DEPARTMENT OF HEALTH Pr HUMAN SERVICES Centers for Medicare & Medicaid Services JFK Federal Building, Government Center Room 2275 Boston. Massachusetts 02203 CENTERS /w MEDIOIRE 8 MED/CAl/D SERVICE5 Division of Medicaid and Children's Health Operations/ Boston Regional Office December 22,2009 JudyAnn Bigby, M.D., Secretary Executive Ofice of Health and Human Services 1 Ashburton Place, Room 1 109 Boston, Massachusetts 02 108 Dear Dr. Bigby: We have reviewed Massachusetts' State Plan Amendment (SPA) No. 09-009, received in the Boston Regional Office on September 30,2009. This amendment implements the new option created by section 214 of the Children's Health Insurance Program Reauthorization Act of 2009 that permits States to extend federally-funded health insurance coverage to certain special status immigrant pregnant women and children. Based on the information provided, we are pleased to inform you that Massachusetts SPA 09-009 is approved, effective August 29,2009. Enclosed is a copy of the CMS-179 form, as well as the approved pages for incorporation in the Massachusetts Medicaid State Plan. The Remarks section of the CMS-179 indicates the changes that were mutually agreed to during the processing of this SPA. Please contact Aaron Wesolowski of my staff if you have any question. Aaron Wesolowski can be reached at 61 7-565-1325 or by email at aaron.wesolowski/i7ic1ns.l~l1s.po\:. Sincerely, Richard R. McGreal Associate Regional Administrator cc: Terry Dougherty, Medicaid Director Michael Coleman, State Plan Coordinator

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services JFK Federal Building, Government Center Room 2275 Boston. Massachusetts 02203 CENERS for MfD/C4RE & MEDIU11D SERUCES Division of Medicaid and Children's Health Operations/ Boston Regional Office June 28,20 10 JudyAnn Bigby, M.D., Secretary Executive OEce of Health and Human Services 1 Ashburton Place, Room 1 109 Boston, Massachusetts 021 08 Dear Dr. Bigby: We have reviewed Massachusetts' State Plan Amendment ("SPA") No. 10-001, received in the Boston Regional Office on March 3 1,201 0. This amendment complies with Section 1 12 of Medicare Improvements for Patients and Providers Act (the "Act"), which amended section 1905(p)(l)(C) of the Act to make the resource limit for Qualified Medicare Beneficiaries (QMB), Specified Low-Income Medicare Beneficiaries (SLMB) and Qualified Individuals (QIs) conform to the resource limit for individuals who qualify for the full subsidy Medicare Part D low income subsidy. Based on the information provided, we are pleased to inform you that Massachusetts SPA 0 10-00 1 is approved, effective January 1,20 10. Enclosed is a copy of the CMS- 179 form, as well as the approved pages for incorporation in the Massachusetts Medicaid State Plan. The Remarks section of the CMS-179 indicates the changes that were mutually agreed to during the processing of this SPA. Please contact Aaron Wesolowski of my staff if you have any question. Aaron Wesolowski can be reached at 61 7-565-1 325 or by email at aaron.wesolowski~.cms.hhs.cov. Sincerely, Richard R. McGreal Associate Regional Administrator cc: Terry Dougherty, Medicaid Director Michael Coleman, State Plan Coordinator

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services JFK Federal Building, Government Center Room 2275 Boston, Massachusetts 02203 CENERS for MEDlGQRE & MfD/U/D SfRVfCfS Division of Medicaid and Children's Health Operations/ Boston Regional Office September 20,20 10 JudyAnn Bigby, M.D., Secretary Executive Ofice of Health and Human Services One Ashburton Place, Room 1 109 Boston, Massachusetts 02 108 Dear Dr. Bigby: We have reviewed Massachusetts' State Plan Amendment ("SPA") No. 10-002, received in the Boston Regional Office on June 25,201 0. This amendment complies with Section 1 15 of the Medicare Improvements for Patients and Providers Act of 2008, which requires States to exempt Medicare cost-sharing benefits paid under the Medicare Savings Programs (MSPs) from estate recovery under section 191 7(b)(l) of the Act. Based on the information provided, we are pleased to inform you that Massachusetts SPA 10-002 is approved, effective April 1,201 0. Enclosed is a copy of the CMS-179 form, as well as the approved pages for incorporation in the Massachusetts Medicaid State Plan. The Remarks section of the CMS-179 indicates the changes that were mutually agreed to during the processing of this SPA. Please inform the federally recognized tribes in Massachusetts of the changes brought forth by this SPA. If you have any questions, please contact Aaron Wesolowski of my staff. Aaron Wesolowski can be reached at 617-565-1325 or by email at aaron.wesolowski(~?ctns.hl~s.~. Sincerely, Richard R. McGreal Associate Regional Administrator cc: Terry Dougherty, Medicaid Director Michael Coleman, State Plan Coordinator

Table of Contents State/Territory Name: Massachusetts State Plan Amendment (SPA) #: 11-006 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form 3) Approved SPA Pages

/s/

/s/ /s/

Revision: HCFA-PM-85-3 (BERC) Supplement 3 to Attachment 2.6-A December 1997 Page 4 State Plan under Title XIX of the Social Security Act OMB No.: 0938-0673 State: Massachusetts Reasonable Limits on Amounts for Necessary Medical or Remedial Care Not Covered under Medicaid

TN: 011-006 Approval Date: 02/03/12 Effective Date: 04/01/11 Supersedes: New

Reasonable and necessary medical and remedial care expenses recognized under State law that are not covered by Medicaid or payable by a third party which are incurred in the three month period prior to the month of application may be allowable deductions. Expenses incurred prior to this three month period are not allowable deductions. For medically necessary services and items not covered by the Medicaid State Plan, the actual paid amount will be used as the deduction, subject to the following limit: the highest of a payment/fee recognized by Medicaid, Medicare, or any commercial payers in the Commonwealth. No deduction shall be allowed for medical and remedial care expenses that were incurred as a result of the imposition of a transfer of resources penalty.

Table of Contents

State/Territory Name: MA

State Plan Amendment (SPA) #: 11-012

This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

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

7500 Security Boulevard, M/S S3-13-15

Baltimore, MD 21244-1850

Center for Medicaid and CHIP Services (CMCS)

Dr. Judy Ann Bigby, Secretary

Executive Office of Health and Human Services State of Massachusetts

One Ashburton Place

Boston, MA 02108 QUN 12,2002 RE: TN 11-012 Dear Dr. Bigby:

We have reviewed the proposed amendment to Attachments 4.19-A and 4.19-B of your Medicaid State plan submitted under transmittal number (TN) 11-012. This amendment proposes to implement Section 2702 of the Affordable Care.Act of 2010 (ACA) and the implementing final rule at 42 CFR 447, Subpart A.

We conducted our review of your submittal according to the statutory requirements at sections 1902(a)(2), 1902(a)(13), 1902(a)(30), 1903(a) and 1923 of the Social Security Act and the implementing Federal regulations at 42 CFR 447. We are pleased to inform you that Medicaid State plan amendment 11-012 is approved effective July 1, 2012. We are enclosing the CMS-179 and the amended plan pages.

If you have any questions, please call Novena James-Hailey at (617) 565-1291.

Sincerely, 7Y

‘ / Cindy Mann Director, (CMSC)

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICIAD SERVICES

FORM APPROVED OMB NO. 6938-0193

TRANSMITTAL AND NOT! ICE OF APPROVAL OF 1. TRANSMITTAL NUMBER: 2. STATE STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES 011-012 MA

3. PROGRAM IDENTIFICATION: TITLE XIX OF THE

SOCIAL SECURITY ACT (MEDICAID)

‘TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE AND MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES

4, PROPOSED EPFECTIVE DATE

enor oTlot [td

5. TYPE OF PLAN MATERIAL (Check One): (CO NEW STATE PLAN

(1) AMENDMENT TO BE CONSIDERED AS NEW PLAN

@ AMENDMENT

COMPLETE BLOCKS 6 THRU 10 IF THIS 1S AN AMENDMENT (Separate Transmittal for each amendment)

6. FEDERAL STATUTE/REGULATION CITATION:

7. FEDERAL BUDGET IMPACT:

42 CFR 447, 434,438 and 1902 (a) (4),1902 (a) (6) and 1903 a, FFY#t I S$ ete cs \ a jy b, REYES S (60206-0034 3, PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: | 9. PAGE NUMBER OF THR SUPERSEDED PLAN SECTION OR ATTACHMENT (Hf Applicable): ion 4.19, page 66c (new) 13 eG, ee Se a1a-B Pd 9 NA t4- ACs) eP 27-32 4: Ag Piet pe 7 a SUBJECT OF AMENDMENT: - . bas

Provider-Preventable Conditions ,

Sevious Reportalbl

eV ents

11. GOVERNOR'S REVIEW (Check One): (1 GOVERNOR'S OFFICE REPORTED NO COMMENT (1) COMMENTS OF GOVERNOR'S OFFICE ENCLOSED (NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

OTHER, AS SPECIFIED: Not required under - 42 CFR 430.12(b)(2)(i)

12. SIGNATURE OF STATE AGENCY OFFICIAL: 16. RETURN TO: Michael P, Coleman

13. TYPED NAME: C4 C/ State Plan Coordinator

JudyAnu Bigby, M.D. Offi . 14, TITLE: ice of Medicaid

Secretary Executive Office of Health and Human Services

- One Ashburton Place, J 1° Fluor

15, DARE SUBMITTED: Boston, MA 02108

FORREGIONAL OF

FICE USE ONLY.

17-DATE RECEIVED:

18. DATE APPROVED:

__JUN 13 2012

PLAN APFROVED = “ONE COPY RETACHED

15 EFFECTIVE nee OF F APPROVED MATERIAL: ag 012

* THUG ATS yh homOsoal

FORM CMS-179 (07-92)

Attachment 4.19-B (3) Page 2 State Plan under Title XIX of the Social Security Act State: Massachusetts Methods Used to Determine Rates of Payment for Private Psychiatric Hospital Outpatient Services

Citation 42 CFR 447, 434, 438, and 1902(a)(4), 1902(a)(6), and 1903

Payment Adjustment for Provider Preventable Conditions The Medicaid agency meets the requirements of 42 CFR Part 447, Subpart A, and sections

1902(a)(4),1902(a)(6), and 1903 with respect to non-payment for provider-preventable conditions.

Other Provider-Preventable Conditions

The State identifies the following Other Provider-Preventable Conditions for non-payment under Attachment 4.19-B(3) of this State plan, where applicable:

fE:3| Wrong surgical or other invasive procedure performed on a patient; surgical or other invasive procedure performed on the wrong body part; surgical or other invasive procedure performed on the wrong patient.

oO Additional Other Provider-Preventable Conditions identified below: - None.

No reduction in payment for a provider preventable condition will be imposed on a provider when the condition defined as a PPC for a particular patient existed prior to the initiation of treatment for that patient by that provider.

Reduction in provider payment may be limited to the extent that the following apply: (i) the identified provider preventable conditions would otherwise result in an increase in payment; (ii) the State can reasonably isolate for nonpayment the portion of the payment directly related to treatment for, and related to, the provider preventable condition.

A State plan must ensure that nonpayment for provider-preventable conditions does not prevent access to services for Medicaid beneficiaries.

Payment Method:

EOHHS will pay hospitals in accordance with the requirements of 42 CFR Part 447, Subpart A, and sections 1902(a)(4), 1902(a)(6) and 1903 with respect to non- Payment for provider-preventable conditions, effective for dates of service on or after July 1, 2012.

Provider preventable conditions (“PPCs”) are defined as those conditions that are identified as Other Provider-Preventable Conditions (“OPPCs”) above. The OPPCs include the three National Coverage Determinations (the “NCDs”) listed above

When a hospital reports a PCC, MassHealth will not pay for services which the hospital indicates are PPC-related and will exclude all reported PPC-related costs/services when determining future year payment rates that are calculated using a data source that would otherwise include the PPC.

TN: 011-012 Approval Date: JUN 13 2012 Effective Date: 07/01/12 Supersedes: New

Attachment 4.19-B (3) Page 3 State Plan under Title XIX of the Social Security Act State: Massachusetts Methods Used to Determine Rates of Payment for Private Psychiatric Hospital Outpatient Services

The federal non-payment provision also applies to third-party liability and crossover payments by MassHealth

Charges for services, including co-payments or deductions, deemed non-billable to MassHealth are not billable to the member.

In the event that individual cases are identified throughout the PPC implementation period, the Commonwealth shall adjust reimbursements according to the methodology above.

TN: 011-012 Approval Date: JUN 12.2012 Effective Date: 07/01/12 Supersedes: New

Attachment 4.19-B (2) Page 4 State Plan under Title XIX of the Social Security Act ‘ State: Massachusetts Methods Used to Determine Rates of Payment for Chronic Disease and Rehabilitation Hospital Outpatient Services

C. Provider Preventable Conditions

Citation 42 CFR 447, 434, 438, and 1902(a)(4), 1902(a)(6), and 1903

Payment Adjustment for Provider Preventable Conditions The Medicaid agency meets the requirements of 42 CFR Part 447, Subpart A, and sections 1902(a)(4),1902(a)(6), and 1903 with respect to non-payment for provider-preventable conditions.

Other Provider-Preventable Conditions

The State identifies the following Other Provider-Preventable Conditions for non-payment under Attachment 4.19-B(2) (Chronic Disease and Rehabilitation Hospital Outpatient Services) of this State plan where applicable.

__X__ Wrong surgical or other invasive procedure performed on a patient; surgical or other invasive procedure performed on the wrong body part; surgical or other invasive procedure performed on the wrong patient.

__X___ Additional Other Provider-Preventable Conditions identified below:

© The following Hospital Acquired Conditions as identified by Medicare, as they may be updated by CMS:

Foreign object retained after surgery.

Air Embolism

Blood incompatibility

Stage II and IV Pressure Ulcers

Falls and Trauma, related to:

fractures

dislocations

intracranial injuries

crushing injuries

burns e other injuries

6. Manifestations of poor glycemic control, including: e diabetic ketoacidosis

nonketotic hyperosmolar coma

hypoglycemic coma

secondary diabetes with hyperosmolarity

vPYwnr

TN: 011-012 Approval Date: JUN 12 2012 Effective Date: 07/01/12 Supersedes: New

Attachment 4.19-B (2) Page § State Plan under Title XIX of the Social Security Act State: Massachusetts

Methods Used to Determine Rates of Payment for Chronic Disease

and Rehabilitation Hospital Outpatient Services

e Inaddition, the following:

_

11.

Intraoperative or immediately postoperative death in a ASA class 1 patient Patient death or serious disability associated with the use of contaminated drugs, devices or biologics provided by the healthcare facility.

Patient death or serious disability associated with the use or function of a device in patient care, in which the device is used or functions other than as intended. Patient death or serious disability associated with patient elopement (disappearance)

. Patient suicide or attempted suicide resulting in serious disability, while being

cared for in a healthcare facility

Patient death or serious disability associated with a medication error (¢.g., errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation or wrong route of administration)

Maternal death or serious disability associated with labor or delivery in a low- risk pregnancy while being cared for in a healthcare facility.

Death or serious disability (kernicterus) associated with failure to identify and: treat hyperbilirubinemia in neonates.

Patient death or serious disability due to spinal manipulative therapy

. Patient death or serious disability associated with the use of restraints or bedrails

while being cared for in a health care facility Death or significant injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs within or on the grounds of a healthcare facility

No reduction in payment for a provider preventable condition will be imposed on a provider when the condition defined as a PPC for a particular patient existed prior to the initiation of treatment for that patient by that provider.

Reductions in provider payment may be limited to the extent that the following apply: (i) The identified provider preventable conditions would otherwise result in an increase in payment; (ii) The State can reasonably isolate for nonpayment the portion of the payment directly related to treatment for, and related to, the provider preventable condition.

A State plan must ensure that nonpayment for provider-preventable conditions does not prevent access to services for Medicaid beneficiaries.

Payment Method:

EOHHS will pay hospitals in accordance with the requirements of 42 CFR Part 447, Subpart A, and sections 1902(a)(4), 1902(a)(6) and 1903 with respect to non-payment for provider-preventable conditions, effective for dates of service on or after July 1, 2012.

Provider preventable conditions (“PPCs”) are defined as those conditions that are identified as

TN: 011-012 Supersedes: New

Approval Date: SUN 12 2012 Effective Date: 07/01/12

Attachment 4.19-B (2) Page 6 State Plan under Title XIX of the Social Security Act . State: Massachusetts Methods Used to Determine Rates of Payment for Chronic Disease and Rehabilitation Hospital Outpatient Services

Other Provider-Preventable Conditions (“OPPCs”) above. The OPPCs include the three National Coverage Determinations (the “NCDs”) and the Additional Other Provider Preventable Conditions (“Additional OPPCs”) that are listed above

When a hospital reports a PCC, MassHealth will reduce payments to the Hospital as follows:

1. Payments for Outpatient Services: MassHealth will not pay for services which the hospital indicates are PPC-related and will exclude all reported PPC-related costs/services when determining future year payment rates that are calculated using a data source that would otherwise include the PPC.

2. Follow-Up Care in Same Hospital: If a hospital reports that it provided follow-up outpatient services that were solely the result of a previous PPC (inpatient or outpatient) that occurred while the member was being cared for at a facility covered under the same hospital license. MassHealth will not pay for the reported follow-up services. If the hospital reports that non-PPC-related services were provided during the follow-up visit, payment will be made, but MassHealth will exclude all reported PPC-related costs/services when determining future year payment rates that are calculated using a data source that would otherwise include the PPC.

The federal non-payment provision also applies to third-party liability and crossover payments by MassHealth

Charges for services, including co-payments or deductions, deemed non-billable to MassHealth are not billable to the member.

In the event that individual cases are identified throughout the PPC implementation period, the Commonwealth shall adjust reimbursements according to the methodology above.

D. Serious Reportable Events

The non-payment provisions set forth in this Section IID. apply to the following serious reportable events (SREs), where applicable: 1. Infant discharged to the wrong person. 2. Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances. 3. Any instance of care ordered by or provided by someone impersonating a physician, nurse,

TN: 011-012 Approval Date: JN 1.9 2012 Effective Date: 07/01/12 Supersedes: New .

Attachment 4.19-B (2) . Page 7 State Plan under Title XIX of the Social Security Act State: Massachusetts Methods Used to Determine Rates of Payment for Chronic Disease and Rehabilitation Hospital Outpatient Services

pharmacist, or other licensed health care provider. 4. Abduction of a patient of any age. 5. Sexual assault on a patient within or on the grounds of the healthcare facility.

Hospitals are prohibited from charging or seeking payment from MassHealth or the Member for Hospital services that are made necessary by, or are provided as a result of, a serious reportable event occurring on premises covered under the Hospital license that was preventable, within the Hospital’s control, and unambiguously the result of a system failure, as described in DPH regulations at 105 CMR 130.332 as in effect on the date of service. Non-reimbursable Hospital services include:

1. All services provided during the outpatient visit during which a preventable SRE occurred;

and

2. All services provided during readmissions and follow-up outpatient visits as a result of a non-billable SRE provided:

a. at a facility under the same license as the Hospital at which a non-billable SRE occurred; or

b. on the premises of a separately licensed hospital with common ownership or a common corporate parent of the Hospital at which a non-billable SRE occurred.

3. Charges for services, including co-payments or deductibles, deemed non-billable to MassHealth are not billable to the Member.

Non-payment provisions also apply to third-party liability and crossover payments by MassHealth.

A Hospital not involved in the occurrence of a preventable SRE that also does not meet the criteria in number 2 above, and that provides inpatient or outpatient services to a patient who previously incurred an SRE may bill MassHealth for all medically necessary Hospital services provided to the patient following a preventable SRE.

TN: 011-012 Approval Date: ‘JUN 12 2012 xstective Date: 07/01/12 Supersedes: New

Attachment 4.19-A (2b) Page 7

State Plan under Title XIX of the Social Security Act State: Massachusetts Methods Used to Determine Rates of Payment for Privately-Owned Psychiatric Hospital Services

C. Provider Preventable Conditions

Citation 42 CFR 447, 434, 438, and 1902(a)(4), 1902(a)(6), and 1903

Payment Adjustment for Provider Preventable Conditions ; The Medicaid agency meets the requirements of 42 CFR Part 447, Subpart “A, and sections 1902(a)(4), 1902(a\(6), and 1903 with respect to non-payment for provider-preventable conditions.

Health Care-Acquired Conditions

The State identifies the following Health Care-Acquired Conditions for non-payment under Attachment 4.19-A(2b) (Privately-Owned Psychiatric Hospital Services) of this State plan, where applicable.

[El Hospital-Acquired Conditions as identified by Medicare other than Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) following total knee replacement or hip replacement surgery in pediatric and obstetric patients.

Other Provider-Preventable Conditions The State identifies the following Other Provider-Preventable Conditions for non-payment under Attachment 4.19-A(2b) (Privately-Owned Psychiatric Hospital Services)of this State plan, where applicable.

_@ Wrong surgical or other invasive procedure performed on a patient; surgical or other invasive procedure performed on the wrong body part; surgical or other invasive procedure

performed on the wrong patient. Additional Other Provider-Preventable Conditions identified below: None.

No reduction in payment for a provider preventable condition will be imposed on a provider when the condition defined as a PPC for a particular patient existed prior to the initiation of treatment for that patient by that provider.

Reductions in provider payment may be limited to the extent that the following apply: (i) The identified provider preventable conditions would otherwise result in an increase in payment; (ii) The State can reasonably isolate for nonpayment the portion of the payment directly related to treatment for, and related to, the provider preventable condition. :

A State plan must ensure that nonpayment for provider-preventable conditions does not prevent access to services for Medicaid beneficiaries.

