002 MassHealth Standard

(A) Overview. (1) 130 CMR 505.002 contains the categorical requirements and financial standards for MassHealth Standard serving children, young adults, parents, caretaker relatives, people who are pregnant, disabled individuals, certain individuals with breast or cervical cancer, certain individuals who are HIV positive, independent foster-care adolescents, Department of Mental Health members, and medically frail as such term is defined in 130 CMR 505.008(F). (2) Persons who receive Supplemental Security Income (SSI) benefits from the Social Security Administration (SSA) are eligible for MassHealth Standard. (3) Persons who receive Transitional Aid to Families with Dependent Children (TAFDC) cash assistance from the Department of Transitional Assistance (DTA) are eligible for MassHealth Standard. (4) Children, adults, and parents and caretaker relatives who receive Emergency Aid to the Elderly, Disabled and Children (EAEDC) cash assistance are eligible for MassHealth Standard if they meet the citizenship and immigration requirements described at 130 CMR 504.002: U.S. Citizens and 130 CMR 504.003(A)(1): Qualified Noncitizens, (2): Qualified Noncitizens Barred, and (3): Nonqualified Individuals Lawfully Present. (5) Persons who do not otherwise meet the requirements of 130 CMR 505.002, but who meet the AFDC rules that were in effect on July 16, 1996, are eligible for MassHealth Standard. (6) Persons eligible for MassHealth Standard coverage are eligible for medical benefits as described at 130 CMR 450.105(A): MassHealth Standard and 130 CMR 508.000: MassHealth: Managed Care Requirements. (B) Eligibility Requirements for Children and Young Adults. Children and young adults may establish eligibility for MassHealth Standard coverage subject to the requirements described in 130 CMR 505.002(B). (1) Children Younger than One Year Old. (a) A child younger than one year old born to an individual who was not receiving MassHealth Standard on the date of the child's birth is eligible if 1. the modified adjusted gross income of the MassHealth MAGI household is less than or equal to 200% of the federal poverty level (FPL); and 2. the child is a citizen as described in 130 CMR 504.002: U.S. Citizens or a lawfully present immigrant as described in 130 CMR 504.003(A): Lawfully Present Immigrants. (b) A child born to an individual who was receiving MassHealth on the date of the child's birth is automatically eligible for one year and is exempt from the requirement to provide verification of citizenship and identity. (c) A child receiving MassHealth Standard who receives inpatient services on the date of their first birthday remains eligible until the end of the stay for which the inpatient services are furnished. (2) Children One through 18 Years Old. (a) A child one through 18 years old is eligible if 1. the modified adjusted gross income of the MassHealth MAGI household is less than or equal to 150% of the FPL; and 2. the child is a citizen as described in 130 CMR 504.002: U.S. Citizens or a lawfully present immigrant as described in 130 CMR 504.003(A): Lawfully Present Immigrants. (b) Eligibility for a child who is pregnant is determined under 130 CMR 505.002(D). (3) Young Adults 19 through 20 Years Old. (a) A young adult is eligible if 1. the modified adjusted gross income of the MassHealth MAGI household is less than or equal to 150% of the FPL; and 2. the young adult is a citizen as described in 130 CMR 504.002: U.S. Citizens or a lawfully present immigrant as described in 130 CMR 504.003(A): Lawfully Present Immigrants. (b) A young adult receiving MassHealth Standard who receives inpatient services on the date of their 21st birthday remains eligible until the end of the stay for which the inpatient services are furnished. (c) Eligibility for a young adult who is pregnant is determined under 130 CMR 505.002(D). (C) Eligibility Requirements for Parents and Caretaker Relatives. (1) A parent or caretaker relative of a child younger than 19 years old is eligible for MassHealth Standard coverage if (a) the modified adjusted gross income of the MassHealth MAGI household is less than or equal to 133% of the FPL; (b) the individual is a citizen as described at 130 CMR 504.002: U.S. Citizens or a qualified noncitizen as described in 130 CMR 504.003(A)(1): Qualified Noncitizens; and (c) 1. the parent lives with their children, and assumes primary responsibility for the child’s