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 156 December 15, 2006 TO: MassHealth Staff FROM: Beth Waldman, Medicaid Director RE: Missing Critical Data This letter transmits regulations for handling applications for MassHealth that are missing information. These regulations establish the missing critical data (MCD) file. The MCD file is currently being used for both waiver and traditional-community applicants. The MCD file was created for situations in which an application cannot be processed due to missing, incomplete, or unclear data that is critical to initiating the eligibility process. These regulations are effective January 1, 2007. MANUAL UPKEEP Insert Remove Trans. By 502.001 502.001 E.L. 137 502.002 -- -- 515.001 (5 of 8) 515.001 (5 of 8) E.L. 95 515.001 (7 of 8) 515.001 (7 of 8) E.L. 147 516.001 516.001 E.L. 123 516.002 -- -- 516.004 516.004 E.L. 137 130 CMR: DIVISION OF MEDICAL ASSISTANCE Trans. by E.L. 156 Rev. 01/01/07 MASSHEALTH THE REQUEST FOR BENEFITS Chapter 502 Page 502.001 502.001: Medical Benefit Request (MBR) (A) Filing an Application. To apply for MassHealth, a person or his or her eligibility representative must file a Medical Benefit Request (MBR) at a MassHealth Enrollment Center or MassHealth outreach site. All members of the family group, as defined in 130 CMR 501.001, must be listed on the MBR whether or not they are applying for MassHealth. (B) Corroborative Information. The MassHealth agency requests all corroborative information necessary to determine eligibility. The applicant must supply such information within 60 days of the date of the Request for Information. (C) Corroborative Information Received. If all necessary information is received, except verification of immigration status and/or verification of a person’s HIV-positive status, within the 60-day period referenced in 130 CMR 502.001(B), the MBR is considered complete. The completed MBR activates the MassHealth agency's eligibility process for determining the coverage type providing the most comprehensive medical benefits for which the applicant is eligible. (D) Corroborative Information Not Received. If the necessary information is not received within the 60-day period referenced in 130 CMR 502.001(B), the MassHealth agency notifies the applicant of the deactivation of the MBR. (E) Missing or Inconsistent Information on the MBR. (1) If an MBR is received at a MassHealth Enrollment Center or a MassHealth outreach site and the applicant did not answer all required questions on the MBR, the MassHealth agency is unable to determine the applicant’s eligibility for MassHealth. (2) The MassHealth agency requests responses to all of the unanswered questions necessary to determine eligibility. The MassHealth agency must receive such information within 14 days of the date of the request for the information. (3) If responses to all unanswered questions necessary to determine eligibility are received within 14 days of the date of the notice referenced in 130 CMR 502.001(E)(2), the MBR activates the MassHealth agency’s eligibility process for determining: (a) the coverage type providing the most comprehensive medical benefits for which the applicant is eligible, based on the date the MBR was received by the MassHealth agency; or (b) the need to request any corroborative information necessary to determine eligibility, as provided in 130 CMR 502.001(B), (C), and (D). (4) If responses to all unanswered questions necessary for determining eligibility are not received within the 14-day period referenced in 130 CMR 502.001(E)(2), the MassHealth agency notifies the applicant that it is unable to determine eligibility for MassHealth and returns the incomplete MBR to the applicant with the notice. The date that the incomplete MBR was received will not be used in any subsequent eligibility determinations. (5) Inconsistent answers are treated as unanswered. 130 CMR: DIVISION OF MEDICAL ASSISTANCE Trans. by E.L. 156 Rev. 01/01/07 MASSHEALTH THE REQUEST FOR BENEFITS Chapter 502 Page 502.002 502.002: Reactivating the Medical Benefit Request Except as provided in 130 CMR 501.003(E), if all required information is received by the MassHealth agency after the 60-day period described in 130 CMR 502.001(D), or after a denial of eligibility, the MassHealth agency reactivates the MBR and considers it submitted as of the date the information is received, and the medical coverage date is established in accordance with 130 CMR 502.006. A new MBR must be completed if all required information is not received within one year of receipt of the previous MBR. 502.003: Presumptive Eligibility for Children (A) The MassHealth agency may determine a child presumptively eligible for either MassHealth Standard or MassHealth Family Assistance based on the family group’s self-declaration of gross income. A child may be presumptively eligible for medical benefits under Family Assistance only if he or she does not have health insurance. (B) Coverage for services under Presumptive Eligibility begins on the 10th day before the date the MassHealth agency receives the Medical Benefit Request. Presumptive Eligibility coverage ends 60 days from the begin date, or when the MassHealth agency makes an eligibility determination, whichever is earlier. (C) A child may receive Presumptive Eligibility only once in a 12-month period. 