130 CMR 501.00 — MassHealth: General Policies

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TABLE OF CONTENTS

Section

130 CMR 501.00 MassHealth: General Policies

501.001 Definition of Terms

501.001: Definition of Terms

501.002 Introduction to MassHealth

501.002: Introduction to MassHealth

501.003 MassHealth Coverage Types

501.003: MassHealth Coverage Types

501.004 Administration of MassHealth

501.004: Administration of MassHealth

501.005 Individuals and Families Eligible for or Receiving Medical Assistance on June 30, 1997

501.005: Individuals and Families Eligible for or Receiving Medical Assistance on June 30, 1997

501.006 Children Receiving Benefits under the Children’s Medical Security Plan on August 3, 1998

501.006: Children Receiving Benefits under the Children’s Medical Security Plan on August 3, 1998

501.007 Receiving Public Assistance from Another State

501.007: Receiving Public Assistance from Another State (130 CMR 501.008 Reserved)

501.009 Rights of Applicants and Members

501.009: Rights of Applicants and Members

501.010 Responsibilities of Applicants and Members

501.010: Responsibilities of Applicants and Members

501.011 Referrals to Investigative Units

501.011: Referrals to Investigative Units (130 CMR 501.012 Reserved)

501.013 Estate Recovery

501.013: Estate Recovery

501.014 Voter Registration

501.014: Voter Registration

501.015 Reimbursement of Certain Out-of-pocket Medical Expenses

501.015: Reimbursement of Certain Out-of-pocket Medical Expenses

501.016 Severability

501.016: Severability

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501.001 Definition of Terms

501.001: Definition of Terms

The terms listed in 130 CMR 501.001 have the following meanings for the purposes of MassHealth, as described in 130 CMR 501.000 through 508.000. If a definition conflicts with federal law, the federal law supersedes.

Accountable Care Organization (ACO). An entity that enters into a population-based payment model contract with EOHHS as an accountable care organization, wherein the entity is held financially accountable for the cost and quality of care for an attributed or enrolled member population. ACOs include Accountable Care Partnership Plans, Primary Care ACOs, and MCO- administered ACOs.

Accountable Care Partnership Plan. A type of ACO with which the MassHealth agency contracts under its ACO program to provide, arrange for, and coordinate care and certain other medical services to members on a capitated basis and which is approved by the Massachusetts Division of Insurance as a health-maintenance organization (HMO) and which is organized primarily for the purpose of providing health care services.

Access to Health Insurance The ability to obtain employer-sponsored health insurance for an uninsured family member where an employer would contribute at least 50% of the premium cost, and the health insurance offered would meet the basic-benefit level.

American Indian or Alaska Native. A person who (1) is a member of a federally recognized tribe, band, or group as defined in Title 25 of U.S.C.; (2) is an Eskimo, Aleut, or other Alaska Native enrolled by the Secretary of the Interior, pursuant to the Alaska Native Claims Settlement Act at 43 U.S.C. 1601 et seq.; or (3) has been determined eligible to receive health care services from Indian HealthCare Providers as an Indian pursuant to 42 CFR 136.12 or Title V of the Indian HealthCare Improvement Act.

Appeal A written request, by an aggrieved applicant or member, for a fair hearing.

Appeal Representative. An Appeal Representative as defined in 130 CMR 610.004: Definitions.

Applicant A person who completes and submits an application for MassHealth.

Application A request for health benefits that is received by the MassHealth agency and includes all required information and a signature by the applicant or their authorized representative. The application may be submitted at www.MAHix.org, or the applicant may complete a paper application, complete a telephone application, or apply in person at a MassHealth Enrollment Center (MEC).

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Authorized Representative. (1) A person or an organization identified as the authorized representative of an applicant or member in a completed Authorized Representative Designation Form or another form prescribed by the MassHealth agency that has been signed by the authorized representative and, if applicable, the applicant or member and submitted to the MassHealth agency and in which the authorized representative agrees to comply with applicable rules regarding confidentiality and conflicts of interest in the course of representing the applicant or member; provided that such person or organization must be (a) a person or organization designated by the applicant or member in writing to act responsibly on their behalf in connection with the eligibility process and other ongoing communications with the MassHealth agency; (b) a person acting responsibly on behalf of the applicant or member and who is sufficiently aware of such applicant’s or member’s circumstances to assume responsibility for the accuracy of the statements made on their behalf during the eligibility process and in other communications with the MassHealth agency, such as a family member or friend; provided that the applicant or member in this case cannot provide written designation and does not otherwise have an individual who can act on their behalf such as an existing authorized representative, guardian, conservator, personal representative of the estate, holder of power of attorney, or an invoked health care proxy; or (c) a person who has, under applicable law, authority to act on behalf of the applicant or member in making decisions related to health care or payment for health care including, but not limited to, a guardian, conservator, personal representative of the estate of an applicant or member, holder of power of attorney, or an invoked health care proxy. (2) An authorized representative will have the authority to complete and sign an application on the applicant’s behalf, select a health plan on the applicant’s or member’s behalf, complete and sign a renewal form on the member’s behalf, receive copies of the applicant’s or member’s notices and other communications from the MassHealth agency (which may include protected health care information, personal data, and financial information), and act on behalf of the applicant or member in all other matters with the MassHealth agency or the Connector, including representing the applicant or member at an appeal provided that, with respect to a person serving as an authorized representative pursuant to 130 CMR 501.001: Authorized Representative (1)(c), authority to act on behalf of the applicant or member is determined by the applicable law or underlying legal document.

Basic-benefit Level (BBL). (1) Benefits provided under a health insurance plan that include a broad range of medical benefits as defined in the minimum creditable coverage core services requirements in 956 CMR 5.03(1)(a); provided that the annual deductible and the annual maximum out-of-pocket costs under that plan do not exceed the maximum amounts the Massachusetts Health Connector sets for deductibles and out-of-pocket costs in order for a plan to be considered minimum creditable coverage, as set forth at 956 CMR 5.03(2)(b)2. and 3., and 956 CMR 5.03(2)(c), respectively, and as may be illustrated in administrative bulletins published by the

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Massachusetts Health Connector, and as are in effect on the first day coverage under that plan begins.