care, in the case of a parent who is separated or divorced, has custody of their children, or has children who are absent from home to attend school; or 2. the caretaker relative lives with children to whom they are related by blood, adoption, or marriage (including stepsiblings), or is a spouse or former spouse of one of those relatives, and assumes primary responsibility for the child’s care if neither parent lives in the home. (2) The parent or caretaker relative complies with 130 CMR 505.002(M). (D) Eligibility Requirements for People who are Pregnant. (1) A person who is pregnant is eligible if (a) the modified adjusted gross income of the MassHealth MAGI household is less than or equal to 200% of the FPL; and (b) the individual is a citizen as described in 130 CMR 504.002: U.S. Citizens, lawfully present immigrant, nonqualified PRUCOL, or other noncitizen as described in 130 CMR 504.003: Immigrants. (2) In determining the MassHealth MAGI household size, the unborn child or children are counted as if born and living with the person. (3) Eligibility, once established, continues for the duration of the pregnancy. (4) Eligibility for postpartum care for pregnant individuals who meet the requirements of 130 CMR 505.002(B)(2) and (3), (C) through (H), and (L) continues for 12 months following the termination of the pregnancy plus an additional period extending to the end of the month in which the 12-month period ends. (E) Disabled Individuals. (1) Disabled Adults. A disabled adult 21 through 64 years old or a disabled young adult 19 through 20 years old who does not meet the requirements described at 130 CMR 505.002(B)(3)(a)1. is eligible for MassHealth Standard coverage if they meet the following requirements: (a) the individual is permanently and totally disabled as defined in 130 CMR 501.001: Definition of Terms; (b) the modified adjusted gross income of the MassHealth Disabled Adult household as described in 130 CMR 506.002(C): MassHealth Disabled Adult Household is less than or equal to 133% of the FPL, or the individual is eligible under § 1634 of the Social Security Act (42 U.S.C. § 1383c) as a disabled adult child or as a disabled widow or widower, or is eligible under the provisions of the Pickle Amendment as described at 130 CMR 519.003: Pickle Amendment Cases; (c) the individual is a citizen as described in 130 CMR 504.002: U.S. Citizens or a qualified noncitizen as described in 130 CMR 504.003(A)(1): Qualified Noncitizens; and (d) the individual complies with 130 CMR 505.002(M). (2) Determination of Disability. Disability is established by (a) certification of legal blindness by the Massachusetts Commission for the Blind (MCB); (b) a determination of disability by the SSA; or (c) a determination of disability by the Disability Evaluation Services (DES). (3) Extended MassHealth Eligibility. Disabled persons whose SSI disability assistance has been terminated and who are determined to be potentially eligible for MassHealth continue to receive MassHealth Standard until the MassHealth agency makes a determination of ineligibility. (F) Individuals with Breast or Cervical Cancer. (1) Eligibility Requirements. An individual with breast or cervical cancer is eligible for MassHealth Standard coverage if they meet all the following requirements: (a) the individual is younger than 65 years old; (b) the individual has been certified by a physician to need treatment for breast or cervical cancer, including precancerous conditions; (c) the modified adjusted gross income of the MassHealth MAGI household is less than or equal to 250% of the federal poverty level (FPL); (d) for individuals with breast or cervical cancer whose MassHealth MAGI household modified adjusted gross income is greater than 133% of the FPL, but does not exceed 250% of the FPL, the individual must 1. be uninsured; or 2. have insurance that does not provide creditable coverage. An individual is not considered to have creditable coverage when the individual is in a period of exclusion for treatment of breast or cervical cancer, has exhausted the lifetime limit on all benefits under the plan, including treatment of breast or cervical cancer, or has limited scope coverage or coverage only for specified illness; or 3. be an American Indian or Alaska Native who is provided care through a medical care program of the Indian Health Service or of a tribal organization; (e) the individual is a citizen as described in 