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 169 November 1, 2007 TO: MassHealth Staff FROM: Tom Dehner, Medicaid Director RE: Revisions to Regulations about Job Update Form MassHealth is revising the regulations to clarify that the Department of Revenue (DOR) Update Form must be returned by the member within 30 days from the date on the MA21 notice that is sent with the form. These regulations were effective July 1, 2007. MANUAL UPKEEP Insert Remove Trans. By 502.007 502.007 E.L. 157 502.008 502.008 E.L. 148 516.007 516.007 E.L. 117 130 CMR: DIVISION OF MEDICAL ASSISTANCE Trans. by E.L. 169 Rev. 07/01/07 MASSHEALTH THE REQUEST FOR BENEFITS Chapter 502 Page 502.007 (3) the member is no longer eligible for MassHealth. (C) The MassHealth agency does not notify the member if there is no change in the member’s coverage type, premium payment, or premium assistance payment. (D) If the member’s coverage type changes, the start date for the new coverage type is determined as follows. (1) If the new coverage type provides more comprehensive benefits to the member, coverage is effective as of the date of the written notice with the following exceptions. (a) Coverage for the purchase of medical benefits under Basic is effective upon the member’s enrollment with a MassHealth managed care provider. (b) Coverage for the purchase of medical benefits under Essential is effective upon the member’s enrollment in the Primary Care Clinician (PCC) Plan. MassHealth Essential members who are aliens with special status are afforded eligibility under MassHealth Limited pursuant to 130 CMR 505.007(E). (c) Coverage for premium assistance under Basic and Essential is effective in the calendar month following the date of the written notice. MassHealth Essential members receiving premium assistance who are aliens with special status are afforded eligibility under MassHealth Limited pursuant to 130 CMR 505.007(E). (d) Premium assistance payments under Family Assistance begin in the month of the MassHealth agency’s eligibility determination, or in the month the insurance deduction begins, whichever is later. (2) If the new coverage type provides less comprehensive benefits to the member, coverage is effective subsequent to the member’s receipt of a timely written notice in accordance with 130 CMR 610.015. (E) If the member fails to provide a written update of his or her circumstances within 60 days of the MassHealth agency’s request, MassHealth coverage is terminated, except as provided in 130 CMR 502.007(G). If the member subsequently submits a written update, the MassHealth agency determines his or her eligibility as of the date the written update is received. If the applicant is determined eligible, the medical coverage date is established in accordance with the rules in 130 CMR 502.006. (F) If the member fails to provide verification of information within 60 days of the MassHealth agency’s request, MassHealth coverage is terminated. (1) Except as provided at 130 CMR 501.003(E), if required verifications are received within one year of receipt of the previous MBR or written update on a prescribed form, coverage is reinstated 10 days before receipt of the verifications unless the member is determined eligible for the purchase of medical benefits under MassHealth Basic or Essential, or premium assistance under Basic, Essential, or Family Assistance. For those members, the medical coverage date is established in accordance with the rules in 130 CMR 502.006. Coverage under Essential is also subject to the funding restrictions described at 130 CMR 505.007. 130 CMR: DIVISION OF MEDICAL ASSISTANCE Trans. by E.L. 169 Rev. 07/01/07 MASSHEALTH THE REQUEST FOR BENEFITS Chapter 502 Page 502.008 (2) If required verifications are not received within one year of receipt of the previous MBR or written update on a prescribed form, a new MBR must be completed. (G) The MassHealth agency matches files of MassHealth members who appear on the Department of Revenue (DOR) records as “new hires” or for whom DOR has received quarterly wage reporting information. If the DOR records contain data that is inconsistent with information previously recorded on the MassHealth case file, the MassHealth agency sends a notice with a Job Update form to the MassHealth member whose name appears on the DOR file. MassHealth must receive the completed Job Update form within 30 days from the date on the notice. If the Job Update form is not received within the 30-day period, MassHealth coverage for the family group is terminated. If the member submits a written update after the end of the 30-day period, the MassHealth agency determines family group eligibility as of the date the written update is received and the start date of MassHealth coverage is established in accordance with 130 CMR 502.006. 502.008: Notice (A) All applicants and members receive a written notice of the eligibility determination for MassHealth. The notice contains an eligibility decision for each member of the family group who has requested MassHealth, and either provides information so the applicant or member can determine the reason for any adverse decision or directs the applicant or member to such information. (B) Members also receive a notice, in accordance with 130 CMR 610.015, of any loss of coverage, or any changes in coverage type, premium, or premium assistance payments. (C) The notices described in 130 CMR 502.008(A) and (B) provide information about the applicant's and member's right to a fair hearing, with the exception of notices about eligibility for presumptive coverage as described at 130 CMR 505.002(C)(3) and 505.005(C)(2), and for prenatal coverage as described at 130 CMR 505.003. Information about the appeal process is found at 130 CMR 610.000. 502.009: Voluntary Withdrawal The applicant or eligibility representative may voluntarily withdraw his or her request for MassHealth. 502.010: Issuance of a MassHealth Card (A) The MassHealth agency issues a MassHealth card to new members, with the exception of those who receive premium assistance under (1) MassHealth Family Assistance for children, as described at 130 CMR 505.005(B); (2) MassHealth Family Assistance for adults, as described at 130 CMR 505.005(C); (3) MassHealth Basic, as described at 505.006(C); or (4) MassHealth Essential, as described at 505.007(C). (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. 169 Rev. 07/01/07 MASSHEALTH THE ELIGIBILITY PROCESS Chapter 516 Page 516.007 (D) The MassHealth agency matches files of MassHealth members who appear on the Department of Revenue (DOR) records as “new hires” or for whom DOR has received quarterly wage reporting information. If the DOR records contain data that is inconsistent with information previously recorded on the MassHealth case file, the MassHealth agency sends a notice with a Job Update form to the MassHealth member whose name appears on the DOR file. MassHealth must receive the completed Job Update form within 30 days from the date on the notice. If the Job Update form is not received within the 30-day period, MassHealth coverage for the family group is terminated. If the member submits a written update after the end of the 30-day period, the MassHealth agency determines family group eligibility as of the date the written update is received and the start date of MassHealth coverage is established in accordance with 130 CMR 516.005. 516.007: Notice (A) All applicants and members, as well as certain others described below in 130 CMR 516.007, receive written notice of the determination of their eligibility for MassHealth. The notice contains an eligibility decision for each member who has requested MassHealth, and provides information enabling the applicant or member to determine the reason for any adverse decision. (B) Members also receive notice of any changes in coverage type or patient-paid amount, or loss of coverage. (C) In addition to sending notices to applicants and members, such written notices are provided to the institution or eligibility representative, as well as to 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 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) The MassHealth agency issues a MassHealth card to new members, 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.