130 CMR 516.00 — MassHealth: The Eligibility Process

1 130 CMR: DIVISION OF MEDICAL ASSISTANCE

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130 CMR 516.000: MASSHEALTH: THE ELIGIBILITY PROCESS

TABLE OF CONTENTS

Section

130 CMR 516.00 MassHealth: The Eligibility Process

516.001 Application for Benefits

516.001: Application for Benefits

516.002 Reactivating the Application

516.002: Reactivating the Application

516.003 Verification of Eligibility Factors

516.003: Verification of Eligibility Factors

516.004 Matching Information

516.004: Matching Information

516.005 Time Standards for Eligibility Determination

516.005: Time Standards for Eligibility Determination

516.006 Coverage Dates

516.006: Coverage Dates

516.007 Continuing Eligibility

516.007: Continuing Eligibility

516.008 Notice

516.008: Notice

516.009 Voluntary Withdrawal

516.009: Voluntary Withdrawal

516.010 Issuance of a MassHealth Card

516.010: Issuance of a MassHealth Card

516.011 Severability

516.011: Severability

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130 CMR 516.000: MASSHEALTH: THE ELIGIBILITY PROCESS

516.001 Application for Benefits

516.001: Application for Benefits

(A) Filing an Application (1) Application. To apply for MassHealth (a) for a person living in the community, the person or their authorized representative must file a complete paper Senior Application and all required supplements or apply in person at a MassHealth Enrollment Center (MEC); or (b) for a person in need of long-term-care services in a nursing facility, the person or their authorized representative must file a complete paper Senior Application and all required supplements or apply in person at a MEC. (2) Date of Application (a) The date of application is the date the application is received by the MassHealth agency. (b) An application is considered complete if it complies with 130 CMR 516.001(C). (c) If an applicant described in 130 CMR 519.002(A)(1) has been denied SSI in the 30- day period before the date of application for MassHealth, the date of application for MassHealth is the date the person applied for SSI. (3) Paper Applications or In-person Applications at the MassHealth Enrollment Center (MEC)—Missing or Inconsistent Information (a) If an application is received at a MEC or MassHealth outreach site and the applicant did not answer all required questions on the Senior Application, or if the Senior Application is unsigned, the MassHealth agency is unable to determine the applicant’s eligibility for MassHealth. (b) The MassHealth agency requests responses to all of the unanswered questions necessary to determine eligibility. The MassHealth agency must receive such information within 15 days of the date of the request for the information. (c) If responses to all unanswered questions necessary to determine eligibility are received within 15 days of the date of the request referred to in 130 CMR 516.001(A)(3)(b), the MassHealth agency will request any corroborative information necessary to determine eligibility, as provided in 130 CMR 516.001(B) and (C). (d) If responses to all unanswered questions necessary for determining eligibility are not received within the 15-day period referred to in 130 CMR 516.001(A)(3)(b), the MassHealth agency notifies the applicant that it is unable to determine eligibility. The date that the incomplete application was received will not be used in any subsequent eligibility determinations. If the required response is received after the 15-day period, the eligibility process commences and the application is considered submitted on the date the response is received, provided that if the required response is submitted more than one year after the initial incomplete application, a new application must be completed. (e) Inconsistent answers are treated as unanswered.

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130 CMR 516.000: MASSHEALTH: THE ELIGIBILITY PROCESS

(B) Corroborative Information. The MassHealth agency requests all corroborative information necessary to determine eligibility. (1) The MassHealth agency sends the applicant written notification requesting the corroborative information generally within five days of receipt of the application. (2) The notice advises the applicant that the requested information must be received within 30 days of the date of the request and of the consequences of failure to provide the information.

(C) Receipt of Corroborative Information. If the requested information, with the exception of verification of citizenship, identity, and immigration status, is received within 30 days of the date of the request, the application is considered complete. The MassHealth agency will determine the coverage type providing the most comprehensive medical benefits for which the applicant is eligible. If such information is not received within 30 days of the date of the request, MassHealth benefits may be denied.

