official

Submitted By: Alison Kirchgasser

Last Revision Jun 19, 2014 Date:

Submit Date: Mar 28, 2014

coms CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

Separate Child Health Insurance Program Cs15 MAGI-Based Income Methodologies * .

2102(b)(1)(B)(v) of the SSA and 42 CFR 457.315

The CHIP Agency will apply Modified Adjusted Gross Income methodologies for all’ separate CHIP covered groups. as described below, and consistent with 42 CFR 457.315 and 435.603(b) through (i).

In the case of determining ongoing eligibility for enrollees determined eligible for CHIP on or before December 31. 2013. MAGI- based income methodologies will not be applied until March 31, 2014 or the next regularly-scheduled renewal of eligibility, whichever is later.

If the state covers pregnant women. in determining family size for the eligibility determination of a pregnant woman. she is counted as herself plus each of the children she is expected to deliver.

In determining family size for the eligibility determination of the other individuals in a household that includes a pregnant woman: C The pregnant woman is counted just as herself. C The pregnant woman is counted just as herself, plus one. @ The pregnant woman is counted as herself, plus the number of children she is expected to deliver. Financial cligibility is determined consistent with the following provisions: When determining eligibility for new applicants. financial eligibility is based on current monthly income and family size. When determining eligibility for current beneficiaries, financial eligibility is based on: @ Current monthly household income and family size. C Projected annual household income for the remaining months of the current calendar year and family size. In determining current monthly or projected annual household income. the state will use reasonable methods to: Include a prorated portion of the reasonably predictable increase in future income and/or family size. Account for a reasonably predictable decrease in future income and/or family size.

Except as provided at 42 CFR 457.315 and 435.603(d)(2) through (d)(4), household income is the sum of the MAGI-based income of every individual included in the individual's household.

Household income includes actually available cash support. exceeding nominal amounts. provided

: IN by the person claiming an individual described at §435.603(f)(2)(i) as a tax dependent. °

The CHIP Agency certifies that it has submitted and received approval for the conversion for all separate CHIP covered group income standards to MAGI-equivalent standards.

An attachment is submitted.

PRA Disclosure Statement

SEP 2 2 2014

SPA# MA-14-0013 Approval Date: Effective Date: January 1, 2014 Page 1 of 2

CHIP Eligibility According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid 0MB control number. The valid 0MB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collecticm. If you have comments concerning the accurac) of the time estimate(s) or suggestions for improving this form, please write to: CMS. 7500 Security Boulevard. Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05. Baltimore. Maryland 21244-1850. SPA# MA-14-0013 SEP 2 2 2014 Approval Date: ------------ Effective Date: January 1, 2014 Page 2 of2

coms CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

CS7

Separate Child Health Insurance Program | Eligibility - Targeted Low-Income Children

2102(b)(1 (B)(v) of the SSA and 42 CFR 457.310, 315 and 320

Ir Targeted Low-Income Children - Uninsured children under age 19 whose household income is within standards established by the state.

The CHIP Agency operates this covered group in accordance with the following provisions: Age

Must be under age 19. Income Standards

Income standards are applied statewide.

Are there any exceptions, e.g. populations in a county which may qualify under either a statewide income No standard or a county income standard?

Statewide Income Standards

Begin with lowest age range first.

Please note that the lower bound for CHIP eligibility should be the highest standard used for Medicaid poverty- level children for the same age group or groups entered here.

From Age To Age Above (% FPL) Up to & including (% FPL) + jlo 1 200 300 + ih 19 150 300

Age ranges may overlap. If there is an overlap, provide an explanation. Include the age ranges for each income standard that has overlapping ages and the reason for having different income standards.

Special Program for Children with Disabilities Does the state have a special program for children with disabilities? | Yes

Is the program available to all eligible targeted low-income children? | Yes

Program Description

SPA# MA-14-0013 Approval Date: Effective Date: January 1, 2014

SEP 2 2 Page | of 2

ccMs CHIP Eligibility

Describe disability criteria used.

Children under age 19 may establish eligibility for MH CommonHealth under Title XX1 provided they are uninsured: are ineligible for MH Standard: have family group gross income that is less than or equal to 300% FPL; and, are permanently and totally disabled (PTD) as defined below: Children meeting the following requirements shall be considered PTD.

(A) For 18 Year Old (yo)- The child is unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment (PMI) that:

(a) can be expected to result in death; or

(b) has lasted or can be expected to last for a continuous period of not less than 12 mos.

(2)For purposes of this definition. an 18yo shall be determined to be disabled only if his or her physical or mental impairments are of such severity that the individual is not only unable to do his or her previous work, but cannot. considering age, education, and work experience. engage in any other kind of substantial gainful work that exists in the national economy. regardless of whether such work exists in the immediate area in which the individual lives. whether a specific job vacancy exists. or whether the individual would be hired if he or she applied for work. “Work that exists in the national economy” means work that exists in significant numbers, either in the region where such an individual lives or in several regions of the country.

(B) For Under 18 - The child has any medically determinable PMI of comparable severity to that which is required of an 18yo, or is unable to engage in age-appropriate activities (AAA). For purposes of this definition, an individual under I8yos shall be determined to be disabled only if the child’s PMI are of such severity that the child is unable to engage in AAAs.

Verification of Disability: Disability shall be verified by one of the following: certification of legal blindness from MCB;

a determination of disability (DOD) by the SSA;

or a DOD by MH's Disb. Determ.

Describe program. including additional benefits offered:

Disabled children who do not qualify for MassHealth Standard are enrolled in CommonHealth. Uninsured CommonHealth members (children) are required to participate in the MassHealth managed care organization (MCO) or the MassHealth Primary Care Clinician (PCC) Plan unless they have Medicare or access to other health insurance that meets the MassHealth basic-benefit level. [fa member meets one or both of those exclusions. they still must enroll with the MassHealth behavioral-health contractor.

Under the Massachusetts 1115 waiver, there are no income limits for CommonHealth. Premiums charged to this population are exactly the same as for children that are eligible under our CHIP program (MassHealth Family Assistance).

MassHealth CommonHealth covered services are equivalent to MassHealth Standard (Medicaid benefit package) covered services with the following exception: out of state services are covered for emergencies only.

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response. including the time to review instructions. search existing data resources. gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS. 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore. Maryland 21244-1850.

V.20130709

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SPA# MA-14-0013 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

CHIP Eligibility Separate Child }fe,lth l-Sl!.llft t!q@t Ct · · Eli ibility- Coverage From¢o,ct Ji1'itf. 42 CTR 457.10 0MB Control Number: 093 8-1148 Expiration date: I 0/31/2014 CS9  Coverage From Conception to Birth - Coverage from conception to birth when the mother is not eligible for Medicaid. [ZI The CHIP Agency operates this covered group in accordance with the following provisions: Age Standard From conception through birth. Does the state have an additional age definition or other age-related conditions? Income Standards Income standards arc applied statewide. ,Yes I Are there any exceptions. e.g. populations in a county which may qualify under either a statewide income standard or a E]o county income standard? Statewide Income Standard The statewide income standard is: From zero up to !200 J % FPL  Exempted from requirement of providing or applying for a Social Security Number.  Exempted from requirement of verifying citizenship status. PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid 0MB control number. The valid 0MB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response. including the time to review instructions. search existing data resources. gather the data needed, and complete and review the information collection. If you have comments conceming the accurac) or the time estimate(s) or suggestions for improving this form, please write to: CMS. 7500 Security Boulevard, Attn: PRA Reports Clearance Oflicer, Mail Stop C4-26-05, Baltimore. Maryland 21244-1850. SPA# MA-14-0013 SEP 2 2 2014 Approval Date:----------- Effective Date: January 1, 2014 Page I of I

_____________________________________________________________________________ Table of Contents State/Territory Name: Massachusetts State Plan Amendments (SPA) #: MA-16-0004-CHIP This file contains the following documents in the order listed: 1) Approval Letter 2) Final Approved State Plan

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services

7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1850

CENTERS FOR MEDICARE & MEDICAID SERVICES (CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

MAY 1 8 2016

Robin Callahan

Deputy Medicaid Director

Massachusetts Executive Office of Health and Human Services Office of Medicaid

1 Ashburton Place, 11th floor

Boston, MA 02108

Dear Ms. Callahan:

I am pleased to inform you that your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA), MA-16-0004-CHIP, submitted on March 31, 2016, has been approved. The SPA has a retroactive effective date of July 1, 2015.

This SPA is approved to add applied behavior analysis (ABA) as a covered benefit for all CHIP eligible children with a diagnosis of autism spectrum disorder. The state received approval for Medicaid SPA, MA-014-028, on April 6, 2016, to add this benefit to the Medicaid state plan.

Your title XXI project officer is Ms. Joyce Jordan. She is available to answer questions concerning this amendment and other CHIP-related issues. Ms. Jordan’s contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services Mail Stop S2-01-16

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-3413

Facsimile: (410) 786-5882

E-mail: Joyce.Jordan@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Ms. Jordan and to Mr. Richard McGreal, Associate Regional Administrator in our Boston Regional Office. Mr. McGreal’s address is:

Centers for Medicare & Medicaid Services

Division of Medicaid and Children’s Health Operations JFK Federal Building

15 New Sudbury Street, Room 2325

Boston, MA 02203-0003

Page 2 - Ms. Robin Callahan If you have additional questions, please contact Mr. Manning Pellanda, Director, Division of State Coverage Programs, at (410) 786-5143. We look forward to continuing to work with you and your staff. cc: Anne Marie Costello Acting Director Mr. Richard McGreal, ARA, CMS Region I, Boston

Page 1 State Plan under title XXI of the Social Security Act Children’s Health Insurance Program

Commonwealth of Massachusetts Introduction

TN: 016-014 Approval Date: 05/18/16 Effective Date: 07/01/15 CHIP #17 (Required under 4901 of the Balanced Budget Act of 1997 (New section 2101(b)))

State/Territory:

Massachusetts (Name of State/Territory)

As a condition for receipt of Federal funds under Title XXI of the Social Security Act, (42 CFR, 457.40(b))

________________________________________________________________________ (Signature of Governor, or designee, of State/Territory, Date Signed)

submits the following Child Health Plan for the Children’s Health Insurance Program and hereby agrees to administer the program in accordance with the provisions of the approved Child Health Plan, the requirements of Title XXI and XIX of the Act (as appropriate) and all applicable Federal regulations and other official issuances of the Department.

The following State officials are responsible for program administration and financial oversight (42 CFR 457.40(c)):

Name: Daniel Tsai

Position/Title: Assistant Secretary for MassHealth Name: Matthew Klitus Position/Title: Chief Financial and Strategy Officer Name: Robin Callahan Position/Title: Deputy Medicaid Director and CHIP Director

*Disclosure. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 09380707. The time required to complete this information collection is estimated to average 160 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, write to: CMS, 7500 Security Blvd., Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Page 2 State Plan under title XXI of the Social Security Act Children’s Health Insurance Program

Commonwealth of Massachusetts Introduction

TN: 016-014 Approval Date: 05/18/16 Effective Date: 07/01/15 CHIP #17 Introduction: Section 4901 of the Balanced Budget Act of 1997 (BBA), public law 1005-33 amended the Social Security Act (the Act) by adding a new title XXI, the Children’s Health Insurance Program (CHIP). In February 2009, the Children’s Health Insurance Program Reauthorization Act (CHIPRA) renewed the program. The Patient Protection and Affordable Care Act of 2010 further modified the program.

This template outlines the information that must be included in the state plans and the state plan amendments (SPAs). It reflects the regulatory requirements at 42 CFR Part 457 as well as the previously approved SPA templates that accompanied guidance issued to States through State Health Official (SHO) letters. Where applicable, we indicate the SHO number and the date it was issued for your reference. The CHIP SPA template includes the following changes: o Combined the instruction document with the CHIP SPA template to have a single document. Any modifications to previous instructions are for clarification only and do not reflect new policy guidance. o Incorporated the previously issued guidance and templates (see the Key following the template for information on the newly added templates), including: • Prenatal care and associated health care services (SHO #02-004, issued November 12, 2002) • Coverage of pregnant women (CHIPRA #2, SHO # 09-006, issued May 11, 2009) • Tribal consultation requirements (ARRA #2, CHIPRA #3, issued May 28, 2009) • Dental and supplemental dental benefits (CHIPRA # 7, SHO # #09-012, issued October 7, 2009) • Premium assistance (CHIPRA # 13, SHO # 10-002, issued February 2, 2010) • Express lane eligibility (CHIPRA # 14, SHO # 10-003, issued February 4, 2010) • Lawfully Residing requirements (CHIPRA # 17, SHO # 10-006, issued July 1, 2010) o Moved sections 2.2 and 2.3 into section 5 to eliminate redundancies between sections 2 and 5. o Removed crowd-out language that had been added by the August 17 letter that later was repealed. The Centers for Medicare & Medicaid Services (CMS) is developing regulations to implement the CHIPRA requirements. When final regulations are published in the Federal Register, this template will be modified to reflect those rules and States will be required to submit SPAs illustrating compliance with the new regulations. States are not required to resubmit their State plans based on the updated template. However, States must use the updated template when submitting a State Plan Amendment.

Federal Requirements for Submission and Review of a Proposed SPA. (42 CFR Part 457 Subpart A) In order to be eligible for payment under this statute, each State must submit a Title XXI plan for approval by the Secretary that details how the State intends to use the funds and fulfill other requirements under the law and regulations at 42 CFR Part 457. A SPA is approved in 90 days unless the Secretary notifies the State in writing that the plan is disapproved or that specified additional information is needed. Unlike Medicaid SPAs, there is only one 90 day review period, or clock for CHIP

Page 3 State Plan under title XXI of the Social Security Act Children’s Health Insurance Program

Commonwealth of Massachusetts Introduction

TN: 016-014 Approval Date: 05/18/16 Effective Date: 07/01/15 CHIP #17 SPAs, that may be stopped by a request for additional information and restarted after a complete response is received. More information on the SPA review process is found at 42 CFR 457 Subpart A.

When submitting a State plan amendment, states should redline the changes that are being made to the existing State plan and provide a “clean” copy including changes that are being made to the existing state plan.

The template includes the following sections:

1. General Description and Purpose of the Children’s Health Insurance Plans and the Requirements- This section should describe how the State has designed their program. It also is the place in the template that a State updates to insert a short description and the proposed effective date of the SPA, and the proposed implementation date(s) if different from the effective date. (Section 2101); (42 CFR, 457.70) 2. General Background and Description of State Approach to Child Health Coverage and Coordination- This section should provide general information related to the special characteristics of each state’s program. The information should include the extent and manner to which children in the State currently have creditable health coverage, current State efforts to provide or obtain creditable health coverage for uninsured children and how the plan is designed to be coordinated with current health insurance, public health efforts, or other enrollment initiatives. This information provides a health insurance baseline in terms of the status of the children in a given State and the State programs currently in place. (Section 2103); (42 CFR 457.410(A)) 3. Methods of Delivery and Utilization Controls- This section requires a description that must include both proposed methods of delivery and proposed utilization control systems. This section should fully describe the delivery system of the Title XXI program including the proposed contracting standards, the proposed delivery systems and the plans for enrolling providers. (Section 2103); (42 CFR 457.410(A)) 4. Eligibility Standards and Methodology- The plan must include a description of the standards used to determine the eligibility of targeted low-income children for child health assistance under the plan. This section includes a list of potential eligibility standards the State can check off and provide a short description of how those standards will be applied. All eligibility standards must be consistent with the provisions of Title XXI and may not discriminate on the basis of diagnosis. In addition, if the standards vary within the state, the State should describe how they will be applied and under what circumstances they will be applied. In addition, this section provides information on income eligibility for Medicaid expansion programs (which are exempt from Section 4 of the State plan template) if applicable. (Section 2102(b)); (42 CFR 457.305 and 457.320)

Page 4 State Plan under title XXI of the Social Security Act Children’s Health Insurance Program

Commonwealth of Massachusetts Introduction

TN: 016-014 Approval Date: 05/18/16 Effective Date: 07/01/15 CHIP #17 5. Outreach- This section is designed for the State to fully explain its outreach activities. Outreach is defined in law as outreach to families of children likely to be eligible for child health assistance under the plan or under other public or private health coverage programs. The purpose is to inform these families of the availability of, and to assist them in enrolling their children in, such a program. (Section 2102(c)(1)); (42CFR, 457.90) 6. Coverage Requirements for Children’s Health Insurance- Regarding the required scope of health insurance coverage in a State plan, the child health assistance provided must consist of any of the four types of coverage outlined in Section 2103(a) (specifically, benchmark coverage; benchmark-equivalent coverage; existing comprehensive state-based coverage; and/or Secretary- approved coverage). In this section States identify the scope of coverage and benefits offered under the plan including the categories under which that coverage is offered. The amount, scope, and duration of each offered service should be fully explained, as well as any corresponding limitations or exclusions. (Section 2103); (42 CFR 457.410(A)) 7. Quality and Appropriateness of Care- This section includes a description of the methods (including monitoring) to be used to assure the quality and appropriateness of care and to assure access to covered services. A variety of methods are available for State’s use in monitoring and evaluating the quality and appropriateness of care in its child health assistance program. The section lists some of the methods which states may consider using. In addition to methods, there are a variety of tools available for State adaptation and use with this program. The section lists some of these tools. States also have the option to choose who will conduct these activities. As an alternative to using staff of the State agency administering the program, states have the option to contract out with other organizations for this quality of care function. (Section 2107); (42 CFR 457.495) 8. Cost Sharing and Payment- This section addresses the requirement of a State child health plan to include a description of its proposed cost sharing for enrollees. Cost sharing is the amount (if any) of premiums, deductibles, coinsurance and other cost sharing imposed. The cost-sharing requirements provide protection for lower income children, ban cost sharing for preventive services, address the limitations on premiums and cost-sharing and address the treatment of pre- existing medical conditions. (Section 2103(e)); (42 CFR 457, Subpart E) 9. Strategic Objectives and Performance Goals and Plan Administration- The section addresses the strategic objectives, the performance goals, and the performance measures the State has established for providing child health assistance to targeted low income children under the plan for maximizing health benefits coverage for other low income children and children generally in the state. (Section 2107); (42 CFR 457.710) 10. Annual Reports and Evaluations- Section 2108(a) requires the State to assess the operation of the Children’s Health Insurance Program plan and submit to the Secretary an annual report which includes the progress made in reducing the number of uninsured low income children. The report is due by January 1, following the end of the Federal fiscal year and should cover that Federal Fiscal Year. In this section, states are asked to assure that they will comply with these requirements, indicated by checking the box. (Section 2108); (42 CFR 457.750)

Page 5 State Plan under title XXI of the Social Security Act Children’s Health Insurance Program

Commonwealth of Massachusetts Introduction

TN: 016-014 Approval Date: 05/18/16 Effective Date: 07/01/15 CHIP #17 11. Program Integrity- In this section, the State assures that services are provided in an effective and efficient manner through free and open competition or through basing rates on other public and private rates that are actuarially sound. (Sections 2101(a) and 2107(e); (42 CFR 457, subpart I) 12. Applicant and Enrollee Protections- This section addresses the review process for eligibility and enrollment matters, health services matters (i.e., grievances), and for states that use premium assistance a description of how it will assure that applicants and enrollees are given the opportunity at initial enrollment and at each redetermination of eligibility to obtain health benefits coverage other than through that group health plan. (Section 2101(a)); (42 CFR 457.1120)

Program Options. As mentioned above, the law allows States to expand coverage for children through a separate child health insurance program, through a Medicaid expansion program, or through a combination of these programs. These options are described further below: o Option to Create a Separate Program- States may elect to establish a separate child health program that are in compliance with title XXI and applicable rules. These states must establish enrollment systems that are coordinated with Medicaid and other sources of health coverage for children and also must screen children during the application process to determine if they are eligible for Medicaid and, if they are, enroll these children promptly in Medicaid. o Option to Expand Medicaid- States may elect to expand coverage through Medicaid. This option for states would be available for children who do not qualify for Medicaid under State rules in effect as of March 31, 1997. Under this option, current Medicaid rules would apply.

