130 CMR 517.00 — MassHealth: Universal Eligibility Requirements

1 130 CMR: DIVISION OF MEDICAL ASSISTANCE

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130 CMR 517: MASSHEALTH: UNIVERSAL ELIGIBILITY REQUIREMENTS

TABLE OF CONTENTS

Section

130 CMR 517.00 MassHealth: Universal Eligibility Requirements

517.001 Universal Eligibility Requirements

517.001: Universal Eligibility Requirements

517.002 Residence Requirements

517.002: Residence Requirements

517.003 Residence of Institutionalized Individuals

517.003: Residence of Institutionalized Individuals (130 CMR 517.004 Reserved)

517.005 Persons Institutionalized for Mental Disease

517.005: Persons Institutionalized for Mental Disease

517.006 Social Security Number (SSN)

517.006: Social Security Number (SSN) (130 CMR 517.007 Reserved)

517.008 Potential Sources of Healthcare

517.008: Potential Sources of Healthcare

517.009 Assignment of Rights to Medical Support and Third-party Payments

517.009: Assignment of Rights to Medical Support and Third-party Payments

517.010 Waiver of Cooperation for Good Cause

517.010: Waiver of Cooperation for Good Cause

517.011 Assignment of Rights to Spousal Support

517.011 : Assignment of Rights to Spousal Support

517.012 Assignment of Third-party Recoveries

517.012: Assignment of Third-party Recoveries

517.013 Severability

517.013: Severability

2 130 CMR: DIVISION OF MEDICAL ASSISTANCE

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130 CMR 517: MASSHEALTH: UNIVERSAL ELIGIBILITY REQUIREMENTS

517.001 Universal Eligibility Requirements

517.001: Universal Eligibility Requirements

All MassHealth applicants and members must meet the requirements of 130 CMR 517.000 as a condition of eligibility.

517.002 Residence Requirements

517.002: Residence Requirements

As a condition of eligibility, an applicant or member must be a resident of the Commonwealth of Massachusetts.

(A) Unless otherwise specified, (1) individuals 21 years of age and older are residents of the Commonwealth if they are living in the Commonwealth and either (a ) intend to reside in the Commonwealth, with or without a fixed address; or (b ) have entered the Commonwealth with a job commitment or are seeking employment, whether or not they are currently employed; or (2) individuals 21 years of age and older who are not capable of stating intent as defined in 42 CFR 435.403(c) are residents of the Commonwealth if they are living in the Commonwealth; or (3) for any other non-institutionalized individuals 21 years of age and older not subject to 130 CMR 517.002(A)(1) or (2), their residence is determined in accordance with 45 CFR 233.40, the rules governing residence under the Transitional Aid to Families with Dependent Children (TAFDC) Program.

(B) Unless otherwise specified, (1) individuals younger than 21 years of age are residents of the Commonwealth if they are capable of indicating intent, are either married or emancipated from their parents, and meet the requirements of 130 CMR 517.003(A)(1); or (2) individuals younger than 21 years old not described in 130 CMR 517.002(B)(1) are residents of the Commonwealth if they are (a ) living in the Commonwealth, with or without a fixed address; or (b ) living with their parent or caretaker who is a resident of the Commonwealth in accordance with the requirements of 130 CMR 517.002(A)(1).

(C) Individuals of any age who are receiving a state supplementary payment (SSP) are residents of the Commonwealth if the Commonwealth is the state paying the SSP.

(D) Individuals of any age who are receiving federal payments for foster care and adoption assistance under Title IV-E of the Social Security Act are residents of the Commonwealth if the Commonwealth is the state where the individuals live.

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130 CMR 517: MASSHEALTH: UNIVERSAL ELIGIBILITY REQUIREMENTS

(E)(1) The individual's residency is considered verified if the individual has attested to Massachusetts residency and the residency has been confirmed by electronic data matching with federal or state agencies or information services. (2) If residency cannot be verified through electronic data matching or there is conflicting information, the MassHealth agency may require documentation to validate residency.