TN: 011-012 Approval Date: JUN 12 2012 — rettective Date: 07/01/12 Supersedes: New

Attachment 4.19-A (2b) Page 8

State Plan under Title XIX of the Social Security Act State: Massachusetts

Methods Used to Determine Rates of Payment for Privately-Owned Psychiatric Hospital Services

Payment Method

EOHHS will pay participating psychiatric hospitals and substance abuse and treatment hospitals in accordance with the requirements of 42 CFR Part 447, Subpart A, and sections 1902(a)(4), 1902(a)(6) and 1903 with respect to non-payment for provider-preventable conditions, effective for dates of service on or after July 1, 2012.

Provider preventable conditions (“PPCs”) are defined as those conditions that are identified as Health Care-Acquired Conditions (“HCACs”) and Other Provider-Preventable Conditions (‘OPPCs”) above. The OPPCs consist of the three National Coverage Determinations (the “NCDs”) that are listed above.

When a hospital reports a PPC that the hospital indicates was not present on admission, MassHealth will reduce payments to the hospital as follows:

1.

Inpatient Per Diem Rate: a. MassHealth will not pay the Inpatient Per Diem Rate if the hospital reports

that only PPC-related services were delivered on that day, and will exclude all reported PPC-related costs/services when determining future year payment rates that are calculated using a data source that would otherwise include the PPC.

. MassHealth will pay the Inpatient Per Diem Rate if the hospital reports that

non-PPC related services were also delivered on that day, but will exclude all reported PPC-related costs/services when determining future year payment rates that are calculated using a data source that would otherwise include the PPC.

2. Administrative Day Per-Diem Rate:

a. MassHealth will not pay the per diem if the hospital reports that only PPC-

related services were delivered on that day, and will exclude all reported PPC-related costs/services when determining future year payment rates that are calculated using a data source that would otherwise include the PPC.

. MassHealth will pay the per diem if the hospital reports that non-PPC-related

services were also delivered on that day, but will exclude all reported PPC- related costs/services when determining future year payment rates that are calculated using a data source that would otherwise include the PPC.

The federal non-payment provision also applies to third-party liability and crossover payments by

MassHealth.

TN: 011-012 Supersedes: New

Approval Date: JUN 122012 Effective Date: 07/01/12

Attachment 4.19-A (2b) Page 9

State Plan under Titte XIX of the Social Security Act State: Massachusetts Methods Used to Determine Rates of Payment for Privately-Owned Psychiatric Hospital Services

Charges for services, including co-payments or deductibles, deemed non-billable to MassHealth are not billable to the member.

In the event that individual cases are identified throughout the PPC implementation period, the Commonwealth shall adjust reimbursements according to the methodology above.

TN: 011-012 Approval Date: JUN 12 2012 Ettective Date: 07/01/12 Supersedes: New

Attachment 4.19-B Page 8 State Plan under Title XIX of the Social Security Act State: Massachusetts

Methods and Standards for Establishing Payment Rates - Other Types of Care

Citation 42 CFR 447, 434, 438, and 1902(a)(4), 1902(a)(6), and 1903

Payment Adjustment for Provider Preventable Conditions The Medicaid agency meets the requirements of 42 CFR Part 447, Subpart A, and sections

1902(a)(4),1902(a)(6), and 1903 with respect to non-payment for provider-preventable conditions.

Other Provider-Preventable Conditions

The State identifies the following Other Provider-Preventable Conditions for non-payment under Attachment 4.19-B (Other Types of Care) of this State plan, for these services, where applicable:

X-ray services

Physician services

Optometric services

Clinic services** -

Dental services

Podiatry services

FQHC /RHC services

Licensed Freestanding Birth Center services

X__ Wrong surgical or other invasive procedure performed on a patient; surgical or other invasive procedure performed on the wrong body part; surgical or other invasive procedure performed on the wrong patient.

Additional Other Provider-Preventable Conditions identified below: - None.

No reduction in payment for a provider preventable condition will be imposed on a provider when the condition defined as a PPC for a particular patient existed prior to the initiation of treatment for that patient by that provider.

Reduction in provider payment may be limited to the extent that the following apply: (i) the identified provider preventable conditions would otherwise result in an increase in payment; (ii) the State can reasonably isolate for nonpayment the portion of the payment directly related to treatment for, and related to, the provider preventable condition.

A State plan must ensure that nonpayment for provider-preventable conditions does not prevent access to services for Medicaid beneficiaries.

Payment Method: Effective for dates of service on or after July 1, 2012, MassHealth will not pay for OPPC-related services if the provider reports an Other Provider Preventable Condition (OPPC). Ifa provider’s future year payment rate is calculated using a data source that would otherwise include the OPPC, all reported OPPC-related costs/services will be excluded from the calculation.

The federal non-payment provision also applies to third-party liability and crossover payments by MassHealth.

TN 011-012 Approval Date: JUN 1 2 2012 Effective Date: 07/01/12 Supersedes: New

Attachment 4.19-B Page 9 State Plan under Title XIX of the Social Security Act State: Massachusetts Methods and Standards for Establishing Payment Rates — Other Types of Care

Charges for services, including co-payments or deductibles, deemed non-billable to MassHealth are not billable to the member.

In the event that individual cases are identified throughout the PPC implementation period, the Commonwealth shall adjust reimbursement according to the methodology above.

** See Attachment 4.19-B, page 10 for Payment Adjustments for Provider Preventable Conditions for Freestanding Ambulatory Surgery Center services.

TN 011-012 Approval Date: JUN 12 2012 Effective Date: 07/01/12 Supersedes: New :

Attachment 4.19-B Page 10 State Plan under Title XIX of the Social Security Act State: Massachusetts

Methods and Standards for Establishing Payment Rates — Other Types of Care

Citation

42 CFR 447, 434, 438, and 1902(a)(4), 1902(a)(6), and 1903

Payment Adjustment for Provider Preventable Conditions — Freestanding Ambulatory Surgery Center (FASC) Services

The Medicaid agency meets the requirements of 42 CFR Part 447, Subpart A, and sections 1902(a)(4),1902(a)(6), and 1903 with respect to non-payment for provider-preventable

conditions.

Other Provider-Preventable Conditions The State identifies the following Other Provider-Preventable Conditions for non-payment under Attachment 4.19-B of this State Plan (Other Types of Care), for Freestanding Ambulatory Surgery Center (FASC) services, where applicable:

X__ Wrong surgical or other invasive procedure performed on a patient; surgical or other invasive procedure performed on the wrong body part; surgical or other invasive procedure performed on the wrong patient.

X__ Additional Other Provider-Preventable Conditions identified below:

e The following Hospital Acquired Conditions as identified by Medicare, as they may be updated by CMS:

Foreign object retained after surgery Air Embolism Blood incompatibility Stage II and IV Pressure Ulcers Falls and Trauma, related to: y fractures

dislocations intracranial injuries crushing injuries burns

e other injuries 6. Manifestations of poor glycemic control, including: e diabetic ketoacidosis e nonketotic hyperosmolar coma e hypoglycemic coma e secondary diabetes with hyperosmolarity

wPrwndr

e Inaddition, the following:

1. 2.

3.

Intraoperative or immediately postoperative death in a ASA class 1 patient

Patient death or serious disability associated with the use of contaminated drugs, devices or biologics provided by the healthcare facility.

Patient death or serious disability associated with the use or function of a device in patient care, in which the device is used or functions other than as intended.

TN 011-012 Supersedes: New

Approval Date: JUN i 2 2012 . Effective Date: 07/01/12

Attachment 4.19-B Page 11 State Plan under Title XIX of the Social Security Act State: Massachusetts Methods and Standards for Establishing Payment Rates — Other Types of Care

Patient death or serious disability associated with patient elopement (disappearance)

Patient suicide or attempted suicide resulting in serious disability, while being cared

for in a healthcare facility

6. Patient death or serious disability associated with a medication error (e.g., errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation or wrong route of administration)

7. Maternal death or serious disability associated with labor or delivery in a low-risk pregnancy while being cared for in a healthcare facility.

8. Death or serious disability (kernicterus) associated with failure to identify and treat hyperbilirubinemia in neonates.

9. Patient death or serious disability due to spinal manipulative therapy

10. Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a health care facility

11. Death or significant injury of a patient or staff member resulting from a physical

assault (i.e., battery) that occurs within or on the grounds of a healthcare facility

we

No reduction in payment for a provider preventable condition will be imposed on a provider when the condition defined as a PPC for a particular patient existed prior to the initiation of treatment for that patient by that provider.

Reduction in provider payment may be limited to the extent that the following apply: (i) the identified provider preventable conditions would otherwise result in an increase in payment; (ii) the State can reasonably isolate for nonpayment the portion of the payment directly related to treatment for, and related to, the provider preventable condition.

A State plan must ensure that nonpayment for provider-preventable conditions does not prevent access to services for Medicaid beneficiaries.

Payment Method:

Effective for dates of service on or after July 1, 2012, MassHealth will not pay the FASC for OPPC- related services if the FASC reports an Other Provider Preventable Condition (OPPC). Ifa future year FASC payment rate is calculated using a data source that would otherwise include the OPPC, all reported OPPC-related costs/services will be excluded from the calculation.

The federal non-payment provision also applies to third-party liability and crossover payments by MassHealth.

Charges for services, including co-payments or deductibles deemed non-billable to MassHelath are not billable to the member.

In the event that individual cases are identified throughout the PPC implementation period, the Commonwealth shall adjust reimbursement according to the methodology above.

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Attachment 4.19-B Page 12 State Plan under Title XIX of the Social Security Act State: Massachusetts Methods and Standards for Establishing Payment Rates —- Other Types of Care

Payment Adjustment for Serious Reportable Events — Freestanding Ambulatory Surgery Center (ASC) services

Serious Reportable Events (SREs)

The State identifies the following serious reportable events for which it applies the following non- payment method for Freestanding Ambulatory Surgery Center (FASC) services under Attachment 4.19-B, where applicable: 1. Infant discharged to the wrong person 2. Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances. 3. Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare provider 4. Abduction of a patient of any age 5. Sexual assault on a patient within or on the grounds of a health care facility

Non-Payment Method:

Effective for dates of service on or after July 1, 2012, MassHealth will not pay the FASC for the facility component if an SRE listed above occurs on premises covered by the FASC license that was preventable, within the FASC’s control, and unambiguously the result of a system failure, as described in applicable Massachusetts Department of Public Health regulations as in effect on the date of the service. MassHealth will also not pay the FASC the facility component for FASC services that are made necessary by, or are provided as a result of such an SRE.

Nonpayment provisions also apply to third-party liability and crossover payments by MassHealth. Charges for services, including co-payments or deductibles, deemed non-billable to MassHealth are not billable to the member. :

** These Serious Reportable Events are not Provider Preventable Conditions.

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Attachment 4.19-B (1) Page 13

State Plan Under Title XIX of the Social Security Act

State: Massachusetts

Methods Used to Determine Rates of Payment for Acute Outpatient Hospital Services

VL Other

and Performance Based Payment Metheds

A. Provider Preventable Conditions

Citation

42 CFR 447, 434, 438, and 1902(a)(4), 1902(a)(6), and 1903

Payment Adjustment for Provider Preventable Conditions The Medicaid agency meets the requirements of 42 CFR Part 447, Subpart A, and sections 1902(a)(4),1902(a)(6), and 1903 with respect to non-payment for provider- preventable conditions.

Other Provider-Preventable Conditions

The State identifies the following Other Provider-Preventable Conditions for non- payment under Attachment 4.19-B (1), (Acute Outpatient Hospital Services) of this State plan, where applicable.

p.4

Wrong surgical or other invasive procedure performed on a patient; surgical or

other invasive procedure performed on the wrong body part; surgical or other invasive procedure performed on the wrong patient.

X__ Additional Other Provider-Preventable Conditions identified below:

Vener

The following Hospital Acquired Conditions as identified by Medicare, as they may be updated by CMS:

Foreign object retained after surgery. Air Embolism

Blood incompatibility

Stage I and IV Pressure Ulcers Falls and Trauma, related to:

fractures dislocations intracranial injuries crushing injuries burns

other injuries

Manifestations of poor glycemic control, including:

e e e

diabetic ketoacidosis

nonketotic hyperosmolar coma hypoglycemic coma

secondary diabetes with hyperosmolarity

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Approval Date: JUN 12 2012 Effective Date: 07/01/12

Attachment 4.19-B (1)

Page 14 State Plan Under Title XIX of the Social Security Act State: Massachusetts

Methods Used to Determine Rates of Payment for Acute Outpatient Hospital Services

LL.

In addition, the following:

Intraoperative or immediately postoperative death in a ASA class 1 patient

Patient death or serious disability associated with the use of contaminated drugs, devices or biologics provided by the healthcare facility.

Patient death or serious disability associated with the use or function of a device in patient care, in which the device is used or functions other than as intended.

Patient death or serious disability associated with patient elopement (disappearance) Patient suicide or attempted suicide resulting in serious disability, while being cared for in a healthcare facility

Patient death or serious disability associated with a medication error (¢.g., errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation or wrong route of administration)

Maternal death or serious disability associated with labor or delivery in a low-risk pregnancy while being cared for in a healthcare facility.

Death or serious disability (kemicterus) associated with failure to identify and treat hyperbilirubinemia in neonates. ~ :

Patient death or serious disability due to spinal manipulative therapy

. Patient death or serious disability associated with the use of restraints or bedrails

while being cared for in a health care facility Death or significant injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs within or on the grounds of a healthcare facility

No reduction in payment for a provider preventable condition will be imposed ona provider when the condition defined as a PPC for a particular patient existed prior to the initiation of treatment, ‘for that patient by that provider. :

Reduction in provider payment may be limited to the extent that the following apply: (i) the identified provider preventable conditions would otherwise result in an increase in payment; (ii) the State can reasonably isolate for nonpayment the portion of the payment directly related to treatment for, and related to, the provider preventable condition.

A State plan must ensure that nonpayment for provider-preventable conditions does not prevent access to services for Medicaid beneficiaries.

Payment Method:

EOHHS will pay hospitals in accordance with the requirements of 42 CFR Part 447, Subpart A, and sections 1902(a)(4), 1902(a)(6) and 1903 with respect to non-payment for provider- preventable conditions, effective for dates of service on or after July 1, 2012.

Provider preventable conditions (“PPCs”) are defined as those conditions that are identified as Other Provider-Preventable Conditions (“OPPCs”) above. The OPPCs include the three National Coverage Determinations (the “NCDs”) and the Additional Other Provider Preventable Conditions (“Additional OPPCs”) that are listed above.

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Attachment 4.19-B (1)

Page 15 State Plan Under Title XIX of the Social Security Act

State: Massachusetts Methods Used to Determine Rates of Payment for Acute Outpatient Hospital Services

When a Hospital reports a PCC, MassHealth will reduce payments to the Hospital as follows:

1. PAPE:

a. MassHealth will not pay the PAPE if the Hospital reports that only-PPC- related services were delivered during the episode of care, and will exclude all reported PPC-related costs/services when determining future year payment rates that are calculated using a data source that would otherwise include the PPC.

b. MassHealth will pay the PAPE if the Hospital reports that non-PPC related services were also delivered during the same episode of care, but will exclude all reported PPC-related costs/services when determining future year payment rates that are calculated using a data source that would otherwise include the PPC.

2. Outpatient Hospital Payments for Hospital-Based Physician Services: MassHealth will not pay for outpatient Hospital-based physician services reported as PPC-related services.

3. Follow-Care in Same Hospital: If a Hospital reports that it provided follow-up outpatient hospital services that were solely the result of a previous PPC (inpatient or outpatient) that occurred while the member was being cared for at a facility covered under the same hospital license., MassHealth will not pay for the reported follow-up services. If the hospital reports that non—PPC-related services were provided during the follow-up episode of care, payment will be made, but MassHealth will exclude all PPC-related costs/services when determining future year payment rates that are calculated using a data source that would otherwise include the PPC.

The federal non-payment provision also applies to third party liability and crossover payments by MassHealth.

Charges for services, including co-payments or deductibles, deemed non-billable to MassHealth are not billable to the member. 7

In the event that individual cases are identified throughout the PPC implementation period, the Commonwealth shall adjust reimbursement according to the methodology above.

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Attachment 4.19-B (1) Page 16 State Plan Under Title XIX of the Social Security Act State: Massachusetts Methods Used to Determine Rates of Payment for Acute Outpatient Hospital Services

B. Serious Reportable Events

The non-payment provisions set forth in this Section VI.B. apply to the following serious reportable events (SREs), where applicable:

1. Infant discharged to the wrong person

2. Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances

3. Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed health care provider.

4. Abduction of a patient of any age.

5. Sexual assault on a patient within or on the grounds of the healthcare re facility

Hospitals are prohibited from charging or seeking payment from MassHealth or the Member for Hospital and Hospital-Based Physician services that are made necessary by, or are provided as a result of, a serious reportable event occurring on premises covered under the Hospital license that was preventable, within the Hospital’s control, and unambiguously the result of a system failure, as described in DPH regulations at 105 CMR 130.332 as in effect on the date of service. Non- reimbursable Hospital and Hospital-Based Physician services include:

1. All services provided during the outpatient visit during which a preventable SRE occurred; and

2. All services provided during readmissions and follow-up outpatient visits as a result of a non-billable SRE provided:

a ata facility under the same license as the Hospital at which a non-billable SRE occurred; or

b. on the premises of a separately licensed hospital with common ownership or a common corporate parent of the Hospital at which a non-billable SRE occurred.

3. Charges for services, including co-payments or deductibles, deemed non-billable to MassHealth are not billable to the Member.

The non-payment provision also applies to third-party liability and crossover payments by MassHealth.

A Hospital not involved in the occurrence of a preventable SRE that also does not meet the criteria in number 2 above, and that provides inpatient or outpatient services to a patient who previously incurred an SRE may bill MassHealth for all medically necessary Hospital and Hospital-Based Physician services provided to the patient following a preventable SRE.

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Attachment 4.19-A(2a) . Page 14 State Plan under Title XIX of the Social Security Act State: Massachusetts Methods for Establishing Payment Rates — Privately-Owned Chronic Disease and Rehabilitation Inpatient Hospital Services

Vv. Provider Preventable Conditions

Citation 42 CFR 447, 434, 438, and 1902(a)(4), 1902(a)(6), and 1903

Payment Adjustment for Provider Preventable Conditions The Medicaid agency meets the requirements of 42 CFR Part 447, Subpart A, and sections

1902(a)(4),1902(a)(6), and 1903 with respect to non-payment for provider-preventable conditions.

Health Care-Acquired Conditions

The State identifies the following Health Care-Acquired Conditions for non-payment under Attachment 4.19-A(2a) (Privately-Owned Chronic Disease and Rehabilitation Inpatient Hospital Services) of this State plan where applicable.

{& Hospital-Acquired Conditions as identified by Medicare other than Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) following total knee replacement or hip replacement surgery in pediatric and obstetric patients.

Other Provider-Preventable Conditions

The State identifies the following Other Provider-Preventable Conditions for non-payment under Attachment 4.19-A(2a) (Privately-Owned Chronic Disease and Rehabilitation Inpatient Hospital Services) of this State plan where applicable.

@& Wrong surgical or other invasive procedure performed on a patient; surgical or other invasive procedure performed on the wrong body part; surgical or other invasive procedure performed on the wrong patient.

Additional Other Provider-Preventable Conditions identified below:

Intraoperative or immediately postoperative death in a ASA class 1 patient . Patient death or serious disability associated with the use of contaminated drugs, devices or biologics provided by the healthcare facility.

3. Patient death or serious disability associated with the use or function of a device in patient

care, in which the device is used or functions other than as intended.

Patient death or serious disability associated with patient elopement (disappearance)

Patient suicide or attempted suicide resulting in serious disability, while being cared for in a

healthcare facility

6. Patient death of serious disability associated with a medication error (e.g., errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation or wrong route of administration)

7. Maternal death or serious disability associated with labor or delivery in a low-risk pregnancy while being cared for in a healthcare facility.

8. Death or serious disability (kernicterus) associated with failure to identify and treat

hyperbilirubinemia in neonates.

Ne

wa

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Attachment 4.19-A(2a) Page 15 State Plan under Title XIX of the Social Security Act State: Massachusetts Methods for Establishing Payment Rates — Privately-Owned Chronic Disease and Rehabilitation Inpatient Hospital Services

9. Patient death or serious disability due to spinal manipulative therapy

10. Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a health care facility ,

11. Death or significant injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs within or on the grounds of a healthcare facility

No reduction in payment for a provider preventable condition will be imposed on a provider when the condition defined as a PPC for a particular patient existed prior to the initiation of treatment for that patient by that provider.

Reductions in provider payment may be limited to the extent that the following apply: (i) The identified provider preventable conditions would otherwise result in an increase in payment; (ii) The State can reasonably isolate for nonpayment the portion of the payment directly related to treatment for, and related to, the provider preventable condition.

A State plan must ensure that nonpayment for provider-preventable conditions does not prevent access to services for Medicaid beneficiaries.

Payment Method

EOHHS will pay hospitals in accordance with the requirements of 42 CFR Part 447, Subpart A, and sections 1902(a)(4), 1902(a)(6) and 1903 with respect to non-payment for provider- preventable conditions, effective for dates of service on or after July 1, 2012.

Provider preventable conditions (“PPCs”) are defined as those conditions that are identified as Health Care-Acquired Conditions (“HCACs”) and Other Provider-Preventable Conditions (“OPPCs”) above. The OPPCs include the three National Coverage Determinations (the “NCDs”) and the Additional Other Provider Preventable Conditions (“Additional OPPCs”) that are listed above.

When a hospital reports a PPC that the hospital indicates was not present on admission, MassHealth will reduce payments to the hospital as follows: 1. Inpatient Per Diem Rate:

a. MassHealth will not pay the Inpatient Per Diem Rate if the hospital reports that only PPC-related services were delivered on that day and will exclude all reported PPC-related costs/services when determining future year payment rates that are calculated using a data source that would otherwise include the PPC. .

b. MassHealth will pay the Inpatient Per Diem Rate if the hospital reports that non-PPC related services were also delivered on that day but will exclude all reported PPC-related costs/services when determining future year payment rates that are calculated using a data source that would otherwise include the PPC.