Medicaid Expansion- CHIP SPA Requirements In order to expedite the SPA process, states choosing to expand coverage only through an expansion of Medicaid eligibility would be required to complete sections: • 1 (General Description) • 2 (General Background) They will also be required to complete the appropriate program sections, including: • 4 (Eligibility Standards and Methodology) • 5 (Outreach) • 9 (Strategic Objectives and Performance Goals and Plan Administration including the budget) • 10 (Annual Reports and Evaluations).

Page 6 State Plan under title XXI of the Social Security Act Children’s Health Insurance Program

Commonwealth of Massachusetts Introduction

TN: 016-014 Approval Date: 05/18/16 Effective Date: 07/01/15 CHIP #17 Medicaid Expansion- Medicaid SPA Requirements States expanding through Medicaid-only will also be required to submit a Medicaid State Plan Amendment to modify their Title XIX State plans. These states may complete the first check-off and indicate that the description of the requirements for these sections are incorporated by reference through their State Medicaid plans for sections: • 3 (Methods of Delivery and Utilization Controls) • 4 (Eligibility Standards and Methodology) • 6 (Coverage Requirements for Children's Health Insurance) • 7 (Quality and Appropriateness of Care) • 8 (Cost Sharing and Payment) • 11 (Program Integrity) • 12 (Applicant and Enrollee Protections) indicating State

• Combination of Options- CHIP allows states to elect to use a combination of the Medicaid program and a separate child health program to increase health coverage for children. For example, a State may cover optional targeted-low income children in families with incomes of up to 133 percent of poverty through Medicaid and a targeted group of children above that level through a separate child health program. For the children the State chooses to cover under an expansion of Medicaid, the description provided under “Option to Expand Medicaid” would apply. Similarly, for children the State chooses to cover under a separate program, the provisions outlined above in “Option to Create a Separate Program” would apply. States wishing to use a combination of approaches will be required to complete the Title XXI State plan and the necessary State plan amendment under Title XIX.

Proposed State plan amendments should be submitted electronically and one signed hard copy to the Centers for Medicare & Medicaid Services at the following address:

Name of Project Officer Centers for Medicare & Medicaid Services 7500 Security Blvd Baltimore, Maryland 21244 Attn: Children and Adults Health Programs Group Center for Medicaid, CHIP and Survey & Certification Mail Stop - S2-01-16

Page 1 State Plan under title XXI of the Social Security Act Children’s Health Insurance Program

Commonwealth of Massachusetts

Section 1. General Description and Purpose of the Children’s Health Insurance Plans and the Requirements

TN: 016-004 Approval Date: 05/18/16 Effective Date: 07/01/15 CHIP #17

1.1. The state will use funds provided under Title XXI primarily for (Check appropriate box) (Section 2101)(a)( 1)); (42 CFR 457.70):

Guidance: Check below if child health assistance shall be provided primarily through the development of a separate program that meets the requirements of Section 2101, which details coverage requirements and the other applicable requirements of Title XXI.

1.1.1 Obtaining coverage that meets the requirements for a separate child health program (Sections 2101(a)(1) and 2103); OR

Guidance: Check below if child health assistance shall be provided primarily through providing expanded eligibility under the State’s Medicaid program (Title XIX). Note that if this is selected the State must also submit a corresponding Medicaid SPA to CMS for review and approval.

1.1.2. Providing expanded benefits under the State’s Medicaid plan (Title XIX) (Section 2101(a)(2)); OR

Guidance: Check below if child health assistance shall be provided through a combination of both 1.1. and 1.2. (Coverage that meets the requirements of Title XXI, in conjunction with an expansion in the State’s Medicaid program). Note that if this is selected the state must also submit a corresponding Medicaid state plan amendment to CMS for review and approval.

1.1.3.

A combination of both of the above. (Section 2101(a)(2))

1.1-DS

The State will provide dental-only supplemental coverage. Only States operating a separate CHIP program are eligible for this option. States choosing this option must also complete sections 4.1-DS, 4.2-DS, 6.2-DS, 8.2-DS, and 9.10 of this SPA template. (Section 2110(b)(5)) 1.2

Check to provide an assurance that expenditures for child health assistance will not be claimed prior to the time that the State has legislative authority to operate the State plan or plan amendment as approved by CMS. (42 CFR 457.40(d))

1.3

Check to provide an assurance that the State complies with all applicable civil rights requirements, including title VI of the Civil Rights Act of 1964, title II of the Americans

Page 2 State Plan under title XXI of the Social Security Act Children’s Health Insurance Program

Commonwealth of Massachusetts

Section 1. General Description and Purpose of the Children’s Health Insurance Plans and the Requirements

TN: 016-004 Approval Date: 05/18/16 Effective Date: 07/01/15 CHIP #17 with Disabilities Act of 1990, section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, 45 CFR part 80, part 84, and part 91, and 28 CFR part 35. (42CFR 457.130)

Guidance: The effective date as specified below is defined as the date on which the State begins to incur costs to implement its State plan or amendment. (42 CFR 457.65) The implementation date is defined as the date the State begins to provide services; or, the date on which the State puts into practice the new policy described in the State plan or amendment. For example, in a State that has increased eligibility, this is the date on which the State begins to provide coverage to enrollees (and not the date the State begins outreach or accepting applications).

1.4 Provide the effective (date costs begin to be incurred) and implementation (date services begin to be provided) dates for this SPA (42 CFR 457.65). A SPA may only have one effective date, but provisions within the SPA may have different implementation dates that must be after the effective date.

Effective date: October 1, 1997 Implementation date: August 24, 1998

SPA #1 (Benchmark Change) Submission date: October 12, 2001 Approval date: March 22, 2002 Effective date: January 1, 2002 Implementation date: January 1, 2002

SPA #2 (Compliance) Submission date: June 28, 2002 Approval date: September 19, 2002 Effective date: August 24, 2001 Implementation date: August 24, 2001

SPA #3 (Cost Sharing) Submission date: April 8, 2003 Approval date: June 23, 2003 Effective date: March 1, 2003 Implementation date: March 1, 2003

Page 3 State Plan under title XXI of the Social Security Act Children’s Health Insurance Program

Commonwealth of Massachusetts

Section 1. General Description and Purpose of the Children’s Health Insurance Plans and the Requirements

TN: 016-004 Approval Date: 05/18/16 Effective Date: 07/01/15 CHIP #17 SPA # 4 (Healthy Start) Submission date: April 24, 2003 Approval date: September 15, 2003 Effective date: November 1, 2002 Implementation date: November 1, 2002

SPA #5 (Family Assistance Expansion) Submission date: May 2, 2006 Approval date July 20, 2006 Effective date: July 1, 2006 Implementation date: July 1, 2006

SPA #6 (CHIPRA Legally Residing Immigrants) Submission date: March 12, 2010 Approval date: February 9, 2012 Effective date: August 29, 2009 Implementation date: August 29, 2009

SPA #6 (CHIPRA Dental Requirement) Submission date: March 12, 2010 Approval date: February 9, 2012 Effective date: August 29, 2009 Implementation date: October 1, 2009

SPA #6 (RWJ Grant and State Share) Submission date: March 12, 2010 Approval date: February 9, 2012 Effective date: August 29, 2009 Implementation date: March 12, 2010

SPA #7 (Health Services Initiative)

Submission date: June 28, 2010

Approval date: August 29, 2011

Effective date: July 1, 2009 Implementation date: July 1, 2009

Page 4 State Plan under title XXI of the Social Security Act Children’s Health Insurance Program

Commonwealth of Massachusetts

Section 1. General Description and Purpose of the Children’s Health Insurance Plans and the Requirements

TN: 016-004 Approval Date: 05/18/16 Effective Date: 07/01/15 CHIP #17 SPA #8 (Express Lane Renewal) Submission date: January 27, 2012 Approval date: November 9, 2012 Effective date: January 23, 2012 Implementation date: January 23, 2012

SPA#9 (Health Services Initiative) Submission date: June 26, 2012 Approval date: October 16, 2012 Effective date: October 1, 2011 Implementation dates: October 1, 2011 for the following provisions: Child At-Risk Hotline; Teen Pregnancy Prevention Program; Youth Violence Prevention Program; Youth Parents Support Program; and Safe and Successful Youth Program. January 1, 2014 for the following provisions: Children’s Medical Security Plan; Failure to Thrive Program; Pediatric Sexual Assault Nurse Examiner (SANE) Program; and Pediatric Palliative Care.

SPA #10 (in MMDL as 013-0026) (CS24, CHIP Application)

Submission date: December 30, 2013 through the MMDL

Approval date: May 5, 2014

Effective date: October 1, 2013 Implementation date: October 1, 2013

SPA #11 (in MMDL as 014-0003) (CS3, CHIP Medicaid Expansion) Submission Date: January 16, 2014 through the MMDL Approval date: December 22, 2014 Effective date: January 1, 2014 Implementation date: January 1, 2014

SPA #12 (in MMDL as 014-0005) (CS14, CHIP 2101(f)) Submission date: February 11, 2014 through the MMDL Approval date: April 15, 2014 Effective date: January 1, 2014 Implementation date: January 1, 2014

Page 5 State Plan under title XXI of the Social Security Act Children’s Health Insurance Program

Commonwealth of Massachusetts

Section 1. General Description and Purpose of the Children’s Health Insurance Plans and the Requirements

TN: 016-004 Approval Date: 05/18/16 Effective Date: 07/01/15 CHIP #17 SPA #13 (in MMDL as 014-0013) (CS7, CS9, CS15 CHIP MAGI Eligibility and Income) Submission date: March 28, 2014 through the MMDL Approval date; September 22, 2014 Effective date: January 1, 2014 Implementation date: January 1, 2014

SPA #14 (in MMDL as 014-0006) (CS17-21, CS28 CHIP non-financial eligibility) Submission date: March 28, 2014 through the MMDL Approval date: September 22, 2014 Effective date: January 1, 2014 Implementation date: January 1, 2014

SPA #15 (Unborn child option benefits) (TN-14-014) Submission date: June 27, 2014 Approval date: March 11, 2015 Effective date: January 1, 2014 Implementation date: January 1, 2014

SPA #16 (Health Services Initiative) (TN-014-015) Submission date: June 27, 2014 Approval date: December 8, 2014 Effective date: July 1, 2013 Implementation date: July 1 2013 for the following H.S.I provision: “Services for Homeless Youth”

SPA #17 (Applied Behavior Analysis) (TN-016-004) Submission date: March 31, 2016 Approval date: May 18, 2016 Effective date: July 1, 2015 Implementation date: July 1, 2015

Page 6 State Plan under title XXI of the Social Security Act Children’s Health Insurance Program

Commonwealth of Massachusetts

Section 1. General Description and Purpose of the Children’s Health Insurance Plans and the Requirements

TN: 016-004 Approval Date: 05/18/16 Effective Date: 07/01/15 CHIP #17 1.4 Superseding Pages of MAGI CHIP State Plan Material State: Massachusetts

Transmittal Number SPA Group PDF # Description Superseded Plan Section(s) MA-14-0013 Approval Date: 09/22/2014 Effective/Implementation Date: January 1, 2014 MAGI Eligibility & Methods CS7

CS9

CS15 Eligibility – Targeted Low Income Children

Eligibility - Coverage From Conception to Birth

MAGI-Based Income Methodologies Supersedes sections Geographic Area 4.1.1, Age 4.1.2, all but the “transfer of income” language in Income 4.1.3 and the prenatal language in 4.1.9

MA-14-0003 Approval Date: 12/22/2014 Effective/Implementation Date: January 1, 2014 XXI Medicaid Expansion CS3 Eligibility for Medicaid Expansion Program Supersedes Medicaid Expansion eligibility information in section 6 MA-14-0005 Approval Date: 04/15/2014 Effective/Implementation Date: January 1, 2014 Establish 2101(f) Group CS14 Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards A reference to this SPA is included in the Medicaid Expansion eligibility portion of section 6 MA-13-0026 Approval Date: 05/05/2014 Effective/Implementation Date: October 1, 2013 Eligibility Processing CS24 Eligibility Process Supersedes all of section 4.3 except for the precedence language pertaining to Medicaid and the richest benefits and all of section 4.4 except for the Express Lane Renewal language

Page 7 State Plan under title XXI of the Social Security Act Children’s Health Insurance Program

Commonwealth of Massachusetts

Section 1. General Description and Purpose of the Children’s Health Insurance Plans and the Requirements

TN: 016-004 Approval Date: 05/18/16 Effective Date: 07/01/15 CHIP #17 Transmittal Number SPA Group PDF # Description Superseded Plan Section(s) MA-14-0006 Approval Date: 09/22/2014 Effective/Implementation Date: January 1, 2014 Non-Financial Eligibility CS17

CS18

CS19

CS20

CS21

CS28 Non-Financial Eligibility – Residency

Non-Financial Eligibility – Citizenship

Non-Financial Eligibility – Social Security Number

Non-Financial Eligibility – Substitution of Coverage

Non-Financial Eligibility – Non-Payment of Premiums

Non-Financial Eligibility – Presumptive Eligibility for Children Supersedes section 4.1.5, with the exception of the 2 scenario examples

Supersedes the citizenship and immigration language in 4.1.9

Supersedes the social security number language in 4.1.9

Supersedes section 4.4.4

Supersedes section 8.7

Supersedes the language on Presumptive Eligibility for Standard and Family Assistance in sections 4.1.9 and 4.3

1.4- TC Tribal Consultation (Section 2107(e)(1)(C)) Describe the consultation process that occurred specifically for the development and submission of this State Plan Amendment, when it occurred and who was involved.

Verification of Tribal Consultation is attached.

Page 1 State Plan under title XXI of the Social Security Act Children’s Health Insurance Program

Commonwealth of Massachusetts

Section 2. General Background and Description of State Approach to Child Health

TN: 2014-014 Approval Date: 09/22/14 Effective Date: 01/01/14 CHIP #15 Coverage and Coordination (Section 2102 (a)(1)-(3)) and (Section 2105)(c)(7)(A)-(B))

2.1. Describe the extent to which, and manner in which, children in the state including targeted low-income children and other classes of children, by income level and other relevant factors, such as race and ethnicity and geographic location, currently have creditable health coverage (as defined in 42 CFR 457.10). To the extent feasible, make a distinction between creditable coverage under public health insurance programs and public-private partnerships (See Section 10 for annual report requirements). (42 CFR 457.80(a))

Table 2a displays the distribution of children by insurance status based on the Current Population Survey (CPS) data made available by the U.S. Bureau of the Census. The CPS is an annual national survey providing data on health insurance coverage, income, employment status, demographic characteristics and other family and individual characteristics. The CPS is considered the most reliable source of estimates of the uninsured population at the state level. To enhance the statistical reliability of demographic estimates contained in this data, the Commonwealth completed an analysis using a merged database comprising survey samples from the March, 1993 supplement and the March, 1994 supplement. In this analysis, the 1993-1994 data is considered a proxy for estimating the current distribution of Massachusetts children based on income, age and health insurance status.

Although more recent data from the March, 1995 supplement is available, it is not comparable to the 1993 and 1994 data for purposes of this analysis because survey questions were changed. The March, 1996 supplement contains a Massachusetts sample too small in aggregate to provide statistically reliable estimates.

Data has been manipulated by the Massachusetts Institute of Social and Economic Research at the University of Massachusetts in Amherst.

Table 2b displays the distribution of insured children by type of health care coverage.

Page 2 State Plan under title XXI of the Social Security Act Children’s Health Insurance Program

Commonwealth of Massachusetts

Section 2. General Background and Description of State Approach to Child Health

TN: 2014-014 Approval Date: 09/22/14 Effective Date: 01/01/14 CHIP #15

Table 2a. Health Insurance Status of Children in Massachusetts by Age and Income Level (1) Uninsured Children

Federal Poverty Level Age 0 - 6 Age 7 - 12 Age 13 - 17 Age 18 (2) Total 0% - 100% FPL 12,738 10,215 9,581 2,072 34,607 101% - 133% FPL 7,985 1,840 5,710 828 16,362 134% - 150% FPL 3,149 266 2,600 353 6,369 151% - 200% FPL 2,338 6,623 9,506 1,410 19,876 201% - 400% FPL 15,016 10,868 15,380 3,544 44,808 401% + FPL 14,055 2,941 4,432 2,607 24,035 Total 55,281 32,753 47,210 10,814 146,058

Insured Children

Federal Poverty Level Age 0 - 6 Age 7 - 12 Age 13 - 17 Age 18 Total 0% - 100% FPL 92,244 69,043 38,390 4,005 203,682 101% - 133% FPL 32,829 27,732 23,640 1,948 86,150 134% - 150% FPL 14,899 9,679 10,841 1,072 36,490 151% - 200% FPL 39,240 29,630 21,585 2,832 93,287 201% - 400% FPL 194,427 161,942 135,331 17,751 509,451 401% + FPL 178,375 151,055 122,694 32,066 484,189 Total 552,013 449,080 352,482 59,674 1,413,249

(1) Based on 1995, 1996, and 1997 Merged Current Population Survey (CPS) data. (2) Estimated based on CPS and Census data.