(2) Exceptions (a) For the avoidance of doubt, instruments including but not limited to Health Reimbursement Arrangements, Flexible Spending Arrangements, as described in IRS Pub. 969, or Health Savings Accounts, as described at IRC § 223(c)(2), cannot be used to reduce the health insurance deductible in order to meet the basic-benefit level requirement. (b) The MassHealth agency reserves the right to set its own annual deductible and maximum out-of-pocket limits. If the MassHealth agency deems it appropriate to set its own annual deductible and maximum out-of-pocket limits, a sub-regulatory bulletin will be issued.

Behavioral Health Contractor. The entity contracted with EOHHS to provide, arrange for, and coordinate behavioral health care and other services to members on a capitated basis.

Blindness. A visual impairment, as defined in Title XVI of the Social Security Act. Generally, Blindness means visual acuity with correction of 20/200 or less in the better eye, or a peripheral field of vision contracted to a 10° radius or less, regardless of the visual acuity.

Business Day. Any day during which the MassHealth agency’s offices are open to serve the public.

Caretaker Relative. An adult who is the primary care giver for a child; is related to the child by blood, adoption, or marriage; or is a spouse or former spouse of one of those relatives, and who lives in the same home as that child, provided that neither parent is living in the home.

Case File. The written collection of documents and information required to determine eligibility and to provide benefits to applicants and members.

Certified Application Counselor (CAC). An individual who is certified by the MassHealth agency and the Connector to provide assistance in completing applications and renewal forms.

Child. A person younger than 19 years old.

Citizen. See 130 CMR 504.002: U.S. Citizen.

Commonwealth Health Insurance Connector Authority or Health Connector or Connector. The entity established pursuant to M.G.L. c. 176Q § 2.

ConnectorCare. The program administered by the Health Connector pursuant to M.G.L. c. 176Q to provide premium assistance payments and point-of-service cost-sharing subsidies to eligible

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individuals enrolled in health plans.

Continuous Eligibility (CE). Certain groups of people may receive a period of continuous coverage upon initial eligibility determination or after a successful eligibility renewal. (1) Applicable coverage types, groups of members who are eligible for CE periods, and timeframes of continuous coverage are found in 130 CMR 505.002, 130 CMR 505.004, 130 CMR 505.005, and 130 CMR 505.008. (2) A CE period lasts from initial determination or renewal until the person is picked up for their next renewal. If MassHealth determines the person remains eligible for MassHealth, another period of continuous eligibility may be granted. If the person does not respond to their renewal within the given timeframe, or is found to be ineligible for MassHealth, MassHealth will not grant the person another CE period. (3) MassHealth may upgrade a person who is in a CE period to a richer coverage type during the CE period. MassHealth will not downgrade, except in cases where a change in immigration status requires a downgrade under federal law, or terminate coverage during a person’s CE period until their CE period is over, unless one of the exceptions below applies. MassHealth may end a person’s CE period outside of the completed renewal period for the following reasons: (a) voluntary withdrawal; (b) person moved out of state; (c) a child attains age 19; (d) death of eligible member; or (e) the agency determines that eligibility was erroneously granted at the most recent determination, redetermination or renewal of eligibility because of agency error or fraud, abuse, or perjury attributed to the individual.

Couple. Two persons who are married to each other according to the laws of the Commonwealth of Massachusetts.

Coverage Start Date (or Start Date of Coverage). The date medical coverage begins.

Coverage Type. A scope of medical services, other benefits, or both that is available to members who meet specific eligibility criteria. MassHealth coverage types include the following: MassHealth Standard (Standard), MassHealth CommonHealth (CommonHealth), MassHealth CarePlus (CarePlus), MassHealth Family Assistance (Family Assistance), and MassHealth Limited (Limited). The scope of services or covered benefits for each coverage type is found at 130 CMR 450.105: Coverage Types.

Custodial Parent. (1) the parent with whom a child's physical custody has been established by a court order or binding separation, divorce, or custody agreement; or (2) if no such order or agreement exists, the parent with whom the child spends most nights;

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or (3) if the child spends an equal number of nights with each parent, it is determined by the Internal Revenue Service (IRS) tax rules.

Day. A calendar day unless a business day is specified.

Deductible. The total dollar amount of incurred medical expenses that an applicant, whose income exceeds MassHealth income standards, must be responsible for before the applicant is eligible for MassHealth as described at 130 CMR 506.009: The One-time Deductible.

Deductible Period. A specified six-month period within which an applicant for MassHealth, whose income exceeds MassHealth income standards, may become eligible, based on disability, through incurred and/or paid medical expenses of the applicant or any member of the MassHealth Disabled Adult Household as described in 130 CMR 506.009: The One-time Deductible.

Disability Evaluation Services (DES). A unit that consists of physicians and disability evaluators who determine permanent and total disability of an applicant or member seeking coverage under a MassHealth program for which disability is a criterion, using criteria established by the Social Security Administration (SSA) under Title XVI and criteria established under state law. This unit may be a part of a state agency or under contract with a state agency.

Disabled. Having a permanent and total disability as defined in Title XVI of the Social Security Act.

Disabled Adult Household. See 130 CMR 506.002(C): MassHealth Disabled Adult Household.

Disabled Working Adult. A person who is engaged in substantial gainful activity but otherwise meets the definition of disabled, as defined in Title XVI of the Social Security Act.

Duals Demonstration Dual Eligible Individual. For purposes of the Duals Demonstration Program, a MassHealth member must meet all of the following criteria: (1) be 21 through 64 years old at the time of enrollment; (2) be eligible for MassHealth Standard as defined in 130 CMR 450.105(A): MassHealth Standard or MassHealth CommonHealth as defined in 130 CMR 450.105(E): MassHealth CommonHealth; (3) be enrolled in Medicare Parts A and B, be eligible for Medicare Part D, and have no other health insurance that meets the basic-benefit level as defined in 130 CMR 501.001; and (4) live in a designated service area of an ICO.

Duals Demonstration Program. The MassHealth state Demonstration to Integrate Care for Duals Demonstration Dual Eligible Individuals.

Eligibility Process. Activities conducted for the purposes of determining, redetermining, and

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maintaining the eligibility of a MassHealth applicant or member.

Fair Hearing. An administrative, adjudicatory proceeding conducted according to 130 CMR 610.000: MassHealth: Fair Hearing Rules to determine the legal rights, duties, benefits, or privileges of applicants and members.

Family Group. A family, couple, or individual.

Federal Poverty Level (FPL). Income standards issued annually in the Federal Register to account for the last calendar year's increase in prices as measured by the Consumer Price Index. MassHealth within its discretion updates the FPL standards accordingly each year in March.

Fee-for-service. A method of paying for medical services provided by any MassHealth participating provider with no limit on provider choice.

