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 180 July 15, 2008 TO: MassHealth Staff FROM: Tom Dehner, Medicaid Director RE: Revisions to the Regulations about Coverage Types MassHealth is revising the regulations to clarify that MassHealth Senior Buy-In and Buy-In are available for Medicare beneficiaries who are under the age of 65. All Medicare beneficiaries, regardless of age, are eligible for these programs if they meet certain income and asset requirements. These emergency regulations are effective August 1, 2008. MANUAL UPKEEP Insert Remove Trans. By 505.000 505.000 E.L. 109 505.001 505.001 E.L. 123 505.008 505.008 (1 of 2) E.L. 123 505.009 505.008 (2 of 2) E.L. 117 506.001 506.001 E.L. 171 130 CMR: DIVISION OF MEDICAL ASSISTANCE Trans. by E.L. 180 Rev. 08/01/08 MASSHEALTH COVERAGE TYPES Chapter 505 Page 505.000 TABLE OF CONTENTS Section 505.001: Introduction 505.002: MassHealth Standard 505.003: MassHealth Prenatal 505.004: MassHealth CommonHealth 505.005 MassHealth Family Assistance 505.006: MassHealth Basic 505.007: MassHealth Essential 505.008: MassHealth Limited 505.009: MassHealth Senior Buy-In and Buy-In 130 CMR: DIVISION OF MEDICAL ASSISTANCE Trans. by E.L. 180 Rev. 08/01/08 MASSHEALTH COVERAGE TYPES Chapter 505 Page 505.001 505.001: Introduction 130 CMR 505.000 explains the categorical requirements and financial standards that must be met to qualify for a MassHealth coverage type. The rules of financial responsibility and calculation of financial eligibility are detailed in 130 CMR 506.000. (A) The MassHealth coverage types are the following: (1) Standard - for families, pregnant women, children, disabled individuals, and women with breast or cervical cancer; (2) Prenatal - for pregnant women; (3) CommonHealth - for disabled adults and disabled children who are not eligible for MassHealth Standard; (4) Family Assistance - for children, certain employed adults, and persons who are HIV positive who are not eligible for MassHealth Standard or CommonHealth; (5) Basic - for the long-term unemployed who have income at or below 100 percent of the federal poverty level, and who are receiving services or are on a waiting list to receive services from the Department of Mental Health (DMH), as identified by the DMH to MassHealth, or for individuals or members of a couple who receive EAEDC cash assistance; (6) Essential - for the long-term unemployed and for disabled long-term unemployed aliens with special status who have income at or below 100 percent of the federal poverty level and are not eligible for MassHealth Basic; and (7) Limited - for nonqualified aliens and aliens with special status. (8) Senior Buy-In and Buy-In - for certain Medicare beneficiaries. (B) The financial standards referred to in 130 CMR 505.000 et seq. depend on the family group size, which may be composed of an individual, couple, or family, as defined in 130 CMR 501.001. 505.002: MassHealth Standard (A) Overview. (1) 130 CMR 505.002 contains the categorical requirements and financial standards for MassHealth Standard serving families, children under 19, pregnant women, disabled individuals, parents and caretaker relatives described in 130 CMR 519.005(C)(1), and women with breast or cervical cancer. (2) Persons eligible for Standard coverage are eligible for medical benefits as described in 130 CMR 450.105(A) and 130 CMR 508.000. (3) Persons who do not otherwise meet the requirements of 130 CMR 505.002, but who meet the AFDC rules that were in effect on July 16, 1996, are eligible for MassHealth Standard. 130 CMR: DIVISION OF MEDICAL ASSISTANCE Trans. by E.L. 180 Rev. 08/01/08 MASSHEALTH COVERAGE TYPES Chapter 505 Page 505.008 505.008: MassHealth Limited (A) Eligibility Requirements. (1) MassHealth Limited is available to persons who meet the financial and categorical requirements of MassHealth Standard, except women described at 130 CMR 505.002(H), 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. (5) Aliens with special status who are eligible for MassHealth Essential in accordance with 130 CMR 505.007(E) are automatically eligible for MassHealth Limited. (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. 180 Rev. 08/01/08 MASSHEALTH COVERAGE TYPES Chapter 505 Page 505.009 (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. 505.009: MassHealth Senior Buy-In and Buy-In (A) MassHealth Senior Buy-In and Buy-In coverage are available to Medicare beneficiaries who are not eligible for MassHealth Standard, in accordance with 130 CMR 519.010 and 519.011. MassHealth Standard members receive this benefit under 130 CMR 505.002(G). (B) Income and assets for benefits provided under 130 CMR 519.010 and 519.011 are determined in accordance with 130 CMR 520.000. 130 CMR: DIVISION OF MEDICAL ASSISTANCE Trans. by E.L. 180 Rev. 08/01/08 MASSHEALTH FINANCIAL REQUIREMENTS Chapter 506 Page 506.001 506.001: Introduction (A) 130 CMR 506.000 describes the rules governing financial eligibility for MassHealth. These rules are based on the size of the family group and countable income. (B) The formula for income standards used in the determination of financial eligibility, the deductible income standards, the premiums for Family Assistance, CommonHealth, and the Children’s Medical Security Plan (CMSP), and the Family Assistance premium assistance payment formulas are also contained in 130 CMR 506.000. (C) Financial eligibility for MassHealth Senior Buy-In and Buy-In is determined in accordance with 130 CMR 519.010, 519.011, and 520.000. 506.002: Financial Responsibility In determining eligibility for MassHealth, the gross income of all family group members is counted and compared to an income standard based on the family group size. Caretaker relatives and parents of children under age 19 who are pregnant or who are parents may choose whether or not to be part of the child’s family group. Family groups are comprised of families, couples, or individuals, as defined in 130 CMR 501.001. 506.003: Countable Income Eligibility is based on the family group's gross countable earned and unearned income as defined in 130 CMR 506.003, except as described in 130 CMR 506.003(C) below. (A) Gross Earned Income. (1) Gross earned income is the total amount of compensation received for work or services performed without regard to any deductions. (2) Gross earned income for the self-employed is the total amount of business income listed or allowable on a U.S. Tax Return. (3) Seasonal income is income derived from an income source that is associated with a particular time of the year. Annual gross income is divided by 12 to obtain a monthly gross income with the following exception: if the applicant or member has a disabling illness or accident during or after the seasonal employment period that prevents the person's continued or future employment, only current income will be considered in the eligibility determination. (B) Gross Unearned Income. (1) Gross unearned income is the total amount of income that does not directly result from the individual's own labor before any income deductions are made. (2) Unearned income includes, but is not limited to, social security benefits, railroad retirement benefits, pensions, annuities, federal veterans' benefits, and interest and dividend income. (C) Rental Income. Rental income is the total amount of gross income less any deductions listed or allowable on an applicant’s or member’s U.S. Tax Return.