516.002 Reactivating the Application

516.002: Reactivating the Application

The MassHealth agency will reactivate the application after a denial of eligibility for failure to provide requested verifications.

(A) If the requested information is received within 30 days of the date of denial, the date of receipt of one or more of the verifications is considered the date of reapplication.

(B) The date of reapplication replaces the date of the denied application. The applicant’s earliest date of eligibility for MassHealth is based on the date of reapplication.

(C) If the reapplication is subsequently denied and not appealed, the applicant must submit a new application to pursue eligibility for MassHealth. The earliest date of eligibility for MassHealth is based on the date of the new application.

(D) If the denial is due to excess assets, the date of reapplication is described at 130 CMR 520.004: Asset Reduction.

(E) A new application is required if a reapplication is not received within 30 days from the date of denial.

516.003 Verification of Eligibility Factors

516.003: Verification of Eligibility Factors

The MassHealth agency requires verification of eligibility factors including income, assets, residency, citizenship, immigration status, and identity as described in 130 CMR 517.000: MassHealth: Universal Eligibility Requirements, 130 CMR 518.000: MassHealth: Citizenship and Immigration, and 130 CMR 520.000: MassHealth: Financial Eligibility.

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130 CMR 516.000: MASSHEALTH: THE ELIGIBILITY PROCESS

(A) Information Matches. The MassHealth agency initiates information matches with federal and state agencies and other informational services, as described at 130 CMR 516.004, when an application is received, in order to verify eligibility.

(B) Electronic Data Sources. If electronic data sources are unable to verify or are not reasonably compatible with the attested information, additional documentation will be required from the individual.

(C) Request for Information Notice. If additional documentation is required, including corroborative information as described at 130 CMR 516.001(B), a Request for Information Notice will be sent to the applicant, listing all requested verifications and the deadline for submission of the requested verifications.

(D) Time Standards. The following time standards apply to the verification of eligibility factors. (1) The applicant or member has 30 days from the receipt of the Request for Information Notice to provide all requested verifications. (2) If the applicant or member fails to provide verification of information within 30 days of receipt of the MassHealth agency’s request, MassHealth coverage is denied or terminated. (3) A new application is required if a reapplication is not received within 30 days of the date of denial.

(E) Reasonable Opportunity to Verify Citizenship and Identity or Immigration Status. The MassHealth agency provides applicants and members with a reasonable opportunity period to provide satisfactory documentary evidence of citizenship and identity or immigration status if the MassHealth agency’s electronic data matches are unable to verify the applicant’s citizenship or immigration status. (1) Time Standards. The reasonable opportunity period begins on, and extends 90 days from, the date on which an applicant or member receives a reasonable opportunity notice. (2) Coverage Start Date. (a) Coverage for individuals who receive a reasonable opportunity period begins on the date the Request for Information Notice is sent. (b) If satisfactory documentary evidence of citizenship and identity or immigration status is received before the end of the reasonable opportunity period, retroactive coverage is provided for the verified coverage type in accordance with 130 CMR 516.006.

(F) Reasonable Opportunity Extension. Applicants or members who have made a good-faith effort to resolve inconsistencies or obtain verification of immigration status may receive a 90-day extension. Requests for a reasonable opportunity extension must be made before the expiration of the verification time period.

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130 CMR 516.000: MASSHEALTH: THE ELIGIBILITY PROCESS

(G) Verification Exceptions for Special Circumstances. Except with respect to the verifications of citizenships and immigration status, the MassHealth agency will permit, on a case-by-case basis, self-attestation of individuals for all eligibility criteria when documentation does not exist at the time of application or renewal, or is not reasonably available, such as in the case of individuals who are homeless or have experienced domestic violence or a natural disaster.

516.004 Matching Information

516.004: Matching Information

The MassHealth agency initiates information matches with other agencies and information sources when an application is received in order to update or verify eligibility. These agencies and information sources may include, but are not limited to, the following agencies: Federal Data Services Hub, the Department of Unemployment Assistance, the Department of Public Health's Bureau of Vital Statistics, the Department of Industrial Accidents, the Department of Veterans Services, the Department of Revenue, the Bureau of Special Investigations, the Social Security Administration, Systematic Alien Verification for Entitlements, the Department of Transitional Assistance, health insurance carriers, and banks and other financial institutions.