Page 3 State Plan under title XXI of the Social Security Act Children’s Health Insurance Program

Commonwealth of Massachusetts

Section 2. General Background and Description of State Approach to Child Health

TN: 2014-014 Approval Date: 09/22/14 Effective Date: 01/01/14 CHIP #15

Table 2b Coverage of Insured Children in Massachusetts by Age and Income (1) Insured Children

Federal Poverty Level Age 0 - 6 Age 7 - 12 Age 13 - 17 Age 18 (2) Total 0% - 100% FPL 92,244 69,043 38,390 4,005 203,682 101% - 133% FPL 32,829 27,732 23,640 1,948 86,150 134% - 150% FPL 14,899 9,679 10,841 1,072 36,490 151% - 200% FPL 39,240 29,630 21,585 2,832 93,287 201% - 400% FPL 194,427 161,942 135,331 17,751 509,451 401% + FPL 178,375 151,055 122,694 32,066 484,189 Total 552,013 449,080 352,482 59,674 1,413,249

Children Covered by Employer Related Group Health Insurance

Federal Poverty Level Age 0 - 6 Age 7 - 12 Age 13 - 17 Age 18 Total 0% - 100% FPL 7,408 13,282 9,544 873 31,107 101% - 133% FPL 16,258 11,201 8,891 745 37,095 134% - 150% FPL 8,847 6,181 8,612 652 24,291 151% - 200% FPL 19,349 14,747 13,678 1,863 49,638 201% - 400% FPL 157,962 129,847 111,084 14,844 413,737 401% + FPL 162,714 139,641 107,194 29,539 439,088 Total 372,539 314,899 259,003 48,516 994,957

Children Covered by Other Health Insurance (3)

Federal Poverty Level Age 0 - 6 Age 7 - 12 Age 13 - 17 Age 18 Total 0% - 100% FPL 84,835 55,761 28,846 3,132 172,575 101% - 133% FPL 16,571 16,531 14,749 1,203 49,054 134% - 150% FPL 6,052 3,497 2,230 420 12,199 151% - 200% FPL 19,891 14,883 7,907 969 43,649 201% - 400% FPL 36,465 32,095 24,247 2,907 95,714 401% + FPL 15,661 11,414 15,500 2,526 45,101 Total 179,475 134,180 93,479 11,158 418,292

(1) Based on 1995, 1996, and 1997 Merged Current Population Survey data. (2) Estimated based on CPS and Census data. (3) Includes Medicaid, Medicare, CHAMPUS, and Other Insurance.

Page 4 State Plan under title XXI of the Social Security Act Children’s Health Insurance Program

Commonwealth of Massachusetts

Section 2. General Background and Description of State Approach to Child Health

TN: 2014-014 Approval Date: 09/22/14 Effective Date: 01/01/14 CHIP #15 Updated children’s uninsurance data for the State Plan Amendment submitted on April 28, 2006: The information in the table below is the Unduplicated Number of Children Ever Enrolled in SCHIP in Massachusetts for the two most recent reporting periods.

Program FFY 2004 FFY 2005 Percent change FFY 2004-2005 SCHIP Medicaid Expansion Program 119,377 115,858 (3.0%) Separate Child Health Program 47,131 42,715 (9.3%) Three-year averages in the number and/or rate of uninsured children Massachusetts based on the Current Population Survey (CPS) are shown in the table below, along with the percent change between 1996-1998 and 2001-2004.

Uninsured Children Under Age 19 Below 200 Percent of Poverty Uninsured Children Under Age 19 Below 200 Percent of Poverty as a Percent of Total Children Under Age 19 Period Number Std. Error Rate Std. Error 1996-1998 70 15.5 4.6 1.0 1998-2000 68 15.5 4.2 0.9 2000-2002 40 9.9 2.6 0.7 2002-2004 53 11.7 3.4 0.7 Percent change 1996- 1998 vs. 2002-2004 -24.3 NA -26.1 NA

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Section 2. General Background and Description of State Approach to Child Health

TN: 2014-014 Approval Date: 09/22/14 Effective Date: 01/01/14 CHIP #15 2.2. Describe the current state efforts to provide or obtain creditable health coverage for uncovered children by addressing: (Section 2102)(a)(2) (42CFR 457.80(b))

2.2.1. The steps the state is currently taking to identify and enroll all uncovered children who are eligible to participate in public health insurance programs (i.e., Medicaid and state-only child health insurance):

Massachusetts has many efforts currently underway to identify and enroll eligible children in either MassHealth. These efforts are described below.

MassHealth MassHealth has made significant strides in outreach, application processing and enrollment of eligible children with the development of the EOHHS Virtual Gateway. The goal of the Virtual Gateway (VG) is to provide a single point of intake, eligibility screening, and referral services for applicants. This allows potential applicants of health and human services in the Commonwealth, either directly through the web or with assistance from a health and human services agency or a patient-accounts staff person, to obtain information and to gain access to available HHS programs. In addition, providers are also able to track electronically submitted applications.

Application volume through the VG for MassHealth and Uncompensated Care Pool (UCP) determinations increased steadily since implementation. By the end of FY 2005, the VG deployment had reached provider sites constituting 80% of UCP volume. There are currently 120 MassHealth providers using the VG, made up of 72 hospitals and 48 community health centers.

The Virtual Gateway has been pivotal in improving access to MassHealth since its implementation in October 2004. Access improvements have resulted in an 8.4% increase in family enrollment and a 6.7% increase in children’s enrollment in MassHealth in the period October 2004 to November 2005.

In the last quarter of FFY05, MassHealth awarded $500,000 in mini-grants to 22 community-based organizations across the state to increase MassHealth enrollment. These grants will help provide critical access to people who are already eligible for MassHealth but not enrolled. MassHealth is working closely with these grantees to give them the knowledge and tools to enroll new MassHealth members. One component of this effort is training those grantees who are not already doing so to submit electronic applications for MassHealth. Each of the grantees has tailored programs specific to the people and regions they serve. To buttress training provided by MassHealth, grantees will use novel approaches for outreach, including health fairs, public notices, multi-lingual

Page 6 State Plan under title XXI of the Social Security Act Children’s Health Insurance Program

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Section 2. General Background and Description of State Approach to Child Health

TN: 2014-014 Approval Date: 09/22/14 Effective Date: 01/01/14 CHIP #15 collaborations with YMCAs, YWCAs, hospitals, community service organizations, soup kitchens, homeless shelters, clinics, schools, and businesses, as well print, radio, and television marketing campaigns.

Massachusetts continues as a Robert Wood Johnson Foundation Covering Kids’ site, collaborating with Health Care for All. MassHealth also continues to work with the medical community including the Massachusetts Hospital Association, the Massachusetts Medical Society, and the American Academy of Pediatrics to promote the MassHealth program. Providers are encouraged to participate in training sessions on MassHealth and are supplied with enrollment kits titled “What to do when an Uninsured Child Shows up at your Door”.

Additionally, to support member education efforts, MassHealth continues to provide funding for the Health Access Networks (HANs). HANs were developed in partnership with the University of Massachusetts Medical School’s Area Health Education Center (AHEC) as a forum to share information, strategies, and experiences on effective member education practices. HANs have been established in each of the six regional areas and continued to meet monthly during SFY05. MassHealth Operations continues to fund this effort as MassHealth Technical Forums. The meetings currently promote information dissemination, sharing of best practices, and building of community/public sector linkages to increase targeted outreach and member education information about MassHealth.

MassHealth has also elected the Express Lane Renewal option to provide a simplified renewal process for eligible Medicaid Expansion CHIP children (133% to at or below 150% of the federal poverty level for children aged 1 to 5 years old; 114% to at or below 150% of the federal poverty level for children aged 6 to 17 years old; and 0% to at or below 150% of the federal poverty level for children aged 18 years old). This option is also provided for unborn-CHIP children from 0% to at or below 150% of the federal poverty level. Gross income is used for all income calculations. The Express Lane renewal process allows Medicaid Expansion CHIP and CHIP children who are also receiving Supplemental Nutrition Assistance Program (SNAP) benefits to have their eligibility renewed through an automatic process that will not require a paper renewal form. This process promotes retention of children in health benefits

Page 7 State Plan under title XXI of the Social Security Act Children’s Health Insurance Program

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Section 2. General Background and Description of State Approach to Child Health

TN: 2014-014 Approval Date: 09/22/14 Effective Date: 01/01/14 CHIP #15 Children’s Medical Security Plan (CMSP) CMSP is a state-funded program that provides coverage for certain preventive and ambulatory medical services for children of any income who are not eligible for MassHealth. EOHHS has created a single point of access for the two programs. There is a streamlined, single application for both MassHealth and CMSP. An application is reviewed first for MassHealth eligibility. If the child is determined ineligible for MassHealth, an eligibility determination is automatically made for CMSP.

Other EOHHS Programs There are several other programs operated by EOHHS agencies that also evaluate families for potential eligibility for MassHealth and CMSP. These programs include:

• Early Intervention Programs: Early Intervention Programs (EIPs), certified by the Department of Public Health, offer developmental services to both insured and uninsured children. EIPs are reimbursed by the Department of Public Health for services delivered to uninsured children. EIP staff provides information about CMSP and MassHealth to families with uninsured children.

• School-Based Health Centers: Thirty-one school-based health centers in the Commonwealth are funded by the Department of Public Health to offer comprehensive primary care services to children and adolescents who are students at the schools served by the centers. The sites are able to bill MassHealth, CMSP and other insurers for services delivered, and also provide services to uninsured children. Additionally, these sites are required to provide information about CMSP and MassHealth to children who indicate they are uninsured.

• Community-Based Primary Care: Forty-nine community-based primary care sites are funded by the Department of Public Health to offer supportive services to ease access to medical primary care. These services, which include social services, nutrition and health education, outreach, case management and transportation, are available to both insured and uninsured children. Medical services provided to uninsured children are billed to the Commonwealth’s uncompensated care pool. Additionally, these 49 primary care sites are required to provide information about CMSP and MassHealth to children who are uninsured.

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TN: 2014-014 Approval Date: 09/22/14 Effective Date: 01/01/14 CHIP #15 • The Supplemental Nutrition Program for Women, Infants and Children (WIC): WIC sites are operated under the auspices of the Department of Public Health. The program provides nutritious food to supplement the regular diet of pregnant women, infants and children under age five who meet federal and state income and adjunct eligibility requirements. Women and children under five years old qualify if the combined family income is at or below 185% FPL. WIC staff encourages uninsured pregnant women and parents and guardians of uninsured children to apply for MassHealth. Staff also refers uninsured clients with higher levels of income to CMSP.

• Disproportionate Share Hospitals: These hospitals are MassHealth providers that serve a disproportionate share of low income and uninsured people. The hospitals are entitled to apply to the Commonwealth’s free care pool for payment for health care services delivered to uninsured patients. In addition, staff at these hospitals is able to assist uninsured patients in applying for CMSP and MassHealth benefits.

• Case Management Program for Children with Special Health Care Needs: The Department of Public Health employs regionally-based case managers who offer case management services to children with special health care needs and their families. These case managers often assist families with MassHealth or CMSP applications, if the child is uninsured. Case managers also provide other social services that may increase access to medical primary care services, including identification of providers with experience in treating children with special health care needs and assisting the family with accessing transportation or other necessary services.

• Early Intervention Partnerships and Healthy Families Home Visiting Programs: Under these home visiting programs operated by the Department of Public Health, community-based providers perform home visiting services for high-risk pregnant women, and first-time teen mothers. Home visitors perform many activities, including assisting the pregnant women or mothers in accessing health insurance through either CMSP or MassHealth, as well as facilitating the child’s access to primary medical care services.

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TN: 2014-014 Approval Date: 09/22/14 Effective Date: 01/01/14 CHIP #15 • The Municipal Medicaid Program: MassHealth contracts with municipalities to provide direct health care services to special education students and to assist with administration of the Medicaid program in general. One of the activities that is included in the administration is identification of potential MassHealth eligibles, and referral of those eligibles to MassHealth. In addition, under the Municipal Medicaid program, school health personnel are working to increase coordination with the MassHealth managed care system.

2.2.2. The steps the state is currently taking to identify and enroll all uncovered children who are eligible to participate in health insurance programs that involve a public-private partnership:

MassHealth continues to form public/private partnerships with Massachusetts employers through its premium assistance programs.

MassHealth encourages employer-sponsored coverage for low-income employees and their families through a combination of the SCHIP program and its 1115 Waiver. MassHealth provides premium assistance payments on behalf of eligible children with family income at or below 300% FPL (before disregards). In addition, under the 1115 Waiver, MassHealth provides premium assistance to eligible adults who work for a qualified small employer and makes an incentive payment to the small employer.

2.3. Describe the procedures the state uses to accomplish coordination of SCHIP with other public and private health insurance programs, sources of health benefits coverage for children, and relevant child health programs, such as title V, that provide health care services for low-income children to increase the number of children with creditable health coverage. (Previously 4.4.5.)

(Section 2102)(a)(3) and 2102(c)(2) and 2102(b)(3)(E)) (42CFR 457.80(c))

EOHHS will assess children’s eligibility for both Title XIX and Title XXI programs. EOHHS is the Commonwealth’s Title XIX agency and has been charged with expanding its health programs to cover Title XXI populations. Eligibility for MassHealth Title XIX and MassHealth Title XXI will be determined simultaneously. The Medical Benefit Request (MBR) is used to assess eligibility for all MassHealth programs (Title XIX and Title XXI), as well as the Children’s Medical Security Plan. Sufficient information is collected on the MBR to assess if the applicant is eligible for any MassHealth coverage type (e.g. MassHealth Standard, CommonHealth or Family Assistance). The MBR information is data entered into MassHealth’s eligibility system (MA21) to invoke an eligibility

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TN: 2014-014 Approval Date: 09/22/14 Effective Date: 01/01/14 CHIP #15 determination. MA21 is designed to assign the most comprehensive coverage type to the eligible applicant. See Section 4.4.1 for a more detailed description of the eligibility process.

If a child with family income between 150% and 300% of the FPL (before disregards) appears to have access to health insurance through an employer, MassHealth will conduct a health insurance investigation to determine if the insurance meets MassHealth standards and is cost effective. If there is access to qualified health insurance coverage, the children will be eligible for premium assistance towards the cost of their employer sponsored insurance. Children between 200 and 300% of the FPL may be subject to a waiting period of up to six months for coverage if they are found to have dropped employer-sponsored insurance within the previous six months (see section 4.4.4.2).

The MBRs of children who are ineligible for MassHealth are automatically processed for CMSP and Safety Net Care.

MassHealth notices include information regarding the WIC program if a family member is pregnant or under age five.

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Check here if the State elects to use funds provided under Title XXI only to provide expanded eligibility under the State’s Medicaid plan, and continue on to Section 4.

Guidance: In Section 3.1., discussion may include, but is not limited to: contracts with managed health care plans (including fully and partially capitated plans); contracts with indemnity health insurance plans; and other arrangements for health care delivery. The State should describe any variations based upon geography, as well as the State methods for establishing and defining the delivery systems. Should the State choose to cover unborn children under the Title XXI State plan, the State must describe how services are paid. For example, some states make a global payment for all unborn children while other states pay for services on fee-for-services basis. The State’s payment mechanism and delivery mechanism should be briefly described here.

Section 2103(f)(3) of the Act, as amended by section 403 of CHIPRA, requires separate or combination CHIP programs that operate a managed care delivery system to apply several provisions of section 1932 of the Act in the same manner as these provisions apply under title XIX of the Act. Specific provisions include: section 1932(a)(4), Process for Enrollment and Termination and Change of Enrollment; section 1932(a)(5), Provision of Information; section 1932(b), Beneficiary Protections; section 1932(c), Quality Assurance Standards; section 1932(d), Protections Against Fraud and Abuse; and section 1932(e), Sanctions for Noncompliance. If the State CHIP program operates a managed care delivery system, provide an assurance that the State CHIP managed care contract(s) complies with the relevant sections of section 1932 of the Act. States must submit the managed care contract(s) to CMS’ Regional Office servicing them for review and approval.

In addition, states may use up to 10 percent of actual or estimated Federal expenditures for targeted low-income children to fund other forms of child health assistance, including contracts with providers for a limited range of direct services; other health services initiatives to improve children’s health; outreach expenditures; and administrative costs (See 2105(c)(2)(A)). Describe which, if any, of these methods will be used.

Examples of the above may include, but are not limited to: direct contracting with school-based health services; direct contracting to provide enabling services; contracts with health centers receiving funds under section 330 of the Public Health Service Act; contracts with hospitals such as those that receive disproportionate share payment adjustments under section 1886(d)(5)(F) or 1923 of the Act; contracts with other

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hospitals; and contracts with public health clinics receiving Title V funding. If applicable, address how the new arrangements under Title XXI will work with existing service delivery methods, such as regional networks for chronic illness and disability; neonatal care units, or early-intervention programs for at-risk infants, in the delivery and utilization of services. (42CFR 457.490(a))

3.1. Delivery Standards Describe the methods of delivery of the child health assistance using Title XXI funds to targeted low-income children. Include a description of the choice of financing and the methods for assuring delivery of the insurance products and delivery of health care services covered by such products to the enrollees, including any variations. (Section 2102)(a)(4) (42CFR 457.490(a))

Check here if the State child health program delivers services using a managed care delivery model. The State provides an assurance that its managed care contract(s) complies with the relevant provisions of section 1932 of the Act, including section 1932(a)(4), Process for Enrollment and Termination and Change of Enrollment; section 1932(a)(5), Provision of Information; section 1932(b), Beneficiary Protections; section 1932(c), Quality Assurance Standards; section 1932(d), Protections Against Fraud and Abuse; and section 1932(e), Sanctions for Noncompliance. The State also assures that it will submit the contract(s) to the CMS’ Regional Office for review and approval. (Section 2103(f)(3))

Guidance: In Section 3.2., note that utilization control systems are those administrative mechanisms that are designed to ensure that enrollees receiving health care services under the State plan receive only appropriate and medically necessary health care consistent with the benefit package.

Examples of utilization control systems include, but are not limited to: requirements for referrals to specialty care; requirements that clinicians use clinical practice guidelines; or demand management systems (e.g., use of an 800 number for after-hours and urgent care). In addition, the State should describe its plans for review, coordination, and implementation of utilization controls, addressing both procedures and State developed standards for review, in order to assure that necessary care is delivered in a cost-effective and efficient manner. (42CFR, 457.490(b))

MassHealth uses Title XXI funds to deliver child health assistance through the following MassHealth coverage types: MassHealth Standard, MassHealth CommonHealth, MassHealth Family Assistance (including the Family Assistance Expansion for Children - FAEC), and MassHealth Prenatal . Coverage types are described below.

