Commonwealth of Massachusetts
Executive Office of Health and Human Services
Office of Medicaid
www.mass.gov/masshealth

Eligibility Operations Memo 13-06
September 1, 2013




TO:	MassHealth Eligibility Operations Staff
FROM:	Amy Andrade, Director, Member and Provider Services  

RE:	Revisions to Income Deductions in Assessing the Patient Paid Amount
		

Introduction

MassHealth is revising its regulations about income deductions for 
necessary medical and remedial care expenses under 130 CMR 520.026(E).
		

Background

Effective immediately, MassHealth will determine an applicant’s or 
member’s patient paid amount as described in this memo.

MassHealth may allow certain income deductions for the applicant’s or 
member’s incurred necessary medical and remedial care expenses. These 
expenses must not be payable by a third party, accounted for under any 
provision of 130 CMR 520.004, or allocated to meet a deductible in 
accordance with 130 CMR 520.027 through 130 CMR 520.034. These 
expenses must be for medical or remedial care recognized under state law 
and not covered by MassHealth as of the member’s coverage start date. 
The total must be within reasonable limits.

MassHealth considers expenses to be within reasonable limits if they are:

* not incurred before the first day of the third month before 
the date of application, as described at 130 CMR 516.002;

* not incurred as a result of a transfer of resources for less 
than fair market value or during the imposition of a 
penalty period; and

* certified by a treating physician or other medical provider 
as being medically necessary.

Additionally MassHealth may limit the amount deducted to the 
MassHealth payment rate for such services.
		
(continued on next page)


Eligibility Operations Memo 13-06
September 1, 2013
Page 2	

Revised Procedure

In order to be considered by MassHealth, the necessary medical and 
remedial care must be incurred during the three-month retroactive period 
and should be submitted during the eligibility process. The notice 
assessing the patient paid amount will reflect the deductions found to be 
applicable in accordance with 130 CMR 520.026(E)(2)(c).

If the medical bills are received after MassHealth has issued its approval 
notice including a calculation of the patient paid amount, or the medical 
bills are not submitted within the eligibility process, the member may 
appeal the notice assessing the patient paid amount. Alternatively, the 
member or applicant may submit the bills and supporting documents to 
the MassHealth Enrollment Center and worker who processed the 
application within 30 days of the date of the notice. Deductions are not 
allowed for medical and remedial care bills that are not received within 
the specified time limits, or if the member does not establish that the 
medical services or remedial care expenses were medically necessary in 
accordance with 130 CMR 520.026(E).  If MassHealth determines that the 
deductions are not allowed, MassHealth will notify the member.
		

Questions

If you have any questions about this memo, please have your MEC 
designee contact the Policy Hotline.