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 117 January 1, 2004

TO:	MassHealth Staff
FROM:     Beth Waldman, Acting Commissioner
RE:	Revision to Covered Services for Aliens with Special Status

MassHealth is reissuing a revision to the regulations concerning certain applicants and members described as aliens with special status (AWSS).
In July 2003, regulations were promulgated, ending the availability of MassHealth benefits that are solely state-funded to certain immigrants described as aliens with special status (AWSS) under 130 CMR 504.002(D) and 518.002(D). The conforming amendments were filed as emergency regulations and the emergency was inadvertently allowed to expire. Therefore, MassHealth is refiling these revisions, so these regulations conform to other MassHealth regulations that are in effect.
These regulations were filed as an emergency, effective January 1, 2004.

MassHealth Eligibility Letter 117 January 1, 2004 Page 2
MANUAL UPKEEP

Insert
505.002	(3 of 5)
505.008 (1 of 2)
505.008 (2 of 2)
515.001 (2 of 8)
515.002
515.008
516.004 516.007
519.000 519.001
519.003	(1 of 2)
519.006
519.007 (1 of 4) 519.007 (4 of 4) 519.009 519.012
520.001 520.003 520.030 520.035

Remove
Trans. By
505.002 (3 of 5)	E.L. 114	
505.008 (1 of 2)	E.L. 109	
505.008 (2 of 2)	E.L. 109	
515.001 (2 of 8)	E.L. 104	
515.002	E.L. 104	
515.008	E.L. 104	
516.004	E.L. 104	
516.007	E.L. 104	
519.000	E.L. 104	
519.001	E.L. 104	
519.003 (1 of 2)	E.L. 104	
519.006	E.L. 114	
519.007 (1 of 4)	E.L. 104	
519.007 (4 of 4)	E.L. 104	
519.009	E.L. 104	
519.012	E.L. 104	
520.001	E.L. 104	
520.003	E.L. 104	
520.030	E.L. 104	
520.035	E.L. 104	

521.004 (1 of 2)

521.004 (1 of 2)

E.L. 104

130 CMR: DIVISION OF MEDICAL ASSISTANCE
Trans. by E.L. 117
MASSHEALTH
COVERAGE TYPES	Chapter    505
Rev. 01/01/04	(3 of 5)    Page	505.002
(2) A caretaker relative is eligible for Standard coverage provided:
(a)	the caretaker relative chooses to be part of the family group;
(b)	the family group gross income is less than or equal to 133 percent of the federal-poverty level; and
(c)	the caretaker relative lives with children to whom he or she is related by blood, adoption, or marriage, or is a spouse or former spouse of one of those relatives, provided neither parent lives in the home.
(E)	Eligibility Requirements for Pregnant Women.
(1)	A pregnant woman whose family group gross income is less than or equal to 200 percent of the federal-poverty level is eligible for Standard coverage. In determining the family group size, the unborn child or children are counted as if born and living with the mother.
(2)	Eligibility, once established, continues for the duration of the pregnancy. Eligibility for postpartum care continues for 60 days following the termination of the pregnancy plus an additional period extending to the end of the month in which the 60-day period ends.
(3)	The Division notifies pregnant women who are aliens with special status aged 19 or older and nonqualified aliens of their potential eligibility for the Healthy Start Program.
(F)	Disabled Individuals.
(1)	Extended MassHealth Eligibility. Disabled persons whose SSI-Disability assistance has been terminated, and who are determined to be potentially eligible for MassHealth, continue to receive MassHealth Standard coverage until the Division makes a determination of ineligibility.
(2)	Disabled Adults. A disabled adult under age 65 may establish eligibility for MassHealth Standard coverage if he or she meets the following requirements:

(a)	the individual is permanently and totally disabled as defined in 130 CMR 501.001; and
(b)	the family group gross income is less than or equal to 133 percent of the federal-poverty level, or the individual is eligible under section 1634 of the Social Security Act (42 U.S.C. § 1383c) as a disabled adult child or as a disabled widow or widower, or is eligible under the provisions of the Pickle Amendment as described at 130 CMR 519.003.
(a)	
130 CMR: DIVISION OF MEDICAL ASSISTANCE
Trans. by E.L. 117
MASSHEALTH
COVERAGE TYPES	Chapter    505
Rev. 01/01/04	(1 of 2)    Page	505.008
(D) Funding. State legislation does not provide funding for MassHealth Essential after September 30, 2004. Essential benefits will not be provided after this date unless a legislative extension is authorized.
505.008: MassHealth Limited
(A)	Eligibility Requirements.
(1)	MassHealth Limited is available to persons who meet the financial and categorical
requirements of MassHealth Standard and are:
(a)	nonqualified aliens described in 130 CMR 504.002(E) (nonqualified aliens are not required to furnish or apply for a social security number);
(b)	aliens with special status described in 130 CMR 504.002(D) who are under age 19 and are eligible for premium assistance under MassHealth Family Assistance; or
(c)	aliens with special status who are adults described in 130 CMR 504.002(F)(2)(d).