Filing Status. An Internal Revenue Service term. The five filing statuses are single, married filing a joint return, married filing a separate return, head of household, and qualifying widow(er) with dependent children. The rate at which income is taxed is determined by the filing status.

Gross Income. The total money earned or unearned, such as wages, salaries, rents, pensions, or interest, received from any source without regard to deductions.

Health Insurance. Coverage of health care services by a health insurance company, a hospital- service corporation, a medical-service corporation, a managed care organization, or Medicare. Coverage of health care services by MassHealth, Health Safety Net, or Children’s Medical Security Plan (CMSP) is not considered health insurance.

Health Safety Net. A source of funding for certain health care under 101 CMR 613.00: Health Safety Net Eligible Services and 101 CMR 614.00: Health Safety Net Payments and Funding.

Hospital-determined Presumptive Eligibility. The MassHealth agency will provide time-limited coverage, in accordance with 130 CMR 502.003(H): Hospital-determined Presumptive Eligibility, for individuals who are determined to be presumptively eligible by a qualified hospital, as defined at 130 CMR 450.110(B).

Incarceration. The confinement in a penal institution of an individual. An individual is not incarcerated if they are on parole, probation, or home release, and do not return to the institution for overnight stays.

Inconsistency Period. The time frame that an individual has to provide verifications needed to determine eligibility for health insurance offered by the Connector.

Integrated Care Organization (ICO). An organization with a comprehensive network of medical,

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behavioral health care, and long-term services and supports that integrates all components of care, either directly or through subcontracts, and has contracted with the Executive Office of Health and Human Services (EOHHS) and the Centers for Medicare & Medicaid Services (CMS) and been designated as an ICO to provide services to dual eligible individuals under M.G.L. c. 118E. ICOs are responsible for providing enrollees with the full continuum of Medicare- and MassHealth-covered services.

Interpreter. A person who translates for an applicant or member who has limited English proficiency or a hearing impairment.

Lawfully Present Immigrants. See 130 CMR 504.003(A): Lawfully Present Immigrants.

Limited English Proficiency. Persons who are unable to communicate effectively in English because their primary language is not English and who have not developed fluency in English.

Lump-sum Payment. A one-time only payment that represents either a windfall payment, or the accumulation of recurring countable income, such as retroactive unemployment compensation or federal veterans’ retirement benefits. Payments such as gifts, inheritances, and personal injury awards, to the extent that they are not included in modified adjusted gross income, are not considered lump-sum payments.

Managed Care. A system of primary care and other medical services that are provided and coordinated by a MassHealth managed care provider, a SCO, an ICO, or the behavioral health contractor in accordance with the provisions of 130 CMR 450.117: Managed Care and 130 CMR 508.000: MassHealth: Managed Care Requirements.

Managed Care Organization (MCO). Any entity with which the MassHealth agency contracts under its MCO program to provide, arrange for, and coordinate care and certain other medical services to members on a capitated basis, and is approved by the Massachusetts Division of Insurance as a health maintenance organization (HMO) and is organized primarily for the purpose of providing health care services.

MassHealth Agency. The Executive Office of Health and Human Services in accordance with the provisions of M.G.L. c. 118E.

MassHealth MAGI Household. See 130 CMR 506.002(B): MassHealth MAGI Household Composition.

MassHealth Managed Care Provider. An MCO, Accountable Care Partnership Plan, Primary Care ACO, or the Primary Care Clinician Plan.

MCO-administered ACO. A type of ACO with which the MassHealth agency contracts under its ACO program and is administered through an MCO.

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Medical Benefits. Payment for health insurance or medical services provided to a MassHealth member.

Member. An individual determined by the MassHealth agency to be eligible for MassHealth.

Modified Adjusted Gross Income (MAGI). Modified adjusted gross income as defined in section 36(B)(d)(2) of the Internal Revenue Code with the following exceptions: (1) an amount received as a lump sum only counts as income in the month received; (2) scholarships, awards, or fellowship grants used for education purposes and not for living expenses are excluded from income; (3) certain taxable income received by American Indians and Alaska Natives is excluded from income as described in 42 CFR § 435.603(e).

Navigator. An individual who is certified by the Health Connector to assist an applicant with electronic and paper applications to establish eligibility and enroll in coverage through the Health Connector. In addition, a navigator provides outreach and education about insurance options offered through the Health Connector.

Nonqualified Individuals Lawfully Present. See 130 CMR 504.003(A)(3): Nonqualified Individuals Lawfully Present.

Nonqualified Person Residing under Color of Law (Nonqualified PRUCOLs). See 130 CMR 504.003(C): Nonqualified Persons Residing under Color of Law (Nonqualified PRUCOLs).

One-adult-with-one-child Policy. A health insurance policy that covers a family consisting of one adult and one child.

Other Noncitizen. See 130 CMR 504.003(D): Other Noncitizens.

Parent of a Child Younger than 19 Years Old. Natural, adoptive, or stepmother or stepfather of a child.

Permanent and Total Disability. A disability as defined under Title XVI of the Social Security Act or under applicable state laws. (1) For Adults 18 Years of Age or Older. (a) The condition of an individual, 18 years of age or older, who is unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment that

1. can be expected to result in death; or
2. has lasted or can be expected to last for a continuous period of not less than 12 months. (b) For purposes of 130 CMR 501.001: Permanent and Total Disability, an individual 18 years of age or older is determined to be disabled only if their physical or mental

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impairments are of such severity that the individual is not only unable to do their previous work, but cannot, considering age, education, and work experience, engage in any other kind of substantial gainful work that exists in the national economy, regardless of whether such work exists in the immediate area in which the individual lives, whether a specific job vacancy exists, or whether the individual would be hired if they applied for work. "Work that exists in the national economy" means work that exists in significant numbers, either in the region where such an individual lives or in several regions of the country. (2) For Children Younger than 18 Years Old. The condition of an individual younger than 18 years old who has any medically determinable physical or mental impairment, or combination of impairments, of comparable severity to an impairment or combination of impairments that disables an adult, or are of such severity that the child is unable to engage in age-appropriate activities, as defined in Title XVI of the Social Security Act as in effect on July 1, 1996.

Person with Breast or Cervical Cancer. An individual who has submitted verification that they have breast or cervical cancer.

Person who is HIV Positive. A person who has submitted verification that they have tested positive for the human immunodeficiency virus (HIV).