130 CMR 504.002: U.S. Citizens or a qualified noncitizen as described in 130 CMR 504.003(A)(1): Qualified Noncitizens; and (f) the individual does not otherwise meet the requirements for MassHealth Standard described at 130 CMR 505.002(B) through (E). (2) Premiums. Individuals who meet the requirements of 130 CMR 505.002(F) are assessed a monthly premium in accordance with 130 CMR 506.011: MassHealth and the Children’s Medical Security Plan (CMSP) Premiums. (3) Duration of Eligibility. Individuals meeting the requirements of 130 CMR 505.002(F) are eligible for MassHealth Standard for the duration of their cancer treatment. (G) Eligibility Requirements for Individuals Who Are HIV Positive. An individual who is HIV positive is eligible for MassHealth Standard coverage if (1) the individual is younger than 65 years old; (2) the individual has verified their HIV positive status by providing a letter from doctor, qualifying health clinic, laboratory, or AIDS service provider or organization. The letter must indicate the individual’s name and their HIV-positive status; (3) the modified adjusted gross income of the MassHealth MAGI household is less than or equal to 133% of the FPL; (4) the individual is a citizen as described in 130 CMR 504.002: U.S. Citizens or a qualified noncitizen as described in 130 CMR 504.003(A)(1): Qualified Noncitizens; and (5) the individual does not meet the requirements for MassHealth Standard described at 130 CMR 505.002(B) through (E). (H) Eligibility Requirements for Former Foster-care Individuals. (1) An individual who was in foster care under the responsibility of a state or tribe and enrolled in Medicaid coverage on their 18th birthday, or later date of aging out, receives MassHealth Standard coverage until (a) their 26th birthday if the individual is a citizen, as described at 130 CMR 504.002: U.S. Citizens, or qualified noncitizen, as described at 130 CMR 504.003(A)(1): Qualified Noncitizens; or (b) their 21st birthday if the individual is a qualified noncitizen barred, as described at 130 CMR 504.003(A)(2): Qualified Noncitizens Barred, or a nonqualified individual lawfully present, as described at 130 CMR 504.003(A)(3): Nonqualified Individuals Lawfully Present. (2) An individual who was in foster care under the responsibility of a state or tribe on their 18th birthday and not enrolled in Medicaid coverage receives MassHealth Standard coverage until their 21st birthday if the individual is a citizen, as described at 130 CMR 504.002: U.S.US Citizens, a qualified noncitizen as described at 130 CMR 504.003(A)(1): Qualified Noncitizens, a qualified noncitizen barred, as described at 130 CMR 504.003(A)(2): Qualified Noncitizens Barred, or a nonqualified individual lawfully present, as described at 130 CMR 504.003(A)(3): Nonqualified Individuals Lawfully Present. (I) Eligibility Requirements for Department of Mental Health (DMH) Members. An individual who receives services from the DMH, or has been determined eligible for such services and is on a waiting list, is eligible for MassHealth Standard if the individual (1) is younger than 65 years old; (2) has modified adjusted gross income of the MassHealth MAGI household of less than or equal to 133% of the FPL; (3) is a citizen as described at CMR 504.002: U.S. Citizens or qualified noncitizen as described at 130 CMR 504.003(A)(1): Qualified Noncitizens; and (4) is not otherwise eligible for MassHealth Standard. (J) Eligibility Requirements for Individuals Who Are Medically Frail. An individual who is medically frail is eligible for MassHealth Standard if the individual (1) is younger than 65 years old; (2) is medically frail as defined at 130 CMR 505.008(F); (3) has modified adjusted gross income of the MassHealth MAGI household of less than or equal to 133% of the FPL; (4) is a citizen as described at 130 CMR 504.002: U.S. Citizens or qualified noncitizen as described at 130 CMR 504.003(A)(1): Qualified Noncitizens; and (5) has been determined to meet the eligibility criteria for MassHealth CarePlus and has elected to receive MassHealth Standard benefits. (K) Eligibility Requirements for Certain Emergency Aid to the Elderly, Disabled and Children (EAEDC) Recipients. (1) Eligibility Requirements. Certain EAEDC recipients are eligible for MassHealth Standard. if (a) the individual is 1. a child and is a citizen as defined in 130 CMR 504.002: U.S. Citizens or a lawfully present immigrant as defined in 130 