502.004: Matching Information The MassHealth agency initiates information matches with other agencies and information sources when an MBR is received in order to update or verify eligibility. These agencies and information sources may include, but are not limited to, the following: the Division of Unemployment Assistance, Department of Public Health's Bureau of Vital Statistics, Department of Industrial Accidents, Department of Veterans' Services, Department of Revenue, Bureau of Special Investigations, Internal Revenue Service, 130 CMR: DIVISION OF MEDICAL ASSISTANCE Trans. by E.L. 156 Rev. 01/01/07 MASSHEALTH GENERAL POLICIES Chapter 515 Page 515.001 (5 of 8) Interpreter — a person who translates for an applicant or member who has limited English proficiency or a hearing impairment. Irrevocable Trust — a trust that cannot be in any way revoked by the grantor. Jointly Held Resources — resources that are owned by an individual in common with another person or persons in a joint tenancy, tenancy-in-common, or similar arrangement. Life Estate — a life estate is established when all of the remainder legal interest in a property is transferred to another, while the legal interest for life rights to use, occupy, or obtain income or profits from the property is retained. Limited English Proficiency — an inadequate ability to communicate in the English language. Look-Back Period — a period of consecutive months that the MassHealth agency may review for transfers of resources to determine if a period of ineligibility for payment of nursing-facility services should be imposed. Lump-Sum Income — a one-time payment, such as an inheritance or the accumulation of recurring income. Medical Benefits — payment for medical services provided to a MassHealth member. Member — a person determined by the MassHealth agency to be eligible for MassHealth. Nursing-Facility Resident — an individual who is a resident of a nursing facility, is a resident in any institution, including an intermediate-care facility for the mentally retarded (ICF/MR), for whom payment is based on a level of care equivalent to that received in a nursing facility, is in an acute hospital awaiting placement in a nursing facility, or lives in the community and would be institutionalized without community-based services provided in accordance with 130 CMR 519.007(B). Patient-Paid Amount — the amount that a member in a long-term-care facility must contribute to the cost of care under the laws of the Commonwealth of Massachusetts. Period of Ineligibility — the period of time during which the MassHealth agency denies or withholds payment for nursing-facility services because the individual has transferred resources for less than fair-market value. 130 CMR: DIVISION OF MEDICAL ASSISTANCE Trans. by E.L. 156 Rev. 01/01/07 MASSHEALTH GENERAL POLICIES Chapter 515 Page 515.001 (7 of 8) Pooled Trust — a trust that meets all the following criteria as determined by the MassHealth agency. (1) The trust was created by a nonprofit organization. (2) A separate account is maintained for each beneficiary of the trust, but the assets of the trust are pooled for investment and management purposes. (3) The account in a pooled trust was created for the sole benefit of the individual by the individual, the individual's parents or grandparents, or by a legal guardian or court acting on behalf of the individual. (4) The trust provides that the Commonwealth of Massachusetts will receive amounts remaining in the account upon the death of the individual up to the amount paid by the MassHealth agency for services to the individual. The trust may retain reasonable and appropriate amounts as determined by the MassHealth agency. (5) The individual was disabled at the time his or her account in the pool was created. Promissory Note — a written promise to pay another. Quality Control — a system of continuing review to measure the accuracy of eligibility decisions. Reapplication – the MassHealth agency’s reopening of the application process when the application has been denied pursuant to 130 CMR 516.001(D). Redetermination — a review of a member's circumstances to establish whether he or she remains eligible for benefits. Resources — all income and assets owned by the individual or the spouse. For the purposes of determining eligibility, resources include income and assets to which the individual or the spouse is or would be entitled whether or not they are actually received. This term has the same meaning as “assets” as defined in 42 U.S.C. 1396p(e)(1). Reverse Mortgage — a loan on the equity value of a house paid in installments by a lender to the homeowner who is aged 60 or older. Revocable Trust — a trust whose terms allow the grantor to take action to regain any of the property or funds in the trust. Senior Medical Benefit Request (SMBR) — a form prescribed by the MassHealth agency to be completed by the applicant or eligibility representative, and submitted to the MassHealth agency as a request for MassHealth benefits. Skilled-Nursing Services — the planning, provision, and evaluation of goal-oriented nursing care that requires specialized knowledge and skills acquired under the established curriculum of a school of nursing approved by a board of registration in nursing. Such services include only those services that must be provided by a registered nurse, a licensed practical nurse, or a licensed 130 CMR: DIVISION OF MEDICAL ASSISTANCE Trans. by E.L. 156 Rev. 01/01/07 MASSHEALTH THE ELIGIBILITY PROCESS Chapter 516 Page 516.001 516.001: Overview (A) Eligibility Process. The eligibility process consists of the activities conducted for the purpose of determining, redetermining, and maintaining eligibility. (B) Filing an Application. To apply for MassHealth, a person or his or her eligibility representative must file a Senior Medical Benefit Request (SMBR) at a MassHealth Enrollment Center or MassHealth outreach site. (C) Corroborative Information. The MassHealth agency requests all corroborative information necessary to determine eligibility. (1) The MassHealth agency sends the applicant written notification requesting the corroborative information generally within five days of the receipt of the SMBR. (2) The notice advises the applicant that the requested information must be received within 30 days of the date of the request, and of the consequences of failure to provide the information. (D) Receipt of Corroborative Information. If the requested information, with the exception of verification of immigration status, is received within 30 days of the date of the request, the SMBR is considered complete. The completed SMBR activates the MassHealth agency’s eligibility process for determining the coverage type providing the most comprehensive medical benefits for which the applicant is eligible. If such information