130 CMR 522.00 — MassHealth: Other Division Programs

1 130 CMR: DIVISION OF MEDICAL ASSISTANCE

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130 CMR 522.000: MASSHEALTH: OTHER DIVISION PROGRAMS

TABLE OF CONTENTS

Section

130 CMR 522.00 MassHealth: Other Division Programs

522.001 Massachusetts Insurance Connection for Individuals with AIDS or HIV (Closed to New

522.001: Massachusetts Insurance Connection for Individuals with AIDS or HIV (Closed to New Applicants)

522.002 Refugee Resettlement Program

522.002: Refugee Resettlement Program

522.003 Adoption Assistance and Foster Care Maintenance

522.003: Adoption Assistance and Foster Care Maintenance

522.004 Children’s Medical Security Plan (CMSP)

522.004: Children’s Medical Security Plan (CMSP)

522.005 Severability

522.005: Severability

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130 CMR 522.000: MASSHEALTH: OTHER DIVISION PROGRAMS

522.001 Massachusetts Insurance Connection for Individuals with AIDS or HIV (Closed to New

522.001: Massachusetts Insurance Connection for Individuals with AIDS or HIV (Closed to New Applicants)

(A) Introduction. The Massachusetts Insurance Connection for Individuals with AIDS or HIV Program (MIC) is a health insurance buy-in program administered by the MassHealth agency for individuals with acquired immunodeficiency syndrome (AIDS) or human immunodeficiency virus (HIV). MIC is closed to new applicants effective January 1, 2020. Program participants may continue to receive benefits through MIC for as long as they meet the requirements of 130 CMR 522.001(B).

(B) Eligibility Requirements. The MassHealth agency may pay the monthly private and group health insurance premiums of a program participant and their spouse and dependent children, provided that the program participant (1) was enrolled in the MIC Program as of December 31, 2019, and remains continuously enrolled in the MIC Program (continuous enrollment ends when a program participant has not been enrolled in the MIC Program for six months); (2) had a health insurance policy (group or private) before becoming eligible for MIC (individuals who elect to continue employer-based group health insurance are subject to the provisions of the Omnibus Budget Reconciliation Act of 1990 [OBRA] and the Consolidated Omnibus Budget Reconciliation Act of 1985 [COBRA], P.L. 99-272) that has comprehensive coverage, as determined by the MassHealth agency on an individual basis; (3) has a diagnosis of AIDS or HIV; (4) applies for and meets the Social Security Administration's definition of disability for AIDS or HIV; (5) is a resident of Massachusetts; and (6) in conjunction with their spouse and dependent children, has a gross annual income that does not exceed 300% of the annualized federal poverty level income standard for a household of that size.

(C) MIC Members Eligible for a MassHealth Coverage Type That Provides or Pays for Comprehensive Coverage (1) Members cannot be simultaneously enrolled in MIC and a MassHealth coverage type that provides or pays for comprehensive coverage. (2) If a MIC member is found eligible for a MassHealth coverage type that provides or pays for comprehensive coverage, the MIC member shall have 30 days to choose either continuing their enrollment in MIC or enrolling in the comprehensive MassHealth coverage. When a member is eligible for both MIC and comprehensive MassHealth coverage and does not choose between the two, the member shall by default keep their current coverage type. (3) The MIC member shall be disenrolled from MIC when they choose to enroll in a comprehensive MassHealth coverage type. (4) A former MIC member will lose the continuous enrollment status described in 130 CMR 522.001(B)(1) if they are enrolled in comprehensive MassHealth coverage for six months or more.

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130 CMR 522.000: MASSHEALTH: OTHER DIVISION PROGRAMS

(5) During the first six months after disenrolling from MIC and enrolling in comprehensive MassHealth coverage, the member may request to go back to the MIC Program, be disenrolled from their comprehensive MassHealth coverage type, and be considered continuously enrolled in MIC under 130 CMR 522.001(B)(1). Such disenrollment from comprehensive MassHealth coverage shall be treated as a voluntary withdrawal from their MassHealth coverage. (6) An MIC member who disenrolls from MIC to enroll in comprehensive MassHealth coverage shall be given written notice of their rights under 130 CMR 522.001, including how MassHealth enrollment affects their future eligibility for MIC as described in 130 CMR 522.01.