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MassHealth Standard

Delivery system options: managed care organization (MCO) or primary care clinician (PCC) plus behavioral health program (BHP). Standard members who have other comprehensive third-party health insurance and those who have not yet enrolled in a managed care plan may obtain services from any MassHealth provider on a fee-for-service basis.

MassHealth CommonHealth

Delivery system options: Generally CommonHealth members obtain services on a fee-for-service basis. Uninsured CommonHealth members may, at their option, participate in the MassHealth managed care network.

MassHealth Standard and CommonHealth Premium Assistance Program (MSCPA)

MassHealth Standard and CommonHealth members may receive premium assistance toward the employee’s full share of the cost of employer-sponsored health insurance through the MSCPA program. Additionally, MassHealth will cover any MassHealth covered services not covered by the member’s private health insurance or on a fee-for-service basis.

MassHealth Family Assistance (including FAEC)

(A) Premium Assistance

Delivery system options: Premium Assistance payments are made to parents to subsidize the employee share of employer-sponsored insurance (ESI). All medical services are provided through the ESI. Dental services are provided directly by MassHealth on a fee-for-service basis. .

(B) Purchase of Medical Benefits

Delivery system options: Generally, managed care (MCO or PCC plus BHP) Family Assistance members who have not yet enrolled in a managed care plan may obtain services from any MassHealth provider on a fee–for-service basis and behavioral health services through the Behavioral Health Plan. MassHealth Family Assistance members who are eligible to receive covered services through

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other state agencies under agreement with MassHealth may obtain services on a fee-for-service basis as well. MassHealth Prenatal

Delivery system options: fee-for-service.

Methods of delivering insurance product and services

MassHealth members receive services through the following.

Primary Care Clinician (PCC) Plan Provider Network and the PCC Plan’s Behavioral Health Program (BHP)

The PCC plan is a primary care case management program administered by MassHealth. In the PCC Plan, members enroll with a primary care clinician (PCC), who provides most primary and preventive care. There are currently approximately 1,100 PCC practices in the PCC Plan network, including individual physicians, group practices, community health center, independent nurse practitioners, and hospital outpatient departments. MassHealth monitors the performance of providers in the network, including developing and implementing quality improvement. The BHP is a managed behavioral health care program that offers a comprehensive provider network including a broad spectrum of mental health and substance abuse providers who provide a full continuum of mental health and substance abuse services to eligible members. Covered mental health benefits are described in section 6. Members enrolled in the PCC Network are automatically enrolled in the BHP: there are no pre-enrollment assessments required. In addition, eligible members are only disenrolled if they become ineligible for managed care or enroll in an MCO, as MassHealth MCOs are separately responsible for behavioral health services for their members.

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MassHealth contracts with a vendor to administer and manage its BHP.

BHP Linkage with the PCC Plan

The BHP vendor is required to facilitate communication and coordination of care with primary care clinicians and to establish annual BHP – PCC linkage improvement goals. Managed Care Organization (MCO) Provider Network

MassHealth currently contracts with MCOs that provide comprehensive health coverage, including medical, pharmacy, and behavioral health services, to MassHealth Standard members and Family Assistance members, as well as to uninsured CommonHealth members who opt to participate in the MCO network. The network of MassHealth MCOs reflects industry trends towards mixed models, a combination of staff, network, and IPA. MCOs are available to MassHealth members throughout the state, although not all contracting MCOs are statewide. MassHealth members enrolled in MCOs choose a primary care provider (PCP) from among an MCO’s list of participating providers. These MCO participating providers must assure equal access to MassHealth member (i.e., PCPs may not be closed to MassHealth members if they are open to commercial MCO members). Fee-for-service

Members may receive certain services on a fee-for-service basis. Rates for these services are established either through contracts with MassHealth or regulations promulgated by the Massachusetts Executive Office of Health and Human Services. Any provider who meets program participation requirements set forth in the MassHealth regulations and provider agreements may participate in the MassHealth program.

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School Based Health Centers (SBHC)

School health clinics (hereinafter referred to as School-Based Health Centers, or SBHCs) have linkage to primary care providers in the PCC Plan. Some MCOs also have contractual agreements with School Based Health Centers (SBHC) to pay the SBHC for care delivered to members enrolled in the MCO.

SBHCs are operated as satellite sites of existing MassHealth providers. If the provider that operates the SBHC is a PCC, then the qualified SBHC site can act as an arm of that PCC, and treat those students who are enrolled with the operating provider as their PCC. SBHCs use the provider number of the existing MassHealth provider of which they are a satellite. If the provider is an MCO, the MCO pays the SBHC from the MCO capitation paid by MassHealth. Where SBHCs do not have their own provider agreements, they cannot claim payment from MassHealth directly. School Based Medicaid

School Based Medicaid providers have linkage to PCPs in both the PCC and MCO Plans. Special education-related services are paid for by either the municipality or the child’s insurer, including MassHealth. Family Planning

PCC members are guaranteed confidentiality and unrestricted access to Family Planning services by being able to obtain these services from any participating provider without consulting their PCC or obtaining prior approval from MassHealth. MassHealth members enrolled in an MCO may access Family Planning services provided by the MCO. However, such MCO enrollees may also receive Family Planning services from any Family Planning provider without consulting their PCP or MCO and are not required to obtain prior approval from MassHealth. For Family Planning services provided by MassHealth providers not participating in the MCO network, MassHealth reimburses the provider on a fee-for-service basis.

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Payment mechanisms

PCC Payment Mechanisms Fee-for-service

MassHealth currently reimburses both PCCs and non-PCCs on a fee-for-service basis. Enhancement

MassHealth pays PCCs an enhancement for most office and home visits when they see one of its members. An enhanced fee is not paid for referrals. MassHealth also pays PCCs an enhancement for providing EPSDT services according to the periodicity schedule. These additional payments compensate PCCs for the case management functions they perform. Prospective Interim Payment (PIP)

A prospective interim payment (PIP) is also available to PCCs. The PIP is an optional monthly cash advance for PCCs. The payment is made at the beginning of each month and is equal to twenty-five percent (25%) of MassHealth’s average monthly payment to the PCC for services to the PCC’s plan members in the previous quarter. Reconciliations occur using subsequent claims submissions.

BHP Payment Mechanisms

Capitation and Risk Sharing Arrangements

MassHealth pays a different per member per day capitation rate for each rating category. A rating category groups members by eligibility status and reflects assumptions about projected service utilization and cost. MassHealth and the BHP vendor share the risk of over or underspending according to actuarially sound risk corridors.

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MCO Payment Mechanisms Capitation Payments

MassHealth pays the MCOs a monthly capitation rate on a per-member per- month basis, based on a member’s rating category. Capitation rates are developed commensurate with the risk facing an MCO. Rating categories, therefore, are distinguished either by differences in expected utilization of services among groups of MassHealth members and differences in the covered services for which the MCOs are capitated. Capitation rates are established in accordance with regulations at 42 CFR 438.6 regarding actuarial soundness. The MCOs are at full risk for nearly all members, with the exception of certain small risk pools for high-needs children. In addition, MassHealth offers the MCOs the option to purchase stop-loss insurance coverage for persons with disabilities.

MassHealth reconciles estimated capitation payments with actual enrollment volume.

In addition, pursuant to Section 2105(a)(1)(D)(ii), Massachusetts will use administrative funds to offer “Health Services Initiatives” under the plan. Programs offered as part of these Health Services Initiatives with the overarching goal of improving the health of children (defined at 42 CFR 457.10 as “individual(s) under the age of 19 including the period from conception to birth”). Please note that, to the extent that any program does provide services to individuals age 19 or over, reimbursement will only be claimed for services or activities targeted towards children under age 19. The Health Services Initiatives will be activities funded by state appropriations to the Executive Office of Health and Human Services or the Executive Office of Education, and administered by related state departments or agencies, as described below. Specific Health Services Initiatives include the following programs:

• Healthy Families

Healthy Families is a statewide neonatal and postnatal home parenting education and home visiting programs for at-risk newborns. This program is administered by the Massachusetts Children’s Trust Fund (MCTF), a quasi-public agency that receives its state appropriation via the Department of Early Education and Care. MCTF provides funding through contracts with community-based human services organizations that furnishes the home visiting services to at-risk families. MCTF selects providers pursuant to Requests for Responses (RFR). The program is designed to prevent child abuse and neglect; achieve optimal health, growth and development in infancy and early childhood; and prevent repeat teen pregnancies. Specific services include home visits in which staff model and support positive parent-child interactions; teach about child development; help the family to

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provide a safe and enriching environment for children; provide crisis intervention as needed; and connect the family with other services as needed.

• School Based Health Programs

School based health programs are sponsored by the Massachusetts Department of Public Health (DPH). School based health programs that are included as part of the Health Services Initiative are:

o “Essential School Health Services,” which strengthens the infrastructure of school health services in the area of school nursing. The program provides funding to eligible school districts through RFRs with the goal of creating and expanding the Essential School Services structure and standards throughout the Commonwealth. This program provides school-age children access to a school health service program that includes nursing assessment/health education; medication management; and screenings with respect to postural, height/weight, hearing, oral health, and vision.

o “Safe Spaces,” which provides suicide prevention and violence prevention programs for Gay, Lesbian, Bisexual and Transgender (GLBT) Youth. Through Safe Spaces, DPH funds youth development programs across Massachusetts; the programs are selected pursuant to an RFR issued by DPH. The programs are not necessarily based in schools and may provide services during after-school hours or weekends. The programs engage young people in shared decision-making, expanding life skills, leadership development, and affirming support around multidimensional GLBT identity development which includes successfully navigating race, ethnicity, gender expression, national origin, language, sexual orientation, socio-economic background, age, religion and ability.

• Nutrition Programs for Children:

o “School Breakfast Programs,” which provide nutritious breakfasts to children on school days and during summer vacation. The program is funded with state appropriations that are supplemental to federal funding. All children may participate, but low income children are eligible for free or reduced price meals depending on family income. The Department of Elementary and Secondary Education (DESE) provides funding to school districts based on schools meeting the criteria of: • meeting the requirements of "Severe Need Schools" which are defined as schools where 40 percent or more of the lunches served to students at the

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school in the second preceding year were served free or at a reduced prices; and • having on file a combined total of fifty or more free and reduced price meal applications as of October of the preceding school year.

Expenditures claimed as part of this Health Services Initiative exclude expenditures used as “maintenance of effort” for other federal grants.

o “State-Funded WIC”, provides the following services through peer counseling and professional medical staff: breastfeeding support, dietary assessments, nutrition education and counseling, immunization screening and referrals to other health and social services. To administer this program, DPH uses an RFR process to select qualified community based organizations, such as community health centers and community action programs, which provide the services.

• Smoking Prevention and Cessation Programs

Through Smoking Prevention and Cessation Programs, DPH funds a wide range of activities to promote tobacco control and prevention. The activities serve a wide variety of populations, including children, adolescents, families, and adults. Only the expenditures associated with programs directed toward individuals below the age of 19 will be claimed under CHIP Health Services Initiative. DPH funding supports: o Production and dissemination of educational materials for youth and parents; o Funding to non-profit organizations (via an RFR process) to promote activities - such as interactive web sites and short-movie contests - to discourage youth from tobacco use.

• Family Planning Programs

Through Family Planning Programs, DPH provides the following services at family planning sites throughout the state. o Comprehensive family planning services, including complete gynecological and breast exams, cervical cancer screening, diagnosis and treatment of sexually transmitted diseases, contraceptive supplies including emergency contraception, pregnancy testing, follow-up and referral for identified medical problems, and other pre-conceptional care. o Individual health education and counseling on reproductive anatomy and physiology, all contraceptive methods, AIDS/HIV, sexually transmitted diseases, all options for positive pregnancy tests, infertility, and other related health concerns.

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o Outreach and education to local communities and populations. These activities vary with each program but may include classes in schools and community organizations on reproductive health, sexuality, and HIV prevention; training and resources for teachers, health care providers and parents; peer education programs; participation in community coalitions; and collaboration with other organizations serving high risk populations.

• DDS/DESE Project to Prevent Out of Home Residential Placements

This project provides services to youth with disabilities to enable the youth to live at home rather than in residential facilities. The project is sponsored by the Massachusetts Department of Developmental Services (DDS) and the Massachusetts Department of Elementary and Secondary Education (DESE). DDS receives funds from DESE to provide community based supports to students who a.) meet DDS eligibility criteria for services and b.) also receive special education services. The goal is to provide community based services to enable the youth to continue living with their families and prevent placement in a residential facility.

Services are provided through this project are based on the individual needs of youth and are planned in conjunction with the families. Most services are provided in the child’s home. Each child’s needs and services are determined through an individualized plan reviewed with the DDS authorized case manager. The program empowers the youths’ parents to arrange for the services needed for their children by providing the parents with funds to purchase necessary services. The range of services are diverse and may include behavioral intervention analysis and training, speech therapy, physical therapy, occupational therapy, adaptive equipment, specialized nutrition, and activities of daily living training.

• The Children’s Medical Security Plan to provide primary and preventive health services for uninsured children from birth through age 18.

The Children’s Medical Security Plan (CMSP) provides coverage for primary and preventive health services for uninsured children from birth through age 18 who are not eligible for MassHealth. The CMSP is managed by the Executive Office of Health and Human Services (EOHHS). Eligibility for CMSP is determined by MassHealth, and re-determinations are conducted annually. CMSP covers medically necessary medical, behavioral-health, dental, and pharmacy services, but not inpatient services.

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• Child At-Risk Hotline for after hours reporting of suspected child abuse and neglect.

The Department of Children and Families engages a private social services agency to provide telephone coverage for reports of child abuse and neglect during nights and weekends. The staff triage reports and communicate information to the state agency.

• Teen Pregnancy Prevention Program

The Department of Public Health engages community based agencies to provide science-based teen pregnancy prevention strategies to high-risk adolescents.

• Failure to Thrive Program

The Department of Public Health oversees the Failure to Thrive Program which focuses on providing evaluation and treatment for infants or children who are exhibiting childhood malnutrition and growth failure known as Failure to Thrive. The overall goal of the program is to improve the growth and developmental outcome of the children. The Department of Public Health contracts with hospitals and community health centers to provide services by multidisciplinary teams.

• Youth Violence Prevention Program

The Department of Public Health oversees the Youth Violence Prevention Program. Community based organizations provide comprehensive youth violence prevention programs to youth in at-risk communities.

• Pediatric Sexual Assault Nurse Examiner (SANE) Program

The SANE program is administered by the Department of Public Health and provides direct patient care to adolescents and children who disclose sexual assault and who go to SANE designated Emergency Departments or Children’s Advocacy Centers across Massachusetts. The nurses of the SANE program provide direct patient care to individuals who disclose sexual assault. This includes necessary medical exams, testing, and preventive treatment for HIV, STDs, and pregnancy. These services are the first step in psychological, physical, and emotional healing for the child.

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• Pediatric Palliative Care

The Department of Public Health funds the Pediatric Palliative Care Program which helps children with life-limiting illnesses and their families gain a sense of control in their lives. A network of licensed hospices helps children and their caregivers manage the pain and other symptoms brought on by illness.

• Young Parents Support program

The Department of Children and Families funds this program whose goal is to strengthen parenting skills of low-income young mothers for the ultimate benefit of their children.

• Safe and Successful Youth Program

The Executive Office of Health and Human Services oversees this program whose goal is to support a full continuum of services to support young men most likely to be victims or perpetrators of violence.

• Services for Homeless Youth

Through Services for Homeless Youth, the Department of Early Education and Care (EEC) contracts with licensed organizations to provide a stable, nurturing environment that meets the individual, developmental, behavioral and emotional needs of homeless youth. Each family is assessed for their unique issues and needs and the provider develops a “Family Service Plan” to address the needs. Each child is assessed for developmental concerns and where developmental delays are identified, appropriate referrals are made. Parents are provided access to parenting programs, a variety of community resources (e.g., WIC), nutritional guidance, information on building positive parent-child interactions, and skills to help identify the best quality child care for their children. Based on the “Family Service Plan”, when therapeutic supports are needed (medical, psychological, etc.), providers assist parents in accessing needed services.

Expenditures claimed as part of this Health Services Initiative exclude costs for providing services to MassHealth covered members.

3.2. Describe the utilization controls under the child health assistance provided under the plan for targeted low-income children. Describe the systems designed to ensure that enrollees receiving health care services under the State plan receive only appropriate and medically necessary health care consistent with the benefit package described in the approved State plan. (Section 2102)(a)(4) (42CFR 457.490(b))

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Primary Care Clinician (PCC) Plan Provider Network

A PCC Plan Provider must sign MassHealth PCC Provider Contract and meet the requirements specified in the Contract. The requirements include, but are not limited to: informing members about service availability, referral processes, grievance procedures, after-hour call-in systems, and procedures for appointments, emergencies and urgent care; providing 24-hour/7-day/week telephone coverage system with physician back- up; making necessary referrals, and monitoring all Medicaid-covered services which require a referral; and ensuring that care is provided in accordance with acceptable medical practices and professional standards.

The PCC is responsible for authorizing most specialty services. Members can access any MassHealth provider for specialty services; however, some services require that members first obtain authorization from their PCC.

The PCC must provide primary care as appropriate, and maintain an adequate appointment system that ensures prompt access to medical care.

PCC Network Management

The PCC Plan Network Management Services (NMS) is a clinically focused management system that monitors, measures, and analyzes health care delivery by PCCs. The major goal of Network Management Services is to improve health care delivery systems that promote improved member health outcomes.

The NMS program assists PCCs and MassHealth by: measuring, monitoring and promoting improvements in health care delivery and outcomes; conducting visits to PCC practices; producing data reports; and assisting PCCs in understanding their utilization statistics. The NMS program also conducts periodic regional information meetings with PCCs, and performs provider-relations, information, and referral activities through the PCC Plan Hotline.

NMS site visits focus primarily on PCCs with large practices. Regional Network managers make site visits to these PCCs to review the Profile Reports, discuss how the measures reflect on the PCC practice, and help formulate improvement plans to address opportunities for improvement.

The PCC Plan Hotline is toll free and staffed by PCC Plan Hotline Provider Service

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Representatives. Providers may call the PCC Plan Hotline for information regarding the PCC Plan or MassHealth. Managed Care Organization (MCO) Provider Network MCO qualifications and responsibilities

MassHealth’s MCO contract details the MCOs’ qualifications and responsibilities. MassHealth’s decision to contract with an MCO is largely based on that organization’s ability to meet MassHealth-defined contract requirements concerning:

• Access, member services and utilization; • Quality; • Behavioral health; and, • Financial stability.