2. Administrative Per-Diem (AD) Rate:

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a. MassHealth will not pay the per diem if the hospital reports that only PPC- related services were delivered on that day, and will exclude all reported PPC-related costs/services when determining future year payment rates that are calculated using a data source that would otherwise include the PPC.

b. MassHealth will pay the per diem if the hospital reports that non-PPC-related services were also delivered on that day but will exclude all reported PPC- related costs/services when determining future year payment rates that are calculated using a data source that would otherwise include the PPC.

3. Follow-Up Care in Same Hospital: If a hospital reports that it provided follow-up inpatient hospital services that were solely the result of a previous PPC (inpatient or outpatient) that occurred while the member was being cared for at a facility covered under the same hospital license, MassHealth will not pay for the reported follow-up services. If the hospital reports that non-PPC-related services were provided on any day during the follow-up stay, payment will be made for that day, but MassHealth will exclude all reported PPC-related costs/services when determining future year payment rates that are calculated using a data source that would otherwise include the PPC.

The federal non-payment provision also applies to third-party liability and crossover payments by MassHealth.

Charges for service, including co-payments or deductibles, deemed non-billable to MassHealth are not billable to the member.

In the event that individual cases are identified throughout the PPC implementation period, the Commonwealth shall adjust reimbursements according to the methodology above.

VI. Serious Reportable Events (SREs)

The non-payment provisions set forth in this Section VI apply to the following serious reportable events (SREs), where applicable:

1. Infant discharged to the wrong person. 2. Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances. 3. Any Instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist or other licensed health care provider. 4. Abduction of a patient of any age. | 5. Sexual assault on a patient within or on the grounds of a health care facility. |

Hospitals are prohibited from charging or seeking payment from MassHealth or the Member for hospital services that are made necessary by, or are provided as a result of, a serious reportable event occurring on premises covered under the hospital license that was preventable, within the hospital’s control, and unambiguously the result of a system failure, as described in DPH regulations at 105 CMR 130.332 as in effect on the date of service. Non-reimbursable hospital services include:

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1. All services provided during the inpatient stay during which a preventable SRE occurred, from the date the SRE occurred through discharge, not to exceed 60 days; and

2. All services provided during readmissions and follow-up outpatient visits as a result of a non-billable SRE provided: .

a. at a facility under the same license as the hospital at which a non-billable SRE occurred; or

b. on the premises of a separately licensed hospital with common ownership or a common corporate parent of the hospital at which a non-billable SRE occurred.

3. Charges for services, including co-payments or deductibles, deemed non-billable to MassHealth are not billable to the Member.

Non-payment provisions also apply to third-party liability and crossover payments by MassHealth.

A hospital not involved in the occurrence of a preventable SRE that also does not meet the criteria in number 2 above, and that provides inpatient or outpatient services to a patient who previously incurred an SRE may bill MassHealth for all medically necessary services provided to the patient following a preventable SRE.

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Attachment 4.19-A(3) Page 27 State Plan under Title XIX of the Social Security Act State: Massachusetts Methods Used to Determine Rates of Payment for Services in State-Owned Non-Acute Hospitals

XI. Provider Preventable Conditions

Citation 42 CFR 447, 434, 438, and 1902(a)(4), 1902(a)(6), and 1903

Payment Adjustment for Provider Preventable Conditions The Medicaid agency meets the requirements of 42 CFR Part 447, Subpart A, and sections

1902(a)(4),1902(a)(6), and 1903 with respect to non-payment for provider-preventable conditions.

Health Care-Acquired Conditions

The State identifies the following Health Care-Acquired Conditions for non-payment under Attachment 4.19-A(3) (State-Owned Non-Acute Hospitals) of this State plan where applicable.

X_Hospital-Acquired Conditions as identified by Medicare other than Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) following total knee replacement or hip replacement surgery in pediatric and obstetric patients.

Other Provider-Preventable Conditions The State identifies the following Other Provider-Preventable Conditions for non-payment under Attachment 4.19-A(3) (State-Owned Non-Acute Hospitals) of this State plan, where applicable.

X Wrong surgical or other invasive procedure performed on a patient; surgical or other invasive procedure performed on the wrong body part; surgical or other invasive procedure performed on the wrong patient

X Additional Other Provider-Preventable Conditions identified below For State-owned Non-Acute Hospitals operated by the Department of Public Health only, where applicable:

e The following Hospital Acquired Conditions as identified by Medicare, as they may be updated by CMS:

Foreign object retained after surgery. Air Embolism Blood incompatibility Stage III and IV Pressure Ulcers Falls and Trauma, related to:

e fractures

e dislocations

e intracranial injuries

WwaYno

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Attachment 4.19-A(3) Page 28 State Plan under Title XIX of the Social Security Act State: Massachusetts Methods Used to Determine Rates of Payment for Services in State-Owned Non-Acute Hospitals

¢ crushing injuries e burns e — other injuries 6. Manifestations of poor glycemic control, including: e diabetic ketoacidosis e nonketotic hyperosmolar coma e hypoglycemic coma ¢ secondary diabetes with hyperosmolarity —

e In addition, the following:

1. Intraoperative or immediately postoperative death ina ASA class 1 patient

2. Patient death or serious disability associated with the use of contaminated drugs, devices or biologics provided by the healthcare facility.

3. Patient death or serious disability associated with the use or function of a device in patient care, in which the device is used or functions other than as intended. .

4. Patient death or serious disability associated with patient elopement (disappearance)

5. Patient suicide or attempted suicide resulting in serions disability, while being cared for in a healthcare facility \ .

6. Patient death or serious disability associated with a medication error (e.g., errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation or wrong route of administration)

7. Maternal death or serious disability associated with labor or delivery in a low-risk pregnancy while being cared for in a healthcare facility.

8. Death or serious disability (kernicterys) associated with failure to identify and treat hyperbilirubinemia in neonates. .

9. Patient death or serious disability due to spinal manipulative therapy

10. Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a health care facility

11. Death or significant injury of a patient or staff member resulting from a physical assault (ie., battery) that occurs within or on the grounds of a healthcare facility

No reduction in payment for a provider preventable condition will be imposed on a provider when the condition defined as a PPC for a particular patient existed prior.to the initiation of treatment for that patient by that provider. :

Reductions in provider payment may be limited to the extent that the following apply: (i) The identified Provider preventable conditions would otherwise result in an increase in payment, (ii) The State can

reasonably isolate for noripayment the portion of the payment directly related to treatment for, and related to, the provider preventable condition. ‘ :

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Attachment 4.19-A(3) Page 29 State Plan under Title XIX of the Social Security Act State: Massachusetts Metheds Used to Determine Rates of Payment for Services in State-Owned Non-Acute Hospitals

A State plan must ensure that nonpayment for provider-preventable conditions does not prevent access to services for Medicaid beneficiaries.

Payment Method A. State-Owned Non-Acute Hospitals Operated by the Department of Mental Health

EOHHS will pay hospitals in accordance with the requirements of 42 CFR Part 447, Subpart A, and sections 1902(a)(4), 1902(a)(6) and 1903 with respect to non-payment for provider-preventable conditions, effective for dates of service on or after July 1, 2012.

For inpatient services, provider preventable conditions (“PPCs”) are defined as those conditions that are identified as Health Care-Acquired Conditions (“HCACs”) and Other Provider-Preventable Conditions (‘““OPPCs”) above. The OPPCs consist of the three National Coverage Determinations (the “NCDs”) that are listed above.

For outpatient services, provider preventable conditions (“PPCs”) are defined as those conditions that are identified as Other Provider-Preventable Conditions (“OPPCs”) above. The OPPCs consist of the three National Coverage Determinations (the “NCDs”) that are listed above.

When a hospital reports a PPC that the hospital indicates was not present on admission, MassHealth will reduce payments to the hospital by not paying for services which the hospital indicates are PPC-related, excluding PPC-related costs/services during any retrospective reconciliation, and excluding any PPC-related costs /services when determining future year payment rates that are calculated using a data source that would otherwise include the PPC.

The federal non-payment provision also applies to third-party liability and crossover payments by MassHealth.

Charges for services, including co-payments or deductibles, deemed non-billable to MassHealth are not billable to the member.

In the event that individual cases are identified throughout the PPC implementation period, the Commonwealth shall adjust reimbursements according to the methodology above.

B. State-Owned Non-Acute Hospitals Operated by the Department of Public Health

EOHHS will pay hospitals in accordance with the requirements of 42 CFR Part 447, Subpart A, and sections 1902(a)(4), 1902(a)(6) and 1903 with respect to non-payment for

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Attachment 4.19-A(3) Page 30 State Plan under Title XIX of the Social Security Act State: Massachusetts Methods Used to Determine Rates of Payment for Services in State-Owned Non-Acute Hospitals

provider-preventable conditions, effective for dates of service on or after July 1, 2012.

For inpatient services, provider preventable conditions (“PPCs”) are defined as those conditions that are identified as Health Care-Acquired Conditions (“HCACs”) and Other Provider-Preventable Conditions (“OPPCs”) above. The OPPCs include the three National Coverage Determinations (the “NCDs”) and the Additional Other Provider Preventable Conditions (“Additional OPPCs”) that are listed above.

For outpatient services, provider preventable conditions (“PPCs”) are defined as those conditions that are identified as Other Provider-Preventable Conditions (“OPPCs”) above. The OPPCs include the three National Coverage Determinations (the “NCDs”) and the Additional Other Provider Preventable Conditions (“Additional OPPCs”) that are listed above.

When a hospital reports a PPC that the hospital indicates was not present on admission, MassHealth will reduce payments to the hospital by not paying for services which the hospital indicates are PPC-related, excluding PPC-related costs/services during any retrospective reconciliation, and excluding any PPC-related costs/services when determining future year payment rates that are calculated using a data source that would otherwise include the PPC.

If a hospital reports that it provided follow-up services that were solely the result of a previous PPC (inpatient or outpatient) that occurred while the member was being cared for at a facility covered under the same hospital license, MassHealth will not pay for the reported follow-up services. If the hospital reports that non-PPC-related services were provided during the follow- up stay or visit, payment will be made, but MassHealth will exclude PPC-related costs/services during any retrospective reconciliation and will exclude any PPC-related costs /services when

determining future year payment rates that are calculated using a data source that would otherwise include the PPC.

The federal non-payment provision also applies to third-party liability and crossover payments by MassHealth. :

Charges for services, including co-payments and deductibles, deemed non-billable to MassHealth are not billable to the member.

In the event that individual cases are identified throughout the PPC implementation period, the commonwealth shall adjust reimbursements according to the methodology above.

XII. Serious Reportable Events for State-Owned Non-Acute Hospitals Operated by the Department of Public Health

The non-payment provisions set forth in this Section XII apply to the following serious reportable events (SREs) only for state-owned non-acute hospitals operated by the Department of Public Health, where applicable:

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1, Infant discharged to the wrong person.

2. Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances.

3. Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed health care provider.

4, Abduction of a patient of any age.

5. Sexual assault on a patient within or on the grounds of a healthcare facility.

Hospitals are prohibited from charging or seeking payment from MassHealth or the Member for Hospital services that are made necessary by, or are provided as a result of, a serious reportable event occurring on premises covered under the Hospital license that was preventable, within the Hospital’s control, and unambiguously the result of a system failure, as described in DPH regulations at 105 CMR 130.332 as in effect on the date of service. Non-reimbursable Hospital services include:

1. All services provided during the inpatient stay during which a preventable SRE occurred, from the date the SRE occurred through discharge, not to exceed 60 days; and

2. All services provided during the outpatient visit during which a preventable SRE occurred; and

3. All services provided during readmissions and follow-up outpatient visits as a result of a non-billable SRE provided:

a. ata facility under the same license as the Hospital at which a non-billable SRE occurred; or

b. on the premises of a separately licensed hospital with common ownership or a common corporate parent of the Hospital at which a non-billable SRE occurred.

4. Charges for services, including co-payments or deductibles, deemed non-billable to MassHealth are not billable to the Member.

Non-payment provisions also apply to third-party liability and crossover payments by MassHealth.

A Hospital not involved in the occurrence of a preventable SRE that also does not meet the criteria in number 3 above, and that provides inpatient or outpatient services to a patient who previously incurred an SRE may bill MassHealth for all medically necessary Hospital services provided to the patient following a preventable SRE.

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Attachment 4.19-A (1) Page 36

State Plan Under Title XIX of the Social Security Act

State: Massachusetts

Methods Used to Determine Rates of Payment for Acute Inpatient Hospital Services

VI. Provider Preventable Conditions

Citation Payment Adjustment for Provider Preventable Conditions

42 CFR 447,434,438 and

1902(a) (4), 1902 (a) (6) and 1903

The Medicaid agency meets the requirements of 42 CFR Part 447, Subpart A, and sections 1902 (a) (4), 1902 (a) (6) and 1903 with respect to non-payment for provider-preventable conditions.

Health Care-Acquired Conditions

The State identifies the following Health-Care Acquired Conditions for non- payment under Attachment 4.19-A(1), (Acute Inpatient Hospital Services) under this State plan.

&

Hospital Acquired Conditions as identified by Medicare other than Deep Vein Thrombosis (DVT)/ Pulmonary Embolism (PE) following total knee

replacement or hip replacement surgery in pediatric and obstetric patients.

Other Provider-Preventable Conditions

The State identifies the following Other Provider-Preventable Conditions for non-payment under Attachment 4.19-A(1), (Acute Inpatient Hospital Services) under this State plan.

&

Wrong surgical or othér invasive procedure performed on a patient; surgical or other invasive procedure performed on the wrong body part; surgical or other invasive procedure perforined on the wrong patient,

Additional Other Provider-Preventable Conditions identified below.

. Intraoperative or immediately postoperative death in a ASA class 1 patient

Patient death or serious disability associated with the use of contaminated drugs, devices or biologics provided by the healthcare facility.

Patient death or serious disability associated with the use or function of a device in patient care, in which the device is used or functions other than as intended.

Patient death or serious disability associated with patient. elopement (disappearance)

Patient suicide or attempted suicide resulting in serious disability, while being cared for in a healthcare facility

Patient death or serious disability associated with a medication error (e.g.,

" errors involving the wrong drug, wrong dose, wrong patient, wrong time,

wrong rate, wrong preparation or wrong route of administration) Maternal death or serious disability associated with labor or delivery in a low-risk pregnancy while being cared for in a healthcare facility.

TN: 011-012 Supersedes: New

JUN 12 202

Approval Date: Effective Date: 07/01/12

Attachment 4.19-A (1) Page 37 State Plan Under Title XIX of the Social Security Act State: Massachusetts Methods Used to Determine Rates of Payment for Acute Inpatient Hospital Services

8. Death or serious disability (kernicterus) associated with failure to identify and treat hyperbilirubinemia in neonates.

9. Patient death or serious disability due to spinal manipulative therapy

10. Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a health care facility

11. Death or significant injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs within or on the grounds of a healthcare facility

No reduction in payment for a provider preventable condition will be imposed on a provider when the condition defined as a PPC for a particular patient existed prior to the initiation of treatment for that patient by that provider.

Reduction in provider payment may be limited to the extent that the following apply: (i) the identified provider preventable conditions would otherwise result in an increase in payment; (ii) the State can reasonably isolate for nonpayment the portion of the payment directly related to treatment for, and related to, the provider preventable condition.

A State plan must ensure that nonpayment for provider-preventable conditions does not prevent access to services for Medicaid beneficiaries.

Payment Method:

EOHHS will pay hospitals in accordance with the requirements of 42 CFR Part 447, Subpart A, and sections 1902(a)(4), 1902(a)(6) and 1903 with respect to non-payment for provider-preventable conditions, effective for dates of service on or after July 1, 2012.

Provider preventable conditions (“PPCs”) are defined as those conditions that are identified as Health Care-Acquired Conditions (“HCACs”) and Other Provider-Preventable Conditions (“OPPCs”) listed above. The OPPCs include the three National Coverage Determinations (the “NCDs”) and the Additional Other Provider Preventable Conditions (“Additional OPPCs”) that are listed above.

When a Hospital reports a PPC that the Hospital indicates was not present ‘on admission, MassHealth will reduce payments to the Hospital as follows:

1. SPAD:

a. MassHealth will not pay the SPAD if the Hospital reports that only PPC-related services were delivered during the first 20 days of the inpatient admission, and will exclude all reported PPC-related costs/services when determining future year payment rates that are calculated using a data source that would otherwise include the PPC.

b. MassHealth will pay the SPAD if the Hospital reports that non-PPC related services were also delivered during the first 20 days of the inpatient admission, but will exclude all reported PPC-related costs/services when determining future year payment rates that are calculated using a data source that would otherwise include the PPC.

TN: 011-012 . Supersedes: New Approval Date: JUN 19 2012 Effective Date: 07/01/12

Attachment 4.19-A (1) Page 38 State Plan Under Title XIX of the Social Security Act State: Massachusetts Methods Used to Determine Rates of Payment for Acute Inpatient Hospital Services

2. Psychiatric, Rehabilitation, Administrative Day , Outlier or Transfer Per Diem payments:

a. MassHealth will not pay the per diem if the Hospital reports that only PPC-related services were delivered on that day, and will exclude all reported PPC-related costs/services when determining future year payment rates that are calculated using a data source that would otherwise include the PPC.

b. MassHealth will pay the per diem if the Hospital reports that non-PPC related services

. were also delivered on that day, but will exclude all reported PPC-related costs/services when determining future year payment rates that are calculated using a data source that would otherwise include the PPC.

3. Inpatient Hospital payments for Hospital-Based Physician Services: MassHealth will not pay for inpatient Hospital-based physician services reported as PPC-related services.

4. Follow-up Care in Same Hospital: If a hospital reports that it provided follow-up inpatient hospital services that were solely the result of a previous PPC (inpatient or outpatient) that occurred while the member was being cared for at a facility covered under the same hospital license, MassHealth will not pay for the reported follow-up services. If the Hospital reports that non-PPC-related services were provided during the follow-up stay, payment will be made, but MassHealth will exclude all reported PPC-related costs/services when determining future year payment rates that are calculated using a data source that would otherwise include the PPC.

The federal non-payment provision also applies to third-party liability and crossover payments by MassHealth.

Charges for service, including co-payments or deductibles, deemed non-billable to MassHealth are not billable to the member.

In the event that individual cases are identified throughout the PPC implementation period, the Commonwealth shall adjust reimbursement according to the methodology above.

VU. Serious Reportable Events

This Section VII supersedes in its entirety Section IV.C., above, effective for dates of service on or after July 1, 2012. Effective for dates of service on or after July 1, 2012, the non-payment provisions set forth in this Section VII apply to the following serious reportable events (SREs):

1. Infant discharged to the wrong person

2. Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances

3. Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed health care provider.

4. Abduction of a patient of any age.

5. Sexual assault on a patient within or on the grounds of the healthcare facility.

TN: 011-012 . Supersedes: New Approval Date: JUN 1 2 2012 Effective Date: 07/01/12

Attachment 4.19-A (1)

Page 39 . State Plan Under Title XIX of the Social Security Act State: Massachusetts Methods Used to Determine Rates of Payment for Acute Inpatient Hospital Services

Hospitals are prohibited from charging or seeking payment from MassHealth or the Member for Hospital and Hospital-Based Physician services that are made necessary by, or are provided as a result of, a serious reportable event occurring on premises covered under the Hospital license that was preventable, within the Hospital’s control, and unambiguously the result of a system failure, as described in DPH regulations at 105 CMR 130.332 as in effect on the date of service. Non-reimbursable Hospital and Hospital-Based Physician services include:

1. All services provided during the inpatient admission during which a preventable SRE occurred; and

2. All services provided during readmissions and follow-up outpatient visits as a result of a non- billable SRE provided:

a. ata facility under the same license as the Hospital at which a non-billable SRE occurred; or

b. on the premises of a separately licensed hospital with common ownership or a common corporate parent of the Hospital at which a non-billable SRE occurred.

3. Charges for services, including co-payments or deductibles, deemed non-billable to MassHealth are not billable to the Member.

The non-payment provision also applies to third-party liability and crossover payments by MassHealth.

A Hospital not involved in the occurrence of a preventable SRE that also does not meet the criteria in number 2 above, and that provides inpatient or outpatient services to a patient who previously incurred an SRE may bill MassHealth for all medically necessary Hospital and Hospital-Based Physician services provided to the patient following a preventable SRE.

TN: 011-012 Supersedes: New Approval Date: JUN 1 2 2012 Effective Date: 07/01/12

Table of Contents State/Territory Name: Massachusetts State Plan Amendment (SPA) #: 13-009 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved SPA Pages

/s/

/s/ /s/

Revision: HCFA-PM-91-4 (BPD) Attachment 2.2-A August 1991 Page lla State Plan under Title XIX of the Social Security Act OMB NO.: 0938- State: Massachusetts Groups Covered and Agencies Responsible for Eligibility Determinations

OFFICIAL

Citation(s) B. Optional Groups Other Than the Medically Needy (cont.) 1902 (a) (10) 5. Individuals who would be eligible for Medicaid under the plan if (A) (ii) VID they were in a medical institution, who are terminally ill, and who of the Act receive hospice care in accordance with a voluntary election described in Section 1905 (0) of the act. O The state covers all individuals as described above. The state covers only the following group or groups of individuals: Aged Blind Disabled Individuals under the age of — 21% oO 20 Oo 19 oO 18 Caretaker relatives Pregnant women * Prior to 12/31/13, applies to children under the age of 18. TN: 013-009 Approval Date: 3/27/14 Effective Date: 12/31/13

Supersedes: 96-020 HCEA ID: 7983E

Page 11b

State Plan under Title XIX of the Social Security Act

State: Massachusetts Section 2 Coverage and Eligibility OFFI CLAL ws Bw _

Citation(s)

1902 (e) (13) of 2.1 Application, Determination of Eligibility and Furnishing Medicaid the Act

(e) Express Lane Option. The Medicaid State agency elects the option to rely on the finding from an Express Lane agency when determining whether a child satisfies one or more components of Medicaid eligibility. The Medicaid State agency agrees to meet all of the Federal statutory and regulatory requirements for this option. This authority may not apply to eligibility determinations made before February 4, 2009, or after September 30, 2013.

