Commonwealth of Massachusetts
Executive Office of Health and Human Services
Office of Medicaid
600 Washington Street
Boston, MA  02111
www.mass.gov/masshealth	

		MassHealth
		Eligibility Letter 130
		March 1, 2005

TO:	MassHealth Staff
FROM:	Beth Waldman, Medicaid Director

RE:		HIV Regulation Changes

This letter transmits revised regulations for HIV MassHealth CommonHealth and Family Assistance eligibility.  For HIV-positive applicants and members, MassHealth is revising the CommonHealth categorical requirements for disabled adults and is increasing the Family Assistance federal poverty level eligibility requirement from 133 percent to 200 percent.

These emergency regulations are effective July 1, 2004.

	MANUAL UPKEEP

Insert	Remove	Trans. By

505.004	505.004	E.L. 120
505.005 (5 of 10)	505.005 (5 of 10)	E.L. 106
505.005 (8 of 10)	505.005 (8 of 10)	E.L. 112
505.005 (9 of 10)	505.005 (9 of 10)	E.L. 112

506.006	506.006	E.L. 109

130 CMR:  DIVISION OF MEDICAL ASSISTANCE

Trans. by E.L. 130 	

Rev. 07/01/04	
	MASSHEALTH
	COVERAGE TYPES

Chapter
Page	

505
505.004	

(4)	be ineligible for MassHealth Standard; and

(5)  comply with 130 CMR 505.002(I) and 507.003.

(C)  Disabled Adults.  Disabled adults must meet the following requirements:

(1)  be aged 19 through 64;

(2)  be permanently and totally disabled, as defined in 130 CMR 501.001;

(3)  be ineligible for MassHealth Standard;

(4)  (a)  meet a one-time-only deductible in accordance with 130 CMR 506.009; or

(b)  have family group gross income that is less than or equal to 200 percent of the federal poverty level and provide verification that they are HIV positive; and

(5)  comply with 130 CMR 505.002(I) and 507.003.

(D)  Disabled Children Under Age 18.  Disabled children under age 18 must meet the following requirements:

(1)  be permanently and totally disabled based on the disability criteria for children under age 18, as defined in 130 CMR 501.001; and

(2)  be ineligible for MassHealth Standard.

(E)  Disabled 18-Year-Olds.  Disabled 18-year-olds must meet the following requirements:

(1) (a)  be ineligible for MassHealth Standard; and

(b)  if not working, be permanently and totally disabled based on the disability criteria for adults and 18-year-olds, as defined in 130 CMR 501.001; or

(2)  if working, be permanently and totally disabled based on the disability criteria for adults and 18-year-olds (except for engagement in substantial gainful activity), as defined in 
130 CMR 501.001.

(F)  Determination of Disability.  Disability is established by:

(1)  certification of legal blindness by the Massachusetts Commission for the Blind (MCB);

(2)  a determination of disability by the SSA; or

(3)  a determination of disability by the MassHealth Disability Determination Unit (DDU). 

(G)  MassHealth CommonHealth Premium.  Disabled adults, disabled working adults, and disabled children who meet the requirements of 130 CMR 505.004 may be assessed a premium in accordance with the premium schedule provided in 130 CMR 506.011(I).  No premium is assessed during a deductible period.

130 CMR:  DIVISION OF MEDICAL ASSISTANCE

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	MASSHEALTH
	COVERAGE TYPES
		(5 of 10)	

Chapter
Page	

505
505.005	

(b)  the adult’s family group gross income is less than or equal to 200 percent of the federal poverty level;

(c)  the adult is not eligible for MassHealth Standard or MassHealth CommonHealth;

(d)  the adult has or is enrolled in employer-sponsored health insurance; and

(e)  the adult is employed by a qualified employer, as defined in 130 CMR 501.001.

(2)  Premium Assistance Payment.

(a)  The MassHealth agency makes monthly payments toward the cost of the employer-sponsored health insurance if the adult:

(i)  meets the requirements of 130 CMR 505.005(C)(1); 

(ii)  is responsible for payment of more than the estimated member share described in 130 CMR 506.012(E)(2); and

(iii)  continues to be employed by a qualified employer.

(b)  An adult whose spouse and/or children receive MassHealth benefits must enroll in a couple or family health insurance policy, if offered, if the employer contributes at least 50 percent of the premium cost for that coverage.

(c)  The amount of the premium assistance payment is established in accordance with the  MassHealth premium assistance payment formula described in 130 CMR 506.012(E).

(d)  Premium assistance payments are made in accordance with 130 CMR 506.012(A)(3).

(3)  Eligibility Date.  Premium assistance payments begin in the month of the MassHealth
eligibility determination, or in the month the health-insurance deduction begins, whichever is later.  Each monthly payment is for coverage in the following month.

(D)  Premium Assistance for Persons Who Are HIV Positive.

(1)	Eligibility Requirements.

(a)	Premium assistance under MassHealth Family Assistance is available for 
persons who are HIV positive if they:

(i)  are under the age of 65;

(ii)	have family group gross income that is less than or equal to 200 percent of 
the federal poverty level;

(iii)	are ineligible for MassHealth Standard or MassHealth CommonHealth; 
and

130 CMR:  DIVISION OF MEDICAL ASSISTANCE

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	MASSHEALTH
	COVERAGE TYPES
		(8 of 10)	

Chapter
Page	

505
505.005	

(i)  are under the age of 65;

(ii)  have family group gross income that is less than or equal to 200 percent of the federal poverty level;

(iii)  are ineligible for MassHealth Standard or MassHealth CommonHealth; and

(iv)  do not have health insurance.

