Commonwealth of Massachusetts
Executive Office of Health and Human Services
Division of Medical Assistance
600 Washington Street Boston, MA 02111 www.mass.gov/dma

MassHealth Eligibility Letter 102 April 1, 2003
TO:	Division Staff
FROM:      Douglas S. Brown, Acting Commissioner
RE:	Right to Appeal for Members Enrolled in the Controlled Substance Management
Program
Effective April 1, 2003, the Division may begin enrolling members into the Controlled Substance Management Program pursuant to 130 CMR 406.442. Members who are enrolled into this program have a right to appeal the Division’s decision. 130 CMR 610.032 has been amended to add this right.
These regulations are effective April 1, 2003.
MANUAL UPKEEP

Insert
610.033

Remove
610.033

Trans. By
E.L. 95

130 CMR: DIVISION OF MEDICAL ASSISTANCE
Trans. by E.L. 102
MASSHEALTH
FAIR HEARING RULES	Chapter     610
Rev. 04/01/03	Page	610.033
 (7)	the failure of the Division to act upon a request for assistance within the time limits required by Division regulations;
 (8)	the Division's determination that the member is subject to the provisions of 130 CMR 508.000;
 (9)	the Division's denial of an out-of-area provider under 130 CMR 508.002(F);

 (10)	the Division's disenrollment of a member from a managed-care provider under 130 CMR 508.002(G);
 (11)	a determination by the Division's behavioral health contractor, under 130 CMR 508.003(A), or by one of the Division's managed-care organization (MCO) contractors, under 130 CMR 508.001(B)(2)(b), to deny, reduce, modify, or terminate a covered service, if the member has exhausted all remedies available through the contractor's internal appeals process; and
 (12)	the Division’s determination to enroll a member in the Controlled Substance Management Program under the provisions of 130 CMR 406.442.

 (B)	Nursing facility residents have the right to request an appeal of any nursing facility-initiated transfer or discharge.
 (C)	Determinations of temporary eligibility for presumptive coverage or prenatal coverage are not appealable. See 130 CMR 502.008(C).
 (D)	Employers have the right to request an appeal of any denial or termination from the Insurance Partnership, or to appeal the amount of the Insurance Partnership payment they receive.
610.033:  Coercive or Otherwise Improper Conduct
(A)	Definitions.
 (1)	Coercive conduct means knowingly compelling an applicant, member, or former member by force, threat, intimidation, or other abuse of position to take action that is injurious to his or her best interest and that he or she would not otherwise have done.
 (2)	Improper conduct means reckless and unreasonable abuse of authority that interferes with the applicant's, member's, or former member's exercise of rights under MassHealth.
(B)	Remedies. When a hearing officer has found coercive or otherwise improper conduct on the
part of any Division employee directly involved in the applicant's, member's, or former member's
case at a fair hearing, the enrollment center director will:
 (1)	assign a different worker; and
 (2)	initiate appropriate personnel action including the insertion of a written reprimand and a copy of the written findings, if any, in the worker's personnel file.