(2)	Persons eligible for Limited coverage are eligible for medical benefits as described in 130 CMR 450.105(G). These aliens are eligible for medical benefits under Limited only to the extent that such benefits are not covered by their health insurance.
(3)	Aliens lawfully admitted for a temporary purpose such as students, visitors, and diplomats are eligible for Limited coverage if they meet all other eligibility requirements including residence.
(4)	A child born to a woman who was receiving MassHealth Limited on the date of the child’s birth is automatically eligible for MassHealth Standard for one year provided the child continues to live with the mother.
(B)	Medical Coverage Date.
(1) The medical coverage date for MassHealth Limited begins on the 10th day before the date a Medical Benefit Request is received at any MassHealth Enrollment Center or received by a MassHealth outreach worker at a designated outreach site, if all required verifications, including a completed disability supplement, have been received within 60 days of the date of the Request for Information.

130 CMR: DIVISION OF MEDICAL ASSISTANCE
Trans. by E.L. 117
MASSHEALTH
COVERAGE TYPES	Chapter    505
Rev. 01/01/04	(2 of 2)    Page	505.008
(2) If these required verifications listed on the Request for Information are received after the 60-day period referenced in 130 CMR 505.008(B)(1), the begin date of medical coverage is 10 days before the date on which the verifications were received, if these verifications are received within one year of receipt of the MBR.
(C) Referral to Children’s Medical Security Plan. MassHealth submits the names of children who are eligible for MassHealth Limited coverage to the Children’s Medical Security Plan.
(D) Referral to Healthy Start Program. MassHealth submits names of pregnant women who are eligible for MassHealth Limited coverage to the Healthy Start Program.

130 CMR: DIVISION OF MEDICAL ASSISTANCE
Trans. by E.L. 117
MASSHEALTH
GENERAL POLICIES	Chapter     515
Rev. 01/01/04	(2 of 8)    Page	515.001
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-degree radius or less, regardless of the visual acuity.
Burial Trust — a trust established by an individual solely for funeral expenses, burial expenses, or both.
Business Day — any day during which MassHealth’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 lives in the same home as that child, provided that neither parent is living in the home.
Case File — the permanent written collection of documents and information required to determine eligibility and to provide benefits to applicants and members.
Community Resident — a person who lives in a noninstitutional setting in the community.
Competent Medical Authority — a physician or psychiatrist licensed by any state, a psychologist licensed by the Commonwealth of Massachusetts, or both.
Countable Income — the types of income that are considered in the determination of eligibility.
Countable-Income Amount — gross income less certain business expenses and income deductions.
Couple — two persons married to each other according to the rules of the Commonwealth of Massachusetts.
Coverage Date — the date medical coverage begins.
Coverage Types — a scope of medical services, other benefits, or both that are available to members who meet specific eligibility criteria. These coverage types include the following: MassHealth Standard (Standard), MassHealth Limited (Limited), MassHealth Senior Buy-In (Senior Buy-In), and MassHealth Buy-In (Buy-In). The scope of services or covered benefits for each coverage type is found at 130 CMR 450.105.
Curing of a Transfer — the return, following the transfer for less than fair-market value of a portion of, or the full uncompensated value of, a resource to the individual.
Day — a calendar day unless a business day is specified.

130 CMR: DIVISION OF MEDICAL ASSISTANCE
Trans. by E.L. 117
MASSHEALTH
GENERAL POLICIES	Chapter    515
Rev. 01/01/04	Page	515.002
515.002: Introduction to MassHealth
(A)	The Division of Medical Assistance is responsible for the administration and delivery of
health-care services to members under MassHealth.
(B)	130 CMR 515.000 through 522.000 (referred to as Volume II) provide the requirements for noninstitutionalized persons 65 or older, institutionalized persons of any age, persons who would be institutionalized without community-based services, as defined by Title XIX of the Social Security Act and authorized by Massachusetts General Laws (M.G.L.) c. 118E, and certain Medicare beneficiaries. These regulations are intended to conform to all applicable federal and state laws and will be interpreted accordingly.
(C)	The requirements for coverage of noninstitutionalized low- and moderate-income persons under age 65, as prescribed under a 1115 Medicaid Research and Demonstration Waiver, are described in 130 CMR 501.000 through 508.000.
515.003: MassHealth Coverage Types
(A)	MassHealth provides access to health care by determining eligibility for the coverage type that provides the most comprehensive benefits for a person who may be eligible. Generally, members are provided services on a fee-for-service basis as defined at 130 CMR 515.001.
(B)	MassHealth offers the following types of coverage: MassHealth Standard, MassHealth Limited, MassHealth Senior Buy-In, and MassHealth Buy-In. The type of coverage for which a person is eligible is based on the person's or the spouse's income and assets, as described in 130 CMR 519.000 and 520.000, and immigration status, as described in 130 CMR 518.000.
515.004: Administration of MassHealth
(A)	MassHealth. MassHealth requirements are formulated and eligibility is determined by the Division.
(B)	Other Agencies.