516.005 Time Standards for Eligibility Determination

516.005: Time Standards for Eligibility Determination

(A) For applicants who do not apply on the basis of a disability, a determination of eligibility must be made within 45 days from the date of receipt of the completed application. All requested information must be received within 30 days of the date of request.

(B) For applicants who apply for MassHealth on the basis of a disability, a determination of eligibility must be made within 90 days from the date of receipt of the completed application, including a disability supplement, if required.

(C) If the MassHealth agency determines that unusual circumstances exist, the timeframes for determining eligibility are extended. Unusual circumstances include delay caused by the applicant, by an examining physician, or by other events beyond the control of the MassHealth agency.

516.006 Coverage Dates

516.006: Coverage Dates

(A) Start Date of Coverage. For individuals applying for coverage, the date of coverage for MassHealth is determined by the coverage type for which the applicant may be eligible. 130 CMR 519.000: MassHealth: Coverage Types describes the rules for establishing this date.

(B) End Date of Coverage. MassHealth benefits terminate or downgrade no sooner than 14 days from the date of the termination or downgrade notice unless the MassHealth member timely files an appeal and requests continued MassHealth benefits pending such appeal.

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130 CMR 516.000: MASSHEALTH: THE ELIGIBILITY PROCESS

516.007 Continuing Eligibility

516.007: Continuing Eligibility

(A) Annual Renewals. The MassHealth agency reviews eligibility once every 12 months. Eligibility may also be reviewed as a result of a member’s changes in circumstances or a change in MassHealth eligibility rules, or as a result of a member’s failure to provide verification within requested timeframes. The MassHealth agency updates eligibility based on information received as the result of such review. The MassHealth agency reviews eligibility (1) by information matching with other agencies, health insurance carriers, and information sources; (2) through a written update of the member's circumstances on a prescribed form; (3) through an update of the member’s circumstances, in person; or (4) based on information in the member’s case file.

(B) Eligibility Determinations. The MassHealth agency determines, as a result of this review, if (1) the member continues to be eligible for the current coverage type; (2) the member’s current circumstances require a change in coverage type; or (3) the member is no longer eligible for MassHealth.

(C) Eligibility Reviews. MassHealth reviews eligibility in the following ways. (1) Automatic Renewal. Members whose continued eligibility can be determined based on electronic data matches with federal and state agencies will have their eligibility automatically renewed. (a) The MassHealth agency will notify the member if eligibility has been reviewed using the automatic renewal process. (b) If the member's coverage type changes to a more comprehensive benefit, the start date for the new coverage is determined as described at 130 CMR 519.000: MassHealth Coverage Types. (2) MassHealth Eligibility Renewal Application. If the individual is residing in the community and their continued eligibility cannot be determined based on reliable information in their account or electronic data match with federal and state agencies, a MassHealth eligibility review form must be completed. (a) The MassHealth agency will notify the member of the need to complete the MassHealth eligibility review form. (b) The member will be given 45 days from the date of the request to return the MassHealth eligibility review form.

1. If the review is completed within 45 days, eligibility will be determined using the information provided by the individual with verification confirmed through electronic data matches if available.
2. If the review is not completed within 45 days, eligibility will be terminated within 14 days from the date of the termination notice.
3. If the requested review form is submitted within 30 days from the date of the termination, a second eligibility determination is made within 15 days. Eligibility may be established retroactive to the date of termination, if otherwise eligible.

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130 CMR 516.000: MASSHEALTH: THE ELIGIBILITY PROCESS

(c) If the member's coverage type changes, the start date for the new coverage type is effective as of the date of the written notice.