(b)  The MassHealth agency establishes eligibility under the provisions of 130 CMR 505.005(F) for persons who are under the age of 19 and are HIV positive, and who also meet the requirements of 130 CMR 505.005(E).

(2)  Premium.  Individuals who meet the requirements of 130 CMR 505.005(F) are assessed a monthly premium in accordance with 130 CMR 506.011(I).

(3)  Medical Coverage Date.

(a)  Except as provided in 130 CMR 501.003(E)(2)(a), the medical coverage date for the purchase of medical benefits under MassHealth Family Assistance 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.  However, the medical coverage date will in no event begin before April 1, 2001.

(b)  Except as provided in 130 CMR 501.003(E)(2)(a), if required verifications listed on the Request for Information are received after the 60-day period referenced in 130 CMR 505.005(G)(1)(b), 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 Medical Benefit Request.

(G)  Fee-for-Service Benefits for Persons Who Are HIV Positive.

(1)  Persons Who Have Claimed on the MBR to Be HIV Positive.

(a)  Eligibility Requirements.  Persons who have claimed on the MBR to be HIV
positive may establish temporary eligibility for fee-for-service benefits if they:

(i)  are under the age of 65;

(ii)  have a verified family group gross income that is less than or equal to 200 
percent of the federal poverty level; and

(iii)  are ineligible for MassHealth Standard or MassHealth CommonHealth.

130 CMR:  DIVISION OF MEDICAL ASSISTANCE

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	MASSHEALTH
	COVERAGE TYPES
		(9 of 10)	

Chapter
Page	

505
505.005	

(b)  Time Frames for Verification.

(i)  Persons who have claimed on the MBR to be HIV positive must submit verification of their HIV-positive status within 60 days of their eligibility determination.  If verifications are not submitted, the MassHealth agency redetermines their eligibility as if they were not HIV positive.

(ii)  Verification of HIV-positive status can be a letter from a doctor, qualifying health clinic, laboratory, or AIDS service provider or organization.  The letter must indicate the member’s name and his or her HIV-positive status.

(c)  Members who have other health insurance must access those benefits and must 
show both their private health insurance card and their MassHealth card to providers at the time services are provided.

(d)  Premium.  Individuals who meet the requirements of 130 CMR 505.005(G) are 
assessed a monthly premium in accordance with 130 CMR 506.011(I).

(e)  Medical Coverage Date.

(i)  Except as provided in 130 CMR 501.003(E)(2)(a), the medical coverage date for 
the purchase of medical benefits under MassHealth Family Assistance 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.  However, the medical coverage date will in no event begin before April 1, 2001.

(ii)  Except as provided in 130 CMR 501.003(E)(2)(a), if required verifications listed on the Request for Information are received after the 60-day period referenced in 130 CMR 505.005(G)(1)(b), 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 Medical Benefit Request.

(f)  Premium Assistance for Persons Who Have Not Verified HIV-Positive Status.  
Persons who meet the requirements of both 130 CMR 505.005(G)(1)(a) and 505.005(C) receive benefits under 130 CMR 505.005(D).  If verification of their HIV-positive status is not submitted within 60 days, they receive benefits under 130 CMR 505.005(C), if otherwise eligible.
	
(2)  Persons Who Have Verified Their HIV-Positive Status.

(a)  Eligibility Requirements.  Persons who have verified their HIV-positive status,
in accordance with 130 CMR 505.005(G)(1)(b), may establish eligibility for fee-for-service benefits if they:

(i)  are under the age of 65;

(ii)  have a family group gross income that is less than or equal to 200 percent of the federal poverty level;

	130 CMR:  DIVISION OF MEDICAL ASSISTANCE

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	MASSHEALTH
	FINANCIAL REQUIREMENTS

Chapter
Page	

506
506.006	

506.006:  Transfer of Income

All family group members are required to avail themselves of all potential income.

(A)  If the MassHealth agency determines that income has been transferred for the primary purpose of establishing eligibility for MassHealth, the income is counted as if it were received.

(B)  If the MassHealth agency is unable to determine the amount of available income, the family group remains ineligible until such information is made available.

506.007:  Calculation of Financial Eligibility

(A) 	 The financial eligibility for various MassHealth coverage types is determined by comparing 
the family group's gross monthly income with the applicable income standard for the specific coverage.  In determining gross monthly income, the MassHealth agency multiplies average weekly income by 4.333.

(B)  Generally, eligibility is based on 100 percent of the federal-poverty level for long-term unemployed adults, 133 percent of the federal-poverty level for parents and disabled nonworking adults, and 200 percent of the federal poverty level for children and pregnant women, as well as for adults working for qualified employers and persons who are HIV positive.  Disabled persons with income in excess of these applicable standards may be eligible for MassHealth CommonHealth.  There is no income cap for premium-based CommonHealth.

(C)  The monthly federal-poverty-level income standards are determined according to annual standards published in the Federal Register using the following formula.  The MassHealth agency adjusts these standards in April of each calendar year.

(1)  Divide the annual federal-poverty-level income standard as it appears in the Federal Register by 12.

(2)  Multiply the unrounded monthly income standard by the applicable federal-poverty-level standard.

(3)  Round up to the next whole dollar to arrive at the monthly income standards.

506.008:  Cost-of-Living Adjustment (COLA) Protections

Members whose income increases each January as the result of a COLA remain eligible until the subsequent federal-poverty-level adjustment.