(D) Verifications. Applicants must have submitted the following verifications to the MIC Program coordinator within 45 days of the receipt of the application by the MassHealth agency: (1) a written statement of a diagnosis of AIDS or HIV by the examining licensed physician; (2) documentation of receipt of Social Security disability benefits or Supplemental Security Income; and (3) documentation of gross annual income.

(E ) Redetermination of Eligibility. The MassHealth agency completes a redetermination of eligibility for each program participant on an annual basis or as needed.

(F ) Termination of Benefits (1) When a program participant no longer meets one or more of the conditions in 130 CMR 522.001(B), the MassHealth agency terminates premium payments for that program participant effective on the next premium payment due date. However, the following exceptions apply:

(a) in the event of the death of a qualified individual who has coverage under a family plan, payment for the continuation of the existing plan will not exceed a period of three months following their death; and (b) if a qualified individual relocates to another state, they will be afforded one additional premium payment after relocation to cover the transition period. (2) The MassHealth agency sends written notice to program participants of the termination of premium payments, the reason for the termination, and the individual's right to appeal such termination in accordance with the provisions of 130 CMR 610.000: MassHealth: Fair Hearing Rules.

522.002 Refugee Resettlement Program

522.002: Refugee Resettlement Program

(A) Regulatory Authority. The Refugee Resettlement Program (RRP) is regulated pursuant to Chapter 2 of Title IV of the Immigration and Nationality Act (INA), 8 U.S.C. 1521 and Refugee Medical Assistance (RMA) is provided in accordance with 45 CFR 400 Subpart G.

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130 CMR 522.000: MASSHEALTH: OTHER DIVISION PROGRAMS

(B) Overview (1) The RRP was established by the Refugee Act of 1980. The act authorizes funds for the administration and implementation of social and educational services and employment training and placement, as well as cash assistance and medical assistance to refugees without regard to race, religion, nationality, sex, or political opinion. It is the intent of the act to promote the resettlement and economic self-sufficiency of refugees within the shortest timeframe possible. (2) The Massachusetts Office for Refugees and Immigrants (ORI) is the state agency responsible for the delivery of services to refugees under the RRP. ORI has entered into an agreement with the MassHealth agency to provide RMA to eligible individuals. Refugee resettlement agencies under contract with ORI make the RRP eligibility determination and assist refugees to submit an application for MassHealth.

(C) Eligibility Requirements. Individuals must submit an application for MassHealth and meet the following requirements: (1) having valid documentation of refugee, asylee, Cuban and Haitian entrant, Iraqi and Afghan Special Immigrant Visa (SIV) holder, or Amerasian status from US Citizenship and Immigration Services (USCIS), or of victim of human trafficking status from the federal Administration for Children and Families or USCIS; (2) being a resident of Massachusetts; (3) having modified adjusted gross income (MAGI) of the MassHealth MAGI household that is less than 200% of the federal poverty level standards or meet a deductible in accordance with 130 CMR 520.028 through 520.035; and (4) being ineligible for MassHealth Standard, CommonHealth, CarePlus, and Family Assistance.

(D) Period of Eligibility (1) Eligibility Period. A refugee who meets the eligibility requirements of RMA is eligible to receive MassHealth Standard or CarePlus for a four-month period, or other time period as established pursuant to 45 CFR 400.211, beginning with the date of entry into the United States. (2) End of Eligibility Period. A refugee who has been in the country for 12 months from their date of entry, or other time period as stated in 130 CMR 522.002(D)(1), is no longer eligible for MassHealth under the refugee resettlement program. Such refugee will be notified in advance of termination. (3) Extended MassHealth Eligibility. A refugee who becomes ineligible for MassHealth solely by reason of increased earnings from employment or increased hours of employment will have coverage for the balance of the eligibility period.

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130 CMR 522.000: MASSHEALTH: OTHER DIVISION PROGRAMS

522.003 Adoption Assistance and Foster Care Maintenance

522.003: Adoption Assistance and Foster Care Maintenance

Any child placed in subsidized adoption or foster care under Title IV-E of the Social Security Act is automatically eligible for medical assistance provided by the state where the child resides.