Premium. A charge for payment to the MassHealth agency that may be assessed to members of MassHealth Standard, MassHealth CommonHealth, MassHealth Family Assistance, or the Children’s Medical Security Plan (CMSP).

Premium Assistance Payment. An amount contributed by the MassHealth agency toward the cost of health insurance coverage for certain MassHealth members who meet the criteria in 130 CMR 506.012: Premium Assistance Payments.

Premium Billing Family Group (PBFG). A group of persons who live together. (1) The group can be an individual, a couple who are two persons married to each other according to the rules of the Commonwealth of Massachusetts, or a family. (2) Two parents are members of the same premium billing family group if they are mutually responsible for one or more children who live with them. (3) A family making up a PBFG may consist of (a) a child or children younger than 19 years old, any of their children, and their parents. A child who is absent from the home to attend school is considered as living in the home; (b) siblings younger than 19 years old and any of their children who live together even if no adult parent or caretaker relative is living in the home; or (c) a child or children younger than 19 years old, any of their children, and their caretaker relative when no parent is living in the home.

Premium Tax Credit (PTC). Payment made pursuant to 26 U.S.C. § 36B on behalf of an eligible

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individual to reduce the costs of a health benefit plan premium to the individual.

Primary Care ACO. A type of ACO with which the MassHealth agency contracts under its ACO program.

Primary Care Clinician (PCC) Plan. A managed care option administered by the MassHealth agency through which enrolled members receive primary care and other medical services. See 130 CMR 450.118: Primary Care Clinician (PCC) Plan.

Protected Noncitizens. See 130 CMR 504.003(B): Protected Noncitizens.

Provisional Eligibility. Approval for MassHealth benefits when an applicant's certain self- attested circumstances show eligibility for MassHealth benefits but further verification is required for continued eligibility. (See 130 CMR 502.003: Verification of Eligibility Factors.)

Qualified Health Plan (QHP). A health plan licensed under M.G.L. c. 175, 176A, 176B, or 176G that has received the Commonwealth Health Insurance Connector’s Seal of Approval as meeting the criteria under 45 CFR §155.1000 and is offered through the Health Connector in accordance with the provisions of 45 CFR §155.1010.

Qualified Noncitizens. See 130 CMR 504.003(A)(1): Qualified Noncitizens.

Qualified Noncitizens Barred. See 130 CMR 504.003(A)(2): Qualified Noncitizens Barred.

Quality Control. A system of continuing review to measure the accuracy of eligibility decisions.

Redetermination. A review of a member's circumstances to establish whether they remain eligible for benefits.

Senior Care Organization (SCO). An organization that participates in MassHealth under a contract with the MassHealth agency and the Centers for Medicare & Medicaid Services to provide a comprehensive network of medical, health care, and social service providers that integrates all components of care, either directly or through subcontracts. SCOs are responsible for providing enrollees with the full continuum of Medicare- and MassHealth-covered services.

Sibling. Natural (full or half-blood), adoptive, or stepbrother or stepsister.

Spouse. A person married to the applicant or member according to the laws of the Commonwealth of Massachusetts.

Substantial Gainful Activity. Generally, employment that provides a set amount of gross earnings as determined by the SSA under Title XVI of the Social Security Act.

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Tax Dependent. A qualifying child or qualifying relative, other than the taxpayer or spouse, who entitles the taxpayer to claim a dependency exemption. An individual who files a return but is claimed as a dependent by someone else is still a tax dependent.

Tax Filer. Any individual, including their spouse if married filing jointly, who intends to file a federal tax return for the year in which a member of the tax household is seeking or receives benefits and who claims an exemption for themselves. An individual who files a return but is claimed as a dependent by someone else is still a tax dependent.

Tax Household. All members who are claimed on the tax return, including the tax filer(s) and all dependents.

Third Party. Any person, entity, or program that is or may be responsible for paying all or part of the expenditures for medical benefits.

Young Adult. An individual 19 or 20 years old.

501.002 Introduction to MassHealth

501.002: Introduction to MassHealth

(A) The MassHealth agency is responsible for the administration and delivery of MassHealth services to eligible low- and moderate-income individuals, couples, and families.

(B) 130 CMR 501.000: MassHealth: General Policies through 130 CMR 508.000: MassHealth: Managed Care Requirements provide the MassHealth requirements for children, young adults, parents and caretaker relatives, adults, people who are pregnant, disabled persons, persons who are HIV positive, individuals with breast or cervical cancer, and certain other individuals or couples who are younger than 65 years old and not institutionalized. These requirements are prescribed in accordance with all applicable laws, including Title XIX and Title XXI of the Social Security Act, and MassHealth’s 1115 Medicaid Research and Demonstration Waiver.

(C) 130 CMR 515.000: MassHealth: General Policies through 130 CMR 522.000: MassHealth: Other Division Programs provide the MassHealth requirements for persons who are institutionalized, 65 years of age or older, or who would be institutionalized without community- based services in accordance with all applicable laws, including Title XIX of the Social Security Act.

(D) The MassHealth agency will determine eligibility for low-income subsidies under Medicare Part D, as set forth in the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 and as described in federal regulations at 20 CFR Part 418.

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501.003 MassHealth Coverage Types

501.003: MassHealth Coverage Types

(A) The MassHealth agency provides access to health care by determining eligibility for the coverage type that provides the most comprehensive benefits for an individual who may be eligible.

(B) MassHealth offers several coverage types: Standard, CommonHealth, CarePlus, Family Assistance, and Limited. The coverage type for which a person is eligible is determined based on the individual's income and circumstances, as described in 130 CMR 503.000: Health care Reform: MassHealth: Universal Eligibility Requirements through 505.000: MassHealth: Health care Reform: Coverage Types, and immigration status, as described in 130 CMR 504.000: Health Care Reform: MassHealth: Citizenship and Immigration.

(C) The MassHealth agency may limit the number of people who can be enrolled in Family Assistance. When the MassHealth agency imposes such a limit, no new adult applicants (21 years of age or older) subject to these limitations will be added to Family Assistance, and current adult members in these coverage types who have lost eligibility for more than 30 days for any reason will not be allowed to reenroll until the MassHealth agency reopens enrollment for adults in Family Assistance.

501.004 Administration of MassHealth

501.004: Administration of MassHealth

(A) MassHealth. The MassHealth agency formulates requirements and determines eligibility for all MassHealth coverage types.