(1)	Department of Transitional Assistance (DTA). The Department of Transitional Assistance administers the Emergency Aid for the Elderly, Disabled and Children (EAEDC) Program. Persons receiving EAEDC who are 65 or older are automatically eligible for MassHealth Standard coverage.
(2)	Social Security Administration (SSA). District Social Security offices administer the Supplemental Security Income (SSI) Program and determine the eligibility of persons aged 65 or older. Persons receiving SSI who are 65 or older are automatically eligible for MassHealth Standard coverage.
(1)	
130 CMR: DIVISION OF MEDICAL ASSISTANCE
Trans. By E.L. 117
MASSHEALTH
GENERAL POLICIES	Chapter    515
Rev. 01/01/04	Page	515.008
(3) An appeal on behalf of a deceased person may be filed by an appeal representative, as defined in 130 CMR 515.001.
(G) Right to Inspect the MassHealth Case File. The applicant or member has the right to inspect information in his or her MassHealth case file and contest the accuracy of the information.
(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 MassHealth. 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. MassHealth will inform applicants and members of the availability of interpreter services. Unless the applicant or member chooses to provide his or her own interpreter services, MassHealth will provide either telephonic or other interpreter services whenever:
(1)	the applicant or member who is seeking assistance from MassHealth has limited English proficiency or sensory impairment and requests interpreter services; or
(2)	MassHealth determines such services are necessary.
(J) Right to a Certificate of Creditable Coverage Upon Termination of MassHealth. MassHealth will provide a Certificate of Creditable Coverage to members whose coverage under MassHealth Standard or CommonHealth has ended. MassHealth will issue a Certificate to members within one week of their MassHealth termination, or within one week of the request for a Certificate, as long as the request is made within 24 months of their MassHealth termination. The Certificate may allow members to waive or reduce the length of preexisting-condition waiting periods when they enroll in a new health plan offered by private insurance. If a member’s MassHealth termination also terminates the coverage of his or her dependents, the dependents will be included on the Certificate.
515.008: Responsibilities of Applicants and Members
(A)	Responsibility to Cooperate. The applicant or member must cooperate with MassHealth in providing information necessary to establish and maintain eligibility, and must comply with all the rules and regulations of MassHealth, including recovery.
(B)	Responsibility to Report Changes. The applicant or member must report to MassHealth, within 10 days or as soon as possible, changes that may affect eligibility. Such changes include, but are not limited to, income, assets, inheritances, gifts, transfers of and proceeds from the sale of real or personal property, distributions from or transfers into trusts, address, the availability of health insurance, and third-party liability.
(C)	Cooperation with Quality Control. The Quality Control Division will 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 representative of Quality Control. 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.
(A)	
130 CMR: DIVISION OF MEDICAL ASSISTANCE
Trans. by E.L. 117
MASSHEALTH
THE ELIGIBILITY PROCESS	Chapter    516
Rev. 01/01/04	Page	516.004
of Public Health's Bureau of Vital Statistics, Department of Industrial Accidents, Department of Veteran's Services, Department of Revenue, Bureau of Special Investigations, Internal Revenue Service, Social Security Administration, Alien Verification Information System, Department of Transitional Assistance, and banks and other financial institutions.
516.004:  Time Standards for Eligibility Determination
(A)	For applicants who do not apply on the basis of a disability, a determination of eligibility must be made within 45 days from the date of receipt of the complete application for MassHealth.
(B)	For applicants who apply for MassHealth on the basis of a disability, a determination of eligibility must be made within 90 days from the date of receipt of the complete application, including a disability supplement, if required. If MassHealth determines unusual circumstances exist, the timeframes for determining eligibility will be extended.
516.005:  Coverage Date
The begin date of Standard or Limited coverage may be retroactive to the first day of the third month before the month of application, if covered medical services were received during such period, and the applicant or member would have been eligible at the time services were provided. If more than one application has been submitted and not denied, the begin date will be based on the earliest application that is approved.
516.006:  Eligibility Determination
(A)	MassHealth will review eligibility at least every 12 months with respect to circumstances
that may change. MassHealth will update the file based on information received as the result of
such review. Eligibility may be reviewed:
(1)	as a result of a member's reported changes in circumstances;
(2)	by external matching with other agencies; and
(3)	where matching is not available, through a written update of the member's circumstances on a prescribed form.