(F) Acceptable proof of Massachusetts residency includes the following, as well as any other verification allowed as determined by the MassHealth agency: (1) copy of deed and record of most recent mortgage payment (if mortgage is paid in full, provide a copy of property tax bill from the most recent year); (2) current utility bill or work order dated within the past 60 days; (3) statement from a homeless shelter or homeless service provider; (4) school records (if school is private, additional documentation may be requested); (5) nursery school or daycare records (if school is private, additional documentation may be requested); (6) Section 8 agreement; (7) homeowner’s insurance agreement; (8) proof of enrollment of custodial dependent in public school; (9) copy of lease and record of most recent rent payment; or (10) affidavit supporting residency, signed under pains and penalties of perjury, that states the individual is not visiting Massachusetts for personal pleasure or to receive medical care in a setting other than a nursing facility.

(G) Examples of applicants or members who do not meet the residency requirement for MassHealth are (1) individuals who came to Massachusetts for the purpose of receiving medical care in a setting other than a nursing facility and who maintain a residence outside Massachusetts; (2) individuals visiting Massachusetts for personal pleasure who maintain a residence outside Massachusetts; and (3 ) individuals whose whereabouts are unknown.

(H) Inmates of penal institutions may not receive MassHealth benefits except under one of the following conditions, if they are otherwise eligible for MassHealth: (1) they are inpatients in a medical facility; or (2) they are living outside the penal institution; are on parole, probation, or home release; and are not returning to the institution for overnight stays.

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130 CMR 517: MASSHEALTH: UNIVERSAL ELIGIBILITY REQUIREMENTS

517.003 Residence of Institutionalized Individuals

517.003: Residence of Institutionalized Individuals

(A) Placement by a Public Agency. An individual who has been placed in an institution or a foster care home in another state by a public agency of the Commonwealth shall be considered a resident of the Commonwealth. An individual placed in an institution or a foster care home in the Commonwealth by a public agency of another state shall be considered a resident of that state and not of the Commonwealth. If an individual who has been placed in an institution leaves the institution and is competent at the time of leaving, the individual is a resident of the Commonwealth if they are physically located in the Commonwealth.

(B) Other Institutionalized Individuals. Unless otherwise specified, residency for an institutionalized individual who has not been placed in the institution by a public agency is determined as follows. (1) If the individual is younger than 21 years old, is not married, and is not emancipated, or is 21 years of age or older and became incapable of indicating intent before 21 years old, the individual is a resident of the Commonwealth if (a) the residence of the parent, parents, or legal guardian at the time of placement is the Commonwealth, regardless of the physical location of the individual; (b) the current residence of the parent, parents, or legal guardian who filed the application is the Commonwealth, and the individual is institutionalized in the Commonwealth; (c) in the case of an individual 21 years of age or older who became incapable of indicating intent before 21 years old, the current residence of a parent who filed the application is the Commonwealth, regardless of the physical location of the individual, if the parents reside in separate states; or (d) the current residence of the person or party filing the application is in the Commonwealth, the individual is institutionalized in the Commonwealth, and the individual has been abandoned by their parents and does not have a legal guardian. (2) If the individual is 21 years of age or older and became incapable of indicating intent at or after 21 years old, the individual's state of residence is the Commonwealth if they are institutionalized in the Commonwealth. For any other institutionalized individual 21 years of age or older, the individual is a resident of the Commonwealth if they are residing in and intend to reside in the Commonwealth.

(130 CMR 517.004 Reserved)

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130 CMR 517: MASSHEALTH: UNIVERSAL ELIGIBILITY REQUIREMENTS

517.005 Persons Institutionalized for Mental Disease

517.005: Persons Institutionalized for Mental Disease

(A) Individuals younger than 18 years old and those 65 years of age or older who are patients in a public or private institution for mental disease may be eligible for MassHealth.

(B) Individuals who reach 18 years old while they are patients in an institution for mental disease may be eligible for MassHealth until they reach age 22 years old, provided they are disabled in accordance with Title XVI requirements.

(C) Individuals between 18 and 65 years old who are patients in public or private institutions for mental disease are not eligible for MassHealth, except as provided in 130 CMR 517.005(B). Such individuals may establish eligibility for MassHealth when entering an acute hospital from a public or private institution for mental disease if otherwise categorically and financially eligible.