(B) Other Agencies. (1) Department of Transitional Assistance (DTA). (a) The DTA administers the Transitional Aid to Families with Dependent Children (TAFDC) Program. Persons who meet the requirements of § 1931 of Title XIX (42 U.S.C. § 1396u-1) are automatically eligible for Standard coverage. (b) DTA also administers the Emergency Aid to the Elderly, Disabled and Children (EAEDC) Program. The MassHealth agency provides MassHealth to those persons receiving EAEDC cash assistance as follows: 1. MassHealth Standard: children younger than 19 years old, ; young adults 19 and 20 years old who are citizens, qualified noncitizens, qualified noncitizens barred, and nonqualified individuals lawfully present; parents and caretakers who are citizens or qualified noncitizens; adults 21 through 64 years old who are citizens or qualified noncitizens; children younger than 19 years old; 2. MassHealth Family Assistance: children younger than 19 years old, young adults 19 and 20 years old who are nonqualified persons living under color of law (PRUCOLs), parents and caretakers who are qualified noncitizens barred, nonqualified individuals lawfully present, nonqualified PRUCOLs, and adults 21 through 64 years old who are qualified noncitizens barred, nonqualified individuals lawfully present, and nonqualified PRUCOLs. (2) Social Security Administration (SSA). The SSA administers the Supplemental Security

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Income (SSI) program and determines the eligibility of disabled individuals. Individuals receiving SSI are automatically eligible for Standard coverage. Individuals without health insurance are provided choices of enrollment in a MassHealth managed care provider, SCO, or ICO in accordance with 130 CMR 508.000: MassHealth: Managed Care Requirements. (3) Health Connector. The Health Connector is Massachusetts’s health insurance marketplace where individuals, families, and small businesses can shop among qualified health insurance carriers and choose a health insurance plan. The Health Connector administers qualified health plans (QHPs), premium tax credits (PTC), and the ConnectorCare program. The single, streamlined application is used to determine eligibility for both Health Connector and MassHealth programs as described in 130 CMR 502.000: Health Care Reform: MassHealth: The Eligibility Process. The Health Connector and MassHealth also coordinate eligibility notices and eligibility appeals.

501.005 Individuals and Families Eligible for or Receiving Medical Assistance on June 30, 1997

501.005: Individuals and Families Eligible for or Receiving Medical Assistance on June 30, 1997

(A) Members Who Were Not Subject to a Deductible. (1) Individuals and families (including caretaker relatives) who were receiving medical assistance on June 30, 1997, and whose family group gross income on June 30, 1997 exceeded MassHealth eligibility standards, will be provided Standard coverage for one year after the date of MassHealth implementation, except in the following circumstances: (a) the individual or family no longer lives in Massachusetts; (b) the individual enters an institution; (c) the individual turns 65 years old; (d) the individual or all members of the family are deceased; or (e) the individual or family is no longer categorically eligible. (2) Eligibility for continuing coverage will be reviewed toward the end of this one-year period.

(B) Families Who Have Met a Deductible. (1) Families (including caretaker relatives) with children younger than 18 years old who were receiving medical assistance on June 30, 1997, as a result of meeting a deductible, or who were denied with a deductible before July 1, 1997, and subsequently meet a deductible on or after July 1, 1997, and whose family group gross income exceeds MassHealth standards will be eligible for Standard for one year from the end of the deductible period, except in the following circumstances: (a) the individual or family no longer lives in Massachusetts; (b) the individual enters an institution; (c) the individual turns 65 years old; (d) the individual or all members of the family are deceased; or (e) the individual or family is no longer categorically eligible. (2) A determination of eligibility for MassHealth will be made toward the end of the one- year period.

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(C) Disabled Individuals Who Have Met a Deductible. Disabled individuals who were receiving medical assistance on June 30, 1997, as a result of meeting a deductible, or who met a deductible on or after July 1, 1997, will have their continuing eligibility for MassHealth determined in accordance with then-existing MassHealth regulations.

501.006 Children Receiving Benefits under the Children’s Medical Security Plan (CMSP) on August 3,

501.006: Children Receiving Benefits under the Children’s Medical Security Plan (CMSP) on August 3, 1998

(A) Eligibility. (1) Children who were receiving benefits under the CMSP on August 3, 1998, as well as any siblings in their family, will be treated as a protected status group under MassHealth if they (a) have submitted a complete application (formerly known as Medical Benefit Request) as defined in 130 CMR 502.001: Application for Benefits by March 31, 1999; (b) meet the eligibility requirements of MassHealth; and (c) have an income less than or equal to 200 % of the FPL. (2) Families of children described in 130 CMR 501.006(A)(1) who are determined eligible for Family Assistance will have the option of choosing purchase of medical benefits or premium assistance under Family Assistance if the MassHealth agency determines the child has access to health insurance from an employer other than the Commonwealth of Massachusetts.

(B) Loss of Protected Status. The protected status of a child described in 130 CMR 501.006(A) will end in the following circumstances: (1) the income exceeds 200% of the FPL; (2) the family fails to cooperate with the MassHealth eligibility review; or (3) the child no longer meets MassHealth requirements.

501.007 Receiving Public Assistance from Another State

501.007: Receiving Public Assistance from Another State

People who are receiving public assistance from another state are not eligible for MassHealth.

(130 CMR 501.008 Reserved)

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501.009 Rights of Applicants and Members

501.009: Rights of Applicants and Members

The policies of the MassHealth agency are administered in accordance with federal and state law. Applicants and members must be informed of their rights and responsibilities with respect to MassHealth.

(A) Right to Nondiscrimination and Equal Treatment. The MassHealth agency complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, religion, creed, sexual orientation, or sex (including gender identity and gender stereotyping). A compliance coordinator is designated to administer grievance procedures for discrimination complaints.

(B) Right to Confidentiality. The confidentiality of information obtained by the MassHealth agency during the MassHealth eligibility process is protected in accordance with federal and state regulations. The use and disclosure of information concerning applicants, members, and legally liable third parties is restricted to purposes directly connected with the administration of MassHealth as governed by state and federal law.

(C) Right to Timely Provision of Benefits. Eligible applicants and members have the right to the timely provision of benefits, as defined in 130 CMR 502.000: Health Care Reform: MassHealth: The Eligibility Process.

(D) Right to Information. Persons who inquire about MassHealth, either orally or through a written request, have the right to receive information about medical benefits, coverage type requirements, and their rights and responsibilities as applicants and members of MassHealth.

(E) Right to Apply. Any person, individually or through an authorized representative, has the right, and must be afforded the opportunity without delay, to apply for MassHealth.