(B)	If the member fails to provide a written update or information within 30 days of the request, MassHealth coverage may be terminated.
(C)	If the requested update or information is submitted within 30 days from the date of the termination, a second eligibility determination will be made within 15 days. Eligibility may be established retroactive to the date of termination, if otherwise eligible.
(B)	
130 CMR: DIVISION OF MEDICAL ASSISTANCE
Trans. by E.L. 117
MASSHEALTH
THE ELIGIBILITY PROCESS	Chapter    516
Rev. 01/01/04	Page	516.007
516.007:  Notice
(A)	All applicants and members, as well as certain others described below in 130 CMR 516.007, will receive written notice of the determination of eligibility for MassHealth. The notice will contain an eligibility decision for each member who has requested MassHealth, and provide information enabling the applicant or member to determine the reason for any adverse decision.
(B)	Members will also receive a notice of any changes in coverage type or patient-paid amount, or of loss of coverage.
(C)	In addition to sending notices to applicants and members, such written notices will be provided to the institution or eligibility representative, as well as the community spouse, as defined at 130 CMR 520.016(B)(1)(c). This may include, in the case of death, the executor, administrator, or legal representative of the deceased individual's estate.
(D)	All notices will provide information about the right of the applicant or member to a fair hearing, with the exception of asset assessments described at 130 CMR 520.016. Information about the appeal process is found at 130 CMR 610.000.
516.008:  Voluntary Withdrawal
The applicant or eligibility representative may voluntarily withdraw his or her request for MassHealth. An eligibility representative may also withdraw a request for MassHealth on behalf of a deceased applicant.
516.009:  Issuance of a MassHealth Card
(A) MassHealth will issue a card to a new member, with the exception of those who receive MassHealth Buy-In coverage.
(B) A temporary card may be issued to a member if there is an immediate need.

130 CMR: DIVISION OF MEDICAL ASSISTANCE
Trans. by E.L. 117
MASSHEALTH
COVERAGE TYPES	Chapter    519
Rev. 01/01/04	Page	519.000
TABLE OF CONTENTS
Section
519.001:	Introduction
519.002:	MassHealth Standard
519.003:	Pickle Amendment Cases
519.004:	Disabled Adult Children
519.005:	Community Residents Aged 65 and Older
519.006:	Long-Term-Care Residents
519.007:	Individuals Who Would Be Institutionalized
(130 CMR 519.008 Reserved)
519.009:	MassHealth Limited
519.010:	MassHealth Senior Buy-In
519.011:	MassHealth Buy-In
519.012:	MassHealth CommonHealth

130 CMR: DIVISION OF MEDICAL ASSISTANCE
Trans. by E.L. 117
MASSHEALTH
COVERAGE TYPES	Chapter     519
Rev. 01/01/04	Page	519.001
519.001:  Introduction
(A)	Categorical Requirements and Financial Standards. 130 CMR 519.000 explains the categorical requirements and financial standards that must be met to qualify for a MassHealth coverage type. The rules of financial responsibility and the calculation of financial eligibility are detailed in 130 CMR 520.000.
(B)	MassHealth Coverage Types. The MassHealth coverage types available to individuals aged 65 and older, institutionalized individuals, and those who would be institutionalized without community-based services are the following:
(1) MassHealth Standard;
(1) MassHealth Limited;
(3)	MassHealth Senior Buy-In;
(4)	MassHealth Buy-In; and
(5)	MassHealth CommonHealth.
(C)	Determining Eligibility. MassHealth determines eligibility for the most comprehensive
coverage available to the applicant, although the applicant has the right to choose to have
eligibility determined only for Senior Buy-In or Buy-In coverage. If no choice is made by the
applicant, MassHealth will determine eligibility for all available coverage types.
519.002:  MassHealth Standard
(A) Overview.
(1)	130 CMR 519.002 through 519.007 contain the categorical requirements and asset and income standards for MassHealth Standard, which provides coverage for individuals aged 65 and older, institutionalized individuals, and those who would be institutionalized without community-based services.
(2)	Individuals eligible for MassHealth Standard are eligible for medical benefits on a fee-for-service basis as defined in 130 CMR 515.001. The medical benefits are described in 130 CMR 450.105(A).
(3) The begin date of medical coverage for MassHealth Standard is established in accordance with 130 CMR 516.005.