These requirements define what the MCOs must provide to MassHealth members enrolled in their plan, and are the cornerstone of all contract management activities. MassHealth's contract requirements for MCOs are designed to: • Be consistent with generally accepted standards; • Address the specific needs of the MassHealth population; • Address all significant aspects of the performance of MCOs; • Be set at best practice level and be improvement-oriented; and • Be specific and measurable so that data from measures can be used by MassHealth and the MCO to identify opportunities for improving performance. Coordination of Services

MassHealth members enrolled in MCOs may receive the same covered services as MassHealth members in the PCC Plan. However, there are differences in how services are obtained.

For each member enrolled in an MCO, MassHealth pays the MCO a monthly capitation to provide most, but not all, MassHealth services. MCOs are responsible for providing behavioral health services to MassHealth members enrolled in MCOs. MassHealth members enrolled in an MCO may obtain non-capitated MassHealth services from any MassHealth provider. Contracted MCOs are responsible for coordination of such non- capitated services. This coordination includes informing members of the availability of non-capitated services and the processes for accessing those services.

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School-Based Health Centers (SBHC)

MassHealth’s MCO contracts contain language requiring MCOs to coordinate with SBHCs to improve the quality of, and access to, health care services at SBHCs. The MCOs have undertaken, and will continue, several activities to meet this goal.

The following are examples of these activities: Representatives from DPH’s SBHC program attend MCO meetings. At the meetings, participants address MCO-SBHC linkage issues. MCOs work with SBHCs located in their service area(s), to improve their individual relationships. Each MCO has identified a single contact person for the SBHC to call. Finally, the MCOs and SBHCs are currently investigating other ways to communicate with each other regarding children being seen by both providers. MCO Contract Management

MassHealth maintains a quality-focused, collaborative management approach with its contracted MCOs, an approach that emphasizes continuous quality improvement in several components of service delivery, including clinical care, customer service and administration.

Each MCO's contract management requirements include, but are not limited to, 1) compliance with the contract and with all applicable state and federal laws and regulations, 2) designating a representative to act as a liaison with MassHealth, and 3) participation in and successful completion of performance evaluation activities related to the continuous quality improvement model of contract management utilized by MassHealth. MassHealth oversees compliance by the MCOs using a continuous quality improvement model.

MCO contracts substantially comply with the requirements of the Balanced Budget Act at 42 C.F.R. Part 438.

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Behavioral Health Program Provider Responsibilities

The vendor must develop policies and procedures for the provider network. These policies are subject to review and approval by MassHealth and at a minimum must address:

• Timeliness for rendering services; • Service authorization requests; • Frequency of reviews; • Continued stay/continued care clinical criteria; and, • Required reporting formats.

Through its contracted provider network, the vendor is responsible for providing all medically necessary care, 24 hours a day with the most clinically appropriate provider and at the most clinically appropriate level of care.

The vendor must ensure that members have access to all covered services utilizing the following standards:

• inpatient services – within 15 miles or 30 minutes travel time, whichever requires less travel time; • all other covered services – within 20 miles or no more than 30 minutes travel time, whichever requires less travel time.

In addition, MassHealth requires that members’ access to service is consistent with the degree of urgency as set forth below:

• Emergency services must be provided immediately; • Urgent care must be provided within 48 hours; and • Non-urgent care must be provided within ten (10) working days.

MassHealth also required the vendor to develop a protocol to ensure linkage between primary care providers and BH providers. The vendor and MassHealth’s PCC Plan collaborated to issue a communication protocol to facilitate coordination and integration in the physical and behavioral health treatment of members.

BHP Vendor’s Administration of Diversionary Services

The BHP vendor is required to maintain a network of diversionary services that meet the access standards and to arrange, coordinate, and oversee the provision of medically necessary diversionary services. Diversionary services are provided as alternatives to inpatient mental health services in more community-based, less structured environments. Diversionary services include crisis stabilization, observation and holding beds, partial hospitalization, and psychiatric

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day treatment. The provision of these services are arranged for by the vendor’s clinical staff who receive requests for hospitalization and then make a clinical decision to locate and authorize alternative or “diversionary” services for members, as appropriate. MassHealth monitors the BHP vendor’s compliance for the administration of diversionary services through the following mechanisms:

• The BHP vendor is required to submit utilization and expenditure reports to MassHealth for all diversionary services provided during the reporting period; these reports must be submitted monthly, quarterly, semiannually, and annually. MassHealth analyzes and monitors these reports to determine if the utilization of diversionary services is clinically appropriate;

• MassHealth requires the BHP vendor to submit provider profiles on a semiannual basis;

• On a regular basis, MassHealth reviews patterns of care, monitors case manager activities, and randomly audits vendor records to monitor and ensure the appropriate use of diversionary services;

• On a regular basis, MassHealth requires the vendor to conduct provider site visits to review randomly selected medical records and participate in case conferences;

• MassHealth’s BHP staff regularly join vendor staff supervision meetings and clinical management department meetings to monitor compliance with the administration of diversionary services; and

• MassHealth and DMH review and approve the vendor’s medical necessity criteria, level of care determination criteria, and provider policies and procedures, along with the vendor’s compliance with the administration of these items.

If MassHealth determines that the vendor is not in compliance with the administration of diversionary services, MassHealth will require the BHP vendor to implement a corrective action plan that has been reviewed and approved by MassHealth. MassHealth will then closely monitor the vendor’s compliance with the approved corrective action plan.

BHP Network Management

MassHealth requires the vendor to conduct network management functions. Network management includes:

development, maintenance, and management of the BHP provider network; and, BHP provider contracting, and provider education.

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Specifically, the Network Management service administered by the vendor and monitored by MassHealth includes the following:

• A system for provider profiling and benchmarking;

• A system for the vendor and provider to identify and establish improvement goals and Periodic measurements to track the provider’s progress or lack of progress towards improvement goals;

• Monitor the annual turnover of outpatient providers (e.g., therapists, psychiatrists) and use this information to establish improvement goals for the providers for future periods;

• Corrective action plans for the year, methods to be employed to monitor corrective action plans, implementation, and progress;

• A plan, subject to MassHealth approval, for taking appropriate management action with providers who performance is determined to be unacceptable by the vendor’s network management department; and

• A plan, subject to MassHealth approval, to terminate or take other appropriate management action with providers who may be insolvent or otherwise financially unsound.

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Section 4. Eligibility Standards and Methodology (Section 2102)(b)

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Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 5.

4.1. The following standards may be used to determine eligibility of targeted low-income children for child health assistance under the plan. Please note whether any of the following standards are used and check all that apply. If applicable, describe the criteria that will be used to apply the standard. (Section 2102)(b)(1)(A)) (42CFR 457.305(a) and 457.320(a))

MA-014-0013 MMDL (CS7, CS9 and CS15) supersedes sections 4.1.1., 4.1.2, all but the transfer of income language in section 4.1.3, and the prenatal language in section 4.1.9

4.1.1.

Geographic area served by the Plan:

MassHealth is available statewide.

4.1.2.

Age:

In general, children under age 19 are eligible for Title XXI MassHealth. Eligibility for a coverage type is determined by a combination of age, family income, disability or pregnancy status, and the availability of health insurance. For specific eligibility guidelines, see Attachment 4.1 (d).

4.1.3.

Income:

Title XXI MassHealth has a family income limit of 300% FPL (before disregards, see chart below) and who are not eligible for Medicaid under title XIX. For specific eligibility guidelines see Attachment 4.1 (d).

In the determination of eligibility for MassHealth, the gross income of all family group members is counted and compared to an income standard based on the family group size.

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Section 4. Eligibility Standards and Methodology (Section 2102)(b)

TN: 2014 - 014 Approval Date: 09/22/14 Effective Date: 01/01/14 Chip #15 A family includes natural, step, or adoptive parents who reside with their child(ren) under age 19, and any of their children, or whose child(ren) are absent from home to attend school; or siblings under age 19, and any of their children, who reside together when no parent(s) are present. A family includes both parents when they are mutually responsible for one or more children who reside with them.

Family may also include a child or children under age 19, any of their children, and their caretaker relative when no parent is living in the home. A caretaker relative may choose whether or not to be part of the family.

MassHealth Standard through the CHIP unborn child option is available to uninsured pregnant women with family incomes from zero percent of the FPL up to and including 200 percent of the FPL who are not otherwise eligible for MassHealth Standard.

Countability of Income

Eligibility is based on the family group’s gross countable earned and unearned income and countable rental income, as defined in (A) and (B), (C) below. Income that is not counted in the eligibility determination is defined in (D), below.

(A) Earned Income

Gross earned income is the total amount of compensation received from work or services performed before any income deduction.

Earned income for the self-employed is the total amount of business income listed or allowable on a U.S. tax return, minus allowable business deductions.

For persons who are seasonally employed, annual gross income is divided by 12 to obtain a monthly gross income with the following exception. If the person experiences a disabling illness or accident during or after the seasonal employment period which prevents the person’s continued or future employment, only current available income shall be considered in the eligibility determination.

(B) Gross Unearned Income

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Section 4. Eligibility Standards and Methodology (Section 2102)(b)

TN: 2014 - 014 Approval Date: 09/22/14 Effective Date: 01/01/14 Chip #15 This is income that does not directly result from the individual’s own labor. The total amount of unearned income before any deductions is countable. Unearned income includes, but is not limited to, social security benefits, railroad retirement benefits, pensions, annuities, federal veterans’ benefits, and interest and dividend income.

(C) Rental Income

Rental income is the total amount of gross income, received from a tenant or boarder, less any allowable deductions listed on an applicant's or member's U.S. tax return.

(D) Non-Countable Income

The following types of income are non-countable in the determination of eligibility:

• Income received by a TAFDC, EAEDC, or SSI recipient; • Sheltered workshop earnings; • The portion of Federal veterans benefits identified as aid and attendance benefits, unreimbursed medical expenses, housebound benefits, or enhanced benefits; • Income-in-kind; • Temporary income from U.S. Census Bureau related to Census 2000 activities, or federal unemployment benefits related to the termination of that temporary income. • Roomer and boarder income; and • Any other income excluded as provided by federal laws other than the Social Security Act (see 42 C.F.R. Part 416, Appendix to Subpart K).

Verification of Income

Verification of gross monthly income is mandatory. In lieu of any of the specific sources and verifications listed below, any other evidence of the applicant’s or member’s earned or unearned income is acceptable.

Earned Income

The following are required to verify earned income:

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• Two recent pay stubs; • A signed statement from the employer; or • Most recent U.S. tax return.

Unearned Income

The following are required to verify unearned income:

• Copy of a recent check or stub showing gross income from the source; or • Statement from the income source, where matching is not available.

Rental Income

The following are required to verify rental income • Most recent U.S. tax return

Transfer of Income

All family group members are required to avail themselves of all potential income. If MassHealth determines that income has been transferred for the primary purpose of establishing eligibility for MassHealth, the income is counted as if it were received. If MassHealth is unable to determine the amount of available income, the family group will remain ineligible until such information is made available.

Calculation of Financial Eligibility

The financial eligibility for various MassHealth coverage types is determined by comparing the family group’s gross monthly income with the applicable income standard for the specific coverage. The monthly income standards are determined according to annual FPL standards published by the Federal Register using the following formula:

• Divide the annual federal poverty income standard as it appears in the Federal Register by 12; • Multiply the un-rounded monthly income standard by the applicable FPL standard (e.g. 133%); and • Round up to the next whole dollar to arrive at the monthly income standards.

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MassHealth will adjust these standards in April of each calendar year.

Cost of Living Adjustment (COLA) Protections

Members whose income increases each January as the result of a cost of living adjustment shall remain eligible until the subsequent FPL adjustment.

Income Disregards

Gross Income as % of FPL Income Disregards (as a % of FPL) Below 200% 0 200 0 250 50 300 100

4.1.4.

Resources (including any standards relating to spend downs and disposition of resources):

MA-014-0006 MMDL (CS17) supersedes section 4.1.5, with the exception of the 2 scenario examples

4.1.5.

Residency (so long as residency requirement is not based on length of time in state):

As a condition of eligibility an applicant or member must:

• Live in the Commonwealth, with the intent to remain permanently or for an indefinite period, but is not required to maintain a permanent residence or fixed address; or • Live in the Commonwealth at the time of application having entered the Commonwealth with a job commitment, whether or not currently

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Section 4. Eligibility Standards and Methodology (Section 2102)(b)

TN: 2014 - 014 Approval Date: 09/22/14 Effective Date: 01/01/14 Chip #15 employed, (also applicable to migrant or seasonal workers.)

Examples of applicants or members who generally do not meet the residency requirement for MassHealth are:

• Students under age 19 whose parents reside out of state; and • Individuals who came to Massachusetts for the purpose of receiving medical care in a setting other than a nursing facility, and who maintain a residence outside of Massachusetts.

4.1.6.

Disability Status (so long as any standard relating to disability status does not restrict eligibility):

Children under age 19 may establish eligibility for MassHealth CommonHealth under Title XXI provided they:

• Are uninsured; • Are ineligible for MassHealth Standard; • Have family group gross income that is less than or equal to 300% of the federal poverty level; and, • Are permanently and totally disabled as defined below

Note: disabled children, regardless of income, are covered under CommonHealth through the Commonwealth’s 1115 waiver.

Permanent and Total Disability Children meeting the following requirements shall be considered permanently and totally disabled.

(A) For 18 Year Old Children (1) The child is unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment that: (a) can be expected to result in death; or (b) has lasted or can be expected to last for a continuous period of not less than 12 months.

(2) For purposes of this definition, an 18 year old shall be determined to be disabled only if his or her physical or mental impairments are of such severity that the individual is not only unable to do his or her previous work, but cannot, considering age, education, and work experience, engage

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Section 4. Eligibility Standards and Methodology (Section 2102)(b)

TN: 2014 - 014 Approval Date: 09/22/14 Effective Date: 01/01/14 Chip #15 in any other kind of substantial gainful work that exists in the national economy, regardless of whether such work exists in the immediate area in which the individual lives, whether a specific job vacancy exists, or whether the individual would be hired if he or she applied for work. “Work that exists in the national economy” means work that exists in significant numbers, either in the region where such an individual lives or in several regions of the country.

(B) For Children Under 18 The child has any medically determinable physical or mental impairment of comparable severity to that which is required of an 18 year old, or is unable to engage in age-appropriate activities. For purposes of this definition, an individual under the age of 18 shall be determined to be disabled only if the child’s physical or mental impairments are of such severity that the child is unable to engage in age-appropriate activities.

Verification of Disability Disability shall be verified by one of the following:

• certification of legal blindness from MCB; or • a determination of disability by the Social Security Administration; or • a determination of disability by MassHealth’s Disability Determination Unit (DDU).

4.1.7.

Access to or coverage under other health coverage:

Other Health Coverage A child shall be considered insured and, as a result, ineligible for Title XXI MassHealth if he or she is:

• a member of a family that is eligible for health benefits through a state health benefits plan based on a family member’s employment with a public agency in the state; • eligible for MassHealth Standard and has family group gross income that is less than the standards described in Attachment 4-1 (d); or • covered under a group health plan or under health insurance coverage (as such terms are defined in section 2791 of the Public Health Service Act).

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Section 4. Eligibility Standards and Methodology (Section 2102)(b)

TN: 2014 - 014 Approval Date: 09/22/14 Effective Date: 01/01/14 Chip #15 Access to Health Insurance A child has access to health insurance, for the purpose of determining eligibility for Title XXI MassHealth, where the prospective member, the parent, spouse or legal guardian has access to group health insurance that includes the member, through an employer, the employer contributes at least 50% of the premium cost, and the insurance meets a basic benefit level as defined by MassHealth.

MassHealth will require a Title XXI MassHealth child who has access to health insurance to enroll in the employer sponsored insurance plan if:

• the child is ineligible for MassHealth Standard or CommonHealth; • the family group gross income is between 150% and 300% FPL (before disregards); and • MassHealth has determined it is cost effective to purchase the insurance.

MassHealth will provide premium assistance toward the child’s private health insurance premium payment through MassHealth Family Assistance.

4.1.8.

Duration of eligibility:

A pregnant woman who has been determined eligible for MassHealth Standard, including under the unborn child option, shall continue to be eligible for the duration of her pregnancy and the two calendar months following the month in which her pregnancy ends, regardless of any subsequent changes in family group income. No other children will receive a durational guarantee of eligibility. They will be subject to a periodic review of eligibility.

4.1.9.

Other standards (identify and describe):

All MassHealth members must meet the requirements described in this section. MA-014-0006 MMDL (CS19) supersedes the Social Security Number (SSN) language in 4.1.9

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Social Security Number (SSN) Requirements As a condition of eligibility for any MassHealth coverage type, applicants and members must furnish a SSN. Applicants who do not have a SSN will be notified of their obligation to apply for one.

MassHealth shall verify each applicant's SSN by a computer match with the Social Security Administration.

Right to Know Uses of Social Security Numbers All household members will be given written notice in a booklet accompanying their MassHealth Benefit Request of the following:

• the reason the SSNs are requested; • the computer-matching with SSNs in other personal data files within MassHealth, other government agencies, and elsewhere; and • that failure to provide the SSN of any person receiving or applying for benefits may result in denial or termination of his or her benefits.

Assignment of Rights to Medical Support and Third Party Payments Every legally able applicant or member must assign to MassHealth his or her own rights to medical support and third party payments for medical services provided under MassHealth as well as the rights of those for whom he or she can legally assign medical support and third party payments.

The applicant or member must provide MassHealth with information to help pursue any medical support and source of third party payment, including support available from the absent parent, who is legally obligated to pay for care and services for the applicant/member and/or for person(s) on whose behalf benefits are requested unless he or she can show good cause not to provide this information.

Refusing to comply with the requirements of this section will exclude the applicant or member from receipt of MassHealth benefits unless the applicant or member is a pregnant woman who is eligible for Mass Health Standard or the mother of an unborn child eligible for MassHealth Healthy Start.

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Good Cause for Non-cooperation Good cause for non-cooperation is present if at least one of the following circumstances exists regarding the child of the applicant or member:

• the child was conceived as a result of incest or forcible rape; • legal proceedings for adoption are pending before a court; • a public agency or licensed facility is assisting in resolving the issue of adoption and discussions have not lasted longer than three months; or • cooperation would result in serious harm or emotional impairment to the child or relative with whom the child resides or to the applicant or member.