(1) The Express Lane Option is applied to: O Initial determinations Redeterminations

O Both

(2) A child is defined as younger than age:

O19 O 20 x21

(3) The following public agencies are approved by the Medicaid State agency as Express Lane agencies:

The Massachusetts Department of Transitional Assistance in the administration of the Supplemental Nutrition Assistance Program (SNAP).

TN: 013-009 Approval Date: 3/27/14 Effective Date: 12/31/13 Supersedes: 012-001

Revision: HCFA-PM-91-4 (BPD) Attachment 2.2-A August 1991 Page 12 State Plan under Title XIX of the Social Security Act OMB NO.: 0938-

State: Massachusetts J Groups Covered and Agencies Responsible for Eligibility Determinations ADT CT A

Citation(s)

B. Optional Groups Other Than the Medically Needy (cont.)

42 CFR 435.220 O 6. Individuals who would be eligible for AFDC if their work-related child care costs were paid from earnings rather than by a state agency as a service expenditure. The state’s AFDC plan deducts work-related child care costs from income to determine the amount of AFDC.

O The state covers all individuals as described above.

1902 (a) (10) (A) O The state covers only the following group or groups of individuals:

(ii) and 1905 (a)

of the Act O Individuals under the age of —

O 21

oO 20

Oo 19

oO 18 O Caretaker relatives Os Pregnant women

42 CFR 435.222 7. a. All individuals who are not described in Section 1902

1902 (a) (10)(A) (4i)(D); (a) (10) (A) (i) of the Act, who meet the income and

1902(a) (10) (A) (ai) (IV) resource requirements of the AFDC State Plan, and

and 1905 (a) (i) of who are under the age of:

the Act

21* Oo 20 oO 19 Oo 18. * Prior to 12/31/13, applies to children under age 18 TN: 013-009 Approval Date: 3/27/14 Effective Date: 12/31/13

Supersedes: 91-021 HCFA ID: 7983E

Revision: HCFA-PM-91-4 (BPD) Attachment 2.2-A August 1991 Page 25 State Plan under Title XIX of the Social Security Act OMB NO.: 0938- State: Massachusetts Groups Covered and Agencies Responsible for Eligibility Determinations

OPETELAT

waa —

Citation(s) C. Optional Coverage of the Medically Needy (cont.)

1902 (e) (4) of 4, Newborn children born on or after October 1, 1984 to a woman who is

the Act eligible as medically needy and is receiving Medicaid on the date of the child’s birth. The child is deemed to have applied and been found eligible for Medicaid on the date of birth and remains eligible for one year so long as the woman remains or if pregnant would remain eligible and the child is a member of the woman’s household.

42 CFR 435.308 5. a. Financially eligible individuals who are not described in Section C.3. above and who are under the age of — 2i* O 20 oO 19 O18 or under age 19 who are full-time students in a

secondary school or in the equivalent level of vocational or technical training

Ob. Reasonable classifications of financially eligible individuals under the ages of 21, 20, 19, or 18 as specified below:

O (1) Individuals for whom public agencies are assuming full or partial financial responsibility and who are:

O(a) In foster homes (and are under the age of ).

O (b)_ Imprivate institutions (and are under the age of

).

* Prior to 12/31/13, applies to children under the age of 18.

TN: 013-009 Approval Date: 3/27/14 Effective Date: 12/31/13 Supersedes: 91-021

Revision: _HCFA-PM-91- (BPD) Supplement 8a to Attachment 2.6-A 1991 Page 2 OMB No.: 0938

State Plan under Title XIX of the Social Security Act

State: Massachusetts OEET CIAL ct

Less Restrictive Methods of Treating Income under Section 1902 (r) (2) ofthe

For children who have attained one year of age but have not attained 6 years of age eligible at 133 percent of the Federal poverty level (FPL) under §1902(a)(10)(A)(i)(VI) and 1902(D(D(C)of the Social Security Act (the Act):

Disregard income between 133 percent and 150 percent of the FPL for the family size involved as revised annually in the Federal Register.

For children born after September 30, 1983, who have attained 6 years of age but have not attained 19 years of age eligible at 100 percent of the FPL under §1902(a)(10)(A)(i)(VID and 1902(1)(1)(D)of the Act:

Disregard income between 100 percent and 150 percent of the FPL for the family size involved as revised annually in the Federal Register.

For optional reasonable classifications of children under age 21 covered under 42 CFR 435.222, §1902(a)(10)(A)(ii)(D, and §1902(a)(10)(A)(ii)(IV):

Disregard income between the state’s AFDC payment standard as of 7/16/1996 (as specified on Supplement 1 to Attachment 2.6-A page 1) and 150 percent of the FPL using gross income for the family size involved as revised annually in the Federal Register

TN: 013-009 Approval Date: 3/27/14 Effective Date: 12/31/13 Supersedes: 011-001

Table of Contents

State/Territory Name: Massachusetts State Plan Amendment (SPA) #: 13-0018-MM5 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Superseding Pages Notice 4) Approved SPA Pages

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

JFK Federal Building, Government Center

Room 2275

Boston, Massachusetts 02203

CMS

CENTERS FOR MEDICARE & MEDICAID SERVICES

Division of Medicaid and Children’s Health Operations / Boston Regional Office

May 30, 2014

John Polanowicz, Secretary

Executive Office of Health and Human Services One Ashburton Place, Room 1109

Boston, Massachusetts 02108

Dear Mr. Polanowicz:

We are pleased to enclose a copy of approved Massachusetts State Plan Amendment (SPA) No. 13-0018-MM5 submitted to my office on October 17, 2013. This SPA was submitted to revise your approved Title XIX State plan to affirm the residency regulations under the Affordable Care Act. This SPA has been approved effective January 1, 2014.

Enclosed are copies of the following State plan pages and attachments to be incorporated within a separate section at the end of your approved State plan.

e $88 — Non-Financial Eligibility — State Residency, pages 1-4; and e MA S88 Superseding Pages Document.

If you have any questions regarding this matter you may contact Julie McCarthy at (617) 565- 1244 or by e-mail at Julie. McCarthy@cms.hhs.gov.

Sincerely,

/s/

Richard R. McGreal Associate Regional Administrator

Enclosure/s

ce: Kristin Thorn, Medicaid Director Michael Coleman, State Plan Coordinator

/s/

SUPERSEDING PAGES OF

STATE PLAN MATERIAL TRANSMITTAL NUMBER: STATE: MA-13-0018MM5 Masssachusetts PAGE NUMBER OF THE PLAN SECTION OR PAGE NUMBER OF THE SUPERSEDED PLAN SECTION ATTACHMENT: OR ATTACHMENT (If Applicable): S88 Non-Financial Eligibility- State Residency Section 2.3, Page 13, TN 87-7 Attachment 2.6-A: Page 3, Item 4, TN 91-21

TN 13-0018-MM5 Superseding Pages Document Approval Date: 05/30/2014 Massachusetts Page 1 of 1 Effective Date: 01/01/2014

Medicaid Eligibility

OFFICIAL OMB Control Number 0938-1148

OMB Expiration date: 10/31/2014

Non-Financial Eligibility 588 State Residency 42 CFR 435.403

State Residency

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

Individuals are considered to be residents of the state under the following conditions:

oh Non-institutionalized individuals age 21 and over, or under age 21, capable of indicating intent and who are emancipated or married, if the individual is living in the state and:

f= Intends to reside in the state, including without a fixed address, or (@] Entered the state with a job commitment or seeking employment, whether or not currently employed.

my Individuals age 21 and over, not living in an institution, who are not capable of indicating intent, are residents of the state in which they live.

[@] Non-institutionalized individuals under 21 not described above and non IV-E beneficiary children: {@] Residing in the state, with or without a fixed address, or

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

im Individuals living in institutions, as defined in 42 CFR 435.1010, including foster care homes, who became incapable of indicating intent before age 21 and individuals under age 21 who are not emancipated or married:

im Regardless of which state the individual resides, if the parent or guardian applying for Medicaid on the individual's behalf resides in the state, or

im Regardless of which state the individual resides, if the parent or guardian resides in the state at the time of the individual's placement, or

If the individual applying for Medicaid on the individual's behalf resides in the state and the parental rights of the [@] institutionalized individual's parent(s) were terminated and no guardian has been appointed and the individual is institutionalized in the state.

i Individuals living in institutions who became incapable of indicating intent at or after age 21, if physically present in the state, unless another state made the placement.

[@] Individuals who have been placed in an out-of-state institution, including foster care homes, by an agency of the state.

im Any other institutionalized individual age 21 or over when living in the state with the intent to reside there, and not placed in the institution by another state.

{@] IV-E eligible children living in the state, or

TN 13-0018-MM5 S88 Approval Date: 05/30/2014 Massachusetts Page 1 of 4 Effective Date: 01/01/2014

Cems Medicaid Eligibility

PES YOM AESCARE A AAOMCAND SHEET

[B] Otherwise meet the requirements of 42 CFR 435.403.

OFFICIAL

TN 13-0018-MM5 S88 Approval Date: 05/30/2014 Massachusetts Page 2 of 4 Effective Date: 01/01/2014

Medicaid Eligibility

OFFICIAL

Meet the criteria specified in an interstate agreement. @ Yes (© No

[m] The state has interstate agreements with the following selected states:

XX] Alabama Illinois x] Montana [X] Rhode Island Xx] Alaska [X] Indiana [X<] Nebraska {<] South Carolina Arizona lowa Nevada >] South Dakota ><] Arkansas [X] Kansas >X] New Hampshire [X] Tennessee DX] California [X] Kentucky New Jersey Texas Colorado KX] Louisiana New Mexico Utah

XX] Connecticut x] Maine (1) New York {| Vermont

XX] Delaware KX] Maryland [X] North Carolina Virginia District of Columbia (1) Massachusetts X] North Dakota [X] Washington Florida Michigan | Ohio XX] West Virginia [><] Georgia [><] Minnesota Oklahoma {X<] Wisconsin ><] Hawaii [DX] Mississippi X] Oregon [ Wyoming KX] Idaho [X] Missouri [Xx] Pennsylvania

ml The interstate agreement contains a procedure for providing Medicaid to individuals pending resolution of their residency status and criteria for resolving disputed residency of individuals who (select all that apply):

Are IV-E eligible

LJ Are in the state only for the purpose of attending school

(J) Are out of the state only for the purpose of attending school (J) Retain addresses in both states

Other type of individual

TN 13-0018-MM5 S88 Approval Date: 05/30/2014 Massachusetts Page 3 of 4 Effective Date: 01/01/2014

Medicaid Eligibility OFFICIAL

Name of Type Description IV-E Individuals: New York- [CAMA New York is an associate member of ICAMA. As an associate member they have agreed to abide by the process. + Their agreement is considered a contract with the ICAMA x member states rather than a contract. They agree to provide

Medicaid for Title IV-E eligible children pending the resolution of their state residency.

IV-E Individuals: Wyoming- ICAMA Massachusetts does not have any agreement with Wyoming. + However, according to the American Public Human Services x Association (APHSA), Wyoming abides by the processes

and procedures of the ICAMA.

The state has a policy related to individuals in the state only to attend school. C Yes @ No [@] Otherwise meet the criteria of resident, but who may be temporarily absent from the state.

The state has a definition of temporary absence, including treatment of individuals who attend school in another state.

C Yes @ 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 40 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.

TN 13-0018-MM5 S88 Approval Date: 05/30/2014 Massachusetts Page 4 of 4 Effective Date: 01/01/2014

Table of Contents

State/Territory Name: Massachusetts State Plan Amendment (SPA) #: 13-0027-MM2 This file contains the following documents in the order listed: 1) Approval Letter 2) Additional Companion letter 3) CMS 179 Form/Summary Form (with 179-like data) 4) Superseding Pages Notice 5) Approved SPA Pages 6) Additional Attachments that are part of the state plan

/s/

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services JFK Federal Building, Government Center Room 2275 Boston, Massachusetts 02203

Division of Medicaid and Children’s Health Operations / Boston Regional Office

March 26, 2014

John Polanowicz, Secretary Executive Office of Health and Human Services One Ashburton Place, Room 1109 Boston, Massachusetts 02108

RE: S-94 – Eligibility Process State Plan Amendment (SPA) MA 13-0027-MM2

Dear Mr. Polanowicz:

Enclosed is an approved copy of Massachusetts’ state plan amendment (SPA) MA-13-0027- MM2, which was submitted to CMS on December 30, 2013. SPA MA-13-0027-MM2 incorporates the MAGI-based eligibility process requirements, including the single streamlined application, into Massachusetts’ Medicaid state plan in accordance with the Affordable Care Act. The effective date of this SPA is October 1, 2013.

The approval of SPA MA-13-0027-MM2 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 S94 state plan pages and attachments to be incorporated within a separate section at the end of Massachusetts’ approved state plan:

• S94, pages S94-1 and S94-2 • Attachment 1 – State of Massachusetts’ alternative single streamlined paper application • Attachment 2 – Statement of use with respect to the alternative single streamlined online application

In addition, enclosed is a summary of state plan pages which are superseded by SPA MA-13- 0027-MM2, which should also be incorporated into a separate section in the front of the state plan.

• Superseding Pages of State Plan Material, MA-13-0027-MM2

Page 2 – Secretary Polanowicz

SPA 13-0027-MM2

CMS appreciates the significant amount of work your staff dedicated to preparing this state plan amendment. If you have any questions concerning this SPA, please contact Julie McCarthy at Julie.McCarthy@cms.hhs.gov or (617) 565-1244.

Sincerely,

/s/

Richard R. McGreal Associate Regional Administrator Division of Medicaid & Children’s Health Operations

Enclosure/s

cc: Kristin Thorn, Medicaid Director

Michael Coleman, State Plan Coordinator

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services JFK Federal Building, Government Center Room 2275 Boston, Massachusetts 02203

Division of Medicaid and Children’s Health Operations / Boston Regional Office

March 26, 2014

John Polanowicz, Secretary Executive Office of Health and Human Services One Ashburton Place, Room 1109 Boston, Massachusetts 02108

RE: S-94 – Eligibility Process State Plan Amendment (SPA) MA 13-0027-MM2

Dear Mr. Polanowicz:

This letter is being sent as a companion to Centers for Medicare & Medicaid Services (CMS) approval of state plan amendment (SPA) transmittal MA 13-0027-MM2. CMS is granting approval for Form S94 – Eligibility Process MA 13-0027-MM2, which was submitted to CMS on December 30, 2013. Our review of this submission included a review of the online alternative single streamlined 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 conditions will only be asked of applicants. December 31, 2014 Questions on access to employer-sponsored coverage, when needed for APTC eligibility, will ask about the premium amount of the lowest-cost option offered by the employer. December 31, 2014

Please submit the revised alternative single streamlined online application to CMS for review no later than December 1, 2014 to ensure approval by December 31, 2014. We continue to be available to provide technical assistance.

Page 2 – Secretary Polanowicz

Companion Letter to SPA 13-0027-MM2

If you have any questions about your application, please contact Dena Greenblum at Dena.Greenblum@cms.hhs.gov or (410) 786-8684. If you have any additional questions or require any further assistance, please contact Julie McCarthy at Julie.McCarthy@cms.hhs.gov or (617) 565-1244.

Sincerely,

/s/

Richard R. McGreal Associate Regional Administrator Division of Medicaid & Children’s Health Operations

Enclosure/s

cc: Kristin Thorn, Medicaid Director

Michael Coleman, State Plan Coordinator

Medicaid State Plan Eligibility: Summary Page (CMS 179) State/Territory name: Massachusetts 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. Proposed Effective Date (mm/dd/yyyy) Federal Statute/Regulation Citation Federal Budget Impact Federal Fiscal Year Amount First Year $ Second Year $ Subject of Amendment Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Signature of State Agency Official Submitted By: Alison Kirchgasser Last Revision Date: Mar 24, 2014 Submit Date: Dec 30, 2013 DATE RECEIVED: 12/30/2013 EFFECTIVE DATE OF APPROVED MATERIAL: 10/01/2013 TYPED NAME: Richard R. McGreal PLAN APPROVED – ONE COPY ATTACHED DATE APPROVED: 03/26/2014

SIGNATURE OF REGIONAL OFFICIAL:

/s/

TITLE: Associate Regional Administrator, Division of Medicaid & Children’s Health Operations Boston Regional Office MA-13-0027 10/01/2013 42 CFR 435, Subpart J and Subpart M 2014 0.00 2015 0.00 MA, through this amendment, seeks approval for its alternative single streamlined app. for all insurance affordability programs in MA. This app. 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. The online app. materials enclosed reflect the system as of 10/1/13. To facilitate review we are including a list of systems tickets that reflect the changes being made. The online application gap analysis highlights the differences between the MA’s 10/1 online app. and the CMS 4/29/13 model app. The paper app. materials enclosed are the 10/1/13 and 1/1/14 versions. The paper app. gap analysis highlights the differences between MA’s 1/1 version and the CMS 4/29/13 model app. MA will be in compliance with the requirement at 42 CFR 435.916 to provide members with a pre-populated renewal form containing the information already available as soon as the HIX/IES has the functionality to do so. This is expected to occur for renewals beginning between 4/1/14- 7/1/14. Until this functionality is available within HIX/IES, members will be selected for review on the date of their annual anniversary and they will have 45 days to respond, if the member’s financial eligibility is based on MAGI. The f ill b l d hi i i di d b b ill ll i f i d d f b d i li ibili MA h d l d i i i f f i 2014 ll i f i d d f b k MAGI b d li ibili d i i f h fi i MA h h d Not required under 42 CFR 423.0129(b)(2)(ii)

SUPERSEDING PAGES OF

STATE PLAN MATERIAL TRANSMITTAL NUMBER: STATE: MA-13-0027-MM2 Massachusetts

PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

$94 — Eligibility Process

PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable):

Section 2.1(a), page 10, TN 91-21 Effective 10/01/1991, Approved 06/22/1992

Section 2.1(d), page 11a, TN 91-17 Effective 07/01/1991, Approved 12/02/1991

TN 13-0027-MM2 Massachusetts

Superseding Pages Document Approval Date: 03/26/2014 Page 1 of 1 Effective Date: 10/01/2013

OFFICIAL Medicaid Eligibility

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

42 CFR 435, Subpart J and Subpart M

Eligibility Process

The state meets all the requirements of 42 CFR 435, Subpart J for processing applications, determining and verifying eligibility, and furnishing Medicaid.

Application Processing

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

Oo The single, streamlined application for all insurance affordability programs, developed by the Secretary in accordance with section 1413(b)(1)(A) of the Affordable Care Act

An alternative single, streamlined application developed by the state in accordance with section 1413(b)(1)(B) of the

Affordable Care Act and approved by the Secretary, which may be no more burdensome than the streamlined application developed by the Secretary.

An attachment is submitted.

An alternative application used to apply for multiple human service programs approved by the Secretary, provided that the [1] agency makes readily available the single or alternative application used only for insurance affordability programs to individuals seeking assistance only through such programs.

Indicate which application the agency uses for individuals applying for coverage who may be eligible on a basis other than the applicable modified adjusted gross income standard:

The single, streamlined application developed by the Secretary or one of the alternate forms developed by the state and

(CZ approved by the Secretary, and supplemental forms to collect additional information needed to determine eligibility on such other basis, submitted to the Secretary.

An application designed specifically to determine eligibility on a basis other than the applicable MAGI standard which “~ minimizes the burden on applicants, submitted to the Secretary.

An attachment is submitted.

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 42 CFR 435.1200(f), by telephone, via mail, and in person.

The agency also accepts applications by other electronic means:

@ Yes € No

Page 1 of 2

TN 13-0027-MM2 $94-1

Approval Date: 03/26/2014 Massachusetts

Effective Date: 10/01/2013

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Medicaid Eligibility

Indicate the other electronic means below:

Name of Method Description

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

The agency has procedures to take applications, assist applicants and perform initial processing of applications for the eligibility groups listed below at locations other than those used for the receipt and processing of applications for the title 1V-A program, including Federally-qualified health centers and disproportionate share hospitals.

Parents and Other Caretaker Relatives

Pregnant Women

Infants and Children under Age 19 Redetermination Processing

Redeterminations 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 435.916:

[Ml Once every 12 months

ml 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 [Mj] information to complete the redetermination, it provides the individual with a pre-populated renewal form containing the information already available.

rl Redeterminations of eligibility for individuals whose financial eligibility is not based on the applicable modified adjusted gross income standard are performed, consistent with 42 CFR 435.916 (check all that apply):

Once every 12 months

(FJ Once every 6 months

(1) Other, more often than once every 12 months Coordination of Eligibility and Enrollment

The state meets all the requirements of 42 CFR 435, Subpart M relative to coordination of eligibility and enrollment between Medicaid, CHIP, Exchanges and other insurance affordability programs. The single state agency has entered into agreements with the Exchange and with other agencies administering insurance affordability programs.

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 40 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.

Page 2 of 2

TN 13-0027-MM2 $94-2 Approval Date: 03/26/2014 Massachusetts Effective Date: 10/01/2013

OFFICIAL

HEALTH

Application for Health Coverage ( me assacwuserrs s

*) and Help Paying Costs Instruction

CONNECTOR

Commonwealth of Massachusetts | EQHHS .

Please read these instructions before you fill out the application.

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.

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 are 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)

over >

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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.

To help us see if you are eligible:

* fill out the application completely,

* be sure 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 (TTY: 1-800-497-4648

for people who are deaf, hard of hearing,

or speech disabled).

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Application for Health Coverage ( me aszacsusstrs

. HEALTH ; and Help Paying Costs CONNECTOR Commonwealth of Massachusetts | EQHHS

Please print clearly. Be sure to answer all questions. Fill out all parts of the application and all supplements that apply. If you 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).