130 CMR: DIVISION OF MEDICAL ASSISTANCE
Trans. by E.L. 117
MASSHEALTH
COVERAGE TYPES	Chapter     519
Rev. 01/01/04	(1 of 2)    Page	519.003
(4) MassHealth will pay the following costs for members eligible for MassHealth Standard who meet the requirements of 130 CMR 519.010(A)(1) and (2). Coverage generally begins on the first day of the month following the date of MassHealth's eligibility determination.
(a)	the cost of the Medicare Part B premiums;
(b)	the cost of Medicare Part A premiums for adult members of MassHealth Standard who are entitled to Medicare Part A; and
(c)	the deductibles and coinsurance under Medicare Parts A and B.
(B)	Automatic Eligibility for SSI Recipients.
(1)	Individuals described in 130 CMR 519.002(A)(1) who meet basic, categorical, and financial requirements under the Supplemental Security Income (SSI) program are automatically eligible to receive MassHealth Standard coverage.
(2)	Eligibility for retroactive coverage must be established by MassHealth in accordance with 130 CMR 516.005.
(C)	Extended Eligibility for SSI Recipients. An individual whose SSI assistance has been
terminated, and who is determined to be potentially eligible for MassHealth, will continue to
receive MassHealth Standard coverage until a determination of ineligibility is made by
MassHealth.
519.003: Pickle Amendment Cases
(A) Eligibility Requirements. Under the Pickle Amendment, former SSI recipients whose income exceeds 100 percent of the federal poverty level are eligible for MassHealth Standard provided they:
(1)	or their spouse or both are receiving RSDI benefits;
(2)	were eligible for and received SSI benefits after April 1977;
(3)	would be currently eligible for SSI, in accordance with SSI payment standards at 130 CMR 519.003(B), if the incremental amount of RSDI cost-of-living increases paid to them since the last month subsequent to April 1977, for which they were both eligible for and receiving SSI and entitled to (but not necessarily receiving) RSDI were deducted from the current amount of RSDI benefits. Cost-of-living increases referred to in 130 CMR 519.003 include increases received both by the applicant or member or by the spouse. The spouse need not be otherwise eligible for SSI; and
(4)	have countable assets that are $2,000 or less for an individual, and $3,000 or less for a married couple.
(1)	
130 CMR: DIVISION OF MEDICAL ASSISTANCE
Trans. by E.L. 117
MASSHEALTH
COVERAGE TYPES	Chapter     519
Rev. 01/01/04	Page	519.006
(C) Parents and Caretaker Relatives of Children Under Age 19.
(1)	Eligibility Requirements. Adults who are aged 65 and older and are the parents or caretaker relatives of a child under age 19 receive MassHealth Standard if they meet the requirements of 130 CMR 505.002(B) or (D).
(2)	Other Provisions. The following provisions apply to adults described in 130 CMR 519.005(C)(1): 130 CMR 505.002(A)(2), (G), (I), and (J).
(3)	Countable Income. Eligibility for adults described in 130 CMR 519.005(C)(1) is based on the applicant’s or member’s family group countable earned and unearned income, and the income rules described at 130 CMR 506.002, 506.003, and 506.004.
(4)	Exemption from Asset Limits. The asset limits in 130 CMR 520.003 do not apply to applicants or members described in 130 CMR 519.005(C)(1).
519.006: Long-Term-Care Residents
(A)	Eligibility Requirements. Institutionalized individuals may establish eligibility for
MassHealth Standard coverage subject to the following requirements. They must:
(1)	be under age 18 or aged 65 or older; or, for individuals aged 18 to 64 inclusive, meet Title XVI disability standards or be pregnant;
(2)	be determined medically eligible for nursing-facility services by MassHealth or MassHealth's agent as a condition for payment, in accordance with 130 CMR 456.000;
(3)	contribute to the cost of care as defined at 130 CMR 520.026;
(4)	have countable assets of $2,000 or less for an individual and, for married couples where one member of the couple is institutionalized, have assets that are less than or equal to the standards at 130 CMR 520.016(B); and
(5)	not have transferred resources for the sole purpose of obtaining MassHealth as described at 130 CMR 520.018 and 520.019.
(B)	Verification of Disability or Pregnancy.
(1) Disability is verified by:
(a)	certification of legal blindness by the Massachusetts Commission for the Blind (MCB);
(b)	a determination of disability by the Social Security Administration (SSA); or
(c)	a determination of disability by MassHealth's Disability Determination Unit (DDU). Until this determination is made, the applicant's submission of a completed disability supplement will satisfy the verification requirement.
(a)	
130 CMR: DIVISION OF MEDICAL ASSISTANCE
Trans. by E.L. 117
MASSHEALTH
COVERAGE TYPES	Chapter     519
Rev. 01/01/04	(1 of 4)    Page	519.007
(2) Pregnancy is verified by a written statement from a competent medical authority certifying the pregnancy.
519.007: Individuals Who Would Be Institutionalized
130 CMR 519.007 describes the eligibility requirements for MassHealth Standard coverage for individuals who would be institutionalized if they were not receiving home- and community-based services.
(A) The Kaileigh Mulligan Program. The Kaileigh Mulligan Program enables severely disabled children under the age of 18 to remain at home. The income and assets of their parents are not considered in the determination of eligibility.
(1) Eligibility Requirements. Children under the age of 18 may establish eligibility for the Kaileigh Mulligan Program by meeting the following requirements. They must:
(a)	meet Title XVI disability standards in accordance with the definition of permanent and total disability for children under the age of 18 in 130 CMR 515.001; or have been receiving SSI on August 22, 1996, and continue to meet Title XVI disability standards that were in effect before August 22, 1996;
(b)	have $2,000 or less in countable assets;
(c) have a countable-income amount of $60 or less; or, if greater than $60, meet a deductible in accordance with 130 CMR 520.028 et seq.; and

