Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid 600 Washington Street Boston, MA 02111 www.mass.gov/masshealth Eligibility Operations Memo 09-05 April 1, 2009 TO: MassHealth Eligibility Operations Staff FROM: Russ Kulp, Director, MassHealth Operations RE: Prepopulated Eligibility Review Form Introduction Federal regulations require that MassHealth conducts annual eligibility reviews. To support this requirement and help members with the annual review process, MassHealth is providing, to selected households, an Eligibility Review Form (ERV) that is “prepopulated” with the most recent household information. The implementation of this new ERV — the Prepopulated ERV (PPE) — is outlined in this memo. Prepopulated ERV Overview The Prepopulated ERV (PPE) is designed to provide a member with the household information that is currently on MA21. The member will have the opportunity to review the existing information and make corrections as needed. In addition, the PPE will allow a member to report any new information about their household. A household selected for the PPE process will get the PPE in place of a blank ERV. The PPE will include information on all members who are still active in the household, whether they are open, closed, or pending. Active members are those who do not have a family group number of 00. Households with multiple family groups or with a head of household (HOH) not coded as “self 1” will be excluded from selection for the PPE process. The pilot for the PPE will select Commonwealth Care-households only. (continued on next page) Prepopulated ERV Format The member’s address that will be printed on the PPE is the residential address. The other fields on the PPE that will be prepopulated are * HOH event — Head of Household and Other Family Members; * EIN event — earned income records under Current Working Income section; * UIN and REN events — unearned income records under the Current Nonworking Income section, including rental income; * HIN event — health insurance records under Current Health Insurance section, including private health insurance and Medicare; and * DDU event — members under the Injury, Illness, or Disability section (only those members who are already disabled). Under the Proof of Citizenship/National Status and Identity section, only those family members who are citizens will be listed. The following will be prepopulated in the Proofs We Need column: * Citizenship — if proof of citizenship is needed; * Identity — if proof of identity is needed; * Citizenship an Identity — if proof of both citizenship and identity is needed; * None — if no proof of citizenship and identity is needed. In any section that contains social security numbers, only the last four digits will be printed and the other digits will be replaced by Xs. At this time, health insurance claim numbers cannot be truncated. PPE Mailing In addition to the PPE form, the mailing will include the following forms: * Eligibility Representative Designation (ERD); * Affidavit of Parent or Guardian on Identity of Child under Age 16; and * UNIV-5 (Babel). A sample PPE is attached. Only the sections that could be prepopulated have been reproduced for this example. An actual PPE also contains the entire ERV form, including the sections that will not be prepopulated, such as the cover sheet and instructions. (continued on next page) MEC Responsibilities Starting in March 2009, MA21 will generate the new PPEs and send them to Commonwealth Care-only households. For the initial pilot, the PPEs will be processed at the Taunton MassHealth Enrollment Center (MEC). When the PPE is received at the MEC, staff will record the receipt in MA21 for processing. This action will reactivate the eligibility time for the Commonwealth Care member. PPEs are to be processed following the current procedures for processing ERVs. Questions If you have any questions about this memo, please have your MEC designee contact the Policy Hotline. Sample of Prepopulated Areas on the PPE A. Head of Household and Other Family Members: Head of Household 1. Name: REVIEW, JOHN SSN: XXX-XX-1234 Date of birth: 05/01/1955 Street: 1 MAIN STREET City: BOSTON State: MA Zip: 02111 Phone #:(Home/Cell) 617-222-3333 (Work) 617-333-4444 Does this person want benefits? ( )Yes ( )No Enter address and phone # below if different Home address Street: ___________________________ City: _______________________ State: ___ Zip: ________ Phone #: (Home/Cell) _________ (Work): __________ Mailing address (if different from home address or living in a shelter) Street: ___________________________ City: _______________________ State: ___ Zip: ________ ( ) Homeless Other Family Members 2. Name: REVIEW, WIFE SSN: XXX-XX-3456 Date of birth: 05/01/1948 Relationship to head of household: SPOUSE Is this person still living in this household? ( )Yes ( )No Does this person want benefits? ( )Yes ( )No 3. Name: REVIEW, DAUGHTER SSN: XXX-XX-7890 Date of birth: 05/15/1999 Relationship to head of household: CHILD Is this person still living in this household? ( )Yes ( )No Does this person want benefits? ( )Yes ( )No 4. Name: REVIEW, SON SSN: XXX-XX-1234 Date of birth: 05/15/1997 Relationship to head of household: CHILD Is this person still living in this household? ( )Yes ( )No Does this person want benefits? ( )Yes ( )No B. Proof of Citizenship/National Status and Identity: Proof of Citizenship/National Status and Identity Federal law requires us to get proof of U.S. citizenship/national status and identity for all individuals applying or having their eligibility reviewed for benefits who claim to be U.S. citizens/nationals. You have to give us this proof only once. If you have not given us these proofs before, please see the insert that came with this notice for complete information about acceptable proofs of U.S. citizenship/national status and identity. The insert also provides exceptions for those individuals who may not have to provide this proof. Below is a list of the family members we have on file who claim to be U.S. citizens/nationals. The information we need for each family member is listed under “Proofs We Need.” If we already have this information, or we do not need proofs at this time, “none” will be listed. Name Date of Birth SSN Proofs We Need REVIEW, WIFE 05/01/1955 XXX-XX-1234 Citizenship and Identity REVIEW, CHILD 05/01/1955 XXX-XX-1235 Identity C. Current Working Income: Current Working Income Please review the current income we have on file and answer the questions (Yes or No). If you are still working, please send proof of income, like a copy of two recent pay stubs. If self-employed, see the MassHealth Member Booklet for more information about the needed proof. 1. Name of person working: REVIEW, JOHN Employer name: BANK OF AMERICA Employer address: 100 MAIN ST City: BOSTON State: MA Zip: 02111 Do you still work at this job? ( )Yes ( )No If yes, number of hours per week? ____ Weekly pay before deductions: $ ______ Is health insurance offered that would cover doctors’ visits and hospitalizations? ( )Yes ( )No If you answered no to the above question, was health insurance offered in the last six months? ( )Yes ( )No D. Current Nonworking Income (including rental income): Current Nonworking Income Please review the current nonworking income we have on file and answer the questions (Yes or No). Send proof of this income if you still get this income. Youdo not have to send proof of social security or SSI income. 1. Name of person: REVIEW, JOHN Type of income: PENSION Monthly amount: $400.00 Do you still get this income? ( )Yes ( )No If amount has changed, monthly amount before taxes: $__________ 2. Name of person: REVIEW, WIFE Type of income: PENSION Monthly amount: $300.00 Do you still get this income? ( )Yes ( )No If amount has changed, monthly amount before taxes: $__________ 3. Name of person: REVIEW, WIFE Type of income: RENTAL Property address: 1100 MAIN ST BOSTON MA 02111 Net monthly amount: $300.00 Do you still get this income? ( )Yes ( )No If amount has changed, net monthly amount: $__________ E. Proof Current Health Insurance: Current Health Insurance Please review the current health-insurance information we have on file and answerthe questions (Yes or No). 1. Policyholder name: REVIEW, JOHN Policy number: 1235453456 Insurance company name: BLUE CROSS BLUE SHIELD Policyholder contribution to premium: $100.00 Frequency: MONTHLY Names of covered family members: REVIEW, JOHN REVIEW, WIFE REVIEW, DAUGHTER REVIEW, SON Are you or any of your family members still covered under this health insurance? ( )Yes ( )No If no, what date did it end? / / F. Injury, Illness, or Disability: Injury, Illness, or Disability Our records indicate that the following members have already been determined disabled: REVIEW, JOHN XXX-XX-1234 REVIEW, WIFE XXX-XX-3456