7. ai ee! 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)

[JYes [_]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

(JM CIF

We need a 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. Doyou have a social security number (SSN)? [Yes [__]No If yes, 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 {_]Not eligible to get SSN [_] Eligible for SSN, but have not applied 12. Willyou file a federal income tax return next year? [_]Yes [_JNo (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: (If 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 If yes, 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? 13. Are you pregnant? [__]Yes [_]No 13.a.{f yes, how many children are you expecting? 13.b. What is the due date? (mm/dd/yyyy) 1 Please go to the next page. >

ACA-2 (Rev. 01/14)

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14. Are you applying for health coverage for yourself? [_ ]Yes [JNo

If no, 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. if yes, are you the main person taking care of this child? [_]Yes [_]No 17. Areyou in jail or prison? [_]Yes [_]No If no, go to the next question. T7a. If yes, are you (Check one.): [_]Convicted? What is your expected release date? (mm/dd/yyyy) {_]Not convicted? (For example: confined only) 18. Did you age out of foster care at the age of 18 or older? [_ Yes L] No if yes, were you enrolled in Medicaid when you 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. Are you a U.S. citizen, national, or naturalized U.S. citizen? [ _]Yes [__]No If yes, go to Question 20. 19.a. Ifnno, do you have an eligible immigration status? (See the Member Booklet for more information.) [\"es CE] 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.b. 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? [_]¥es [_]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.f. Are you a spouse or unremarried surviving spouse of an immigrant who is an honorably discharged veteran or an active-duty member of the 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, illness, or disability (including a disabling mental health condition) that has lasted or is expected to last for at least 12 months?

({f legally blind, answer yes.) [_]Yes [_]No Ifo, 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? [JYes [_]No

Ifno, 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

If no, go to the next question. If yes, fill out Part C of Supplement A: Iliness, 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? [Wes [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? [__]live with a spouse? [_]live in arest home? [_Tlive and share expenses with another or others (not a spouse)? [__Jlivein an assisted living facility? [_]live in someone else's home? 26. Check the box below that best describes you. (Optional) [_]American 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 you 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.

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

City State Zip code 3. Is Person 2 homeless? 4, Mailing address (if different from home address)

{es []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

Cl (IF 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 have a social security number (SSN)? [_]Yes [_]No

If yes, 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 [_]Not eligible 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 If yes, name of spouse:_, (If 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

If yes, name of tax filer: How is Person 2 related to the tax filer? 13. Is 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. If yes, is Person 2 the main person taking care of this child? [_]Yes [_]No 17. IsPerson 2 in ail or prison? [_]Yes [_]No If no, go to the next question. T7a. If yes, is Person 2 (Check one.): []Convicted? What is his or her expected release date? (mm/dd/yy) [_ Not convicted? (For example: confined only) 18. Did Person 2 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 [_]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. ls 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 [No Tesponse

Ifno 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. Ifyes, 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. 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 if 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? ["]¥es [_]No

194. ls Person 2a 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) 4 Please go to the next page. >

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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 U.S. 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. if yes, fill out Part B of Supplement A: Illness, 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 page 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. If no, 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. ; If no, go to the next question. If yes, Person 2 will need to give us proof of his or her HIV-positive status. Then MassHealth 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.a. and 25.b.

25.a. When did Person 2 last get SSI? (mm/yyyy) 25.b. Does Person 2 (Please check one.): [_ live alone? [_ live with a spouse? [__]live ina rest home? [live and share expenses with another or others (not a spouse)? [__]live in an assisted living facility? [_]live in someone else's home?

26. Check the box below that best describes Person 2. (Optional) [_JAmerican Indian/Alaska Native (Mashpee Wampanoag) [_]American Indian/Alaska Native (Wampanoag Tribe of Gay Head (Aquinnah)) (_]American Indian/Alaska Native (Other Tribal Nation) [_]Asian [_]Black or African American [_]Hispanic/Latino/Black [_Jkispanic/Latino/White [_]Hispanic/Latino/Other [_]Native Hawaiian or other Pacific Islander [_]White [_]Other

27. If Person 2 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.

Person 3 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 3. Is Person 3 homeless? 4, Mailing address (if different from home address) [Wes [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

CJm CIF 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 If yes, 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 [_]Not eligible to get SSN [__] 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.c. 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 jointly 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 Ifyes, 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 {f no, 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? [_]Yes [_]No 16.a.|f yes, is Person 3 the main person taking care of this child? [_]Yes [_]No 17. IsPerson 3 in jail or prison? [_]Yes [_]No If no, go to the next question. T7a. If yes, is Person 3 (Check one.): [_ Convicted? 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? [ves CL] No

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

“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.a U.S. citizen, national, or naturalized U.S. citizen? [_]Yes [_]No If yes, go to Question 20. 19.2. If no, does Person 3 have an eligible immigration status? (See the Member Booklet for more information.) [_]yes | No []No response

if no or no response, Person 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 Health Safety Net (HSN). Go to Question 20.

19.b. If yes, does Person 3 have an immigration document? [_]Yes [_]No

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 ID 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.e.Is Person 3 an honorably discharged veteran or an active-duty member of the U.S. military? [_]Yes [—]No 19, ls Person 3 a spouse or unremarried surviving spouse of an immigrant who is an honorably discharged veteran or an active-duty member of the U.S. military? [—]Yes [_]No 19.g. Is Person 3 an unmarried dependent child of an immigrant who is an honorably discharged veteran or an active-duty member ofthe U.S. military? [_]Yes [_]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. Is Person 3 HIV positive? [ ]Yes [_]No (Optional) If Person 3 is HIV positive, he or she may he 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.): [__|live alone? [_Jlive with a spouse? [_]live ina rest home? [live and share expenses with another or others (not a spouse)? [_] live 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)) {_]American Indian/Alaska Native (Other Tribal Nation) [_]Asian [_]Black or African American (_]Hispanic/Latino/Black [_Jispanic/Latino/White [_]Hispanic/Latino/Other [__]Native Hawaiian or other Pacific Islander [_]White [_]Other 27. If Person 3 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.

If you 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. ls Person 4 homeless? 4. Mailing address (if different from home address)

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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 CJM (JF

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) If no, check one of the reasons below.

[_JApplied, but have not received SSN [__]Religious exemption [_] Only eligible for nonwork SSN [_INot eligible to get 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. Ifno, answer 12.c. 12.a. Will Person 4 file jointly with aspouse? [_]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

If yes, name of tax filer: How is Person 4 related to the tax filer? 1B. IsPerson 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 fno, go to Part 3: Current Job and Income Information on page 10. If yes, answer all questions below for Person 4. 15. |s 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, Is Person 4 injail or prison? [_]Yes [_]No If no, go to the next question. T7a. If yes, is Person 4 (Check one.): {_]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 U.S. citizen? [_]Yes [_]No If yes, go to Question 20. 19.a. Ifno, does Person 4 have an eligible immigration status? (See the Member Booklet for more information.) [les CE] 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 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 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 [[JNo If yes, what is it?

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

19.e. Is Person 4 an honorably discharged veteran or an active-duty member of the U.S. military? [—]Yes [_]No 19. Is Person 4 a spouse or unremarried surviving spouse of an immigrant who is an honorably discharged veteran or an active-duty member of the U.S. military? [_]Yes [—]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, 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 4 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 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? [_]livewithaspouse? [_]live ina rest home? [_Jlive and share expenses with another or others (not a spouse)? [live in an assisted living facility? [_]live in someone else's home? 26. Check the box below that best describes Person 4. (Optional) [_]American Indian/Alaska Native (Mashpee Wampanoag) [_JAmerican Indian/Alaska Native (Wampanoag Tribe of Gay Head (Aquinnah)) [american Indian/Alaska Native (Other Tribal Nation) [_]Asian [__]Black or African American [_}Hispanic/Latino/Black [_]ispanic/Latino/White [_]Hispanic/Latino/Other [_]Native Hawalian 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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7:\; gece 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.)

[_JEmployed (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 Identification Number (EIN—if you know)

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

If yes, check one. [This job offers health insurance now.

[This job will offer health insurance, starting (mm/dd/yyyy). 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)? [_}¥es 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 a 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.) 3.b. What health insurance changes will this job make for the next year? (if you know) [_TThis 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 amonth [—]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 2 weeks [_]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. \fyour 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 [_JApr [_]May [C]June [July [_JAug [_]Sept [Joct [_]Nov [_]Dec

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Self-employed Income

8.a.(Check one.) [_]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 (Ifnone, 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

If yes, check one. [_IThis 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 dependents)? [Wes 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 [| early + 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.) 10.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. + Howmuch 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)

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. Is this job a sheltered workshop? [_]¥es [__]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. If 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 []Mar [_JApr [_JMay [_]June [[]July [JAug [_]Sept [JOct [Nov [_]Dec

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Self-employed Income 15.a.(Check one.) [_]Partnership [_]$-Corporation [_]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? [_JOrdinary or qualified dividend $ How often? [Pension $ How often? L_Itusts $ How often? LJannuity $ How often? [interest $ How often? [Social Security $ How often? [Net farming/fishing $ How often? [_]Netrentalincome $ How often? [Royalty $ How often? [Jcapital gains $ How often? [_JAlimony received $ How often? {]Gambling proceeds $ How often? [“Jlax-excluded foreign income $ How often? [Taxable military retirement pay (not paid through the Veterans’ Administration) $ How often?

{_JTax refund, credit, or offset of state or local income taxes $ How often?

[_Jother income (Specify:) $ How often?

Deductions allowed on federal tax return Allor 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. {_]Alimony paid $ How often? [Student loan interest $ How often? [_ Other 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: $ 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) (If you 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.) [_JEmployed (Goto 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 1 2. Employer name

Employer address City ‘ State Zip code

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

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

lf yes, check one. [_Jthis job offers health insurance now.

[_ JThis job will offer health insurance, starting (mm/dd/yyyy). 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)? [Wes List the name(s): [No

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

How often? (Check one.) [_]Weekly [_]Monthly [~]Twiceamonth [_]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) L_Jhis 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. + —Howmuch will the employee's premiums be (for an individual plan)? $ How often? (Check one.) [_]Weekly [_]Monthly [_]Twiceamonth [~ ]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 pay for this coverage. For more information, see the Member Booklet for description of coverage. 5, Isthisjob a sheltered 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. Ifthis 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 [_]Apr [_]May [June [_JJuly [_JAug [_]Sept [Joct [Nov [_]Dec Self-employed Income

8.a.(Check one.) [_]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.d. Date this person began getting this income (mm/dd/yyyy) ACA-2 (Rev. 01/14) 13 Please go to the next page. > TN 13-0027-MM2 Attachment 1 Approval Date: 03/26/2014

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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

If yes, check one.

[_] This job offers health insurance now.

[J 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)? [Wes 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 a 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.)

10.b. What health insurance changes will this job make for the next year? (if you know) [_JThis job will stop offering health insurance. [_JThis 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)

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.) If yes, we may be able to help pay for this coverage. For more information, see the Member Booklet for description of coverage. 12. |s this job 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 []Mar [_JApr [JMay [June [JJuly [JAug [Sept [Joct [Nov [_JDec Self-employed Income

15.a.(Check one.) [_]Partnership [_]S-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) ACA-2 (Rev. 01/14) 14 Please go to the next page. > TN 13-0027-MM2 Attachment 1 Approval Date: 03/26/2014

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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? [_]Trusts $ How often? (_JAnnuity $ How often? [ Jinterest $ How often? [_]Social Security $ How often? [_]Net farming/fishing $ How often? [_JNet rental income $ How often? [_JRoyalty $ How often? [_|Capital gains $ How often? [_]Alimony received $ How often? [_JGambling proceeds $ How often? [_}lax-excluded foreign income $ How often? [_}Taxable military retirement pay (not paid through the Veterans’ Administration) $ How often?

[_}1ax 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? [_]Student loan interest $ How often? [_] Other 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: $ Howoften? 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) to be the same next year? [__]Yes [_]No (If you are not sure, answer no to this question.) If no, what do you expect Person 2's total income to be next year? $ (Estimate)

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wee Health 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 Ifyes, fill out Part B of Supplement C: Health Insurance on page 21. 3. Do you 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.)

(]Yes [_]No

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

4m 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 If yes, 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 have a parent who is 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.

Ziti 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. To the 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 56 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.

18. 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, |: (Check one.) {_] permit use of the data for the next five years; or

(_] permit use of the data for: (Check one.)

[CJ one year, [| two years, [_] three years, [_] four years [-] do not 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. If lam 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.

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18. If | think that MassHealth 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 | 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 represent 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. | can file a complaint of discrimination by going to www.hhs.gov/ocr/office/file.

* You can also report changes in any of the following ways.

+ — Sign onto 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.

| 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);

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

¢ — Imay 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

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

First name, middle initial, last name, suffix

Organization name

Send the filled-out application to: Health Insurance Processing Center PO. Box 4405

Taunton, MA 02780 or fax to 617-887-8770.

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SUPPLEMENT A ( a icRTh Iliness, Disability, or Accommodation CONNECTOR

Part A

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

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

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

If yes, name(s): Part B Ifyou 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 []Lowvision—Name(s): L1Blind—Name(s): [_]Deaf—Name(s): [_]Hard of hearing—Name(s): [Developmentally disabled—Name(s): [intellectually disabled—Name(s): L_JPhysically disabled—Name(s): [other (Please explain.)—Name(s): 2. Accommodation [_Trexttelephone (TTY)—Name(s): [_JLarge print publications—Name(s): [_JAmerican Sign Language interpreter—Name(s): [_JVideo Relay Service (VRS)—Name(s): [Communication Access Real-time Translations (CART)—Name(s): {Publications in Braille-Name(s): {_]Assistive listening device—Name(s): [_}Publications in electronic format—Name(s): [_Jother (Please explain.)—Name(s): Part C

If you 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

Ifyes, 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):

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SUPPLEMENT B ( oa ~) American Indian (Al)/Alaska Native (AN) CONNECTOR

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.

If you 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 Middleinitial Last Suffix

1. Isthis person a member of a federally recognized tribe? [_]Yes [_]No If yes, check the box that applies. [American Indian/Alaska Native (Mashpee Wampanoag) [_]American Indian/Alaska Native (Wampanoag Tribe of Gay Head (Aquinnah)) [_ American 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. If no, 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? [Ves [_]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? [_]Yes [_]No If yes, 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. If no, 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. > TN 13-0027-MM2 Attachment 1 Approval Date: 03/26/2014

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SUPPLEMENT C ( aici . 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)

1a. Does this person have a Medicare Part D plan? [_]Yes [_]No If yes, when did coverage start? (mm/dd/yyyy)

L.b. 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 Ifyes, when did coverage start? (mm/dd/yyyy)

2.b. Does this person have a Medigap/Medicare supplemental policy? [_]Yes [_]No If 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 If yes, name(s):

Part B: Federal health insurance benefits

Fill out this part if any 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/yyyy)

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Source: (Check one.)

[_]Employer-sponsored (give employer name): [_]Union-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 [_]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); == Union-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 [_]Everytwoweeks [~]Twiceamonth [~|Monthly [_]Quarterly [_]Yearly ACA-2 (Rev. 01/14) 22 Go back to the application. > TN 13-0027-MM2 Attachment 1 Approval Date: 03/26/2014

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Authorized Representative le me essences

. . HEALTH ; Designation Form CONNECTOR Commonwealth of Massachusetts i 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 I, 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 II, 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, or, 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 * act on your behalf in all other matters with MassHealth and the Massachusetts Health Connector.

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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 your 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 II 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 | 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 ee

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).

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SECTION I: 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 (if you 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

in this 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 filled out by authorized representative. Please print, except for signature

B1. Complete if authorized representative is a person. | certify that | 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 me by MassHealth or the Massachusetts Health Connector. If |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 C.F.R. § 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. | 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 C.ER. § 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. >

TN 13-0027-MM2 Attachment 1 Approval Date: 03/26/2014 Massachusetts Page 27 of 28 Effective Date: 10/01/2013

OFFICIAL

SECTION II: 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 enrollment 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.

| further certify that | will at all times maintain the confidentiality of any information regarding the applicant or member set forth below, that is provided

tome 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's 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 lil: Authorized Representative Designation (appointed by law)

To be 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's 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)

TN 13-0027-MM2 Attachment 1 Massachusetts Page 28 of 28

Approval Date: 03/26/2014 Effective Date: 10/01/2013

OFFICIAL

USE OF THE ALTERNATIVE SINGLE STREAMLINED APPLICATION

O Paper Application Online Application

TRANSMITTAL NUMBER: STATE:

MA-13-0027-MM2 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.

TN 13-0027-MM2 Attachment 2 Approval Date: 03/26/2014 Massachusetts Page 1 of 1 Effective Date: 10/01/2013

OFFICIAL

1.1 My Appeals

My Appeals

IMPORTANT: This Form Cannot Be Used to Appeal Your MassHealth Decision

You cannot use this online form to appeal your MassHealth decision. If you would like to appeal your

MassHealth decision, you must use the form that came in the mail with your MassHeaith letter, For more information about appealing your MassHeaith decision, please call the MassHealth Enrollment Center at 1-888-665-9993 (TTY: 1-888-665-9997). .

if you are trying to update your account, correct a mistake you made in your application, have a problem with enroliment, or have a problem with billing, you should contact the Health Connector’s Customer Service at 1-877-MA-ENROLL (1-877-623-6765). Customer Service can help you with the following:

© Update your household size (adding or removing peopie) © Update your household income

© Update your citizenship/immigration status

© Update whether you have access to other insurance

© Update your residency status

© Update your incarceration status

© Update your American Indian status

© Update your other account information

© Help with enroliment in a health pian

© Problems with your premium bill payment

If you disagree with the action taken by the Massachusetts Health Connector, you have the right to appeal and ask for a hearing before an impartial hearing officer. Issues thet may be addressed through an appeal include:

© Whether you qualify to shop for heaith insurance through the Health Connector, based on © Your residency © Your incarceration status © Your citizenship/immigration status © Whether you qualify for subsidies to help you pay for insurance or the amount of subsidies you qualify for, based on ¢ Income © Family size ® Access to other insurance © Whether you qualify for other benefits because of your American indian status * Failure of the Health Connector to give you timely notice of its action or its failure to take action on you request © Denial of a Financial Hardship Walver or Reduction of Premium Application in most cases, if you would like to appeal an action by the Health Connector, you must submit your appeal request within 30 days from the day you receive notice of the action.

Need more information about submitting an appeal online to the Health Connector. You may also send in the paper appeal request form that you received with the notice you are appealing.

Type Content Functions Mandatory Possible (¥/N/NA) Validation Static IMPORTANT: This Form Cannot Be Used

to Appeal Your MassHealth Decision

You cannot use this online form to appeal your MassHealth decision. If you would like to appeal your MassHealth decision, you must use the form that came in the

TN 13-0027-MM2 Attachment 3 Approval Date: 11/09/2015 State: Massachusetts Page 1 of 253 Effective Date: 07/17/2015

| OF JAIOIAO FICIAL

Type Content Functions Mandatory Possible (Y¥/N/NA) Validation

mail with your MassHealth letter. For more information about appealing your MassHealth decision, please call the MassHealth Enrollment Center at 1-888- 665-9993 (TTY: 1-888-665-9997).

Static If you are trying to update your account, correct a mistake you made in your application, have a problem with enrollment, or have a problem with billing, you should contact the Health Connector’s Customer Service at 1-877-MA-ENROLL (1- 877-623-6765). Customer Service can help you with the following:

e Update your household size (adding or removing people)

. Update your household income

. Update your citizenship/immigration status

. Update whether you have access to other insurance

° Update your residency status ° Update your incarceration status ° Update your American Indian status . Update your other account information . Help with enroliment in a health plan ° Problems with your premium bill payment

Static If you disagree with the action taken by

the Massachusetts Health Connector, you have the right to appeal and ask for a hearing before an impartial hearing officer.

TN 13-0027-MM2 Attachment 3 Approval Date: 11/09/2015 State: Massachusetts Page 2 of 253 Effective Date: 07/17/2015

OFFICIA

Type Content Functions Mandatory Possible (Y/N/NA) Validation

Issues that may be addressed through an appeal include:

. Whether you qualify to shop for health insurance through the Health Connector, based on

° Your residency

° Your incarceration status

° Your citizenship/immigration status

° Whether you qualify for subsidies

to help you pay for insurance or the amount of subsidies you qualify for, based

on

fe} Income

° Family size

() Access to other insurance

e Whether you qualify for other benefits because of your American indian status

. Failure of the Health Connector to

give you timely notice of its action or its failure to take action on you request

° Denial of a Financial Hardship Waiver or Reduction of Premium Application

in most cases, if you would like to appeal an action by the Health Connector, you must submit your appeal request within 30 days from the day you receive notice of

the action.

URL Please click <here> for more information URL takes the about submitting an appeal online to the user to the Health Connector. You may also send in Appeal Form

the paper appeal request form that you

TN 13-0027-MM2 Attachment 3 Approval Date: 11/09/2015 State: Massachusetts Page 3 of 253 Effective Date: 07/17/2015

OFFICIAL

Type Content Functions Mandatory Possible {¥/N/NA) Validation

received with the notice you are appealing.

TN 13-0027-MM2 Attachment 3 Approval Date: 11/09/2015 State: Massachusetts Page 4 of 253 Effective Date: 07/17/2015

yovcaes OFFICIAL

My Enrollments

HEALTH CONNECTOR the eight wlace toe tee right plan

Manage Customer

a My Enrollments You or your family members have selected a health plan through the Health Connector and are able to pay and enrollacthis time. Please note: You or your family members will sul need to send the Health Connector or MassHealth verification documents within a 90 day time period to continue to be eligible for coverage in the plan. ] you chose, Please make sure to send us the documents that we need to ensure that your enrolimentis ie pce | not Interrupted. Go to My Eligibility > Actions - Detail » Documents Required for more detalts. } Application Year: [as

Future Enroliment(s) ~

‘You are currently enrolled in the following plans: Change Amount of Tax Credit you take now

Hl Fesesnciunep eavee evi] | Health Insurance Plan

EFFECTIVE DATE@

ENROLLMENT ID: HEAD OF HOUSEHOLD NAME: SUBMITTED

Renp_14440441894463.