517.006 Social Security Number (SSN)

517.006: Social Security Number (SSN)

(A) Requirements (1) Condition of Eligibility. As a condition of eligibility for MassHealth, all persons applying in the household must furnish an SSN or proof of application for an SSN, except as provided in 130 CMR 517.006(A)(1). The applicant is notified of the obligation to apply for an SSN for any person applying in the household. The MassHealth agency does not require an SSN or proof of application for an SSN for any applicant who (a) attests to a religious exemption as described in federal law; (b) is only eligible for a nonwork SSN; or (c) is not eligible to receive an SSN. (2) Electronic Data Match. The MassHealth agency verifies each SSN by an electronic data match with the Social Security Administration (SSA). (3) Reasonable Opportunity to Verify a Social Security Number (SSN). If the applicant has provided an SSN, the MassHealth agency matches with the SSA to verify the SSN. If the SSA is unable to verify the SSN, the individual is required to verify their SSN. (a) The MassHealth agency provides applicants and members with a reasonable opportunity period to provide an SSN if the SSA is unable to verify the SSN or the individual has not provided the SSN. (b) The reasonable opportunity period begins on, and will extend 90 days from, the date on which an applicant or member receives a Request for Information. (c) While the verification of SSN is pending, the individual will receive benefits if there are no other verifications outstanding.

(B) Right to Know Uses of Social Security Numbers (SSNs). All household members are given a written notice of the following: (1) the reason the SSNs are requested; (2) the computer matching of SSNs with SSNs in other personal data files within (a) the MassHealth agency;

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130 CMR 517: MASSHEALTH: UNIVERSAL ELIGIBILITY REQUIREMENTS

(b) the Federal Data Services Hub, which matches with the SSA; (c) the US Department of Homeland Security (DHS); (d ) the US Internal Revenue Service; and (e ) other federal and state agencies and other informational services; and (3) the possible denial or termination of benefits, if any applicant or member fails to provide their SSN or proof of application for an SSN, unless an exception described in 130 CMR 517.006(A)(1) applies to the applicant or member.

(130 CMR 517.007 Reserved)

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130 CMR 517: MASSHEALTH: UNIVERSAL ELIGIBILITY REQUIREMENTS

517.008 Potential Sources of Healthcare

517.008: Potential Sources of Healthcare

The MassHealth agency is payer of last resort and pays for healthcare and related services only when no other source of payment is available, except as otherwise required by federal law.

(A) Health Insurance. Every applicant and member must obtain and maintain health insurance available at no cost to the member, including, but not limited to, Medicare and insurance purchased by the MassHealth agency in accordance with 130 CMR 506.012: Premium Assistance Payments. Failure to do so may result in loss of eligibility.

(B) Use of Benefits. The MassHealth agency does not pay for any healthcare and related services that are available (1) through the member’s health insurance, if any; or (2) at no cost to the member, including, but not limited to, any such services that are available through any agency of the local, state, or federal government or any entity legally obligated to provide those services.

517.009 Assignment of Rights to Medical Support and Third-party Payments

517.009: Assignment of Rights to Medical Support and Third-party Payments

(A) Every legally able applicant or member must assign to the MassHealth agency their rights to medical support and third-party payments for medical benefits provided under MassHealth as well as the rights of applicants or members for whom they can legally assign medical support and third-party payments.

(B) The applicant or member must fully cooperate with the MassHealth agency in (1) establishing paternity; (2) obtaining any medical support and payments; and (3) identifying and providing information to assist the MassHealth agency in pursuing third parties, including a noncustodial parent, who may be legally obligated to pay for care and services for the applicant or member, or person on whose behalf benefits are requested, unless the applicant or member has grounds to waive cooperation as described in 130 CMR 517.010 or 505.002(D): Eligibility Requirements for People Who Are Pregnant.

(C)(1) The MassHealth agency will deny eligibility for any applicant who does not attest to a willingness to cooperate and will terminate eligibility for any member who refuses to cooperate, unless the applicant or member demonstrates good cause, as described in 130 CMR 517.010, or is a pregnant person who meets the requirements of 130 CMR 505.002(D): Eligibility Requirements for People Who Are Pregnant. (2) The MassHealth agency will not deny or terminate eligibility of any applicant or member who cannot legally assign their own rights, including, but not limited to, a minor child, and who would otherwise be eligible but for the refusal by a person legally able to assign the child’s rights to assign the child’s rights or to cooperate as required in 130 CMR 517.009.