130 CMR: DIVISION OF MEDICAL ASSISTANCE
Trans. by E.L. 117
MASSHEALTH
COVERAGE TYPES	Chapter     519
Rev. 01/01/04	(4 of 4)    Page	519.007
(3) Financial Standards Not Met. Individuals whose income, assets, or both exceed the standards set forth in 130 CMR 519.007(B)(2) may establish eligibility for MassHealth Standard by reducing their assets in accordance with 130 CMR 520.004, by meeting a deductible as described at 130 CMR 520.028 et seq., or by both.
(C) Program of All-Inclusive Care for the Elderly (PACE).
(1)	Overview. The PACE program is a comprehensive health program that is designed to
keep frail, older individuals who are certified eligible for nursing-facility services living in
the community.
(a)	A complete range of health-care services are provided by one designated community-based program with all medical and social services coordinated by a team of health professionals.
(b)	MassHealth administers the program in Massachusetts as the Elder Service Plan (ESP).
(c)	Persons enrolled in PACE have services delivered through managed care:
(i)  in day-health centers;
(ii) at home; and
(iii) in specialty or inpatient settings, if needed.
(2)	Eligibility Requirements. The applicant or member must meet all of the following
criteria:
(a)	be aged 55 or older;
(b)	meet Title XVI disability standards if aged 55 through 64;
(c)	be certified by MassHealth or its agents to be in need of nursing-facility services;
(d)	live in a designated service area;
(e)	have medical services provided in a specified community-based PACE program;
(f)	have countable assets whose total value does not exceed $2,000 or, if married and living with a spouse, does not exceed $3,000 or, if assets exceed these standards, reduce assets in accordance with 130 CMR 520.004; and
(g)	have a countable-income amount, including income of a financially responsible spouse, equal to or less than 100 percent of the federal poverty level; or establish eligibility by meeting a deductible as described in 130 CMR 520.028 et seq. if the income exceeds the 100 percent federal-poverty-level income standards.
(130 CMR 519.008 Reserved)

130 CMR: DIVISION OF MEDICAL ASSISTANCE
Trans. by E.L. 117
MASSHEALTH
COVERAGE TYPES	Chapter     519
Rev. 01/01/04	Page	519.009
519.009:  MassHealth Limited
(A)	Eligibility Requirements.
(1)	MassHealth Limited is available to community residents aged 65 and older meeting the financial and categorical requirements of MassHealth Standard coverage as described at 130 CMR 519.005(A) and (B) and who are nonqualified aliens described in 130 CMR 518.002(E) or are aliens with special status as described in 130 CMR 518.002(D).
(2)	Persons eligible for MassHealth Limited coverage are eligible for medical benefits described at 130 CMR 450.105(G).
(3)	Nonqualified aliens and aliens with special status must meet all other requirements of MassHealth Standard with the exception of furnishing or applying for a social security number.
(4)	Aliens lawfully admitted for a temporary purpose such as students, visitors, and diplomats are eligible for MassHealth Limited coverage provided they meet all other eligibility requirements including residence.
(B)	Coverage Date. The begin date of medical coverage is established in accordance with
130 CMR 516.005.

130 CMR: DIVISION OF MEDICAL ASSISTANCE
Trans. by E.L. 117
MASSHEALTH
COVERAGE TYPES	Chapter     519
Rev. 01/01/04	Page	519.012
(b) MassHealth gives preference to members who were eligible for MassHealth Buy-In, as described in 130 CMR 519.011, or MassHealth Senior Buy-In, as described in 130 CMR 519.010, in December of the previous calendar year when determining an individual’s eligibility for MassHealth Buy-In, as described in 130 CMR 519.011(B), in the subsequent calendar year.
519.012: MassHealth CommonHealth
(A)	Working Disabled Adults.
(1)	Eligibility Requirements. MassHealth CommonHealth for working disabled adults is available to community residents aged 65 and older in the same manner as they are available to those under age 65. This means they must meet the requirements of 130 CMR 505.004(B)(2), (3), and (4).
(2)	Other Provisions. The following provisions apply to CommonHealth applicants and members aged 65 and older: 130 CMR 505.004(A)(2), (F) through (H), (I)(1) and (2), and (J).
(3)	Aliens with Special Status. MassHealth CommonHealth is not available to aliens with special status adults described in 130 CMR 518.002(D). Applicable coverage for these persons is described in 130 CMR 518.002(F)(2).
(B)	Certain Disabled Institutionalized Immigrant Children.
(1)	Eligibility Requirements. MassHealth CommonHealth is available to
institutionalized disabled children who meet the requirements of 130 CMR 505.004(D) and
519.006(A)(2), and who:
(a)	have attained the immigration status described in 130 CMR 518.002(D)(2)(a), (b), or (c), and five years have not passed from the date they attained such status;
(b)	are nonimmigrants under the Immigration and Nationality Act (INA); or
(c)	are aliens paroled into the United States under section 212(d)(5) of the INA for less than one year.
(2)	Other Provisions. The following provisions apply to CommonHealth applicants
and members who are described above in 130 CMR 519.012(B)(1): 130 CMR
505.004(A)(2), (F) through (H), and (I)(1) and (2).
(C)	Financial Eligibility. Financial eligibility for all MassHealth CommonHealth applicants and
members is based on the regulations in 130 CMR 506.000. The regulations in 130 CMR 520.000 do
not apply.