(F) Right to Be Assisted by Others. (1) The applicant or member has the right to be accompanied by any individual of their choice and the right to be represented by an appeal representative as defined in 130 CMR 610.004: Definitions during the appeal process. (2) An application for MassHealth may be filed by an authorized representative as described in the definition of authorized representative in 130 CMR 501.001. (3) An appeal of a MassHealth decision, including one brought on behalf of a deceased person, may be filed by an appeal representative if such appeal representative meets the requirements in 130 CMR 610.016: Appeal Representative. (4) The extent of the authorized representative’s and appeal representative’s authority to act on behalf of the applicant or member is determined by the applicant or member’s delegation of authority, applicable law, or underlying legal document.

(G) Right to Inspect the MassHealth Case File. The applicant or member has the right to inspect

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information in their MassHealth case file and contest the accuracy of the information. The case file may include electronic records used to determine eligibility.

(H) Right to Appeal. The applicant or member has the right to appeal and request a fair hearing as the result of any adverse action or inaction taken by the MassHealth agency. The request will not be granted if the sole issue is a federal or state law requiring an automatic change adversely affecting members.

(I) Right to Interpreter Services. The MassHealth agency provides free aids and services to applicants and members with a disability or limited English proficiency, such as qualified interpreters and written information in other formats or languages, in accordance with the requirements of federal and state law.

501.010 Responsibilities of Applicants and Members

501.010: Responsibilities of Applicants and Members

(A) Responsibility to Cooperate. The applicant or member must cooperate with the MassHealth agency in providing information necessary to establish and maintain eligibility and must comply with all the rules and regulations of MassHealth, including recovery and obtaining or maintaining available health insurance. The MassHealth agency may request corroborative information necessary to maintain eligibility, including obtaining or maintaining available health insurance. The applicant or member must supply such information within 60 days of the receipt of the agency’s request. If the member does not cooperate, MassHealth benefits may be terminated.

(B) Responsibility to Report Changes. The applicant or member must report to the MassHealth agency, within ten days or as soon as possible, changes that may affect eligibility. Such changes include, but are not limited to, income, the availability of health insurance, and third-party liability.

(C) Cooperation with Quality Control. The MassHealth agency may periodically conduct an independent review of eligibility factors in a sampling of case files. When a case file is selected for review, the member must cooperate with the MassHealth agency. Cooperation includes, but is not limited to, a personal interview and the furnishing of requested information. If the member does not cooperate, MassHealth benefits may be terminated.

501.011 Referrals to Investigative Units

501.011: Referrals to Investigative Units

Intentional false statements or fraudulent acts made in connection with obtaining medical benefits or payments under MassHealth are punishable under M.G.L. c. 118E, § 39 by fines, imprisonment, or both. In all cases of suspected fraud, MassHealth agency staff will make a referral to the Bureau of Special Investigations or other appropriate agencies.

(130 CMR 501.012 Reserved)

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501.013 Estate Recovery

501.013: Estate Recovery

(A) Introduction. (1) The MassHealth agency will recover the amount of payment for medical benefits correctly paid from the estate of a deceased member. Recovery is limited to payment for all services provided (a) while the member was 65 years of age or older, except on or after October 1, 1993, while the member was 55 years of age or older; and (b) on or after March 22, 1991, while the member, regardless of age, was institutionalized, and the MassHealth agency determined that the member could not reasonably be expected to return home. (c) Effective for dates of death on or after December 31, 2016, MassHealth will offset the estate recovery claim by the total of any premiums paid to the MassHealth agency on behalf of the member when the member was 55 years of age or older. (2) The estate includes all real and personal property and other assets in the member's probate estate. (3) Notwithstanding 130 CMR 501.013(A)(1) and in accordance with 42 U.S.C. 1396p(b)(B), the MassHealth agency will not recover Medicare cost-sharing benefits described at 42 U.S.C. 1396(a)(10)(E) with dates of payment on or after January 1, 2010, for persons who received such benefits under 130 CMR 505.002: MassHealth Standard, 130 CMR 505.007: Medicare Savings Program (MSP, also called Buy-In), 130 CMR 519.010: Medicare Savings Program (MSP) – Qualified Medicare Beneficiaries (QMB), or 130 CMR 519.011: Medicare Saving Program (MSP) – Specified Low Income Medicare Beneficiaries and Qualifying Individuals. (a) The date of payment for Medicare cost-sharing deductibles, coinsurance, and copayments is the date the MassHealth agency received the claim. (b) The date of payment for premium payments is the date the MassHealth agency paid the premium.

(B) Exceptions. (1) Long-term Care Insurance Exception. No recovery for nursing facility or other long-term care services may be made from the estate of any person who meets the following requirements. (a) The member was institutionalized; and (b) The member notified the MassHealth agency that they had no intent of returning home; and (c) On the date of admission to the long-term care institution, the member had long-term care insurance that, when purchased, or at any time thereafter, met the requirements of 130 CMR 515.014: Long-term-care Insurance Minimum Coverage Requirements for MassHealth Exemptions and the Division of Insurance regulations at 211 CMR 65.09(1)(e)2.

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(2) Cost Effectiveness Exception. Effective for dates of death on or after May 14, 2021, in probate estates of members where the probate petition certifies under the penalties of perjury that the total assets in a member’s estate are valued at $25,000 or less, MassHealth has determined that it is not cost effective to pursue recovery. In such estates, MassHealth waives its right to recovery, and will not file a claim or otherwise pursue recovery. MassHealth reserves the right to file a claim and recover in such estates if probate filings do not sufficiently identify the value of the estate or if later probate filings or proceedings or investigation identify or establish that the total assets in the estate exceed $25,000.00.

(C) Deferral of Estate Recovery. Recovery will not be required until after the death of a surviving spouse, if any, or while there is a surviving child who is younger than 21 years old, or a child of any age who is blind or permanently and totally disabled.

(D) Waiver of Estate Recovery Due to Undue Hardship. The MassHealth agency will waive its estate recovery claim if the agency determines that satisfaction of the claim would cause an undue hardship. An undue hardship does not exist solely because recovery will prevent any heir from receiving an anticipated inheritance. The duly court-appointed personal representative or public administrator of the deceased member’s probate estate may apply for a waiver of estate recovery due to undue hardship. The application for a waiver and supporting documents must be received by the MassHealth agency within 60 days of the agency’s notice of claim. The types of waivers of estate recovery due to undue hardship are as follows. (1) Waiver of Estate Recovery Due to Residence and Financial Hardship. (a) For notice of claims presented on or after November 15, 2003, but before May 14, 2021, recovery will be waived if MassHealth determines all of the following conditions have been met.