Assignment for Third Party Recoveries As a condition of eligibility, an applicant or member must inform MassHealth when a household member is involved in an accident, or suffers from an illness or injury which has or may result in a lawsuit or insurance claim. The applicant or member must:

• file a claim for compensation; • assign to MassHealth the right to recover an amount equal to the MassHealth benefits provided from either the member or the third party; and • provide information about the third party claim and cooperate with MassHealth's Post Payment Recovery Unit unless MassHealth determines that cooperation would not be in the best interests of, or would result in serious harm or emotional impairment to, the applicant or member.

MA-014-0006 MMDL (CS18) supersedes the Citizenship and Immigration language in 4.1.9

Citizenship and Immigration Requirements In determining eligibility for Title XXI MassHealth, a child must be a citizen or a qualified alien, as defined in section 431 of the Personal Responsibility and Work Opportunity Act of 1996 (PRWORA), as amended. Alternatively, a child must be otherwise eligible and lawfully residing in

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Section 4. Eligibility Standards and Methodology (Section 2102)(b)

TN: 2014 - 014 Approval Date: 09/22/14 Effective Date: 01/01/14 Chip #15 the United States as allowed for under the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) and as described in Section 4.1.10 below.

Verifications of Citizenship and Immigration Status For aliens, a determination of eligibility will be made once the application is complete except for documentation of immigration status. Aliens who have not submitted documentation of immigration status within sixty days of the date of the eligibility determination, or whose verification cannot be confirmed by the U.S. Immigration and Naturalization Service, shall subsequently be ineligible. . An otherwise eligible lawfully residing individual as provided for in section 214 of CHIPRA will be verified to continue to lawfully reside in the United States using the documentation presented to the Commonwealth by the member on initial enrollment. If the Commonwealth cannot successfully verify that the member is lawfully residing in the United States in this manner, it shall require the member provide further documentation or other evidence.

For citizens, a determination of eligibility will be made once the application is complete except for documentation of citizenship and/or identity status. Citizens who have not submitted documentation of citizenship and identity status within sixty days of the date of the eligibility determination, shall subsequently be ineligible unless an extension is requested.

Title XXI MassHealth Specific Eligibility Requirements by Coverage Type

In addition to other requirements described in Section 4, a child must meet the specific Title XXI eligibility requirements of each coverage type. The requirements for MassHealth CommonHealth are described in Section 4.1.6. Eligibility requirements for MassHealth Standard, Family Assistance (direct coverage and premium assistance), and Prenatal follow.

(A) MassHealth Standard MassHealth Standard is available to uninsured children under the age of 19 subject to the following requirements.

Unborn Children An unborn child is eligible if the gross income of the family group is less than or equal to 200% FPL and the unborn child’s mother is otherwise ineligible for MassHealth Standard. The unborn child or children are counted as if born and living with the mother in determining family group size.

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Children under One A child under one is eligible if the gross income of the family group is greater than 185% FPL and less than or equal to 200% FPL.

A MassHealth Standard-eligible child who is receiving inpatient hospital services on the date of his or her first birthday shall remain eligible until the end of the stay for which the inpatient services are furnished.

Children Aged One through Eighteen Children aged one through eighteen are eligible for MassHealth Standard if the gross income of the family group meets the income standards described in Attachment 4-1 (d). If the individual is pregnant, the unborn child or children are counted as if born and living with the mother in determining family group size.

MA 14-0006 MMDL (CS28) supersedes the language on Presumptive eligibility for Standard and Family Assistance in section 4.1.9

Presumptive Eligibility for Standard An uninsured child whose self-declared family group income meets the financial requirements of MassHealth Standard shall be determined presumptively eligible in accordance with the requirements described at Section 4.3.

(B) MassHealth Family Assistance (including FAEC) – Direct Coverage Direct coverage under MassHealth Family Assistance is available to uninsured children aged one through eighteen provided:

• the gross income of the family group is greater than 150% but less than or equal to 300% FPL (before disregards) • the child is ineligible for MassHealth Standard and MassHealth CommonHealth; and

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If the individual is pregnant, the unborn child or children are counted as if born and living with the mother in determining family group size.

Time Limited MassHealth Family Assistance A child may receive MassHealth Family Assistance benefits on a fee for service basis for a maximum of 60 days if a member of his or her family group has declared he or she has access to employer- sponsored health insurance benefits. During this 60-day period, MassHealth shall determine if the insurance meets HIPAA and basic benefit level requirements. If the insurance meets these requirements, MassHealth will subsequently require the child to be enrolled in the employer-sponsored health insurance plan and a premium assistance amount will be established as described below.

Presumptive Eligibility for MassHealth Family Assistance An uninsured child whose self-declared family group income is greater than 150% FPL and less than or equal to 300% FPL (before disregards) shall be determined presumptively eligible in accordance with the requirements at Section 4.3.

MassHealth Family Assistance Premiums MassHealth Family Assistance members may be assessed a monthly (health insurance) premium using the schedule below.

%FPL Per child Family maximum 150.1-200.0 $12

$36 200.1-250.0 $20

$60 250.1-300.0 $28

$84

MassHealth Family Assistance members shall be responsible for monthly premium payments beginning with the calendar month following the date of their eligibility determination. MassHealth Family Assistance members who self-identify as members of a federally recognized American Indian tribe or who are Alaskan Natives will not be charged a monthly premium.

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MassHealth Family Assistance members who are determined eligible for another coverage type shall cease to be responsible for the premium payment to MassHealth as of the calendar month in which the coverage type changes.

Members who are assessed a revised premium payment as the result of a reported change shall be responsible for the new monthly premium payment beginning with the calendar month following the reported change.

Delinquent Premium Payments Any portion of a premium payment that is not made within sixty calendar days of the billing date will result in termination of coverage after advance notice. Another coverage period will not begin unless MassHealth collects all premiums that MassHealth determines to be outstanding unless a hardship exemption or payment plan has been granted in accordance with MassHealth regulations.

Once terminated for non-payment of a premium: • if payment is made in full within thirty (30) calendar days of the date of the termination, coverage shall begin retroactive to the date of termination, if otherwise eligible; or • if payment is made in full later than thirty (30) calendar days of the date of the termination, coverage shall begin retroactive to the date of the premium payment, if otherwise eligible.

Voluntary Withdrawal In case of a member's voluntary withdrawal, coverage shall continue, and the member shall be responsible for payment of premiums through the end of the calendar month of withdrawal.

Change in Premium Calculation The premium amount is recalculated when MassHealth is informed of changes in income, or family group size. The premiums may also be recalculated when an adjustment is made to the premium schedule.

(C) Family Assistance/Premium Assistance (including FAEC) Premium assistance under MassHealth Family Assistance is available to children aged one through eighteen between 150 and

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TN: 2014 - 014 Approval Date: 09/22/14 Effective Date: 01/01/14 Chip #15 200% FPL, and to children aged zero through eighteen between 200 and 300% FPL (before disregards), provided:

• the child is ineligible for MassHealth Standard and MassHealth CommonHealth; • the child has access to employer-sponsored health insurance where the employer contributes at least 50% of the premium cost, the insurance meets the basic benefit level; • it is cost-effective to MassHealth to provide premium assistance; and, • for children between 200 and 300% FPL, the child or children has been uninsured for a minimum of six months prior to application, except as specified in section 4.4.4.2.

In order to determine whether an employer –sponsored health plan meets the Basic Benefit Level, MassHealth reviews a copy of the summary of benefits and/or a copy of the policy from either the employee or employer. A Family Assistance coordinator compares the plan to MassHealth’s basic benefit requirements to ensure that the plan includes all state-mandated benefits.

MassHealth makes monthly premium assistance payments on behalf of a child toward the cost of the employer-sponsored health insurance. The premium assistance payment is calculated by using the following information:

• the total health insurance premium; • the employer share of the health insurance premium; and, • the MassHealth-calculated member share of the health insurance premium (if applicable). The member share is

%FPL Per child Family maximum 150.1-200.0 $12

$36 200.1-250.0 $20

$60 250.1-300.0 $28

$84

Alaska Natives and American Indians who are members of federally recognized tribes will not have a calculated member share.

This information will be collected on the MBR. To verify the information, a MassHealth representative will contact the

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TN: 2014 - 014 Approval Date: 09/22/14 Effective Date: 01/01/14 Chip #15 applicant’s employer to collect the required data. Once the information is collected and verified, MassHealth will calculate a premium assistance payment amount.

Estimated Premium Assistance Amount The estimated premium assistance amount equals the total health insurance premium minus the employer share of the premium minus the MassHealth calculated member share of the premium. For example, if the total monthly health insurance premium is $500 and the employer is contributing 70% to the cost of the health insurance premium, then the current employee share is $150 per month. If the family’s income is above 150% FPL, then MassHealth will calculate a member share of the premium based on the number of eligible children in the family ($12 per child, with a $36 maximum). If the MassHealth calculated member share is $24 (2 children X $12), then the MassHealth estimated premium assistance amount will be $126 per month.

Cost-effectiveness test The estimated premium assistance amount will then be compared to the cost of covering eligible individuals under direct coverage.

The estimated premium assistance amount will be compared to the cost of covering the children in the family on MassHealth Family Assistance. Therefore, if a family with two children and one parent applies for coverage, the estimated premium assistance amount would be compared to covering two members on MassHealth’s MCO program, or $300 per month ($150 pmpm1 x 2 children).

Actual Premium Assistance Amount Once the estimated premium assistance amount has been compared to the cost of covering eligible individuals on MassHealth Family Assistance, MassHealth will calculate an actual premium assistance amount.

If the estimated premium assistance amount is less than the cost effective amount (as defined in #2 above), then MassHealth will set the actual premium assistance amount at the estimated premium assistance amount.

1 For demonstration purposes only, represents the average MCO pmpm.

Page 17 State Plan under title XXI of the Social Security Act Children’s Health Insurance Program

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Section 4. Eligibility Standards and Methodology (Section 2102)(b)

TN: 2014 - 014 Approval Date: 09/22/14 Effective Date: 01/01/14 Chip #15 If the estimated premium assistance amount is higher than the cost effective amount (as defined in #2 above), then MassHealth will set the actual premium assistance amount at the cost effective amount. If it is determined that the remainder of the health insurance premium is greater than 5% of the family’s gross income, then the family will be given the choice of enrolling their children in the applicable direct coverage program.

Premium assistance payments are made directly each month on behalf of the children to the parent/policyholder or, if the parent works for a qualified small employer that participates in MassHealth’s Insurance Partnership program, the payments may be made on behalf of the children to either the employer or the health insurance carrier. The qualified employer must reduce the member’s payroll deduction for health insurance by the amount of the premium assistance payment.

In addition to premium assistance payments, MassHealth will pay copays, coinsurance, and deductibles for children eligible for premium assistance provided:

the copay, coinsurance or deductible was incurred as the result of a well baby/well-child care visit; or the policyholder’s annualized share of the employer-sponsored health insurance premiums, combined with copays, coinsurance, and deductibles incurred and paid by members, exceeds five percent of the family group’s gross income in a 12-month period beginning with the date of eligibility for premium assistance.

Members receive an initial notice at the time of eligibility explaining MassHealth’s policy on payment of copays, coinsurance and deductibles. Providers may bill MassHealth directly or members may seek reimbursement from MassHealth. MassHealth has developed a C.A.R.E. kit for families to use in this process. (See Attachment 4.2)

MA-14-0013 (CS9) supersedes the prenatal language in section 4.1.9

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TN: 2014 - 014 Approval Date: 09/22/14 Effective Date: 01/01/14 Chip #15

(D) MassHealth Prenatal MassHealth Prenatal is available to uninsured pregnant women under the age of 19 whose self-declared income is greater than 185% FPL and less than or equal to 200% FPL. The unborn child or children are counted as if born and living with the mother in determining family group size.

Express Lane Renewal Option Certain children under the age of 19 eligible for Medicaid Expansion CHIP and CHIP will meet the criteria for Express Lane Renewal at the time of their annual renewal. The MassHealth agency will identify Medicaid Expansion CHIP children and unborn-CHIP children who have income at or below gross 150% of the federal poverty level (FPL) and are also eligible for SNAP as shown from a data match with the Massachusetts Department of Transitional Assistance. The Massachusetts Department of Transitional Assistance oversees SNAP and will be the designated Express Lane Agency. Children’s Medicaid Expansion CHIP benefits and CHIP benefits will be renewed based on the child’s eligibility for SNAP. This process will be used for renewals only. All members eligible for this process have completed an initial application and have been approved for either Medicaid Expansion CHIP or CHIP and for SNAP. These members will also have their SNAP eligibility recertified on an annual basis.

4.1.10

Check if the State is electing the option under section 214 of the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) to provide coverage to the following otherwise eligible pregnant women and children as specified below who are lawfully residing in the United States including the following:

A child or pregnant woman shall be considered lawfully present if he or she is;

(1) A qualified alien as defined in section 431 of PRWORA (8 U.S.C. § 641); (2) An alien in nonimmigrant status who has not violated the terms of the status under which he or she was admitted or to which he or she has changed after admission; (3) An alien who has been paroled into the United States pursuant to section 212(d)(5) of the Immigration and Nationality Act (INA) (8 U.S.C. § 1182(d)(5)) for less than 1 year, except for an alien paroled for prosecution, for deferred inspection or pending removal proceedings; (4) An alien who belongs to one of the following classes:

(i) Aliens currently in temporary resident status pursuant to section 210 or 245A of the INA (8 U.S.C. §§1160 or 1255a, respectively);

Page 19 State Plan under title XXI of the Social Security Act Children’s Health Insurance Program

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(ii) Aliens currently under Temporary Protected Status (TPS) pursuant to section 244 of the INA (8 U.S.C. §1254a), and pending applicants for TPS who have been granted employment authorization;

(iii) Aliens who have been granted employment authorization under 8 CFR 274a.12(c)(9), (10), (16), (18), (20), (22), or (24);

(iv) Family Unity beneficiaries pursuant to section 301 of Pub. L. 101-649, as amended;

(v) Aliens currently under Deferred Enforced Departure (DED) pursuant to a decision made by the President;

(vi) Aliens currently in deferred action status; or

(vii) Aliens whose visa petition has been approved and who have a pending application for adjustment of status;

(5) A pending applicant for asylum under section 208(a) of the INA (8 U.S.C. § 1158) or for withholding of removal under section 241(b)(3) of the INA (8 U.S.C. § 1231) or under the Convention Against Torture who has been granted employment authorization, and such an applicant under the age of 14 who has had an application pending for at least 180 days; (6) An alien who has been granted withholding of removal under the Convention Against Torture; (7) A child who has a pending application for Special Immigrant Juvenile status as described in section 101(a)(27)(J) of the INA (8 U.S.C. § 1101(a)(27)(J)); (8) An alien who is lawfully present in the Commonwealth of the Northern Mariana Islands under 48 U.S.C. § 1806(e); or (9) An alien who is lawfully present in American Samoa under the immigration laws of American Samoa. .

The State elects the CHIPRA section 214 option for children up to age 19

The State elects the CHIPRA section 214 option for pregnant women through the 60-day postpartum period

4.1.10.1

The State provides assurance that for individuals whom it enrolls in CHIP under the CHIPRA section 214 option that it has verified, both at the time of the individual’s initial eligibility determination and at the time of the eligibility redetermination that the individual continues to be lawfully residing in the United States. The State must first attempt to verify this status using information

Page 20 State Plan under title XXI of the Social Security Act Children’s Health Insurance Program

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TN: 2014 - 014 Approval Date: 09/22/14 Effective Date: 01/01/14 Chip #15 provided at the time of initial application. If the State cannot do so from the information readily available, it must require the individual to provide documentation or further evidence to verify satisfactory immigration status in the same manner as it would for anyone else claiming satisfactory immigration status under section 1137(d) of the Act.

4.2. The state assures that it has made the following findings with respect to the eligibility standards in its plan: (Section 2102)(b)(1)(B)) (42CFR 457.320(b))

4.2.1.

These standards do not discriminate on the basis of diagnosis. 4.2.2.

Within a defined group of covered targeted low-income children, these standards do not cover children of higher income families without covering children with a lower family income. 4.2.3.

These standards do not deny eligibility based on a child having a pre- existing medical condition.

4.3. Describe the methods of establishing eligibility and continuing enrollment. (Section 2102)(b)(2)) (42CFR 457.350)

MA-014-0006 MMDL (CS28) supersedes the language on Presumptive eligibility for Standard and Family Assistance in section 4.3

MA-013-0026 MMDL (CS24) supersedes all of section 4.3 except for the precedence language pertaining to Medicaid and richest benefit and all of section 4.4 with the exception of Express Lane Renewal Option

Page 21 State Plan under title XXI of the Social Security Act Children’s Health Insurance Program

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Section 4. Eligibility Standards and Methodology (Section 2102)(b)

TN: 2014 - 014 Approval Date: 09/22/14 Effective Date: 01/01/14 Chip #15 language in 4.4.1

Application and presumptive eligibility

To apply, a person must file a Medical Benefit Request (MBR).

MassHealth shall request all corroborative information necessary to determine eligibility generally within five (5) business days of receipt of the MBR. The applicant must provide such information within sixty (60) calendar days of the information request.

The request is considered complete on the date all required information with the exception of documentation of immigration status is received. When it is complete, it shall activate MassHealth’s eligibility process of determining the appropriate coverage type providing the most comprehensive medical benefits.

If necessary information is received within the 60 calendar day period, the MBR is considered complete; if not received within the 60 calendar day period, MassHealth shall deactivate the MBR.

Reactivating the Medical Benefit Request If all required information is submitted to MassHealth subsequent to the 60 calendar day period, MassHealth shall reactivate the MBR as of the date the information is submitted. A new MBR must be submitted if all required information is not received within one year of receipt of the previous MBR.

Presumptive Eligibility Process A child may be determined presumptively eligible for Standard or Family Assistance through a presumptive eligibility process based on the household’s self declaration of gross income on the Medical Benefit Request (MBR). A child may only be presumptively eligible for Family Assistance if he or she has no health insurance coverage.

Presumptive eligibility begins 10 calendar days prior to the date the MBR is received at the MEC and lasts until MassHealth makes an eligibility determination. If information necessary to make the eligibility determination is

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TN: 2014 - 014 Approval Date: 09/22/14 Effective Date: 01/01/14 Chip #15 not submitted within 60 days of the begin date, the MBR will be deactivated in accordance with Section 2.2.1.1 and presumptive eligibility will end. A child may receive presumptive eligibility only once in a twelve-month period.