(A) Children receiving state-subsidized adoption payments from a state that is a member of the Interstate Compact on Adoption and Medical Assistance (ICAMA) will be eligible for medical assistance provided by the state where the child resides if that state is a member of ICAMA.

(B) Children receiving state-subsidized adoption payments from a state that is not a member of ICAMA, or any child receiving state-subsidized foster-care payments, will only be eligible for medical assistance provided by their state of origin.

522.004 Children’s Medical Security Plan (CMSP)

522.004: Children’s Medical Security Plan (CMSP)

(A) Regulatory Authority. CMSP is administered pursuant to M.G.L. c. 118E, § 10F.

(B) Overview. CMSP provides coverage to uninsured children younger than 19 years of age who do not qualify for any other MassHealth coverage type, other than MassHealth Limited, and who do not have physician and hospital healthcare coverage. To apply for these benefits, an applicant must submit an application as described in 130 CMR 502.001: Application for Benefits and 502.002: Reactivating the Application.

(C) Eligibility Requirements. Children are eligible for CMSP if they are (1) a resident of Massachusetts, as defined in 130 CMR 503.002: Residence Requirements; (2) younger than 19 years of age; (3) not otherwise eligible for any other MassHealth coverage type, other than MassHealth Limited. Children who are otherwise eligible, and who are not receiving MassHealth coverage as a result of not complying with administrative requirements of MassHealth, are not eligible for CMSP. Children who lose eligibility for MassHealth Family Assistance as a result of nonpayment of premiums, or as a result of not enrolling in employer-sponsored health insurance through Premium Assistance, are not eligible for CMSP; and (4) uninsured. An applicant or member is uninsured if they (a) do not have insurance that provides physician and hospital healthcare coverage; (b) have insurance that is in an exclusion period; or (c) had insurance that has expired or has been terminated.

(D) Premiums. The premium schedule and payment policies for CMSP are described in 130 CMR 506.011: MassHealth and the Children’s Medical Security Plan (CMSP) Premiums.

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130 CMR 522.000: MASSHEALTH: OTHER DIVISION PROGRAMS

(E) Copayments. Members are not required to pay copayments for any covered services.

(F) Medical Coverage Date. Except as provided at 130 CMR 522.004(H), coverage begins on the date of the final eligibility determination. The time standards for determining and redetermining eligibility are described at 130 CMR 502.005: Time Standards for an Eligibility Determination and 502.007: Continuing Eligibility.

(G) Benefits Provided. Benefits provided are described at M.G.L. c. 118E, § 10F. Included benefits are (1) preventive pediatric care; (2) sick visits; (3) office visits, first-aid treatment, and follow-up care; (4) provision of smoking prevention educational information and materials to the parent, guardian, or person with whom the enrollee resides, as distributed by the Department of Public Health; (5) prescription drugs up to $200 per state fiscal year; (6) urgent care visits, not including emergency care in a hospital outpatient or emergency department; (7) outpatient surgery and anesthesia that are medically necessary for the treatment of inguinal hernia and ear tubes; (8) annual and medically necessary eye exams; (9) medically necessary mental-health outpatient services, including substance-use treatment services, not to exceed 20 visits per fiscal year; (10) durable medical equipment, up to $200 per state fiscal year, with an additional $300 per state fiscal year for equipment and supplies related to asthma, diabetes, and seizure disorders only; (11) dental health services, up to $750 per state fiscal year, including preventive dental care, provided that no funds will be expended for cosmetic or surgical dentistry; (12) auditory screening; (13) laboratory diagnostic services; and (14) radiologic diagnostic services.

(H) Enrollment Cap. The MassHealth agency may limit the number of children who can be enrolled in CMSP. When the MassHealth agency imposes such a limit, applicants will be placed on a waiting list when their eligibility has been determined. When the MassHealth agency is able to open enrollment for CMSP, the MassHealth agency will process the applications in the order in which they were placed on the waiting list.

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130 CMR 522.000: MASSHEALTH: OTHER DIVISION PROGRAMS

522.005 Severability

522.005: Severability

The provisions of 130 CMR 522.000 are severable. If any provision of 130 CMR 522.000 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 522.000 or application of those provisions to applicable individuals, entities, or circumstances.

REGULATORY AUTHORITY

130 CMR 522.000: M.G.L. c. 118E.