CMR 504.003(A): Lawfully Present Immigrants; 2. the individual is a young adult and is a citizen as defined in 130 CMR 504.002: U.S. Citizens or a lawfully present immigrant as defined in 130 CMR 504.003(A): Lawfully Present Immigrants; 3. the individual is a parent or caretaker relative and is a citizen as defined in 130 CMR 504.002: U.S. Citizens or a qualified noncitizen as defined in 130 CMR 504.003(A)(1): Qualified Noncitizens; 4. the individual is an adult 21 to 64 and is a citizen as defined in 130 CMR 504.002: U.S. Citizens or a qualified noncitizen as defined in 130 CMR 504.003(A)(1): Qualified Noncitizens; and (b) the individual receives EAEDC cash assistance. (2) Eligibility End Date. Individuals whose EAEDC cash assistance terminates and who are determined to be potentially eligible for MassHealth continue to receive medical benefits under MassHealth Standard until a determination of ineligibility is made by MassHealth. (L) Extended Eligibility. (1) Members of an EAEDC or Transitional Aid to Families with Dependent Children (TAFDC) household whose cash assistance terminates continue to receive four months of MassHealth Standard, or Family Assistance (if enrolled in Family Assistance), coverage beginning in the month the household became ineligible if they are (a) terminated from EAEDC or TAFDC and are determined to be potentially eligible for MassHealth; or (b) terminated from TAFDC because of receipt of or an increase in spousal or child support payments. (2) Members of a TAFDC household who become ineligible for TAFDC for employment- related reasons continue to receive MassHealth Standard for a full 12-calendar-month period beginning with the month after MassHealth determined that they became ineligible for TAFDC if (a) the household continues to include a child; (b) a parent or caretaker relative continues to be employed; and (c) the parent or caretaker relative complies with 130 CMR 505.002(M). (3) Members of a MassHealth MAGI household who receive MassHealth Standard (whether or not they receive TAFDC) and have earnings that raise the MassHealth MAGI household’s modified adjusted gross income above 133% of the FPL continue to receive MassHealth Standard for a full 12-calendar-month period that begins with the month after MassHealth determined that the members’ MAGI exceeds 133% of the FPL if (a) the MassHealth household continues to include a child younger than 19 years old living with the parent or caretaker; (b) a parent or caretaker relative continues to be employed; (c) the parent or caretaker relative complies with 130 CMR 505.002(M); and (d) the member is a citizen or a qualified noncitizen. (4) MassHealth independently reviews the continued eligibility of the TAFDC, EAEDC, and MassHealth MAGI households at the end of the extended period described in 130 CMR 505.002(L)(1) through (3). (5) If an individual in a MassHealth MAGI household who receives MassHealth under 130 CMR 505.002(L)(1) or (2) had income at or below 133% of the FPL during their extended period, and now has income including earnings that raise the MassHealth MAGI modified adjusted gross income above that limit, the MassHealth MAGI household is eligible for another full 12-calendar-month period that begins with the date on which the member’s MAGI exceeds 133% of the FPL if (a) the MassHealth household continues to include a child younger than 19 years old living with the parent or caretaker; (b) a parent or caretaker relative continues to be employed; and (c) the parent or caretaker relative complies with 130 CMR 505.002(M). (6) If a MassHealth MAGI household’s modified adjusted gross income decreases to 133% of the FPL or below during its extended eligibility period, and the decrease is timely reported to MassHealth, the MassHealth MAGI household’s eligibility for MassHealth Standard may be redetermined. If the MassHealth MAGI household’s gross income later increases above 133% of the FPL, the MassHealth MAGI household is eligible for a new extended eligibility period. (M) Use of Potential Health Insurance Benefits. Applicants and members must use potential health insurance benefits in accordance with 130 CMR 503.007: Potential Sources of Health care, and must enroll in health insurance, including Medicare, if available at no greater cost to the applicant or member than they would pay without access to health insurance, or if purchased by MassHealth in accordance with 130 CMR 505.002(O) or 