1. A sale of real property would be required to satisfy a claim against the member's probate estate; and
2. An individual who was using the property as a principal place of residence on the date of the member's death meets all the following conditions: a. the individual lived in the property on a continual basis for two years prior to the member’s admission to an institution, or death, and continued to live in the property at the time the MassHealth agency first presented its claim for recovery against the deceased member’s estate; b. the individual has inherited or received an interest in the property from the deceased member's estate as defined in 130 CMR 501.013(A)(2) and 130 CMR 515.011(A)(2); c. the individual is not being forced to sell the property by other devisees or heirs at law; and d. at the time the MassHealth agency first presented its claim for recovery against the deceased member's estate, the gross annual income of the individual’s family group was less than or equal to 133 % of the applicable federal-poverty- level income standard for the appropriate family size.

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3. The waiver will be conditional for a period of two years from the date the MassHealth agency mails notice that the waiver requirements have been met, or from the date that a court of competent jurisdiction determines that the waiver requirements have been met. If at the end of that period, all circumstances and conditions that must exist for the MassHealth agency to waive recovery still exist, including meeting the same income standards under 130 CMR 501.013(D)(1)(a)2.d., and the real property has not been sold or transferred, the waiver will become permanent and binding. If at any time during the two-year period, the circumstances and conditions for the waiver no longer exist, including meeting the same income standards under 130 CMR 501.013(D)(1)(a)2.d.; the property is sold or transferred; or the individual does not use the property as their primary residence, the MassHealth agency will be notified and its claim may be payable in full. (b) For claims presented on or after May 14, 2021, and upon application for a waiver of estate recovery due to residence and undue hardship by the personal representative or public administrator of the estate, MassHealth will waive recovery without a conditional two-year waiting period provided the personal representative or public administrator establishes to the satisfaction of the MassHealth agency that all the criteria for a residence and undue hardship waiver in 130 CMR 501.013(D)(1)(a)1. and 2. are currently met. (c) Any waivers arising out of notice of claims presented before May 14, 2021, that did not become permanent and binding pursuant to the two-year conditional requirements set forth in 130 CMR 501.013(D)(1)(a)3., and that had not been satisfied and were still subject to the two-year conditional requirements of 130 CMR 515.011(D)(1)(a)3. as of May 14, 2021, will become permanent and binding. (2) Waiver of Estate Recovery Based on Care Provided. For claims presented on or after May 14, 2021, for an heir or devisee inheriting a legal interest in the deceased member’s home, the MassHealth agency will waive estate recovery if the agency determines to its satisfaction that all of the following conditions have been met: (a) the heir or devisee resided in the member’s home on a continual basis for two years prior to the member’s death or admission to an institution; (b) during that time, the member needed, and the heir or devisee provided, a level of care that avoided the member’s admission to a facility; (c) the heir or devisee continues to live in the property at the time the notice of claim is filed; (d) the heir or devisee was left an interest in the home under the member’s will, or inherited the property under the laws of intestacy; (e) the heir is not being forced to sell the property by other devisees or heirs; and (f) the property would have to be sold to satisfy the claim. (3) Waiver of Estate Recovery Due to Financial Hardship Based on Income. (a) For claims presented on or after May 14, 2021, the personal representative or public administrator of a member’s estate may apply for a waiver of estate recovery due to financial hardship based on the income of an heir or heirs or devisee or devisees. If there are multiple heirs or devisees, the personal representative or public administrator must apply for an income-based waiver separately on behalf of each individual. To be

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considered a qualifying heir or devisee, the personal representative or public administrator of the estate must establish the following:

1. the qualifying heir or devisee is inheriting an interest in the member’s estate under the member’s probate estate; and,
2. the family group of a qualifying heir or devisee has a gross income below 400% of the federal poverty level for the two-year period prior to the date the notice of claim is filed. If MassHealth determines that both conditions have been met, the heir is considered a qualifying heir. (b) MassHealth will waive recovery in an amount equal to the value of the qualifying heir’s or devisee’s interest in the estate up to a maximum of $50,000 per qualifying heir or devisee. If there is more than one qualifying heir or devisee in an estate, the total amount of the agency’s estate recovery claim waived for qualifying heirs or devisees must be limited to $100,000. (c) An estate with qualifying heirs or devisees, regardless of whether there are non- qualifying heirs, will be subject to estate recovery based on the lesser of the following:
3. the value of the estate remaining after deducting the amount waived from the total value of the estate for qualifying heirs and devisees; or
4. the amount of the MassHealth claim remaining after deducting the amount waived from the total value of the MassHealth claim. (d) Example 1. The value of the estate is $400,000 and the MassHealth claim is $60,000. There are two heirs who qualify for the waiver, each with an interest in the estate of $50,000 or greater. There are also two heirs who do not qualify. In this example, the waived amount is $100,000 (50,000 + 50,000). After deducting the $100,000 waived amount from the estate there is $300,000 left in the estate, but after deducting the $100,000 waived amount from the $60,000 MassHealth claim there is nothing left in the MassHealth claim. The result is no estate recovery. (e) Example 2. The value of the estate is $350,000 and the MassHealth claim is $500,000. There are two qualifying heirs, each with an interest in the estate of $50,000 or greater. There are also two non-qualifying heirs. In this example, the waived amount is $100,000 (50,000 + 50,000). After deducting the $100,000 waived amount from the estate there is $250,000 left in the estate, and after deducting the $100,000 waived amount from the $500,000 MassHealth claim there is $400,000 remaining in the MassHealth claim. In this example, MassHealth would recover $250,000, since it is less than $400,000.

(E) Outstanding Claims. (1) For claims presented between April 1, 1995 and November 15, 2003, that are still outstanding, recovery will be waived if all requirements under the then-existing MassHealth regulations were met. (2) For claims presented before April 1, 1995, a waiver for hardship did not exist.

