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 138
		October 1, 2005

TO:	MassHealth Staff

FROM:	Beth Waldman, Medicaid Director

RE:	Revisions to Program of All-Inclusive Care for the Elderly (PACE) Regulations

MassHealth is revising the regulations about the Program of All-Inclusive Care for the Elderly (PACE).  The change provides that the income level will be 300% of the SSI federal benefit rate (FBR) for an individual.  This change is consistent with the recently approved increase in the income eligibility level for the Frail Elders Home- and Community-Based Services Waiver.

Changes to 130 CMR 519.002(A)(4) are being made to conform to federal financial guidelines.

These regulations are effective November 1, 2005.

	MANUAL UPKEEP

Insert	Remove	Trans. By

519.003 (1 of 2)	519.003 (1 of 2)	E.L. 123
519.007 (3 of 4)	519.007 (3 of 4)	E.L. 137
519.007 (4 of 4)	519.007 (4 of 4)	E.L. 137

130 CMR:  DIVISION OF MEDICAL ASSISTANCE

Trans. by E.L. 138	

Rev. 11/01/05	
	MASSHEALTH
	COVERAGE TYPES
		(1 of 2)	

Chapter
Page	

519
519.003	

(4)  MassHealth pays 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 full cost of the Medicare Part B premiums for members with countable income that is less than or equal to 120 percent of the federal poverty level;

(b)  the cost of Medicare Part A premiums for adult members of MassHealth Standard who are entitled to Medicare Part A with a countable income that is less than or equal to 100 percent of the federal poverty level; and

(c)  the deductibles and coinsurance under Medicare Parts A and B for members with a countable income that is less than or equal to 100 percent of the federal poverty level.

(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, continues to receive MassHealth Standard coverage until a determination of ineligibility is made by MassHealth.

(D)  Automatic Eligibility for EAEDC Recipients Aged 65 and Older.

(1)  Individuals aged 65 and older who meet the requirements of the EAEDC program administered by DTA and who are United States citizens or qualified aliens, as described in 130 CMR 518.002, are automatically eligible for MassHealth Standard benefits.

(2)  Individuals aged 65 and older who meet the requirements of the EAEDC program administered by DTA and who are aliens with special status, as described in 130 CMR 518.002(D), are automatically eligible for MassHealth Essential benefits under 130 CMR 519.013.

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; 

130 CMR:  DIVISION OF MEDICAL ASSISTANCE

Trans. by E.L. 138	

Rev. 11/01/05	
	MASSHEALTH
	COVERAGE TYPES
		(3 of 4)	

Chapter
Page	

519
519.007	

(b)  A child less than 12 months of age must have global developmental skills significantly below an age-appropriate level and such skills must not be expected to
progress at an age-appropriate rate as indicated by a developmental assessment performed by the child's physician or by another certified professional.

(c)  Regardless of age, the child must also require all of the following:

(i)  direct administration of at least two discrete skilled-nursing services on a daily basis, each of which requires complex nursing procedures as described at 130 CMR 519.007(A)(3);

(ii)  direct management of the child's medical care by a physician or under the supervision of a physician on a monthly basis;

(iii)  assistance in one or more ADLs beyond what is required at an age-appropriate activity level; and

(iv)  any combination of skilled therapeutic services (physical therapy, occupational therapy, speech and language therapy) provided directly by or under the supervision of a licensed therapist at least five times a week. 

(B)  Home- and Community-Based Services Waiver.

(1)  Clinical and Age Requirements.  The Home- and Community-Based Services Waiver allows an applicant or member who is certified by the MassHealth agency or its agents to be in need of nursing-facility services to receive certain waiver services at home provided he or she:

(a)  is 60 years of age or older, and, if under age 65, is permanently and totally disabled in accordance with Title XVI standards; and

(b)	would be institutionalized in a nursing facility, unless he or she receives one or 
more of the services administered by the Executive Office of Elder Affairs under the Home- and Community-Based Services Waiver authorized under Section 1915(c) of the Social Security Act.

(2)  Eligibility Requirements.  In determining eligibility for MassHealth Standard and for waiver services, the MassHealth agency counts the income and assets of only the applicant or member regardless of his or her marital status.  The applicant or member must:

(a)  meet the requirements of 130 CMR 519.007(B)(1)(a) and (b);

(b)  have a countable-income amount less than or equal to 300 percent of the federal benefit rate (FBR) for an individual; and

(c)  have countable assets of $2,000 or less and have not transferred resources for the 
sole purpose of obtaining MassHealth as described at 130 CMR 520.018 and 520.019.

(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

130 CMR:  DIVISION OF MEDICAL ASSISTANCE

Trans. by E.L. 138	

Rev. 11/01/05	
	MASSHEALTH
	COVERAGE TYPES
		(4 of 4)	

Chapter
Page	

519
519.007	

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)  the MassHealth agency 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.  In determining PACE eligibility, the MassHealth agency counts the income and assets of only the applicant or member regardless of his or her marital status.  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 the MassHealth agency 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 assets exceed these standards, reduce assets in accordance with 130 CMR 520.004; and

(g)  have a countable-income amount less than or equal to 300 percent of the federal benefit rate (FBR) for an individual.

(3)  Income Standards Not Met.  Individuals whose income exceeds the standards set forth in 130 CMR 519.007(C)(2) may establish eligibility for MassHealth Standard by meeting a deductible as described at 130 CMR 520.028 et seq.

(130 CMR 519.008 Reserved)