130 CMR 506.012: Premium Assistance Payments. Members must access other health insurance benefits and must show their private health insurance card and their MassHealth card to providers at the time services are provided. (N) Access to Employer-sponsored Insurance and Premium Assistance Investigations for Individuals Who Are Eligible for MassHealth Standard. (1) The MassHealth agency may perform an investigation to determine if individuals receiving MassHealth Standard (a) have health insurance that MassHealth may help pay for; or (b) have access to employer-sponsored health insurance in which MassHealth wants the individual to enroll and for which MassHealth will help pay. (2) The individual receives MassHealth Standard while MassHealth investigates the insurance. (a) Investigations for Individuals Who Are Enrolled in Health Insurance. 1. If the MassHealth agency determines that the health insurance the individual is enrolled in meets the criteria at 130 CMR 506.012: Premium Assistance Payments, the individual is notified in writing that MassHealth will provide MassHealth Standard Premium Assistance Payments as described at 130 CMR 506.012: Premium Assistance Payments. 2. If the MassHealth agency determines that the health insurance the individual is enrolled in does not meet the criteria at 130 CMR 506.012: Premium Assistance Payments, the individual is eligible for MassHealth Standard Direct Coverage. 3. Individuals described at 130 CMR 505.002(F)(1)(d) will not undergo an investigation. (b) Investigations for Individuals Who Have Potential Access to Employer-sponsored Health Insurance. 1. If the MassHealth agency determines the individual has access to employer- sponsored health insurance and the employer is contributing at least 50% of the premium cost and the insurance meets all other criteria described at 130 CMR 506.012: Premium Assistance Payments, the individual is notified in writing that they must enroll in this employer-sponsored coverage. MassHealth allows the individual up to 60 days to enroll in this coverage. Once enrolled in this health insurance plan, MassHealth provides MassHealth Standard Premium Assistance Payments as described in 130 CMR 506.012: Premium Assistance Payments. Failure to enroll in the employer-sponsored health insurance plan at the request of the MassHealth agency will result in the loss or denial of eligibility for all individuals unless the individual is younger than 21 years old or is pregnant. 2. If the MassHealth agency determines the individual does not have access to employer-sponsored health insurance, the individual is eligible for MassHealth Standard Direct Coverage. 3. Individuals described at 130 CMR 505.002(F) and (G) will not undergo an investigation. (O) Medicare Premium Payment. (1) The MassHealth agency, in accordance with the Medicare Savings Program as described at 130 CMR 519.010: Medicare Savings Program (MSP) – Qualified Medicare Beneficiaries (QMBs) and 519.011: Medicare Savings Program (MSP)– Specified Low Income Medicare Beneficiaries (SLMBs) and Qualifying Individuals (QIs), or in accordance with 130 CMR 519.002(E), pays the following for members who meet the requirements of 130 CMR 505.002(C) and (E): (a) the cost of the monthly Medicare Part B premiums; (b) where applicable, the cost of the hospital insurance under Medicare Part A for members who are entitled to Medicare Part A; and (c) where applicable, for the deductibles and coinsurance under Medicare Parts A and B. (2) The coverage begins in accordance with 130 CMR 519.010: Medicare Savings Program (MSP) – Qualified Medicare Beneficiaries (QMBs) and 519.011: Medicare Savings Program (MSP)– Specified Low Income Medicare Beneficiaries (SLMBs) and Qualifying Individuals (QIs). (P) Medical Coverage Date. (1) The medical coverage date for MassHealth Standard is described at 130 CMR 502.006: Coverage Dates, except as described at 130 CMR 505.002(P)(2). (2) Provisional eligibility is described in 130 CMR 502.003(E): Provisional Eligibility. (Q) Continuous Eligibility. (1) Continuous Eligibility, as defined in 501.001: Continuous Eligibility (CE), will be granted to children under age 19. Children in a CE period will receive 12 months of continuous coverage upon completion of initial application or annual renewal period. (2) Coverage will continue without downgrading or ending except for reasons found at 130 CMR 501.001: Definition of Terms. (130 CMR 505.003 Reserved)