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130 CMR 517: MASSHEALTH: UNIVERSAL ELIGIBILITY REQUIREMENTS

517.010 Waiver of Cooperation for Good Cause

517.010: Waiver of Cooperation for Good Cause

(A) Good cause is established if (1) with respect to the obligation to establish paternity of a child born out of wedlock, to obtain medical-care support and payments, or to identify or provide information to assist the MassHealth agency in pursuing a liable third party for a child for whom the applicant or member can legally assign rights, the MassHealth agency finds that cooperation is against the best interest of the child; or (2) with respect to the obligation to cooperate in all cases not covered by 130 CMR 517.010(A)(1), the MassHealth agency finds that cooperation is not in the best interest of the applicant or member or the person for whom the benefit is being requested or furnished because it is anticipated that cooperation will result in reprisal against, and cause serious physical or emotional harm to, the applicant or member or another person.

(B) Good cause for noncooperation includes, but is not limited to, the following circumstances: (1) the child was conceived as a result of incest or forcible rape; (2) legal proceedings for adoption are pending before a court; (3) a public agency or licensed facility is assisting in resolving the issue of adoption and discussions have not lasted longer than three months; or (4) cooperation would result in serious physical or emotional harm to the child, the relative with whom the child resides, or to the applicant or member.

517.011 Assignment of Rights to Spousal Support

517.011: Assignment of Rights to Spousal Support

An institutionalized spouse whose community spouse refuses to cooperate or whose whereabouts is unknown will not be ineligible due to

(A) assets determined to be available for the cost of care in accordance with 130 CMR 520.016(B): Treatment of a Married Couple’s Assets When One Spouse Is Institutionalized; or

(B) their inability to provide information concerning the assets of the community spouse when one of the following conditions is met: (1) the institutionalized spouse assigns to the MassHealth agency any rights to support from the community spouse; (2) the institutionalized spouse lacks the ability to assign rights to spousal support due to physical or mental impairment as verified by the written statement of a competent medical authority; or (3) the MassHealth agency determines that the denial of eligibility, due to the lack of information concerning the assets of the community spouse, would otherwise result in undue hardship.

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130 CMR 517: MASSHEALTH: UNIVERSAL ELIGIBILITY REQUIREMENTS

517.012 Assignment of Third-p arty Recoveries

517.012: Assignment of Third-p arty Recoveries

As a condition of eligibility, an applicant or member must inform the MassHealth agency when the individual or spouse is involved in an accident or suffers from an illness or injury or other loss that has resulted or may result in a lawsuit or insurance claim. The applicant or member must

(A) file an insurance claim for compensation; and

(B) agree to comply with all requirements of M.G.L. c. 118E, § 22, including, but not limited to, (1) assigning to the MassHealth agency or its agent the right to recover an amount equal to the MassHealth benefits provided from the proceeds of any claim or other proceeding against a third party; (2) providing information about the claim or any other proceeding, and fully cooperating with the MassHealth agency or its agent, unless the MassHealth agency determines that cooperation would not be in the best interests of, or would result in serious physical or emotional harm to, the applicant or member, in accordance with 130 CMR 517.010; (3) notifying the MassHealth agency in writing within ten days of filing any claim, civil action, or other proceeding; and (4) repaying and cooperating fully with the MassHealth agency or its agent to ensure the member’s legal representative repays the MassHealth agency from the money received from a third party for all MassHealth benefits provided on or after the date of the accident or other incident, provided that if the member is involved in an accident or other incident after becoming MassHealth eligible, repayment will be limited to MassHealth benefits provided as a result of the accident or incident.

517.013 Severability

517.013:  Severability

The provisions of 130 CMR 517.000 are severable. If any provision of 130 CMR 517.000 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 517.000 or application of those provisions to applicable individuals, entities, or circumstances.

REGULATORY AUTHORITY

130 CMR 517.000: M.G.L. c. 118E.