is not received within 30 days of the date of the request, MassHealth benefits may be denied. (1) Except as provided in 130 CMR 515.003(C), if the requested information is received within 30 days of the date of the denial, the date of receipt of one or more of the verifications is considered the date of reapplication. (2) The date of reapplication replaces the date of the denied SMBR. The applicant’s earliest date of eligibility for MassHealth is based on the date of reapplication. (3) If a reapplication is subsequently denied and not appealed, the applicant must submit a new SMBR to pursue eligibility for MassHealth. The earliest date of eligibility for MassHealth is based on the date of the new SMBR. (E) Missing or Inconsistent Information on the SMBR. (1) If an SMBR is received at a MassHealth Enrollment Center or MassHealth outreach site and the applicant did not answer all required questions on the SMBR, the MassHealth agency is unable to determine the applicant’s eligibility for MassHealth. (2) The MassHealth agency requests responses to all of the unanswered questions necessary to determine eligibility. The MassHealth agency must receive such information within 14 days of the date of the request for the information. 130 CMR: DIVISION OF MEDICAL ASSISTANCE Trans. by E.L. 156 Rev. 01/01/07 MASSHEALTH THE ELIGIBILITY PROCESS Chapter 516 Page 516.002 (3) If responses to all unanswered questions necessary to determine eligibility are received within 14 days of the date of the notice, referenced in 130 CMR 516.001(E)(2), the SMBR activates the MassHealth agency’s eligibility process for determining: (a) the coverage type providing the most comprehensive medical benefits for which the applicant is eligible, based on the date the SMBR was received by the MassHealth agency; or (b) the need to request any corroborative information necessary to determine eligibility, as provided in 130 CMR 516.001(C) and (D). (4) If responses to all unanswered questions necessary for determining eligibility are not received within the 14-day period referenced in 130 CMR 516.001(E)(2), the MassHealth agency notifies the applicant that it is unable to determine eligibility for MassHealth and returns the incomplete SMBR to the applicant with the notice. The date that the incomplete SMBR was received will not be used in any subsequent eligibility determinations. (5) Inconsistent answers are treated as unanswered. 516.002: Date of Application (A) The date of application is the date that a completed SMBR is received at a MassHealth Enrollment Center or MassHealth outreach site. An SMBR is considered complete as provided in 130 CMR 516.001(D). (B) If an applicant described in 130 CMR 519.002(A)(1) has been denied SSI in the 30-day period before the date of application for MassHealth, the date of application for MassHealth is the date the person applied for SSI. 516.003: Matching Information The MassHealth agency initiates information matches with other agencies and information sources when an SMBR is received in order to update or verify eligibility. These agencies and information sources may include, but are not limited to, the following agencies: the Division of Unemployment Assistance, Department of Public Health's Bureau of Vital Statistics, Department of Industrial Accidents, Department of Veterans' Services, Department of Revenue, Bureau of Special Investigations, Internal Revenue Service, Social Security Administration, Alien Verification Information System, Department of Transitional Assistance, and banks and other financial institutions. 130 CMR: DIVISION OF MEDICAL ASSISTANCE Trans. by E.L. 156 Rev. 01/01/07 MASSHEALTH THE ELIGIBILITY PROCESS Chapter 516 Page 516.004 516.004: Time Standards for Eligibility Determination (A) For applicants who do not apply on the basis of a disability, a determination of eligibility must be made within 45 days from the date of receipt of the completed SMBR. All requested information must be received within 30 days of the date of request. (B) For applicants who apply for MassHealth on the basis of a disability, a determination of eligibility must be made within 90 days from the date of receipt of the completed SMBR, including a disability supplement, if required. (C) If the MassHealth agency determines that unusual circumstances exist, the timeframes for determining eligibility are extended. Unusual circumstances include delay caused by the applicant, by an examining physician, or by other events beyond the control of the MassHealth agency. 516.005: Coverage Date The begin date of MassHealth Standard, Essential, or Limited coverage may be retroactive to the first day of the third calendar month before the month of application, if covered medical services were received during such period, and the applicant or member would have been eligible at the time services were provided. If more than one SMBR has been submitted and not denied, the begin date will be based on the earliest SMBR that is approved. For MassHealth Essential, coverage can begin no earlier than June 1, 2004. For MassHealth Essential members enrolled from a waiting list, coverage is determined in accordance with 130 CMR 515.003(C)(2). 516.006: Eligibility Determination (A) The MassHealth agency reviews eligibility at least every 12 months with respect to circumstances that may change. The MassHealth agency updates the file based on information received as the result of such review. Eligibility may be reviewed: (1) as a result of a member's reported changes in circumstances; (2) by external matching with other agencies; and (3) where matching is not available, through a written update of the member's circumstances on a prescribed form. (B) If the member fails to provide a written update or information within 30 days of the request, MassHealth coverage may be terminated. (C) If the requested update or information is submitted within 30 days from the date of the termination, a second eligibility determination is made within 15 days. Eligibility may be established retroactive to the date of termination, if otherwise eligible.