(3) Review Form for Individuals in Need of Long-term-care Services in a Nursing Facility. If the individual is in need of long-term-care services in a nursing facility and their continued eligibility cannot be determined based on reliable information in their account or electronic data match with federal and state agencies, a written update of the member’s circumstances on a prescribed form must be completed. (a) The MassHealth agency will notify the member of the need to complete the prescribed review form. (b) The member will be given 45 days to return the review form to the MassHealth agency.

1. If the review is completed within 45 days, eligibility will be determined using the information provided by the member, with verification confirmed through electronic data matches if available.
2. If the review is not completed within 45 days, eligibility will be terminated within 14 days from the date of the termination notice.
3. If the requested review form is submitted within 90 days from the date of the termination, a second eligibility determination is made within 15 days. Eligibility may be established retroactive to the date of termination, if otherwise eligible. (c) If the member's coverage type changes, the start date for the new coverage type is effective as of the date of the written notice. (4) Periodic Data Matches. The MassHealth agency matches files of MassHealth members with other agencies and information sources as described in 130 CMR 516.004 to update or verify eligibility. (a) If the electronic data match indicates a change in circumstances that would result in potential reduction or termination of benefits, the MassHealth agency will notify the member of the information that was received through the data match and require the member to respond within 30 days of the date of the notice.
4. If the member responds within 30 days and confirms the data is correct, eligibility will be determined using the confirmed data from the electronic data match.
5. If the member responds within 30 days and provides new information, eligibility will be determined using the information provided by the member. Additional verification will be required.
6. If the member does not respond within 30 days, eligibility will be determined using available information received from the electronic data sources. If information necessary for eligibility determination is not available from electronic data sources, MassHealth coverage will be terminated.

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(b) If the electronic data match indicates a change in circumstances that would result in an increase or no change in benefits, the MassHealth agency will automatically update the case using the information received from the electronic data match and redetermine eligibility. If the member’s coverage type changes to a more comprehensive benefit, the member will be sent a notice informing them of the start date for the new benefit. The effective date of the change is the date of the redetermination of eligibility.

516.008 Notice

516.008: Notice

(A) The MassHealth agency provides all applicants and members a written notice of the eligibility determination for MassHealth. The notice contains an eligibility decision for each member who has requested MassHealth, and either provides information so the applicant or member can determine the reason for any adverse decision or directs the applicant or member to such information.

(B) The MassHealth agency also provides to members notice of any changes in coverage type or patient-paid amount, or loss of coverage.

(C) In addition to sending notices to applicants and members, such written notices are provided to the authorized representative; the institution, if authorized by the applicant or member; and the community spouse, as defined at 130 CMR 520.016(B)(1)(c): Right to Appeal. This may include, in the case of death, the executor, administrator, or legal representative of the deceased individual's estate.

(D) All notices provide information about the right of the applicant or member to a fair hearing, with the exception of asset assessments described at 130 CMR 520.016: Long-term Care: Treatment of Assets and notices about federal or state law requiring an automatic change adversely affecting some or all members as described in 42 CFR 431.220(b). Information about the appeal process is found at 130 CMR 610.000: MassHealth: Fair Hearing Rules.

516.009 Voluntary Withdrawal

516.009: Voluntary Withdrawal

The applicant or authorized representative may voluntarily withdraw their application for MassHealth.

516.010 Issuance of a MassHealth Card

516.010: Issuance of a MassHealth Card

(A) The MassHealth agency issues a MassHealth card to new members, with the exception of those who receive MassHealth Buy-in coverage.

(B) A temporary card may be issued to a member if there is an immediate need.

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130 CMR 516.000: MASSHEALTH: THE ELIGIBILITY PROCESS

516.011 Severability

516.011: Severability

The provisions of 130 CMR 516.000 are severable. If any provision of 130 CMR 516.000 or application of any provision to an applicable individual, entity, or circumstance is held invalid or unconstitutional, that holding will not be construed to affect the validity or constitutionality of any remaining provisions of 130 CMR 516.000 or application of those provisions to applicable individuals, entities, or circumstances.

REGULATORY AUTHORITY

130 CMR 516.000: M.G.L. c. 118E.