Data matching and verification

Process for Data Matching MassHealth initiates matches with other agencies, health insurance carriers, and employers when an MBR is received. These agencies and matches include but are not limited to the following: The Division of Unemployment Assistance (DUA), Bureau of Vital Statistics, Veteran’s Services, Department of Revenue (DOR), Bureau of Special Investigations (BSI), Internal Revenue Service (IRS), Social Security Administration (SSA), Alien Verification Information System, Department of Youth Services (DYS), Department of Social Services (DSS), Department of Correction (DOC) and the Department of Transitional Assistance (DTA).

Process for Agency Data Matches Where possible, MassHealth’s eligibility system attempts data verification through automated matching with other MassHealth systems (e.g., MMIS) and external agencies. Initial matching is performed during the MBR screening when the system, based on data entry of the request, checks MassHealth databases and MMIS, to confirm eligibility status and retrieve existing information.

The system also prepares and generates matching requests to other agencies for customer information that has not yet been verified, or is out of date or missing. These matching requests are generated automatically and do not require worker intervention. For applicants, a match is triggered at the time the MBR is received. For on-going cases, a match is triggered when a member reports changes to certain types of information or a report occurs when new employment is reported to DOR by the employer.

As soon as the worker has entered (and reviewed) new household members’ names, dates-of-birth, and SSNs, the system will automatically trigger a request for SSN verification and SSA unearned income information. This information will be processed and returned that same night, for review the following morning by the worker.

The SSN verification processing will identify additional SSNs held by the member, as well as identify a transposition or minor data entry error in the original data entry of the SSN. Following SSN verification, ‘Alerts’ may be posted to a person’s record to indicate an inconsistency.

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Section 4. Eligibility Standards and Methodology (Section 2102)(b)

TN: 2014 - 014 Approval Date: 09/22/14 Effective Date: 01/01/14 Chip #15 Data to Match and Verify Using a gross income test has eliminated the need to verify a host of work-related expenses while elimination of the asset test has obviated the need for the applicant to produce a more complex set of verifications. Verification only of the following (through either the customer or automated matching) is a prerequisite for eligibility determination:

• Income (for all except MassHealth Prenatal, and for presumptive eligibility determinations for MassHealth Standard and MassHealth Family Assistance, and for those without income); • Disability (for CommonHealth); • TPL (from accident or injury); • SSN; • Citizenship and immigration status; and • Access to, and availability of, health insurance.

Matching Agencies MassHealth works with the following agencies to verify eligibility information.

• DUA MassHealth processes matches with DUA for unemployment information. Recipients of unemployment insurance are identified for income matching purposes, and for determining eligibility for Basic. These individuals are paid by DUA for up to thirty (30) weeks following job loss, providing the recipient is unemployment-insurance eligible.

• DOR Provides information on employment status (new hires), and quarterly wages. New hires are reported by employers within fourteen (14) calendar days of their start date. This data will be used to determine eligibility for MassHealth, and to generate an inquiry by MassHealth to the member regarding their employment status and availability of health insurance.

The wage reporting system provides the wages an individual receives on a quarterly basis from employers. If discrepancies regarding wages are noted between MassHealth’s data and DOR’s data regarding an individual, an inquiry will also be generated to the member.

• INS The Alien Status Verification Index (ASVI) provides alien information. This database verifies alien immigration status, containing data for over 50 million

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TN: 2014 - 014 Approval Date: 09/22/14 Effective Date: 01/01/14 Chip #15 aliens.

• SSA SSA provides a variety of data. Social Security income and insurance (Medicare) data is provided on a regular basis through the BENDEX matching system. Social Security numbers are verified by SSA through the NUMIDENT match. SSI income is provided through the SDX match. Finally, Medicare Buy-in data is also transmitted through CMS to SSA. These data matches are considered to provide primary verification of social security and SSI income, and will update the individual’s income directly and generate an eligibility determination.

Eligibility Review MassHealth shall review eligibility with respect to circumstances that may change. MassHealth will update the file based on information received as the result of such review. Eligibility may be reviewed:

• As a result of a member’s reported change in circumstances; • By external matching with other agencies and health insurance carriers; and • Where matching is not available, through a written update of the member’s circumstances on a prescribed form. If the member fails to provide a written update within thirty (30) calendar days of the request, MassHealth coverage may be terminated.

When there are no changes in the member’s circumstances, eligibility shall be redetermined at least once annually.

Member enrollment

Introduction MassHealth uses an enrollment Broker (EB) to educate and enroll all managed care eligible MassHealth members in a health plan. Customer service representatives (CSRs) are employees of the EB. A CSR’s major responsibilities include: educating potential members or their representatives about managed care plans, enrolling managed care eligible MassHealth members into a health care plan, providing customer service to the entire MassHealth population, and administering MassHealth’s non-emergency transportation program for all eligible MassHealth members.

MassHealth members who are not eligible for managed care (e.g., persons with other insurance) do not need to enroll in a health plan because they will receive their care on a fee-for-service basis. Premium Assistance members will access services covered under an employer-sponsored plan according to the terms of those plans.

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MassHealth has established processes for, and provided training to other state agencies in order to facilitate the enrollment into MassHealth of uninsured members serviced by these agencies. Referral and reporting processes have been established between MassHealth and the Department of Public Health, the Division of Unemployment Assistance, the Department of Transitional Assistance and the Commission for the Blind. In addition, all health care agencies and the Office of Refugees and Immigrants have received presentations on health care reform customized to meet the needs of their consumers. All agencies have been or will be provided with MBRs in large quantities.

MassHealth Standard/MassHealth Family Assistance Members All MassHealth Standard/MassHealth Family Assistance members eligible to participate in managed care must enroll with either a MassHealth-contracted Managed Care Organization (MCO) or in the Primary Care Clinician (PCC) plan. During any period a managed care eligible Standard member is not enrolled in a managed care plan, such member will receive mental health and substance abuse services from any MassHealth provider.

Currently, MassHealth has no lock-in policy and members can transfer to another health care plan in their service area at any time.

Description of Enrollment Process CSRs enroll MassHealth managed care eligible members into a health plan under either the PCC plan or an MCO according to MassHealth’s policies, procedures, instructions and timeframes.

The EB tracks and manages all systems activities necessary to enroll all managed care-eligible members. These activities include, but are not limited to, tracking those members who have received enrollment and outreach materials and ensuring timely mailing of appropriate outreach materials.

Receipt of Member Data The EB receives data regarding managed care eligible members from MMIS. Eligibility workers at MassHealth determine MassHealth eligibility. The system then identifies members who meet managed care eligibility criteria and transmits this data to the EB for enrollment into a health plan.

The EB begins all enrollment and outreach mailing activities for Standard members within five (5) business days after receipt of member data from MassHealth.

Outreach Process

Page 26 State Plan under title XXI of the Social Security Act Children’s Health Insurance Program

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Section 4. Eligibility Standards and Methodology (Section 2102)(b)

TN: 2014 - 014 Approval Date: 09/22/14 Effective Date: 01/01/14 Chip #15 The EB must mail enrollment and outreach materials to all Standard and Family Assistance members who become eligible for managed care. Distribution or mailing must occur no later than five (5) business days after the EB receives from MassHealth member enrollment data including: the members’ names, addresses, recipient identification (RID) numbers, categories of assistance, and casehead RIDS and names.

The member has fourteen (14) calendar days to choose a health plan or MassHealth will assign the member to a managed care plan.

Enrollment Package The member receives an enrollment package inviting him or her to choose a health plan. The enrollment package includes information on how to enroll in a health plan, inserts that explain the various health plan options and enrollment form, a description of the member’s legal rights, a self-addressed stamped envelope, and a notice translated into several different languages advising the member to have the information translated immediately. The enrollment package materials indicate that the member has fourteen (14) calendar days to choose a health plan or MassHealth will choose one for the member.

Members may call either an EB or the plan directly for assistance in selecting a primary care physician. For members who are assigned to an MCO, the MCO will contact the member directly to assist them in selecting a PCP.

The EB also must mail enrollment materials to managed care-eligible members on request.

Assignment Members who do not choose a health plan within the fourteen-(14) calendar day time limit will be assigned to a health plan. The term “assign” when used in this document refers to enrollment activities involving members who have not made an affirmative choice of a health plan.

Activities Associated with Non-Responding Members and Timeframes Standard or Family Assistance members who have not responded to the enrollment and outreach materials within fourteen (14) calendar days will be assigned to a managed care plan either systematically or manually. Manual assignments occur when computer assignment is not possible.

Algorithm The assignment methodology takes into account the geographic location of the MCO and PCC plan providers relative to the member’s residence and MassHealth assigns members based on the rate at which a given health plan is selected in a given service

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TN: 2014 - 014 Approval Date: 09/22/14 Effective Date: 01/01/14 Chip #15 area, compared to each of the other available plans as well as other factors such as quality performance and/or enrollment volume.

The assignment algorithm applies only to Standard, Family Assistance, and Basic members who have not been determined to be disabled. MassHealth does not assign members who have been determined disabled to MCOs, but assigns them to a PCC based on disabling condition, geographic location, and, where possible, provider experience.

Manual Assignments Manual assignments are done by EBs and occur when the system is unable to make a zip code, city/town or service area match between the member and an available health plan. Manual assignments, like automatic assignments, are made based on geography and voluntary selection rates.

Additionally, any member who loses and then within 1 year regains managed care eligibility may be automatically re-enrolled with the health plan with which the member was most recently enrolled.

Transfer Policy MassHealth does not have a lock-in policy. Members who either choose or are assigned to a health plan may transfer to another available health plan in their geographic service are at any time for any reason. The transfer process begins when the member calls the Customer Service Center toll free number and requests a transfer. An EB helps the member identify a new health plan in his or her service area.

Member-Initiated Transfers The member-initiated transfer process for members begins when the member calls the Customer Service Center toll free number and requests a transfer. An EB helps the member identify a new health plan in his or her service area. The transfer is processed by the EB within twenty-four (24) hours.

MassHealth-initiated Transfers MassHealth may initiate the transfer of a member based on provider capacity, or if a health plan or primary care clinician terminates its agreement with MassHealth. When MassHealth-initiated transfers are required, MassHealth contacts the members to select a new health plan in their service area.

Provider-Requested Transfers

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TN: 2014 - 014 Approval Date: 09/22/14 Effective Date: 01/01/14 Chip #15 Provider-requested disenrollments begin with a written request sent by the provider to MassHealth. The written request is reviewed for complete information and compared against the Plan’s criteria for member disenrollment. If the provider is able to demonstrate by written request that the member exhibited a pattern of disruptive or non-compliant behavior, the member may be transferred to another PCC or health plan.

Transfers To Another Health Plan A member can transfer from one health plan to another available health plan at any time. The only restrictions are that: (1) the health plan must be in the members’ geographic service area; (2) the members’ request must meet the time and distance guidelines or (3) the member must request and receive approval for an out-of-area transfer using the process for an out-of-area enrollment.

PCC Disenrollment from the PCC Plan or PCP Voluntary Termination from an MCO Plan If a PCC chooses to terminate from the PCC Plan, MassHealth requests that the PCC submit written notice to MassHealth at least thirty (30) days prior to the date of the intended termination. MassHealth sends a letter and enrollment package and asks the member to choose another health plan. The member is instructed to call the Customer Service Center toll free number for assistance in enrolling with a new managed care plan.

If a PCP chooses to terminate from an MCO, the MCO will facilitate informing the member of the termination and will help the member choose another PCP within the MCO. If the member would like to choose a PCP in another MCO plan or a PCC in the PCC Plan, the member is instructed to contact the Customer Service Center toll free number for assistance.

MassHealth Customer Service center

MassHealth’s Enrollment Broker (EB) operates a toll-free customer service center for all MassHealth members. The customer service center is located at 55 Summer Street, 6th Floor, Boston, MA, 02111. The toll-free telephone number is 1-800-841-2900. The toll-free number is an enhanced telephone system with TTY transmission and reception capability and an automatic call distribution system. The EB is required to handle 95% of all incoming calls in three rings or fewer. Additionally, the EB must operate this call center between the hours of 8 a.m. and 5 p.m. EST, Monday through Friday, with the exception of all Federal and designated Massachusetts State holidays.

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Section 4. Eligibility Standards and Methodology (Section 2102)(b)

TN: 2014 - 014 Approval Date: 09/22/14 Effective Date: 01/01/14 Chip #15 The EB is required to have a sufficient number of multi-lingual CSRs to respond to all MassHealth- related calls, letters and occasional walk-in encounters. In addition, the EB must:

• Train all EB staff assigned to the MassHealth toll-free phone number to adequately and appropriately respond to questions relating to any MassHealth benefit package inquiries;

• Assist members eligible for Standard, Basic, or Family Assistance benefits in the resolution of problems relating to the accessibility of health care services, including but not limited to identifying transportation service issues, language barriers, and handicap accessibility issues;

• Respond to and make best efforts to resolve MassHealth-related inquiries and complaints by members, prospective members, people assisting members or acting on their behalf, including members’ family members, other state agencies, advocates or private agency providers;

• Facilitate the resolution of non-clinical service disputes between MassHealth members participating in managed care and their providers;

• Establish procedures, subject to MassHealth’s approval, by which to determine when MassHealth intervention or assistance should be sought and how it should be obtained;

• Maintain standard referral form(s) and procedures for each instance in which the EB determines that MassHealth assistance is required to adequately, appropriately, and correctly resolve or respond to any member-identified issue;

• Ensure call-backs to members within twenty-four (24) hours of receipt, including, but not limited to, after-hour messages received via after-hour voice mail messaging; and

• Ensure that all non-English speaking callers are provided translation services, e.g., EB staff answering telephone calls must speak the caller’s language, or must be able to access interpreter services without disrupting the call by contacting other EBs or utilizing the AT&T Language Line service or similar telephone translation service.

4.3.1 Describe the state’s policies governing enrollment caps and waiting lists (if any). (Section 2106(b)(7)) (42CFR 457.305(b))

Check here if this section does not apply to your state.

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4.4. Describe the procedures that assure that:

4.4.1. Through the screening procedures used at intake and follow-up eligibility determination, including any periodic redetermination, that only targeted low- income children who are ineligible for Medicaid or not covered under a group health plan or health insurance coverage (including access to a state health benefits plan) are furnished child health assistance under the state child health plan. (Section 2102)(b)(3)(A) and 2110(b)(2) (B)); (42CFR 457.310(b), 42CFR 457.350(a)(1) and 457.80(c)(3))

The following section describes the process used to determine eligibility for the most comprehensive MassHealth coverage type for which the applicant is eligible.

Initially, eligibility information is collected on the Medical Benefit Request (MBR) form. Sufficient information is collected to assess if the applicant is eligible for any MassHealth coverage type. This information is then entered into MassHealth's computerized MA21 eligibility system, which then invokes decision trees to establish the most comprehensive coverage for which the individual is eligible.

The decision trees are used by the eligibility system to identify the benefits or programs for which a person is eligible based on his or her personal characteristics and circumstances. All charts assume that the individual meets the Massachusetts residency requirement.

All of the data collected from the MBR is stored on MA21 and when a subsequent change to the member's circumstances is reported, the Decision Tree process is again invoked to assess the impact of that change.

The change event may result in a change to a different coverage type, a change in MassHealth Family Assistance premium, a change in the premium assistance amount, a loss of eligibility, or no change. This process is performed automatically by MA21 and the member is automatically notified of any change in eligibility status or coverage type. In making these determinations, MA21 will also update MMIS with the correct category of assistance, which in turn, dictates the funding source (Title XXI vs. Title XIX).

Children are not eligible for Title XXI MassHealth if they are: (1) an inmate of a public institution as defined at 42 CFR 435.1009; or (2) a patient in an institution for mental diseases as defined 42.CFR 435.1009, at the time of initial application or any redetermination of eligibility.

Page 31 State Plan under title XXI of the Social Security Act Children’s Health Insurance Program

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Section 4. Eligibility Standards and Methodology (Section 2102)(b)

TN: 2014 - 014 Approval Date: 09/22/14 Effective Date: 01/01/14 Chip #15 The Express Lane Renewal process For Medicaid Expansion CHIP and CHIP children who have income at or below gross 150% of the federal poverty level utilizes the current screen and enroll process, which is described above. They will remain enrolled in the most comprehensive coverage type for which they are eligible.

4.4.2. The Medicaid application and enrollment process is initiated and facilitated for children found through the screening to be potentially eligible for medical assistance under the state Medicaid plan under Title XIX. (Section 2102)(b)(3)(B)) (42CFR 457.350(a)(2))

Once an eligibility determination is made by the MA21 system, MMIS is automatically updated to reflect the coverage type for which the child is eligible.

Since MassHealth offers a variety of programs to Massachusetts’ residents, MA21 updates MMIS not only by coverage type but by funding source as well. A unique category of assistance is then assigned to ensure the accuracy of both coverage type and funding source.

These categories will also trigger a referral to MassHealth’s enrollment broker, whenever the child is required to enroll with a primary care clinician or MCO.

4.4.3. The State is taking steps to assist in the enrollment in SCHIP of children determined ineligible for Medicaid. (Sections 2102(a)(1) and (2) and 2102(c)(2)) (42CFR 431.636(b)(4))

As described above in Section 4.4.1 and 4.4.2, MassHealth uses an automated eligibility system to place children in the richest benefit category for which they are eligible. A child who is eligible for Medicaid will automatically be placed in a Title XIX aid category.

MA-014-0006 MMDL (CS20) supersedes all of section 4.4.4.

4.4.4 The insurance provided under the state child health plan does not substitute for coverage under group health plans. Check the appropriate box. (Section 2102)(b)(3)(C)) (42CFR 457.805) (42 CFR 457.810(a)-(c))

Page 32 State Plan under title XXI of the Social Security Act Children’s Health Insurance Program

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Section 4. Eligibility Standards and Methodology (Section 2102)(b)

TN: 2014 - 014 Approval Date: 09/22/14 Effective Date: 01/01/14 Chip #15 4.4.4.1.

Coverage provided to children in families at or below 200% FPL: describe the methods of monitoring substitution.

MassHealth’s premium assistance program, which is based on the combined authority of MassHealth’s 1115 Waiver Insurance Partnership Program and Title XXI, will prevent families from dropping their private health insurance coverage. MassHealth covers children with family incomes at or below 200% of the Federal Poverty Level (FPL) regardless of insurance status at the time of application. Thus, there will be no financial incentive for families to drop private coverage to enroll in MassHealth. To discourage families from dropping their private coverage prior to applying for MassHealth, MassHealth emphasizes in its marketing and outreach materials the availability of premium assistance benefits for insured families. Additionally, when the family applies for MassHealth benefits, MassHealth uses the information included on the Medical Benefit Request (MBR) to complete an intensive health insurance investigation. This investigation includes matching the applicant’s data against MassHealth’s health insurance carrier database. This database includes subscriber lists representing approximately 90% of the health insurance market in the Commonwealth. The investigation also includes contact with the applicant’s employer to determine whether employer-sponsored health insurance is available. The information provided by the employer includes: the total health insurance premium; the current employer contribution towards the premium; and the summary of benefits included in the plan. Through the health insurance investigation, MassHealth will be able to ensure that all applicants who have private health insurance and all applicants with access to employer-sponsored health insurance participate in private coverage.