130 CMR: DIVISION OF MEDICAL ASSISTANCE
Trans. by E.L. 117
MASSHEALTH
FINANCIAL ELIGIBILITY	Chapter     520
Rev. 01/01/04	Page	520.001
520.001:  Introduction to General Financial Requirements
(A)	130 CMR 520.000 describes the rules governing financial eligibility for MassHealth. 130 CMR 520.000 is based on financial responsibility, countable income, and countable assets.
(B)	The methods for the calculation of the countable-income amount, the deductible, and the income standards used in the determination of eligibility are also explained in 130 CMR 520.000.
520.002:  Financial Responsibility
(A)	Community Residents.
(1)	Spouses Living Together.  In the determination of eligibility for MassHealth, the total countable-income amount and countable assets of the individual and the spouse who are living together are compared to an income standard and asset limit, unless one spouse is covered by MassHealth under a home- and community-based services waiver, as described in 130 CMR 519.007(B).
(2)	Spouses Living Apart. When spouses live apart for reasons other than admission to a medical institution, their assets and income are considered mutually available only through the end of the calendar month of separation.
(B)	Residents of Medical Institutions.
(1)	Spouses Living Together. When spouses live in the same long-term-care facility, the income and assets are not mutually available.
(2)	One Spouse Institutionalized.

(a)	If only one spouse is a resident of a medical institution who is expected to remain in the facility for 30 days or more, the community spouse's income is not counted in the determination of eligibility for the institutionalized spouse. The institutionalized spouse may provide for the maintenance needs of the community spouse in accordance with 130 CMR 520.026(B).
(b)	The countable assets of both spouses must be evaluated and a spousal share established in accordance with 130 CMR 520.016(B).
(3)	Institutionalized Child. When a child under age 18 lives in a medical institution, the
income and assets of the parents are considered available only through the end of the calendar
month of separation.

130 CMR: DIVISION OF MEDICAL ASSISTANCE
Trans. by E.L. 117
MASSHEALTH
FINANCIAL ELIGIBILITY	Chapter     520
Rev. 01/01/04	Page	520.003
520.003:  Asset Limit
(A)	The total value of countable assets owned by or available to individuals applying for or
receiving MassHealth Standard or Limited may not exceed the following limits:
(1)	for an individual — $2,000; and
(2)	for a couple living together in the community where there is financial responsibility according to 130 CMR 520.002(A)(1) — $3,000.
(B)	The total value of countable assets owned by or available to individuals applying for or
receiving MassHealth Senior Buy-In, as described in 130 CMR 519.010, or MassHealth Buy-In,
as described in 130 CMR 519.011, may not exceed the following limits:
(1)	for an individual — $4,000; and
(2)	for a couple living together in the community where there is financial responsibility according to 130 CMR 520.002(A)(1) — $6,000.
(C)	The treatment of a married couple's assets when one spouse is institutionalized is described
in 130 CMR 520.016(B).
520.004:  Asset Reduction
(A)	Criteria.
(1)	An applicant whose countable assets exceed the asset limit of MassHealth Standard or
Limited may be eligible for MassHealth:
(a)	as of the date the applicant reduces his or her excess assets to the allowable asset limit without violating the transfer of resource provisions for nursing-facility residents at 130 CMR 520.019(F); or
(b)	as of the date, described in 130 CMR 520.004(C), the applicant incurs medical bills that equal the amount of the excess assets and reduces the assets to the allowable asset limit within 30 days after the date of the notification of excess assets.
(2)	In addition, the applicant must be otherwise eligible for MassHealth.
(B)	Evaluating Medical Bills. MassHealth will not pay that portion of the medical bills equal to
the amount of excess assets. Bills used to establish eligibility:
(1)	cannot be incurred before the first day of the third month prior to the date of application as described at 130 CMR 516.002; and
(2)	must not be the same bills or the same portions of the bills that are used to meet a deductible based on income.
(1)	
130 CMR: DIVISION OF MEDICAL ASSISTANCE
Trans. by E.L. 117

Rev. 01/01/04

MASSHEALTH FINANCIAL ELIGIBILITY

Chapter     520
Page	520.030

520.030:  Calculating the Deductible
The deductible is determined by multiplying the excess monthly income by six. Excess monthly income is the amount by which the applicant's countable-income amount as described in 130 CMR 520.009 exceeds the MassHealth deductible-income standard.
MASSHEALTH DEDUCTIBLE-INCOME STANDARDS