Pian selected for Egas Wahs Costs include Advance Premium Tax Credit of $22 . 0° ‘Tax credit claimed : $22 . °°

MONTHLY INSURANCE HEALTHPLAN = POLICY ANNUAL EST. OUT-OF- PREMIUM CARRIER NAME 1D DEDUCTIBLES © POCKET COSTS $78.0 Bz) ‘Tufts Health $0.%/Person $1,500. / Feconvcnscued cee Set Siver $0./ Family Person HMO/ Silver Oy

Dental Insurance Plan

ENROLLMENT {D: HEAD OF HOUSEHOLD: Letatial sussurrea ON: . EFFECTIVE DATE @ Plan selected for Egas Wahs

wownny: PREMIUM INSURANCE CARRIER DENTAL PLAN NAME POLICYID ANNUAL DEDUCTIBLES

Type Content Functions Mandatory Possible (Y¥/N/NA) Validation Static My Enrollments NA Static You or your family members have selected | NA a health plan through the Health

TN 13-0027-MM2 Attachment 3 Approval Date: 11/09/2015 State: Massachusetts Page 5 of 253 Effective Date: 07/17/2015

OFFICIAL

Type Content Functions Mandatory Possible (Y¥/N/NA) Validation Connector and are able to pay and enroll at this time. Please note: You or your family members will still need to send the Health Connector or MassHealth verification documents within a 90 day time period to continue to be eligible for coverage in the plan you chose. Please make sure to send us the documents that we need to ensure that your enrollment is not interrupted. Go to My Eligibility > Actions — Detail > Documents Required for more details. Dropdown Application Year 2015 2016 Dynamic Current Enrollment(s) Future Enrollment(s) Cancelled Enrollment(s) Static You are currently enrolled in the following Shown for plans Current and Future Enrollments Link Change Amount of Tax Credit you take now | Allows the user to adjust the tax credit amount that they are taking Button Edit Enrollment Allows the user to edit © their enrollment. During closed enrollment, this button will take the user to a Qualifying Life Events

TN 13-0027-MM2 State: Massachusetts

Attachment 3 Page 6 of 253

Approval Date: 11/09/2015 Effective Date: 07/17/2015

AAS OFFICIAL

Type Content Functions Mandatory Possible (¥/N/NA) Validation

Questionnaire before allowing the user to change their enrollment

Button Cancel Enrollment Allows the user to cancel their enrollment

Static Health Insurance Plan

Static Enrollment ID Field values will vary depending on the applicant

Head of Household Name Submitted On

Effective Date

Tooltip Effective Date: NA

This is when the health insurance plan begins providing coverage. Coverage in a plan will begin on the first day of the calendar month selected for coverage if all documentation and payments are received by the required due date.

Button View Detail View enrollment details

Static Plan selected for xxx NA

<plan information entered here>

Static Dential Insurance Plan Shown if the user has a dental enrollment Static Enrollment ID Field values will vary TN 13-0027-MM2 Attachment 3 Approval Date: 11/09/2015

State: Massachusetts Page 7 of 253 Effective Date: 07/17/2015

OFFICIAL

Type Content Functions Mandatory Possible {¥/N/NA) Validation Head of Household Name depending on the applicant Submitted On Effective Date Button View Detail View enrollment details Static Plan selected for xxx NA <plan information entered here> TN 13-0027-MM2 Attachment 3 Approval Date: 11/09/2015

State: Massachusetts Page 8 of 253 Effective Date: 07/17/2015

care waysaenaserrs

CONNECTOR

Rippin nen

Manage Customer

My Profile

Below you can view and edit your personel profil

‘View/Uniock Eligiiity Reasonable Accommodations Basic

* manaerory Fela * First Name Middle Name * Last Name

ae se ae

AccouneNumber

od

Rfid, 1444606104673

Email Address { E-mail Address: J Date of Mirth (MM/DD/YYYY) [eran

Soclal Security Number

Malling Address (Select if ic is the seme as Contact Home Address

Contact Phone

Second PhoneNumber

Contact Pre Preferred Spoken Language

rwacy poy | Terms fuse | obcsimer

TN 13-0027-MM2 State: Massachusetts

Attachment 3 Page 9 of 253

OFFICIAL

Approval Date: 11/09/2015 Effective Date: 07/17/2015

OFFICIAL

Type Content Functions Mandatory Possible Validation (¥/N/NA) Static My Profile Static Below you can view and edit your personal profile information. Button View/Unlock Eligibility Edit the application Link Reasonable Accommodations Only visible after the application has been submitted Static Basic Information Static * Mandatory Field Textbox First Name Alphabetic Entry; Yes hyphens and apostrophes also accepted Textbox Middle Name Alphabetic Entry; hyphens and apostrophes also accepted Textbox Last Name Alphabetic Entry; Yes hyphens and apostrophes also accepted Dropdown | Suffix Choose one from Jr. Sr. Ill &IV Textbox Account Number Auto populated Yes Cannot be edited Textbox Email Address Alphanumeric Entry with special characters such as @,.,- As of 10/7/14 — not a required field Textbox Date of Birth Date format Yes (mm/dd/yyyy) Static Home Address N/A Checkbox | No Home Address Checkbox selection If this is clicked, all home address fields will be grayed out and user will be unable to add text; user will also be unable to click the “select TN 13-0027-MM2 Attachment 3 Approval Date: 11/09/2015

State: Massachusetts

Page 10 of 253

Effective Date: 07/17/2015

OFFICIAL

Type Content Functions Mandatory Possible Validation (¥/N/NA) if it’s the same as Home Address” checkbox in the Mailing Address section Textbox Address 1 Alphanumeric Entry Yes, if “No Home Address” is not checked Textbox Address 2 Alphanumeric Entry Textbox City Alphabetic Textbox Zip Numeric Dropdown | County Auto populated from the zip code entry Choose from dropdown list of counties that match the zip code entered Textbox State Alphabetic Automatically filled in after a zip code and county is selected Checkbox | | intend to reside in If selected along with “no Only be shown if Massachusetts, even if | do not | home address” no IDP person does not have a fixed address. will be performed and provide a MA this person will be home address identified as homeless If yes and eligible for MassHealth, no documentation will need to be provided If yes or no and eligible for QHP/APTC/WRAP, MA mailing address will be used for making all determinations and documentation will be asked accordingly Static Mailing Address N/A Checkbox | Select if the Mailing Address is | Checkbox selection If checked, all the same as the Home Address Mailing Address fields will be filled TN 13-0027-MM2 Attachment 3 Approval Date: 11/09/2015

State: Massachusetts

Page 11 of 253

Effective Date: 07/17/2015

OFFICIAL

Type Content Functions Mandatory Possible Validation (Y/N/NA) with Home Address information; no edits allowed to the Mailing Address fields Textbox Address 1 Alphanumeric Entry Yes Should be mandatory if “Select if it’s the same as Contact Home Address” is not checked. Textbox Address 2 Alphanumeric Entry Textbox City Alphabetic Yes Textbox Zip Numeric Yes Dropdown | County Auto-populated from the | Yes entry Zip code entry Choose from dropdown list Textbox State Alphabetic Auto Yes Automatically filled populated with the zip in after a zip code code and county entry and county is selected Static Contact Phone N/A Textbox Phone Number Numeric Dashes are Yes prefilled Textbox Ext Numeric No Dropdown | Phone Type Alphabetic Yes Default to Cell (Default to “Cell”) Choose from the dropdown list Home, Work ,Cell Textbox Second Phone Number Numeric Dashes are pre- | No (Optional) filled Textbox Ext Numeric No Dropdown | Phone Type Alphabetic No Default Home — Second phone Choose from the number

TN 13-0027-MM2 State: Massachusetts

Attachment 3 Page 12 of 253

Approval Date: 11/09/2015 Effective Date: 07/17/2015

OFFICIAL

Type Content Functions Mandatory Possible Validation (¥/N/NA) default to dropdown list “Home” Home, Work ,Cell Static Contact Preferences N/A Dropdown | Preferred Spoken Language Alphabetic If a language other

— Default display is English

Choose from the dropdown list

English

Arabic Cambodian/Khmer Cape Verdean Creole Chinese - Cantonese Chinese - Mandarin French

Greek

Haitian Creole

Hindi

Italian

Korean

Laotian

Nepalese

Other

Portuguese

Russian

Somali

Spanish

Vietnamese

than English or Spanish is chosen, all written communications will be sent in English

Default to English

Dropdown | Preferred Written Language

Default language set to English

Alphabetic

Choose from the dropdown list

English

Arabic Cambodian/Khmer Cape Verdean Creole Chinese (Cantonese or Mandarin)

French

Haitian Creole

Hindi

Laotian

Nepalese

Other

Portuguese

Russian

Default to English

TN 13-0027-MM2 State: Massachusetts

Attachment 3 Page 13 of 253

Approval Date: 11/09/2015 Effective Date: 07/17/2015

OFFICIAL

Type Content

Functions

Mandatory (¥/N/NA)

Possible Validation

Somali Spanish Vietnamese Greek Italian

TN 13-0027-MM2 State: Massachusetts

Attachment 3 Page 14 of 253

Approval Date: 11/09/2015 Effective Date: 07/17/2015

Start your Application: Begin Process

Learn More

Manage Customer Create Customer

My Account Profile

G BS CONNECTOR he ra place for Bre ght pian

ot

Application Year 2015

Start Your Application: Begin Process

You will be asked In this application if you are interested in getting help paying for heaith coverage. if you are hot interested in getting help paying for coverage, you will not need to answer any questions about your Income,

However, if you would like to see if you can qualify for help, we will ask you a number of questions about your household, your income, and other things that will help us find the best programs and plans for you.

Ifyou are already enrolled in MassHealth, and you still qualify, you may not qualify for additional benefits ‘through the Massachusetts Health Connector.

cy

Ifyou currently are receiving Medicare or are 65 or older and low-income, you may also apply for additional benefits through www.mass.gov/MassHealth.

‘Notice of Consent and Authorization

f You want to use the Massachusetts Health Insurance Exchange (HIX) application service to apply for health benefits and/or health plans such as Advance Premium Tax Credits, Health Connector plans, ConnectorCare, MassHealth, Health Safety Net, Children’s Medical Security Plan, and premium subsidies from the Massachusetts Health Connector for yourself and/or members of your household.

Eom >

To complete this application and obtain initial determinations of eligibility, you must provide personal information about everyone In your household who Is applying. If you are applying for subsidized health benefits you will also have to provide health, health-coverage, and Income information about you and everyone in your household who Is applying. You may have to. provide information about others if their information will affect the eligibility ofthe applicants. We may verify the accuracy of such information using various government and private sources including. ‘our electronic databases as well asthed databases of the Department of Homeland

fet ancltne Secial Gactussin. seach ~

View Privacy Act Statement

‘ ()*! hereby certify under the pains and penalties that | have the authority and consent described above and will, if necessary, perform the actions described above.

SPecAAACCCHPOCRAALOSECLCSEECLSRDSEALEOGEHOLEFEPOREAOAOCHIEEOESCAPVERIDEEETAOESRSESIEES SESE VEDEAELELIELLESLESESCELEUIEESYSEAEEDAISNGEDSIADEAGABEAAERSGOLIEY AAS

Privacy Policy | Termsofuse | oiscisimer

Contact | Accessiblity statement

Q OPTUM" Page 1

Confidential and proprietary | Use pursuant to company instructions | Optum

TN 13-0027-MM2 Attachment 3 Approval Date: 11/09/2015 State: Massachusetts Page 15 of 253 Effective Date: 07/17/2015

Type Content Functions Mandatory (Y/N/NA) Possible Validation

Static Start Your Application: Begin Process Shown when a user lands on this page for the first time

Static Start Your Application Shown any other time a user lands on this page

Static You will be asked in this application if N/A you are interested in getting help paying for health coverage. If you are not interested in getting help paying for coverage, you will not need to answer any questions about your income.

Static However, if you would like to see if you can qualify for help, we will ask you a number of questions about your household, your income, and other things that will help us find the best programs and plans for you.

Static If you are already enrolled in N/A MassHealth, and you still qualify, you ; may not qualify for additional benefits Active link to

through the Massachusetts Health MassHealth: Connector. www.mass.gov/ MassHealth Static lf you currently are receiving Medicare or are 65 or older and low-income, you may also apply for additional benefits through www.mass.gov/MassHealth Static Notice of Consent and Authorization Shown the first time the user sees this page

Notice of Consent and Authorization

You want to use the Massachusetts Health Insurance Exchange (HIX) application service to apply for health benefits and/or health plans such as Advance Premium Tax Credits, Health Connector plans, ConnectorCare and premium subsidies from the Massachusetts Health Connector for yourself and/or members of your household.

Q OPTUM" Page 2

Confidential and proprietary | Use pursuant to company instructions | Optum

TN 13-0027-MM2 Attachment 3 Approval Date: 11/09/2015 State: Massachusetts Page 16 of 253 Effective Date: 07/17/2015

OFFICIAL

Type Content Functions Mandatory (Y/N/NA) Possible Validation

To complete this application and obtain initial determinations of eligibility, you must provide personal information about everyone in your household who is applying. If you are applying for subsidized health benefits you will also have to provide health, health-coverage, and income information about you and everyone in your household who is applying. You may have to provide information about others if their information will affect the eligibility of the applicants. We may verify the accuracy of such information using various government and private sources including our electronic databases as well as the databases of the Department of Homeland Security and the Social Security Administration. Household members who do not want coverage will not be asked questions about citizenship or immigration status.

If you are applying for subsidized health benefits we may also verify the accuracy of such information by using the databases of the Internal Revenue Service and the Massachusetts Department of Revenue. If the information does not match, we may ask you to send us proof of your circumstances. We also will be automatically redetermining eligibility and may check your information at a later time to make sure your information is up to date. We will notify you if something has changed.

We will keep the information provided to us private and only use and disclose it in accordance with applicable law.

To proceed, you must give us certifications about your authority to complete the application and eligibility process on behalf of those individuals applying for benefits, and if applicable, your authority to provide and see information about others.

If applying for benefits for 1) yourself, 2) your own minor child or children, and/or 3) any minor or incapacitated person for whom you are either the legal guardian or for whom you have sufficient information to act responsibly on their behalf, then by electronically signing below, you will be certifying under penalty of perjury that you consent to the use of government and private sources to verify information about you and any such minor child and incapacitated person.

If applying for benefits on behalf of anyone else other than those described above, then by electronically signing below, you also will be certifying under penalty of perjury that you have consent and authorization from such individuals or, if applicable, their parent, guardian, or other legally authorized representative, to act on their behalf to complete this application and any ongoing or subsequent eligibility process and activity, including as examples:

. providing personal information about them, and seeing such information as may be provided by us;

° making choices about coverage options and methods of communication with us

° making changes to the application or related eligibility documents;

° completing and making changes to renewal forms and related documents

. providing information about any change in their circumstances;

. providing consent on their behalf to use government and private sources to verify information provided in

this application and related documents and as may be necessary for continued eligibility; and

° if applying for subsidized health benefits, providing health, health-coverage, and income information about them, and seeing such information as may be provided by us.

4 OPTUM” Page 3

Confidential and proprietary | Use pursuant to company instructions | Optum

TN 13-0027-MM2 Attachment 3 Approval Date: 11/09/2015 State: Massachusetts Page 17 of 253 Effective Date: 07/17/2015

OFFICIAL

Type Content Functions Mandatory (Y/N/NA) Possible Validation

By signing electronically below, you also certify under penalty of perjury that

. you have the authorization of all individuals (or their authorized representatives) not seeking coverage but whose information is necessary for eligibility determinations for others on this application to see and provide their personal information to us and consent to the use of private and government sources to verify such information;

. if applying for subsidized health benefits you also have the authorization of all individuals (or their authorized representatives) not seeking coverage but whose income information is necessary for eligibility determinations for others on this application to see and provide their income information to us and consent to the use of private and government sources to verify such information;

° you have obtained sufficient information from all individuals for whom you are submitting this application or if applicable, from their parent or legally authorized representative, to act responsibly and provide accurate information in completing the application and other related eligibility documents and forms;

. you have informed, or will inform as soon as possible, all adults in your household and the parent or legal guardian of any minor who is not your child about their rights and responsibilities as set forth in this application; and

. you are either:

e over eighteen years of age; or © younger than eighteen years of age and applying on behalf of yourself and/or your minor child.

Link View Privacy Act Statement Active link to Health Connector Privacy Statement — link out to mahealthconnec tor.org

MassHealth Privacy Statement:

http://www.mas s.gov/eohhs/gov /laws- regs/privacy- security/masshe alth/member- information/noti ce-of-privacy-

QQ optum Page 4

Confidential and proprietary | Use pursuant to company instructions | Optum

TN 13-0027-MM2 Attachment 3 Approval Date: 11/09/2015 State: Massachusetts Page 18 of 253 Effective Date: 07/17/2015

OFFICIAL

Type Content Functions Mandatory (Y/N/NA) Possible Validation

practices.html

Checkbox | | hereby certify under the pains and Checkbox Yes penalties that | have the authority and Selection consent described above and will, if necessary, perform the actions described above.

Button Save and Continue Allows the user to move to the next page of the application

Q OPTUM Page 5

Confidential and proprietary | Use pursuant to company instructions | Optum

TN 13-0027-MM2 Attachment 3 Approval Date: 11/09/2015 State: Massachusetts Page 19 of 253 Effective Date: 07/17/2015

OFFICIAL

1.1 Head of Household Information

Head of Household Contact Information

* Mandatory Field

Check here if you are the account holder.

Contact Information * First Name Middle Name * Last Name Egas [ Wahs * Date of Birth (MM/DD/YYYY) Email Address 10/12/1981 Type Content Functions Mandatory Possible (Y/N/NA) Validation Static Head of Household Contact Information N/A Checkbox Check here if you are the account holder Checkbox Selection Textbox First Name Alphabetic Yes Entry; hyphens and apostrophes also accepted Textbox Middle Name Alphabetic Entry; hyphens and apostrophes also accepted Textbox Last Name Alphabetic Yes Entry; hyphens and OPTUM ™ Page 1

Confidential and proprietary | Use pursuant to company instructions | Optum

TN 13-0027-MM2 Attachment 3 Approval Date: 11/09/2015 State: Massachusetts Page 20 of 253 Effective Date: 07/17/2015

OFFICIAL

Type Content Functions Mandatory Possible {Y/N/NA) Validation apostrophes also accepted Dropdown Suffix Choose one from Jr. Sr. Ml & IV Textbox Date of Birth Date format Yes (mm/dd/yyyy) Textbox Email Address Alphanumeric Entry with special As of 10/7 — characters such | nota required as @,.,- field 1.2 Contact Home Address Contact Home Address CINo Home Address * Address 1 1 Main Street Address 2 Apt6 * City *Zip * County * State Boston 02108 | surroux [~| | ma Type Content Functions Mandatory Possible (¥/N/NA) Validation Static Contact Home Address N/A Checkbox No Home Address Checkbox selection If this is clicked, all home address s) OPTUM” Page 2

Confidential and proprietary | Use pursuant to company instructions | Optum

TN 13-0027-MM2

State: Massachusetts

Attachment 3 Page 21 of 253

Approval Date: 11/09/2015 Effective Date: 07/17/2015

OFF

CIAL

Type Content Functions Mandatory Possible (Y¥/N/NA) Validation fields will be grayed out and user will be unable to add text; user will also be unable to click the “select if it’s the same as Home Address” checkbox in the Mailing Address section Textbox Address 1 Alphanumeric Entry Yes, if “No Home Address” is not checked Textbox Address 2 Alphanumeric Entry Textbox City Alphabetic Textbox Zip Numeric Dropdown County Auto populated from the zip code entry Choose from dropdown list of counties that match the zip code entered Textbox State Alphabetic Must be MA Checkbox l intend to reside in If selected along with “no Only be Massachusetts, even if | do not home address” no IDP will shown if have a fixed address. be performed and this person does person will be identified as not provide a homeless MA home address If yes and eligible for MassHeaith, no documentation will need .) OPTUM" Page 3

Confidential and proprietary | Use pursuant to company instructions | Optum

TN 13-0027-MM2

State: Massachusetts

Attachment 3 Page 22 of 253

Approval Date: 11/09/2015 Effective Date: 07/17/2015

OFF

CIAL

Type Content Functions Mandatory Possible (¥/N/NA) Validation to be provided If yes or no and eligible for QHP/APTC/WRAP, MA mailing address will be used for making all determinations and documentation will be asked accordingly 1.3 Contact Mailing Address Contact Mailing Address Select if it's the same as Contact Home Address * Address 1 1 Main Street Address 2 Apté * City *Zip * County * State ponnineeennees a rccerncairannnnniniiny, — pnnnnmunnineannniinn a Boston i $02108 i [ SUFFOLK | MA i Type Content Functions Mandatory Possible (Y/N/NA) Validation Static Contact Mailing Address N/A Checkbox Select if it’s the same as Contact Home Checkbox If checked, all Address selection Mailing Address fields will be filled with Home Address information; no edits allowed to the .) OPTUM" Page 4

TN 13-0027-MM2 State: Massachusetts

Confidential and proprietary | Use pursuant to company instructions | Optum

Attachment 3 Page 23 of 253

Approval Date: 11/09/2015 Effective Date: 07/17/2015

OFFICIAL

Type Content Functions Mandatory Possible (¥/N/NA) Validation Mailing Address fields Textbox Address 1 : Alphanumeric | Yes Should be Entry ¢ mandatory if “Select If it’s the same as Contact Home Address” is not checked. Textbox Address 2 Alphanumeric Entry Textbox City Alphabetic Yes Textbox Zip Numeric Yes Dropdown. County Auto- Yes populated from the entry Zip code entry Choose from dropdown list Textbox State Alphabetic Yes Automatically Auto filled in after a populated zip code and with the zip county is code and selected county entry

; a3 OPTUM" Page 5

Confidential and proprietary | Use pursuant to company instructions | Optum

TN 13-0027-MM2 Attachment 3 Approval Date: 11/09/2015 State: Massachusetts Page 24 of 253 Effective Date: 07/17/2015

OFFICIAL

1.4 Contact Phone/Communication Preferences

Contact Phone . * Phone Number Exe Phone Type (888) 888-8888 | Cell ha Second Phone Number Ext Secondary Phone Type | Home Contact Preferences Preferred Spoken Language Preferred Written Language English | English Type Content Functions Mandatory Possible (Y/N/NA) Validation Static Contact Phone N/A Textbox Phone Number Numeric Dashes are Y prefilled Textbox Ext Numeric Dropdown Phone Type Alphabetic (Default to “Cell”) Choose from the dropdown list Home, Work ,Cell Textbox Second Phone Number Numeric Dashes are N (Optional) pre-filled Textbox Ext Numeric Dropdown — Phone Type Alphabetic Second phone number default Choose from the to “Home” dropdown list . OPTUM i. Page 6

Confidential and proprietary | Use pursuant to company instructions | Optum

TN 13-0027-MM2 Attachment 3 Approval Date: 11/09/2015 State: Massachusetts Page 25 of 253 Effective Date: 07/17/2015

OFFICIAL

Type Content Functions Mandatory Possible (¥/N/NA) Validation

Home, Work ,Cell

Static Contact Preferences N/A

Dropdown — Preferred Spoken Language Alphabetic , if a language Default display other than

is English Choose from the English or dropdown list Spanish is chosen, all written communications will be sent in English

English

Arabic Cambodian/Khmer Cape Verdean Creole Chinese - Cantonese Chinese - Mandarin Default to French English Greek

Haitian Creole Hindi

Italian

Korean Laotian Nepalese Other Portuguese Russian Somali Spanish Vietnamese

Dropdown Preferred Written Language Alphabetic Default to Default English language set to Choose from the

English dropdown list

English

Arabic Cambodian/Khmer Cape Verdean Creole Chinese (Cantonese or Mandarin)

French

Haitian Creole

Hindi

Laotian

Nepalese

Q OPTUM” Page 7

Confidential and proprietary | Use pursuant to company instructions | Optum

TN 13-0027-MM2 Attachment 3 Approval Date: 11/09/2015 State: Massachusetts Page 26 of 253 Effective Date: 07/17/2015

sy OFFICIA

Type Content Functions Mandatory Possible (¥/N/NA) Validation

Other Portuguese Russian Somali Spanish Vietnamese Greek Italian

Submit Button Continue Action: Mouse Click

Keyboard: Enter Alt text: Save and

Continue Submit Button | Back Action: Mouse Click Keyboard: Enter Alt text: Back OPTU mM" Page 8

Confidential and proprietary | Use pursuant to company instructions | Optum

TN 13-0027-MM2 Attachment 3 Approval Date: 11/09/2015 State: Massachusetts Page 27 of 253 Effective Date: 07/17/2015

MOIAAO OFFICIAL

1.1 Is someone helping you?

Is someone helping you?