Through these mechanisms MassHealth ensures that:

• Families with employer-sponsored coverage will be covered through premium assistance under MassHealth’s 1115 Waiver. • Families without private coverage, but with access to employer coverage, will be covered through premium assistance under Title XXI. • Families without private coverage, and without access to employer coverage, will be covered through Title XXI direct

Page 33 State Plan under title XXI of the Social Security Act Children’s Health Insurance Program

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Section 4. Eligibility Standards and Methodology (Section 2102)(b)

TN: 2014 - 014 Approval Date: 09/22/14 Effective Date: 01/01/14 Chip #15 coverage.

MassHealth continuously monitors the effectiveness of these policies. MassHealth monitors members who apply without insurance to determine: how many of those members are required to enroll in employer-sponsored health insurance; how many had no access to employer-sponsored health insurance; and how many had access to employer-sponsored health insurance but were enrolled in direct coverage because the employer-sponsored health insurance did not meet the minimum requirements.

The Commonwealth measures the overall changes in the employer-sponsored insurance market through employer surveys conducted by the Division of Health Care Finance and Policy. Through these surveys, MassHealth is able to monitor changes both in the overall ESI market and within the large and small group markets. These employer statistics may be used to determine whether changes in the MassHealth Family Assistance population are due to specific employer benefit changes or larger trends in the Commonwealth.

Additionally, MassHealth regularly examines movement between direct coverage and premium assistance within the caseload to measure substitution and determine if current crowd-out prevention strategies are effective.

4.4.4.2.

Coverage provided to children in families over 200% and up to 250% FPL: describe how substitution is monitored and identify specific strategies to limit substitution if levels become unacceptable.

MassHealth will continue current crowd-out monitoring activities, with a particular focus on the higher income population of FAEC, including;

(a) Evaluating the biannual employer survey, which is conducted by the Division of Health Care Finance and Policy, and includes information on employer offer rates, contribution rates, and premiums, by size of employer;

(b) Regularly examining movement between direct coverage and premium assistance within the caseload;

Page 34 State Plan under title XXI of the Social Security Act Children’s Health Insurance Program

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Section 4. Eligibility Standards and Methodology (Section 2102)(b)

TN: 2014 - 014 Approval Date: 09/22/14 Effective Date: 01/01/14 Chip #15

(c) Evaluating annual CPS data; and,

(d) Utilizing MassHealth’s health insurance carrier and employer databases to monitor changes in employer offers.

Crowd-out provisions for FAEC (200-300% FPL) MassHealth will not provide direct coverage or premium assistance if the family had employer-sponsored group coverage for applying children within the previous six months. Families which had employer-sponsored group coverage within the previous six months will be subject to a six-month waiting period, from the date of loss of coverage, before being allowed to enroll in FAEC. Exceptions from this waiting period will be made for situations in which:

(a) A child or children has special or serious health care needs;

(b) The prior coverage was involuntarily terminated, including withdrawal of benefits by an employer, involuntary job loss, or COBRA expiration;

(c) A parent in the family group died in the previous six months;

(d) The prior coverage was lost due to domestic violence;

(e) The prior coverage was lost due to becoming self- employed; or

(f) The existing coverage’s lifetime benefits were reduced substantially within the previous six months, or prior employer- sponsored health insurance was cancelled for this reason.

If MassHealth finds a significant level of crowd-out, it will reevaluate the exceptions to the waiting period to determine if they are contributing to crowd-out, and modify them as necessary.

4.4.4.3.

Coverage provided to children in families above 250% FPL: describe how substitution is monitored and identify specific strategies in place to prevent substitution. See 4.4.4.2

Page 35 State Plan under title XXI of the Social Security Act Children’s Health Insurance Program

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Section 4. Eligibility Standards and Methodology (Section 2102)(b)

TN: 2014 - 014 Approval Date: 09/22/14 Effective Date: 01/01/14 Chip #15 4.4.4.4.

If the state provides coverage under a premium assistance program, describe:

The minimum period without coverage under a group health plan, including any allowable exceptions to the waiting period

If a child with income below 200% FPL is uninsured at the time of application and has access to employer-sponsored insurance, the child may receive premium assistance. There is no waiting period. For children with income between 200 and 300% FPL who had employer-sponsored insurance in the previous six months, see section 4.4.4.2 for a description of the required waiting period and exceptions.

The minimum employer contribution The minimum employer contribution is 50% of the total cost of the health insurance premium.

The cost-effectiveness determination The cost effectiveness determination, as described in full detail earlier in Section 4, ensures that the premium assistance payment would not be greater than the amount it would cost for MassHealth to provide services to the member through the direct coverage option.

4.4.4.5 Child health assistance is provided to targeted low-income children in the state who are American Indian and Alaska Native. (Section 2102)(b)(3)(D)) (42 CFR 457.125(a))

MassHealth does not discriminate on the basis of ethnicity when determining eligibility for MassHealth programs. Alaska Native and American Indians who are members of a federally recognized tribe are not required to pay premiums.

Generally, the MassHealth outreach “net” covers the four corners of the state, and should capture any AI/AN. Our MBRs and member handbooks, which are used in our outreach efforts, specifically address AI/AN. MassHealth has had a Taunton MEC outreach worker that makes regular trips out to the hospital on Martha’s Vineyard, which is the primary health care provider for the Wampanoags of Aquinnah and other islanders. In addition,

Page 36 State Plan under title XXI of the Social Security Act Children’s Health Insurance Program

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Section 4. Eligibility Standards and Methodology (Section 2102)(b)

TN: 2014 - 014 Approval Date: 09/22/14 Effective Date: 01/01/14 Chip #15 the Dukes County Health Commission was given a mini-grant to do general outreach, which would have included the AI/AN population on Martha’s Vineyard.

Page 1 State Plan under title XXI of the Social Security Act Children’s Health Insurance Program

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Section 5. Outreach and Coordination

TN: 2014-014 Approval Date: 09/22/14 Effective Date: 01/01/14 CHIP #15

Describe the procedures used by the state to accomplish:

Outreach to families of children likely to be eligible for child health assistance or other public or private health coverage to inform them of the availability of the programs, and to assist them in enrolling their children in such a program: (Section 2102(c)(1)) (42CFR 457.90)

MassHealth will accomplish outreach, providing information, and assisting with program enrollment, using these procedures:

1. Enlist the support of community-based organizations, social service agencies, schools, and advocacy organizations to inform community residents of available health insurance programs; identify uninsured children; assist with the enrollment process; and support the promotion of educational strategies developed to help members utilize their health care services.

a) Periodically award mini-grants to community-based organizations to assist in enrollment of “hard-to-reach” uninsured individuals and families and support post enrollment education strategies. MassHealth and the Department of Public Health (DPH) will continue to collaborate on the issuance and monitoring of a joint RFR.

b) Perform targeted enrollment and member education campaigns for specific communities or vulnerable populations, such as immigrants and homeless populations, that have high numbers of “hard-to-reach” uninsured residents. MassHealth will make regional outreach coordinators available at each of its four MassHealth Enrollment Centers (MECs) to provide outreach, enrollment, and member education training to community-based organizations in these specified areas.

c) Conduct school-based outreach campaigns to distribute informational materials explaining the availability of health insurance to families of children attending public, private, and parochial schools and daycare centers and to work with school nurses and/or other school staff to facilitate the enrollment of uninsured children in the appropriate health insurance program. Special emphasis will be placed on pre- school through first grade settings to reach this statistically-higher uninsured group. MassHealth and DPH will coordinate all activities related to this initiative.

Page 2 State Plan under title XXI of the Social Security Act Children’s Health Insurance Program

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Section 5. Outreach and Coordination

TN: 2014-014 Approval Date: 09/22/14 Effective Date: 01/01/14 CHIP #15

d) Create and distribute promotional materials to community-based agencies and school settings. Offer training and informational sessions at community sites, statewide, at least once per contracted year.

2. Collaborate with primary care providers (including family practice, adult medicine, and pediatric and adolescent health providers) in targeted communities and/or among populations that have high numbers of uninsured residents to furnish information about the availability of free or low-cost health insurance for children.

a) Coordinate MassHealth outreach efforts with the Massachusetts Hospital Association and the Massachusetts League of Community Health Centers.

b) Provide outreach assistance at community health centers, hospital outpatient clinics, WIC sites, Early Intervention programs, home visiting programs and school-based health centers, as requested.

c) Notify school nurses upon changes in eligibility guidelines and/or enrollment procedures.

d) Share informational articles describing recent health program expansions in provider and professional association publications.

e) Make informational presentations at conferences, workshops, and trainings attended by health care providers.

3. MassHealth will initiate and coordinate activities with other state agencies to provide information about health coverage to uninsured children and facilitate program enrollment, where appropriate.

a) Enrolling eligible unborn child enrollees in MassHealth.

b) Cross-training of staff at Department of Social Services (DSS), Department of Transitional Assistance (DTA), Department of Mental Health (DMH), Division of Insurance (DOI), Department of Youth Services (DYS), Department of Revenue (DOR), Office of Refugees and Immigrants (ORI), Division of Unemployment Assistance (DUA), Department of Mental Retardation (DMR), Department of Public Health (DPH), Children’s Trust Fund (CSE), etc. who deliver direct-services to individuals, families and children.

Page 3 State Plan under title XXI of the Social Security Act Children’s Health Insurance Program

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Section 5. Outreach and Coordination

TN: 2014-014 Approval Date: 09/22/14 Effective Date: 01/01/14 CHIP #15

4. MassHealth will develop a multi-media enrollment campaign for targeted underserved populations and promote member information on how to access MassHealth benefits.

a) Use a media consultant to assist with the design and implementation of a media campaign for non-English speaking populations. b) Produce Public Service Announcements (PSAs) for distribution to local ethnic television and radio stations.

c) Solicit free media coverage through newspapers, television, radio, billboards and transit authorities, or make purchase of media coverage when appropriate.

d) Maintain ongoing communication with print media outlets (daily newspapers, weekly community newspapers, and magazines) in targeted communities, regarding outreach activities.

5. MassHealth will perform outreach and enrollment activities specifically related to the Express Lane Renewal option to rely on findings from SNAP to conduct simplified eligibility renewals. This will include the activities listed above as well as:

a. Providing detailed information about the Express Lane Renewal Process to stakeholders, including advocates, community outreach workers/grantees and providers to ensure education of the process to members.

b. Information sharing about Express Lane Renewal at Massachusetts Health Care Training Forums (MTFs)

c. Utilizing the Virtual Gateway listserv to update and educate providers about the Express Lane Renewal process

d. Coordinating with SNAP outreach programs and resources to promote Express Lane Renewal.

Page 1 State Plan under title XXI of the Social Security Act Children’s Health Insurance Program

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Section 6. Coverage Requirements for Children’s Health Insurance (Section 2103)

_________________________________________________________________________________

TN: 2016-004 Approval Date: 05/18/16 Effective Date: 07/01/15 CHIP #17

Check here if the state elects to use funds provided under Title XXI to provide expanded eligibility under the state’s Medicaid plan,

Our Title XXI Medicaid expansion group is newborns 185.1% FPL up to 200% FPL, children ages 1-5 133.1% FPL up to 150% FPL, children ages 6-17 114.1% FPL up to 150% FPL and children age 18 up to 150% FPL. These children are in MassHealth Standard and receive the Medicaid benefit package. [MA-014-0003 MMDL (CS3) and MA-014- 0005 (CS14) MMDL supersede the age and income language above].

6.1. The state elects to provide the following forms of coverage to children: (Check all that apply.) (42CFR 457.410(a))

6.1.1.

Benchmark coverage; (Section 2103(a)(1) and 42 CFR 457.420) 6.1.1.1.

FEHBP-equivalent coverage; (Section 2103(b)(1)) (If checked, attach copy of the plan.) 6.1.1.2.

State employee coverage; (Section 2103(b)(2)) (If checked, identify the plan and attach a copy of the benefits description.) 6.1.1.3.

HMO with largest insured commercial enrollment (Section 2103(b)(3)) (If checked, identify the plan and attach a copy of the benefits description.)

This applies only to Direct Coverage programs, not Premium Assistance. See Section 6.1.4 below.

6.1.2.

Benchmark-equivalent coverage; (Section 2103(a)(2) and 42 CFR 457.430) Specify the coverage, including the amount, scope and duration of each service, as well as any exclusions or limitations. Please attach a signed actuarial report that meets the requirements specified in 42 CFR 457.431. See instructions.

6.1.3.

Existing Comprehensive State-Based Coverage; (Section 2103(a)(3) and 42 CFR 457.440) [Only applicable to New York; Florida; Pennsylvania] Please attach a description of the benefits package, administration, date of enactment. If existing comprehensive state-based coverage is modified, please provide an actuarial opinion documenting that the actuarial value of the modification is greater than the value as of 8/5/97 or one of the benchmark plans. Describe the fiscal year 1996 state expenditures for existing comprehensive state-based coverage.

Page 2 State Plan under title XXI of the Social Security Act Children’s Health Insurance Program

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Section 6. Coverage Requirements for Children’s Health Insurance (Section 2103)

_________________________________________________________________________________

TN: 2016-004 Approval Date: 05/18/16 Effective Date: 07/01/15 CHIP #17

6.1.4.

Secretary-Approved Coverage. (Section 2103(a)(4)) (42 CFR 457.450)

6.1.4.1.

Coverage the same as Medicaid State plan and applicable additional coverage described in the Services Related Expenditures and related Special Terms and Conditions in the Massachusetts 1115 demonstration project (no. 11-w- 00030) for Medicaid expansion children who are in MassHealth Standard and unborn CHIP children who are in MassHealth Standard, except that unborn CHIP children are not eligible for Premium Assistance.

6.1.4.2.

Comprehensive coverage for children under a Medicaid Section 1115 demonstration project for children in MassHealth Family Assistance and CommonHealth

The Basic Benefit Level, as approved by the Secretary under the Massachusetts 1115 Demonstration Project, for premium assistance toward employer sponsored health insurance.

6.1.4.3.

Coverage that either includes the full EPSDT benefit or that the state has extended to the entire Medicaid population 6.1.4.4.

Coverage that includes benchmark coverage plus additional coverage 6.1.4.5.

Coverage that is the same as defined by existing comprehensive state-based coverage 6.1.4.6.

Coverage under a group health plan that is substantially equivalent to or greater than benchmark coverage through a benefit by benefit comparison (Please provide a sample of how the comparison will be done) 6.1.4.7.

Other (Describe)

Page 3 State Plan under title XXI of the Social Security Act Children’s Health Insurance Program

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Section 6. Coverage Requirements for Children’s Health Insurance (Section 2103)

_________________________________________________________________________________

TN: 2016-004 Approval Date: 05/18/16 Effective Date: 07/01/15 CHIP #17

6.2. The state elects to provide the following forms of coverage to children:

Covered services for MassHealth Family Assistance - Direct Coverage (including FAEC)

Non-disabled children who are not eligible for MassHealth Standard and who are in families with income up to 300% FPL are enrolled in MassHealth Family Assistance . Those who do not have cost effective Employer Sponsored Insurance (ESI) receive direct coverage. This coverage is equivalent to the MassHealth Standard (Medicaid benefit package) covered services with the following exceptions: non-emergency transportation, long-term community-based services, personal care services, day habilitation, and adult day health services are not covered. Long-term care is limited to 100 days. Certain services listed below are covered only following prior authorization based on medical necessity.

6.2.1.

Inpatient services (Section 2110(a)(1))

All acute inpatient hospital services such as daily physician intervention, surgery, obstetrics, radiology, laboratory and other diagnostic and treatment procedures.

6.2.2.

Outpatient services (Section 2110(a)(2))

Acute outpatient services include outpatient surgical, and related diagnostic and medical services.

6.2.3.

Physician services (Section 2110(a)(3))

Physician services (primary and specialty) include all medical, radiological, laboratory, anesthesia and surgical.

6.2.4.

Surgical services (Section 2110(a)(4))

Surgical services include services provided in section 6.2.1, 6.2.2, and 6.2.3

6.2.5.

Clinic services (including health center services) and other ambulatory health care services. (Section 2110(a)(5))

Clinical services include services provided in section 6.2.2 and 6.2.3

6.2.6.

Prescription drugs (Section 2110(a)(6))

Legend drugs that are approved by the U.S. Food and Drug Administration

Page 4 State Plan under title XXI of the Social Security Act Children’s Health Insurance Program

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Section 6. Coverage Requirements for Children’s Health Insurance (Section 2103)

_________________________________________________________________________________

TN: 2016-004 Approval Date: 05/18/16 Effective Date: 07/01/15 CHIP #17

6.2.7.

Over-the-counter medications (Section 2110(a)(7))

Non-legend drugs that are approved by the U.S. Food and Drug Administration.

6.2.8.

Laboratory and radiological services (Section 2110(a)(8))

All laboratory services necessary for the diagnosis, treatment, and prevention of disease, and maintenance of health of MassHealth members. All x-rays, including portable x-rays and magnetic resonance imagery (MRI), and radiological services.

6.2.9.

Prenatal care and prepregnancy family services and supplies (Section 2110(a)(9))

All prenatal care and family planning medical services, family planning counseling services, follow-up-care, outreach and community education.

6.2.10.

Inpatient mental health services, other than services described in 6.2.18., but including services furnished in a state-operated mental hospital and including residential or other 24-hour therapeutically planned structural services (Section 2110(a)(10))

6.2.11.

Outpatient mental health services, other than services described in 6.2.19, but including services furnished in a state-operated mental hospital and including community-based services (Section 2110(a)(11)

6.2.12.

Durable medical equipment and other medically-related or remedial devices (such as prosthetic devices, implants, eyeglasses, hearing aids, dental devices, and adaptive devices) (Section 2110(a)(12))

Durable medical equipment, orthotic and prosthetic devices, hearing aids, and eyeglasses are covered when medically necessary and according to the requirements described in the Provider Regulations.

6.2.13.

Disposable medical supplies (Section 2110(a)(13))

6.2.14.

Home and community-based health care services (See instructions) (Section 2110(a)(14))

Home health nursing services such as skilled nursing and home health aide services.

Page 5 State Plan under title XXI of the Social Security Act Children’s Health Insurance Program

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