(F) Fair Market Value and Equity Value. If there will be insufficient proceeds from the sale or

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transfer of the property to satisfy the MassHealth agency’s claim in full from property on which MassHealth has a recorded lien, the fair market value and equity value of all real property that is part of the deceased member’s probate estate must be verified prior to the sale or transfer of said property. (1) The personal representative or public administrator of the probate estate must verify the fair market value by sending to the MassHealth agency a copy of the most recent tax bill or the property tax assessment that was most recently issued by the taxing jurisdiction, provided that this assessment is not one of the following: (a) a special-purpose tax assessment; (b) based on a fixed-rate-per-acre method; or (c) based on an assessment ratio or providing only a range. (2) The personal representative or public administrator of the probate estate must also provide a comparable market analysis or a written appraisal of the property value from a knowledgeable source. Knowledgeable sources include the following: a licensed real-estate agent or broker; a real-estate appraiser; or an official of a bank, savings and loan association; or similar lending organization. The knowledgeable source must not have any real or apparent conflict-of-interest relationship with the estate. (3) The MassHealth agency may also obtain an assessment from a knowledgeable source.

(G) Exemption of Certain Assets from Estate Recovery for American Indians and Alaska Natives. (1) For notice of claims presented on or after July 1, 2009, and upon application for exemption of certain assets from estate recovery by the personal representative or public administrator of the member’s estate, recovery from the following American Indians’ and Alaska Natives’ income, resources, and property will be waived: (a) certain income and resources (such as interests in and income derived from tribal land and other resources currently held in trust status and judgment funds from the Indian Claims Commission and the U.S. Claims Court) that are exempt from Medicaid estate recovery by other laws and regulations; (b) ownership interest in trust and non-trust property, including real property and improvements

1. located on a reservation (any federally recognized Indian tribe’s reservation, pueblo, or colony, including former reservations in Oklahoma, Alaska Native regions established by the Alaska Native Claims Settlement Act at 43 U.S.C. Chapter 33, and Indian allotments) or near a reservation as designated and approved by the Bureau of Indian Affairs of the US Department of the Interior; or
2. for any federally recognized tribe not described in 130 CMR 501.013(G)(1)(b)1., located within the most recent boundaries of a prior federal reservation; (c) income left as a remainder in an estate derived from property protected in 130 CMR 501.013(G)(1)(b), that was either collected by an Indian or by a tribe or tribal organization and distributed to Indians, as long as the individual can clearly trace it as coming from protected property; (d) ownership interests left as a remainder in an estate in rents, leases, royalties, or usage

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rights related to natural resources, including extraction of natural resources or harvesting of timber, other plants and plant products, animals, fish, or fish products, resulting from the exercise of federally protected rights and income either collected by an Indian or by a tribe or tribal organization and distributed to Indians derived from these sources as long as the individual can clearly trace it as coming from protected sources; or (e) ownership interests in or usage rights to items not covered by 130 CMR 501.013(G)(1)(a) through (d) that have unique religious, spiritual, traditional, or cultural significance or rights that support subsistence or a traditional life style according to applicable tribal law or custom. (2) Protection of non-trust property described in 130 CMR 501.013(G)(1) is limited to circumstances when it passes from an Indian, as defined in the Indian Health Care Improvement Act at 25 U.S.C. c. 18, § 4, to one or more relatives (by blood, adoption, or marriage), including Indians not enrolled as members of a tribe and non-Indians, such as spouses or step-children, whom their culture would nevertheless protect as family members, to a tribe or tribal organization, or to one or more Indians.

501.014 Voter Registration

501.014: Voter Registration

(A) Voter registration forms are available through the MassHealth agency to applicants and members who are (1) U.S. citizens; and (2) 18 years of age or older, or who will be 18 years old on or before the date of the next election, in accordance with the National Voter Registration Act of 1993.

(B) Applicants and members are (1) informed of the availability of voter registration forms at application, at the time of an eligibility review, and when there is an address change; (2) offered assistance in completing the voter registration form unless such assistance is refused; and (3) able to submit voter registration forms to the MassHealth agency for transmittal to the proper election offices.

(C) MassHealth agency staff must not (1) seek to influence an applicant's or member's political preference or party registration; (2) display any political preference or party allegiance to the applicant or member; (3) make any statement to an applicant or member or take any action intended to influence the applicant's or member's decision regarding voter registration; or (4) make any statement to an applicant or member or take any action intended to lead the applicant or member to believe that the decision to register or not has any bearing on the availability of services or benefits.

(D) Completed voter registration forms that are submitted to the MassHealth agency are transmitted to the proper local election office for processing within five days of receipt.

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501.015 Reimbursement of Certain Out-of-pocket Medical Expenses

501.015: Reimbursement of Certain Out-of-pocket Medical Expenses

(A) Eligibility Requirements. The following persons will be entitled to reimbursement for certain medical expenses for which they paid, subject to the provisions of 130 CMR 501.015. (1) A member who (a) applied for SSI; (b) was denied SSI benefits by the Social Security Administration (SSA); and (c) had their initial SSA denial overturned through a reconsideration process, administrative hearing, appeals counsel review, federal court review, or reopening under the SSA rules on administrative finality. (2) A member who (a) applied for TAFDC or MassHealth; (b) was denied TAFDC by the Department of Transitional Assistance, or was denied MassHealth by the MassHealth agency; and (c) had their initial denial overturned by a subsequent decision by DTA, the MassHealth agency, the fair hearing process, or the judicial review process.

(B) Limitations. (1) Reimbursement is limited to bills incurred on or after the coverage start date for the applicable coverage type as described in 130 CMR 505.000: Health care Reform: MassHealth: Coverage Types and paid between the date of the erroneous eligibility decision and the date on which the member is notified of MassHealth eligibility. The bill must have been paid by the member, the member's spouse, the parent of a member, or a legal guardian. (2) Reimbursement is also limited to amounts actually paid for care or services that would have been covered under MassHealth had eligibility been determined correctly, even if these amounts exceed the MassHealth rate. Before reimbursing a member for care or services that would have required prior authorization, the MassHealth agency may require submission of medical evidence for consideration under the prior authorization standards. Reimbursement is available even if the medical care or services were furnished by a provider who does not participate in MassHealth.

(C) Verification. (1) Applicants or members seeking reimbursement must provide MassHealth with (a) a bill for medical services that includes

1. the provider's name;
2. a description of the services provided; and
3. the date the service was provided; and (b) proof of payment of the bill presented, such as a canceled check or receipt. (2) Recipients of SSI must also provide documents from the SSA establishing the date of application and the date of application denial.

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501.016 Severability

501.016: Severability

The provisions of 130 CMR 501.000 are severable. If any provision of 130 CMR 501.000 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 501.000 or application of those provisions to applicable individuals, entities, or circumstances.

REGULATORY AUTHORITY

130 CMR 501.000: M.G.L. c. 118E.

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