Number of Persons
1 2

Monthly-Income Standard for Community Residents
$522 650

Monthly-Income Standard for Long-Term-Care-Facility Residents
$60

520.031:  Notification of Potential Eligibility
(A)	MassHealth informs the applicant who has excess monthly income that he or she is currently
ineligible for MassHealth Standard or Limited but may establish eligibility for a six-month period
by meeting the deductible. MassHealth will inform the applicant in writing of the following:
(1)	the deductible amount and the method of calculation;
(2)	the start and end dates of the deductible period;
(3)	the procedures for submitting medical bills;
(4)	his or her responsibility to report all changes in circumstances that may affect eligibility or the deductible amount; and
(5)	that the bills submitted to meet the deductible are the responsibility of the individual and cannot be submitted for MassHealth payment.
(B)	A member who has established eligibility based upon meeting a deductible is only eligible
for MassHealth Standard or Limited until the end of the deductible period. At the end of the
deductible period, MassHealth notifies the member in writing of a new deductible period and
amount, if the countable-income amount continues to exceed applicable income standards.

130 CMR: DIVISION OF MEDICAL ASSISTANCE
Trans. by E.L. 117
MASSHEALTH
FINANCIAL ELIGIBILITY	Chapter     520
Rev. 01/01/04	Page	520.035
520.035:  Conclusion of the Deductible Process
When the total of submitted bills is equal to or greater than the deductible and all other eligibility requirements continue to be met, MassHealth will notify the applicant that he or she is eligible. The member is eligible for payment of all covered medical expenses incurred during that deductible period, other than those submitted to meet the deductible, as long as the member continues to meet all other eligibility requirements during the balance of the deductible period.
520.036:  Copayments Required by MassHealth
MassHealth requires its members to make the copayments described in 130 CMR 520.038, except as excluded in 130 CMR 520.037.
520.037:  Copayment Requirement Exclusions
The following are excluded from the copayment requirement described in 130 CMR 520.038:
(A)	MassHealth members who have not reached their 19th birthday;
(B)	MassHealth members who are pregnant;
(C)	MassHealth members who are in the postpartum period that extends through the last day of the second calendar month following the month in which their pregnancy ends;
(D)	MassHealth Limited members;
(E)	MassHealth Senior Buy-In members or MassHealth Standard members for Medicare-covered
drugs only, when furnished by a Medicare-certified provider;
(F)	MassHealth members who are inpatients in hospitals, nursing facilities, chronic-disease or
rehabilitation hospitals, and intermediate-care facilities for the mentally retarded;
(G)	family-planning services and supplies such as oral contraceptives, contraceptive devices such
as condoms and diaphragms, and contraceptive jellies, creams, foams, and suppositories;
(H) emergency services;
(I) hospice-care services; and
(J) persons receiving medical services through the Emergency Aid to the Elderly, Disabled and Children Program pursuant to 130 CMR 450.106, if they do not receive MassHealth Standard.

130 CMR: DIVISION OF MEDICAL ASSISTANCE
Trans. by E.L. 117
MASSHEALTH
RELATED PROGRAM BENEFITS	Chapter    521
Rev. 01/01/04	(1 of 2)    Page	521.004
(C)	Method of Premium Payment. Payments of health insurance premiums will be made directly to the insurance carrier, the employer, or to the most appropriate party, as determined by MassHealth.
(D)	Review of Cost Effectiveness. MassHealth will review the cost effectiveness of each case at least once every six months for group health insurance plans. In addition, reviews of the cost effectiveness will be completed by MassHealth whenever the cost of the group health insurance plan changes, when any individuals under the policy are no longer eligible for MassHealth, or when there is a change in the services covered under the policy.
(E)	Time Frames for Determining Cost Effectiveness. MassHealth will determine the cost
effectiveness of the insurance plan and notify the member of the decision regarding payment of
the premiums within 60 days of the date MassHealth is notified of a request to enroll in the HIPP.
Additional time may be granted when, for reasons beyond the control of MassHealth or the
member, information needed to establish cost effectiveness cannot be obtained within the 60-day
period.
(F)	Conditions of Eligibility. The member, or a person acting on the member's behalf, will
cooperate in providing information necessary for MassHealth to determine the availability and
cost effectiveness of group health insurance. Individuals who are eligible to enroll in a group
health insurance plan that MassHealth has determined to be cost effective, and who are otherwise
eligible for MassHealth Standard, will apply for enrollment and continue to be enrolled in the
plan as a condition of MassHealth eligibility.
(G)	Failure to Cooperate. The eligibility of a child or spouse for MassHealth will not be affected
by the parent's or spouse's failure to cooperate.
521.004: Reimbursement of Certain Out-of-Pocket Medical Expenses
(A) Eligibility Requirements. The following Standard coverage members will be entitled to reimbursement for certain medical expenses for which they paid, subject to the provisions of this section.
(1) An individual who:
(a)	applied for Supplemental Security Income (SSI);
(b)	was denied SSI benefits by the Social Security Administration; and
(c)	had his or her initial Social Security Administration denial overturned through a
reconsideration process, administrative hearing, appeals counsel review, federal court
review, or reopening under the Social Security Administration rules on administrative
finality.