* Mandatory Field

Enrollment Assister

If a Health Connector Navigator, Certified Application Counselor, issuer Enrollment Assister or Broker Enrollment Assister is helping you with your application, please provide their organization's information below.

Enrollment Assister Organization Name Enroliment Assister ID

i eessonresneresee: peccenesteneneeninatennssiey ; 7

| Full Name |

For help finding an Enrollment Assister Find an Enrollment Assister near me to search for one near you.

Enroliment Assister

Enrollment Assisters can help you understand new coverage options available as a result of national health care reform and find the most affordable coverage that meets your needs.

*Is someone helping you with your application?

@Yes © No Back Type Content Functions Mandatory | Possible (Y/N/NA) Validation Static Enrollment Assister N/A Static If a Health Connector N/A

Navigator, Certified Application Counselor, or issuer Enrollment Assister is helping you with your application,

TN 13-0027-MM2 Attachment 3 Approval Date: 11/09/2015 State: Massachusetts Page 28 of 253 Effective Date: 07/17/2015

OFFICIA

Type Content Functions Mandatory | Possible ({Y/N/NA) Validation please provide their organization’s information below. Textbox Enrollment Assister Alphabetic Entry Organization Name Textbox Enrollment Assister ID Alphanumeric Entry Static For help finding an Open URL in a new page Enrollment Assister click here to search for one https://www.mahealthconnector.org/help- near you. 1.2 Enrollment Assister Enrollment Assister

*Is someone helping you with your application?

Enrollment Assisters can help you understand new coverage options available as a result of national health care reform and find the most affordable coverage that meets your needs.

Enrollment Assisters are people who help you with your application and enrollment in coverage. They can help you understand new coverage options available as a result of national health care reform and find the most affordable coverage that meets your

@yYes ©No Type Content Functions Mandatory Possible (Y/N/NA) Validation Static Enrollment Assister

TN 13-0027-MM2

State: Massachusetts

Attachment 3

Page 29 of 253

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dooms,

1 | OFFICIAL

Type Content Functions Mandatory Possible (¥/N/NA) Validation needs. Enrollment Assisters can be Navigators, Certified Application Counselors, issuer Enrollment Assisters, or Authorized Representatives. Radio Button Is someone helping you with your Button Yes application? Selection Yes, No Submit Button | Save and Continue Action: Mouse Shown if Click person selects “no” Keyboard: Enter Alt text: Save and Continue Submit Button | Back Action: Mouse Shown if Click person selects “no” Keyboard: Enter Alt text: Back 1.3 Enrollment Assister Contact Information Enrollment Assister Contact Information * First Name Middie Name * Last Name Suffix rs rs | | Email Address { Type Content Functions Mandatory Possible (¥/N/NA) Validation Static Enrollment Assister Contact Information | N/A TN 13-0027-MM2 Attachment 3 Approval Date: 11/09/2015

State: Massachusetts Page 30 of 253 Effective Date: 07/17/2015

OFFICIAL

Type Content Functions Mandatory Possible (¥/N/NA) Validation Textbox First Name Alphabetic Yes If the “YES” radio Entry button is selected to the question “Do you want to name someone as your authorized representative?” then First Name field should be mandatory Textbox Middle Name Alphabetic No Entry Textbox Last Name Alphabetic Yes If the “YES” radio Entry button is selected to the question “Do you want to name someone as your authorized representative?” then First Name field should be mandatory Dropdown Suffix Choose one No from the dropdown list of Jr. Sr. Ill, IV Textbox Email Address Alphanumeric | ¥esOptional If First Name & Entry Including Last Name fields special contact characters information, then such as @, ., - Email address field should be mandatory TN 13-0027-MM2 Attachment 3 Approval Date: 11/09/2015

State: Massachusetts

Page 31 of 253

Effective Date: 07/17/2015

OFFICIAL

1.4 Enrollment Assister Mailing Address

Enrollment Assister Organization Mailing Address

*Address 1 Address 2, *City *Zip *County *State | | County a

*Is the person helping you apply for health insurance part of an organization?

@Yes © No *Organization Name Organization ID(if applicable): Type Content Functions Mandatory Possible (¥/N/NA) Validation Static Enrollment Assister Organization Mailing Address Textbox Address 1 Alphanumeric Yes lfthe “YES” radio Entry button is selected

to the question “Do you want to name someone as your authorized representative?~ ” then First Name field should be mandatory

Textbox Address 2 Alphanumeric No

Entry Textbox City Alphabetic Yes If the “YES” radio TN 13-0027-MM2 Attachment 3 Approval Date: 11/09/2015

State: Massachusetts Page 32 of 253 Effective Date: 07/17/2015

OFFICIAL

Type Content Functions Mandatory Possible (¥/N/NA) Validation button is selected to the question “Do you want to name someone as your authorized representative?2 ” then First Name field should be mandatory Textbox Zip Numeric Yes If the “YES” radio button is selected to the question “Do you want to name someone as your authorized representative? ” then First Name field should be mandatory Dropdown County Alphabetic Entry | Yes Choose from the auto populated dropdown list Textbox State Alphabetic Should only Automatically accept MA pre-fills upon entering the zip code and county Radio button | Is the person helping you apply for Button Selection | Yes health insurance part of an Yes, No organization? Textbox Organization Name Alphanumeric Yes If the “YES” radio Entry button is selected to the question “Is this person part of an organization helping you apply for health TN 13-0027-MM2 Attachment 3 Approval Date: 11/09/2015

State: Massachusetts

Page 33 of 253

Effective Date: 07/17/2015

OFFICIAL

Type Content Functions Mandatory Possible (¥/N/NA) Validation insurance?” then Organization Name should be mandatory Textbox Organization ID (if applicable): Alphanumeric No Entry 1.5 Enrollment Assister Phone Number Enrollment Assister Organization Phone Number *Phone Number Phone Type Work Type Content Functions . Mandatory Possible (¥/N/NA) Validation Static Enrollment Assister Organization N/A Phone Number Textbox Phone Number Numeric If the “YES” radio button is selected to the question “Do you want to name someone as your authorized representative?” then First Name field should be mandatory Textbox Ext Numeric Dropdown Phone Type Alphabetic Choose from the dropdown list

TN 13-0027-MM2

State: Massachusetts

Attachment 3 Page 34 of 253

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OFFICIAL

Type Content Functions Mandatory Possible (Y/N/NA) Validation

Home, Work ,Cell

1.6 Enrollment Assister Approval

Signature

In order to authorize your Enrollment Assister to help you complete your application, both of you will need to complete the authorization form and submit it to the address or fax number listed on the form.

*@ Type Applicant Signature(Name must be typed as it appears on the application)

Back Type Content Functions Mandatory Possible (¥/N/NA) Validation Static In order to authorize your Live link to CCA microsite Enrollment Assister to help you | containing detailed complete your application, information on the both of you will need to following forms: complete the appropriate form and submit it to the address or |° the Authorized fax number listed on the form. rele form « the Navigator Designation Form (PDF) e the Certified Application Counselor Form (PDF) the Permission to Share Information form (PDF) the Issuer Enrollment Assister form (PDF) TN 13-0027-MM2 Attachment 3 Approval Date: 11/09/2015

State: Massachusetts Page 35 of 253 Effective Date: 07/17/2015

OFFICIAL

Type

Content

Functions

Mandatory (¥/N/NA)

Possible Validation

Link:

https://www.mahealthcon nector.org/forms/enrolime nt-assister-forms

RadioButton

Signature

Button selection

Textbox

Type Applicant Signature (Name must be typed as it appears on the application)

Alphabetic Entry

Submit Button

Save and Continue

Action: Mouse Click

Keyboard: Enter Alt text: Save and Continue

Submit Button

Back

Action: Mouse Click

Keyboard: Enter Alt text: Back

TN 13-0027-MM2

State: Massachusetts

Attachment 3 Page 36 of 253

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ai OFFICIAL

Do you want help paying for health coverage costs?

* Mandatory Fields

* Who needs health insurance?

© Egas Wahs only © Egas Wahs and other family members © Other family members, not Egas Wahs

*Do you want to find out if you or your family can get help paying for some or all of your health insurance? e @Yes ©No @I'mnotsure

Back Type Content Functions Mandatory Possible (¥/N/NA) Validation Static Do you want help paying for health coverage costs? Static Who needs health insurance? Title of the page Static * Required Information N/A RadioButton Who needs health insurance? Button selection Y Radio button must be e FirstName LastName selected only e FirstName LastName and other family members e Other family members. Not FirstName LastName Submit Button | Save and Continue Action: Mouse Click Keyboard: Enter Alt text: Save and Continue Submit Button | Back Action: Mouse Click Keyboard: Enter TN 13-0027-MM2 Attachment 3 Approval Date: 11/09/2015

State: Massachusetts Page 37 of 253 Effective Date: 07/17/2015

OFFICIAL

Type Content Functions Mandatory Possible {Y/N/NA) Validation

Alt text: Back

Do you want to find out if you can get help paying for health coverage? (YES)

Do you want help paying for health coverage costs?

* Mandatory Fields

* Who needs heatth insurance?

© Egas Wahs only © Egas Wahs and other family members © Other family members, not Egas Wahs

*Do you want to find out if you or your family can get help paying for some or all of your health insurance? oe @iYes ©No Ol'mnotsure

Back Type . Content Functions Mandatory Possible (¥/N/NA) Validation

Static Do you want to find out if you can get Title of the page n/a help paying for health coverage?

RadioButton Do you want to find out if you/your Button Selection Y If you click family can get help paying for health “yes” you can coverage? Yes then click

“save and

No continue” to

I’m not sure move forward with the application through the financial assistance flow

TN 13-0027-MM2 Attachment 3 Approval Date: 11/09/2015

State: Massachusetts Page 38 of 253 Effective Date: 07/17/2015

; OFFICIAL

Type Content Functions Mandatory Possible (¥/N/INA) Validation Tooltip If you choose ‘Yes,’ you'll answer Action: Show on questions about your income to see Mouseover; Hide on

what help you qualify for. if you choose _| Mouse Off ‘No,’ you’ll answer fewer questions, but . you won't be able to get help paying for | Keyboard: Tab coverage. If you’re not sure whether you want to apply for help, answer the questions in the tool below to see if you might be able to qualify.

Button Save & Continue Move to the next section of the application using the FINANCIAL ASSISTANCE flow

Button Back Takes the user to the previous page

TN 13-0027-MM2 Attachment 3 Approval Date: 11/09/2015 State: Massachusetts Page 39 of 253 Effective Date: 07/17/2015

OFFICIAL

Do you want to find out if you/your family can get help paying for health coverage? (NO)

Do you want help paying for health coverage costs?

*Mandatory Fields

* Who needs health insurance?

© Egas Wahs only @ Egas Wahs and other family members © Other family members, not Egas Wahs

*Do you want to find out if you or your family can get help paying for some or all of your health insurance? e @Yes @No Ol'mnotsure

You may be eligible for help with costs. Find out here! (optional)

Even working families can pay less for health coverage.You can be eligible for a free or low-cost ConnectorCare plan,MassHealth, or a tax credit that can be used to lower your monthly premiums right away.You can answer two questions to find out if you may be eligible for free or low-cost health insurance through the Massachusetts Health Connector or MassHeaith:

How many people will be on your federal income tax return for the year you want insurance? (If you aren't sure, tell us how many people live with you, including yourself.)

#

Based on your best guess, do you expect your total household income to be less than $ _ in the year you want health insurance?

oe

© Yes ©No © ldon'tknow

Back Type Content Functions Mandatory Possible {Y/N/NA) Validation Radio Button Do you want to find out if Yes Y If you click you/your family can get help “no” you will see static TN 13-0027-MM2 Attachment 3 Approval Date: 11/09/2015

State: Massachusetts Page 40 of 253 Effective Date: 07/17/2015

OFFICIAL

Type Content Functions _—'| Mandatory | Possible (Y/N/NA) Validation

paying for health coverage? No text on the screen and I’m not sure then you can click “save and continue” to move forward with the application through the NON-FA flow

Toolitp If you choose ‘Yes,’ you'll answer questions about your income to see what help you qualify for. if you choose ‘No,’ you'll answer fewer questions, but you won’t be able to get help paying for coverage. If you’re not sure whether you want to apply for help, answer the questions in the tool below to see if you might be able to qualify.

Static You will answer fewer questions, but you will not get help paying for health coverage.

Button Back Action: Mouse Click

Takes the user back to the previous page

Button Save and Continue Action: Mouse Click

User will move to the next section of the application using the NON- FINANCIAL ASSISTANCE flow

TN 13-0027-MM2 Attachment 3 Approval Date: 11/09/2015 State: Massachusetts Page 41 of 253 Effective Date: 07/17/2015

OFFICIAL

Do you want to find out if you/your family can get help paying for health coverage? (I’M NOT SURE)

Do you want help paying for health coverage costs?

* Mandatory Fields

* Who needs health insurance?

© Egas Wahs only ® Egas Wahs and other family members © Other family members, not Egas Wahs

'*Do you want to find out if you or your family can get help paying for some or all of your health insurance?

e ©Yes ©No @!'mnotsure

conieesarCane plan, MassHealth, or a tax credit that can be used to lower: your: ‘monthly premiums right away. You can answer two questions.to find out if you may be eligible for free or low-cost health insurance

_ through the Massachusetts Health Connector or MassHealth.

You may be eligible for help with costs. Find out here! (optional)

Even working families can pay less for health coverage.You can be eligible for a free or low-cost ConnectorCare plan,MassHealth, or a tax credit that can be used to lower your monthly premiums right away.You can answer two questions to find out if you may be eligible for free or low-cost health insurance through the Massachusetts Health Connector or MassHealth:

How many people will be on your federal income tax return for the year you want insurance? (If you aren’t sure, tell us how many people live with you, including yourself.)

#

Based on your best guess, do you expect your total household income to be less than $ _ in the year you want health insurance?

e

©Yes ©No ©ldon'tknow

TN 13-0027-MM2 Attachment 3 Approval Date: 11/09/2015 State: Massachusetts Page 42 of 253 Effective Date: 07/17/2015

ne OFFICIAL

Based on your best guess, do you expect your total household income to be less than $ _ in the year you want health insurance?

e @Yes ©No Ol don'tknow

application, change: your selection to "Yes" on ‘the question above this tool.

Based on your best guess, do you expect your total household income to be less than $ _ in the year you want health insurance?

e ®@yYes GINo © Idon'tknow

whether you can get help with costs. If you answer ‘No’ you will have fewer questions to answer but you definitely won't be able to get help paying for coverage.

Based on your best guess, do you expect your total household income to be less than $ _ in the year you want heatith insurance?

e © Yes ©No I don't know

for health coverage. To begin the application and see which programs you can qualify for, choose "Yes" on the question above this tool.

Type Content Functions Mandatory Possible (Y/N/NA) Validation Radio Button Do you want to find out if you/your Yes Y If you click family can get help paying for health “Vm not sure” coverage? No we will ask , you two I'm not sure questions to see whether

TN 13-0027-MM2 Attachment 3 Approval Date: 11/09/2015 State: Massachusetts Page 43 of 253 Effective Date: 07/17/2015

OFFICIAL

Type Content Functions Mandatory Possible (¥/N/NA) Validation

you may be eligible for free or low- cost health insurance

Tooltip If you choose ‘Yes,’ you’ll answer questions about your income to see what help you qualify for. if you choose ‘No,’ you'll answer fewer questions, but you won’t be able to get help paying for coverage. If you’re not sure whether you want to apply for help, answer the questions in the tool below to see if you might be able to qualify.

Static Even working families can pay less for health coverage. You can be eligible for a free or low-cost ConnectorCare plan, MassHealth, or a tax credit that can be used to lower your monthly premiums right away.

You can answer two questions to find out if you may be eligible for free or low-cost health insurance through the Massachusetts Health Connector or MassHealth.

How many people will be on -your N/A federal income tax return for the year Static you want insurance? (If you are not sure, tell us how many people live with you, including yourself.)

Numeric values N only Textbox # Static Based on your best guess, do you Yes N expect your total household income to be less than $ _ in the year you No want health insurance? t do not know Tooltip Please include income from all family members. If you are not sure what your household income is, make your best guess. Remember to consider any additional income like Social TN 13-0027-MM2 Attachment 3 Approval Date: 11/09/2015

State: Massachusetts Page 44 of 253 Effective Date: 07/17/2015

OFF

CIAL

Type Content Functions Mandatory Possible (¥/N/NA) Validation Security benefits, rental income, income from a job, income from a pension, and unemployment benefits. You don’t need to include child support or Supplemental Security Income (SSI). Dynamic Based on the information you entered | Response to here, it looks like you may be able to | question “Based on qualify for help paying for health your best guess, do coverage. you expect your total household To begin the application and see income to be less which programs you qualify for, than $_in the year change your selection to ‘Yes’ on the | you want health question above this tool. insurance?” Only shown if radio button is “Yes” Based on what you told us, your Response to income may be too high to get help question “Based on paying for health insurance. You may | your best guess, do still want to answer ‘Yes’ to the you expect your question above this tool if you want total household to find out for sure whether you can income to be less get help with costs. If you answer ‘No’ | than $_ in the year you will have fewer questions to you want health answer but you definitely won’t be insurance?” able to get help paying for coverage. Only shown if radio button is “No” Based on the information you entered | Response to here, it looks like you may be able to question “Based on qualify for help paying for health your best guess, do coverage. you expect your total household To begin the application and see income to be less which programs you can qualify for, | than $_ in the year choose ‘Yes’ on the question above you want health this tool. insurance?” Only shown if radio button is “t do not know” Button Save and Continue Only shown if Yes

or No are selected to the question “Do you want to find out if you can

TN 13-0027-MM2 State: Massachusetts

Attachment 3 Page 45 of 253

Approval Date: 11/09/2015 Effective Date: 07/17/2015

OFFICIAL

Type Content Functions Mandatory Possible (¥/N/NA) Validation

get help paying for ' health coverage?”

The user needs to select yés or no in order to continue with the application through the financial assistance or non- financial assistance flow

Button Back Takes the user to the previous page

TN 13-0027-MM2 Attachment 3 Approval Date: 11/09/2015 State: Massachusetts Page 46 of 253 Effective Date: 07/17/2015

OFFICIAL —

1.1 How Many Are Applying for Health Insurance?

©

Click here for more information on who to include on your application.

How Many are Applying for Health Insurance?

How many people in your family and household want health insurance? Include yourself.

Include your spouse or domestic partner, anyone you claim as dependents on your tax return, anyone under age 19 who you take care of and lives with you, and any unborn children you are expecting.

Ifyou are married, you must file taxes jointly to qualify for an Advance Premium Tax Credit, unless you are a victim of domestic abuse or an abandoned spouse.

Back Type Content Functions Mandatory Possible (Y/N/NA) Validation

Static How Many are Applying for Health N/A

Insurance? + Button How many people in your family and Increase the

household want health insurance? numeric value

Include yourself. - Button How many people in your family and Decrease the

household want health insurance? numeric value

Include yourself. On-screen Include your spouse or domestic Link to CCA page text — partner, anyone you claim as SUBSIDIZED dependents on your tax return, anyone | https://www.mahe APPLICATION | under age 19 who you take care of and | althconnector.org/s

lives with you, and any unborn children | tart

you are expecting.

If you are married, you must file taxes

jointly to qualify for an Advance

Premium Tax Credit, unless you are a

victim of domestic abuse or an

abandoned spouse.

TN 13-0027-MM2 State: Massachusetts

Attachment 3 Page 47 of 253

Approval Date: 11/09/2015 Effective Date: 07/17/2015

OFFICIA

Click .here:for more information:on who. to include on your application. On-screen Use this application for yourself and Link to CCA page text — anyone in your household who needs UNSUBSIDIZE | health or dental insurance coverage. https://www.mahe D ; People in your household could include | althconnector.org/s | APPLICATION | a spouse or domestic partner, a child tart under the age of 26, or a child over the age of 25 if they have a disability. Click:here:for more information on-who to.include on your application. Submit Button | Save and Continue Action: Mouse Click Keyboard: Enter Alt text: Save and Continue Submit Button | Back Action: Mouse Click Keyboard: Enter Alt text: Back TN 13-0027-MM2 Attachment 3 Approval Date: 11/09/2015

State: Massachusetts

Page 48 of 253

Effective Date: 07/17/2015

bsg OFFICIAL

1.2 Who is Applying for Health insurance?

Who is Applying for Health Insurance

Applicant 1 (Head of Household)

* First Name Middle Name * Last Name Suffix

Egas Wahs | [suffer ~:

*

Date of Birth (MM/DD/YYYY) 10/12/1981

Applicant 2

* First Name Middle Name * Last Name Suffix

Child Wahs Suffix

*Date of Birth (MM/DD/YYYY) 10/15/2012

Back Type Content Functions Mandatory Possible (Y/N/NA) Validation Static Who is Applying for Health N/A Insurance

Static Applicant 1 (Head of Household) N/A Y

Textbox First Name Alphabetic Entry Y Pulls contact details from Head of Household Information

TN 13-0027-MM2 Attachment 3 Approval Date: 11/09/2015

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OFFICIAL

Type Content Functions Mandatory Possible (¥/N/NA) Validation

page

Textbox Middle Name Alphabetic Entry N Pulls contact : details from Head of Household Information

page .

Textbox Last Name Alphabetic Entry Y Pulls contact details from Head of Household Information page

Dropdown Suffix : Jr. Sr. Ill, IV Choose from N Pulls contact dropdown list of details from Head of Household Information page

Jr. Sr. IM, IV

Textbox Date of Birth Date Format Y Pulls contact details from Numeric Entry Head of Household Information page

Static Applicant 2 N/A This should only appear if the response to the previous question, “dow many people in your family and household want health insurance? Include yourself” is

TN 13-0027-MM2 Attachment 3 Approval Date: 11/09/2015 State: Massachusetts . Page 50 of 253 Effective Date: 07/17/2015

wn : OFFICIAL

Type Content Functions Mandatory Possible (¥/N/NA) Validation greater than 1 Textbox First Name Alphabetic Entry Y Textbox Middle Name Alphabetic Entry Textbox Last Name Alphabetic Entry Y Dropdown Suffix Choose from the dropdown list of Jr. Sr. Ill, (V Textbox Date of Birth Date Format Y Numeric Entry

1.3 Who is Applying for Health Insurance Summary

Who is Applying for Health Insurance Summary

You are applying for health insurance for these people:

Egas Wahs (Head of Household)

Date of Birth 10/12/1981 Child Wahs Date of Birth 10/15/2012 Back Type Content Functions Mandatory Possible (Y/N/NA) Validation Static Who is Applying for Health N/A Insurance Summary Static You are applying for health insurance for these people: N/A Static FirstName LastName (Head of Alphabetic Entry (is this Household) auto-populated from TN 13-0027-MM2 Attachment 3 Approval Date: 11/09/2015

State: Massachusetts Page 51 of 253 Effective Date: 07/17/2015

OFFICIAL

Type Content Functions Mandatory Possible

(Y/N/NA) ° | Validation

previous page)

Display

Date of Birth

Date Format

Auto-populated from previous screen

Static

FirstName LastName

Alphabetic Entry (is this auto-populated from previous page)

Display

Date of Birth

Date Format

Auto-populated from previous screen

Submit Button

Save and Continue

Action: Mouse Click

Keyboard: Enter Alt text: Save and Continue

Submit Button

Back

Action: Mouse Click

Keyboard: Enter Alt text: Back

TN 13-0027-MM2

State: Massachusetts

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- OFFICIAL

1 Family and Household

Family & Household

In this section, we will ask questions about everyone included on your federal income tax return {if you file taxes) and all family members who live with you, even if they are not applying for health insurance. These questions will help us match you with the right financial assistance programs. if you need help filling out this section, please call Customer Service at 1-877-MA-ENROLL (1-877-623-6765), TTY 1-877-623-7773. You can also get help from a local Navigator or Certified Application Counselor (CAC) through the "Get Assistance” page.

All fields on the Family & Household section are required unless otherwise indicated.

, Call Customer Service at 1-877-

You may need: MA-ENROLL (1-877-623-6765), TTY 1-877-623-7773 for assistance. Support is » Social Security numbers available in all languages. » Document numbers for any people with eligible immigration status who need insurance > Birth dates

© Estimated time for this section: 10 Minutes - 15 Minutes

Type Content Functions Mandatory | Possible (Y/N/NA) | Validation

Static In this section, we will ask questions about everyone included on your federal income https://www.mahealthco tax return (if you file taxes) and all family nnector.org/enrollment-

members who live with you, even if they are | assisters not applying for health insurance. These questions will help us match you with the right financial assistance programs.

if you need help filling out this section, please call Customer Service at 1-877-MA- ENROLL (1-877-623-6765), TTY 1-877-623- 7773. You can also get help from a local Navigator or Certified Application Counselor (CAC) through the “Get Assistance” page.

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Type Content : Functions Mandatory | Possible : (¥/N/NA) Validation

All fields on the Family & Household section are required unless otherwise indicated

Static You may Need: N/A Social Security numbers

Documents aumbers-for any people with an eligible immigration status who need insurance

Birth dates

Static Estimated time for this section: 10 Minutes— | N/A 15 Minutes

Submit Continue Action: Mouse Click Button Keyboard: Enter

Alt text: Continue

1.1 Tell Us About Your Household

Tell Us About Your Household

*if Egas Wahs gets an Advance Premium Tax Credit to help pay for health insurance in 2015, do they agree to file a federal income tax return for tax year 2015? - Egas Wahs may not have needed or chosen to a file federal income tax return in the past, but they will have to file a federal income tax return for any year that they get an Advance Premium Tax Credit. Egas Wahs must check ‘Yes’ to get ConnectorCare or Advance Premium Tax Credit to help pay for their health insurance

©Yes ONo Back Type Content Functions Mandatory Possible (Y/N/NA) Validation Static Tell Us About Your Household N/A RadioButton If FULL_LEGAL_NAME gets an Button selection Advance Premium Tax Credit to TN 13-0027-MM2 Attachment 3 Approval Date: 11/09/2015

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Type Content Functions Mandatory Possible (Y/N/NA) Validation help pay for health insurance in Yes, No 2015, do they agree to file a federal income tax return for tax year 2015?

FULL_LEGAL_NAME may not have needed or chosen to a file federal income tax return in the past, but they will have to file a federal income tax return for any year that they get an Advance Premium Tax Credit. FULL_LEGAL_NAME must check ‘yes’ to get ConnectorCare or Advance Premium Tax Credit to help pay for their health insurance.

Tell Us About Your Household

*If Egas Wahs gets an Advance Premium Tax Credit to help pay for health insurance in 2015, do they agree to file a federal income tax return for tax year 2015? Egas Wahs may not have needed or chosen to a file federal income tax return in the past, but they will have to file a federal income tax return for any year that they get an Advance Premium Tax Credit. Egas Wahs must check ‘Yes’ to get ConnectorCare or Advance Premium Tax Credit to help pay for their health insurance

@Yes @No *\s Egas Wahs considered married for tax filing purposes? @ © Yes ONo Back Type Content Functions Mandatory Possible (Y/N/NA) Validation Radio Button Is [First name] [Last name] Button selection considered married for tax filing purposes? Yes, No Tooltip Answer ‘No’ if you: Will be divorced or legally TN 13-0027-MM2 Attachment 3 Approval Date: 11/09/2015

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separated as of December 31

Are married, but will file taxes next year as Head of Household. People who are married can qualify to file as Head of Household if they live apart from their spouse for the fast 6 months of the tax year and claim at least one other person as a dependent on their taxes. See IRS Publication 501 for more information about filing as Head of Household. If you are unsure whether you will qualify to file as Head of Household, you should consult a tax professional.

Tell Us About Your Household

*If Egas Wahs gets an Advance Premium Tax Credit to help pay for health insurance in 2015, do they agree to file a federal income tax return for tax year 2015? Egas Wahs may not have needed or chosen to a file federal income tax return in the past, but they will have to file a federal income tax return for any year that they get an Advance Premium Tax Credit. Egas Wahs must check ‘Yes’ to get ConnectorCare or Advance Premium Tax Credit to help pay for their health insurance @Yes ©No

*Is Egas Wahs considered married for tax filing purposes? @ @Yes ©No

*Important: Egas Wahs must file a joint income tax return with his or her spouse for 2015 to qualify for certain programs, unless they are a victim of domestic abuse or abandonment. Does Egas Wahs plan to file a joint federal income tax return with his or her spouse for 2015? @ © Yes ©No

Back Type Content Functions Mandatory Possible (¥/N/NA) Validation RadioButton Important: FirstName LastName Button selection Yes must file a joint income tax return : with his or her spouse for 2015to | Yes, No qualify for certain programs, unless they are a victim of domestic abuse or abandonment. Does FirstName TN 13-0027-MM2 Attachment 3 Approval Date: 11/09/2015

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LastName plan to file a joint federal income tax return with his or her spouse for 2015?

Tooltip

Usually, you can only get a tax credit to lower your monthly premiums if you file a joint tax return with your spouse.

However, if you are filing taxes separately because you are a victim of domestic abuse or an abandoned spouse, you may still be able to qualify for a tax credit. Answer ‘No’ to the question about filing taxes jointly. We'll ask you a few more questions about your situation later on in the application. Remember, we won’t share your answers to these questions, or any others in your application.

Added to above question:

FirstName LastName must file a joint income tax with his or her spouse for 2015 to get an Advance Premium Tax Credit or ConnectorCare plan. Does FirstName LastName plan to file a Joint federal income tax return with his or her spouse for 2015?

n/a

n/a

@Yes ©No

© Child Wahs

*Who is Egas Wahs's spouse?

Someone else not seeking health insurance

*Important: Egas Wahs must file a joint income tax return with his or her spouse for 2015 to qualify for certain programs, unless they are a victim of domestic abuse or abandonment. Does Egas Wahs plan to file a joint federal income tax return with his or her spouse for 2015? @

Spouse Name *First Name Middle Name *Last Name Suffix Suffix | *Date of Birth (MM/DD/YYYY) Back TN 13-0027-MM2 Attachment 3 Approval Date: 11/09/2015

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RadioButton Who is FirstName LastName’s Button selection spouse? e FirstName LastName « Someone else not seeking health insurance Textbox Spouse Name First Name If “someone else not Middle Name seeking Last Name health ps insurance” is Suffix checked Date Date of Birth MM/DD/YYYY Y If “someone else not seeking health insurance” is checked

payments

@Yes ©No fF) Child Wans Someone else not seeking health insurance

*Will Egas Wahs claim any dependents on their federal income tax return for 2015? Egas Wahs will claim a personal exemption deduction on their 2015 federal income tax return for any individual listed on this application as a dependent who is enrolled in coverage through the Massachusetts Health Connector and whose premium for coverage is paid in whole or in part by advance

Back Type Content Functions Mandatory Possible (Y/N/NA) Validation

RadioButton Will FirstName LastName and Button selection Yes

FirstName LastName claim any

dependents on their federal Yes, No

income tax for 2015? FirstName

LastName will claim a personal

exemption deduction on their 2015 TN 13-0027-MM2 Attachment 3 Approval Date: 11/09/2015

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federal income tax return for any individual listed on this application as a dependent who is enrolled in coverage through the Massachusetts Health Connector and whose premium for coverage is paid in whole or in part by advance payments.

Checkbox

FirstName LastName

Someone else not seeking health insurance

If FirstName LastName select “yes” to claim dependents, then other household members will be shown in this area

If “someone else not seeking health insurance” is selected the following fields will appear:

Dependent Name* First Name

Middle Name

Last Name

Suffix

Date of Birth*

MM/DD/YYYY

Button

+ Add Dependent

Shown if “Someone else not seeking health insurance” is selected

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claimed as a dependent on someone else’s federal income tax return for 2015?

If you are claimed by someone else as a dependent on their 2015 federal income tax return, this may affect your ability to receive a premium tax credit.* Do not answer yes to this question if this is a child under the age of 21 being claimed by a non-custodial parent.

*Who is the tax filer that will claim Egas Wahs on their income tax return? If Egas Wahs is claimed by a married couple filing a joint tax return, select either spouse below © Child Wahs © Spouse Wahs ©) Someone else not seeking health insurance Tax filer Name *First Name Middie Name *Last Name Suffix | Suffix *Date of Birth (MM/DD/YYYY) Back Type Content Functions Mandatory Possible (¥/N/NA) Validation Radiobutton Will FirstName LastName be _

Information box

Do not answer yes to this question if this is a child under the age of 21 being claimed by a non-custodial

Once this is added as an

information box, remove it from the

parent. question above TN 13-0027-MM2 Attachment 3 Approval Date: 11/09/2015

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*Will Egas Wahs claim any dependents on their federal income tax return for 2015? Egas Wahs will claim a personal exemption deduction on their 2015 federal income tax return for any individual listed on this application as a dependent who is enrolled in coverage through the Massachusetts Health Connector and whose premium for coverage is paid in whole or in part by advance payments @Yes ©No

Child Wahs Someone else not seeking health insurance

*How is Child Wahs related to Egas Wahs? Child

*How is Child Wahs related to Spouse Wahs?

Child

Back

Type Content Functions Mandatory Possible (Y/N/NA) Validation

Dropdown How is FirstName LastName Full list of choices: related to FirstName LastName? Child

Child-in-law

Child of parent’s domestic partner

Cousin

Domestic partner Former spouse Foster child Foster parent Grandchild Grandparent Guardian

Nephew/Niece

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Other relative Parent

Parent-in-law

“Parent’s domestic

partner Sibling/Stepsibling Sibling-in-law Spouse

Stepchild Stepparent Uncle/Aunt Unrelated

Ward

*Does Child Wahs live with Egas Wahs and/or Spouse Wahs?

Yes ©No

Back

RadioButton

Does FirstName LastName live with FirstName LastName and/or FirstName LastName

Button selection

Yes, No

Submit Button Save and Continue Action: Mouse Click Keyboard: Enter Alt text: Save and Continue

Submit Button Back Action: Mouse Click

Keyboard: Enter Alt text: Back

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1.1 Personal Information

Egas Wahs - Personal Information.

» Mandatory Field

*Sex @ Male © Female

*Does Egas Wahs have a Social Security Number? @Yes ONo

We need a 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 on the Social Security Administration website or i the MassHealth Member Booklet for more information. :

*Social Security Number

7

*\Is Egas Wahs the same name that appears on his/her Social Security card? ©ves GINo

Enter the same name as shown on Egas Wahs's Social Security Card * First Name Middle Name * Last Name Suffix

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Egas Wahs - Personal Information

» Mandatory Field

*Sex @Male © Female

*Does Egas Wahs have a Social Security Number?

@Yes @No

We need a 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 soclalsecurity gov . Please see the application instructions on the Social Security Administration website or

the MassHeaith Member Booklet for more information.

*{f no Social Security Number is available please select from the following explanations

Select explanation

xplanation = Illness Exception lust Applied Non-Citizen Exception Religious Exception

Type Content _ | Functions Mandatory Possible (¥/N/NA) Validation Static FirstName LastName — Personal N/A Information Radio Sex* Male, Female Yes Button Radio Does First Name Last Name havea _ | Yes, No Yes Button Social Security Number? Static We need a social security number for every person applying for health | On mouse click, open in new coverage who has one. An SSN is window/tab: optional for persons not applying http://www.mass.gov/eohhs/ for health coverage, but giving us gov/departments/masshealth an SSN can speed up the /applications-and-member- application process. We use SSNs to | forms.html check income and other information to see who is eligible for help with health coverage costs. If someone needs help getting an TN 13-0027-MM2 Attachment 3 Approval Date: 11/09/2015

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Type Content Functions Mandatory Possible (¥/N/NA) Validation 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 on the Social Security Administration website or the MassHealth Member Booklet for more information. Textbox Social Security Number Numeric Value Only a total Text box 1: 3 numeric digits of 9 Text box 2: 2 numeric digits characters Text box 3: 4 numeric digits should be accepted, hyphens automaticall y insert or layout should contain 3 boxes. This information is mandatory only if the previous question of “Do you have a Social Security Number?” has been answered as “YES” Dropdown | If no Social Security Number is if the answer Is “no” to “Does available please select from the First Name Last Name have a following explanations Social Security Number?” Illness Exception Just Applied Non-Citizen Exception Religious Exception Radio ls FirstName LastName the same Yes, No Button name that appears on his/her Social Security card? Static Enter the same name as shown on Only if the name above is FirstName LastName’s Social different from the Social Security card Security card (if radio button selection in row above is “No”)

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Type Content Functions Mandatory Possible . (Y/N/NA) Validation Textbox FirstName Three separate alphabetic Only if the MiddleName value fields (First, Middle, Last name above LastName Names) Is different Suffix Dropdown field for Suffix from the Social : Security card Submit Save and Continue Action: Mouse Click Button Keyboard: Enter Alt text: Save and Continue Button Back Action: Mouse Click

Keyboard: Enter Alt text: Back

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1.1 Citizenship/Immigration Status

Egas Wahs - Citizenship/Immigration Status

More information on Immigration Document Types

» Mandatory Field

*Is Egas Wahs a U.S. Citizen or U.S. National? © @Yes ONo

*Is Egas Wahs a naturalized citizen? © Yes ©No Document Type (select one) © Naturalization certificate * Alien Number: , * Naturalization Certificate Number:

(J tdon't have one.

© Certificate of citizenship * Alien Number: * Citizenship Number: At

C Idon't have one.

Back Type Content Functions Mandatory Possible {Y/N/NA) Validation Static FirstName LastName — N/A Citizenship/Immigration Status URL More information on Immigration | Link to Immigration Document Types guide https://www.mahealt hconnector.org/immig TN 13-0027-MM2 Attachment 3 Approval Date: 11/09/2015

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Type Content Functions Mandatory Possible (Y/N/NA) Validation ration-document- types RadioButton Is FirstName LastName a U.S. Button selection citizen or U.S. National? . Yes, No <this scenario the button selected is “Yes”> Tooltip AUS. citizen is someone who was _ | Action: Show on born in the United States or has Mouseover; Hide on been naturalized as a U.S. citizen Mouse Off (became a U.S. citizen after birth). Keyboard: Tab AUS. national is someone who is aU.S. citizen or a person who is not a U.S. citizen, but owes permanent allegiance to the U.S. (like people born in American Samoa or Swains island) RadioButton Is FirstName LastName a Button selection naturalized citizen? Yes, No Tooltip A naturalized citizen is a person Action: Show on who was not born as a U.S. citizen | Mouseover; Hide on but became one later on. A Mouse Off naturalized citizen can have either a ‘Certificate of Naturalization’ Keyboard: Tab (Form N-500) or a ‘Certificate of Citizenship’ (Form N-560 or N- 561). RadioButton Is FirstName LastName an Conditional

honorably discharged veteran or active duty member of the military, or the spouse or child of an honorably discharged veteran or active duty member of the military?

Only shown if “No” to “(s FirstName LastName a US citizen or US national?”

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Egas Wahs - Citizenship/Immigration Status

More information on Immigration Document Types

* Mandatory Field

*Is Egas Wahs a U.S. Citizen or U.S. National? © ©Yes @No

Check this box if Egas Wahs has an eligible immigration status:

Federal Services will try to verify your immigration status. See the member booklet for more information about immigration statuses. Check the box above to view the list of eligible immigration statuses and select an option, if applicable.

Is Egas Wahs an honorably discharged veteran or active duty member of the military, or the spouse or child of an honorably discharged veteran or active duty member of the military? © Yes ©No

Back Type Content Functions Mandatory Possible (¥/N/NA) Validation Radio Button Is FirstName LastName a U.S. Button selection Citizen or U.S. National? Yes, No <this scenario the button selected is “no”> Checkbox Check this box if FirstName Checkbox selection LastName has an eligible immigration status: Button Selection Document Type (Select one) Static (before Federal Services will try to verify below your immigration status. See the checkbox is member booklet for more http://www.mass.go checked) information about immigration v/eohhs/gov/depart statuses. Check the box above to | ments/massheaith/a view the list of eligible pplications-and- immigration statuses and select an | Member-forms.html option, if applicable. . RadioButton Is FirstName LastName an Conditional honorably discharged veteran or , , active duty member of the Only shown if “No” to TN 13-0027-MM2 Attachment 3 Approval Date: 11/09/2015

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military, or the spouse or child of an honorably discharged veteran or active duty member of the military?

“Is FirstName LastName a US citizen or US national?”

Min Max

Length Length YorN A Number of applicant String Applicant I-94 Number (admission number) SEVIS 1D of applicant Note to End User: SEVIS IDs start with the letter N Sevisid followed by 10 digits. In 10 10 | String {N | this interface, remove the leading letter N and pass only the 10 digits. Foreign Passport Number of applicant applying for 6 12 | String N benefit(s) CO! code for passport presented to SAVE Note: This field is Y-If required if a Passport Passport Number exists in the 1 5 | String Number PassportNumber field. : is See Table 105 - COI present Codes for a list of valid country codes. Visa Number of applicant 8 8 | String N Receipt or card number of applicant Note: The Receipt . Number is 13 characters . ReceiptNumber long, with the first 3 13 13 | String N characters alpha and the remaining 10 characters numeric. Naturalization Certificate number of applicant 7 12 | String N for benefit(s)

Required

Data Element Description

AlienNumber

194Number 11 11 | String N

PassportNumber

CountryOflssuance

VisaNumber

NaturalizationNumber

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