Overview
Under Chapter 118E of the Massachusetts General Laws, the Executive Office of Health and Human Services, through the Division of Medical Assistance, administers the state’s Medicaid program, known as MassHealth. MassHealth provides access to healthcare services for approximately 1.8 million eligible low- and moderate-income children, families, seniors, and people with disabilities annually. In fiscal year 2021, MassHealth paid healthcare providers more than $18.1 billion, of which approximately 45% was funded by the Commonwealth. Medicaid expenditures represent approximately 40% of the Commonwealth’s total fiscal year 2021 budget.
MassHealth’s Managed Care Program
MassHealth’s Managed Care Program consists of two managed care organizations (MCOs), Tufts Health Together and Boston Medical Center HealthNet Plan, which provide healthcare services to members through managed care plans. Each managed care plan assigns members a group of doctors and other healthcare providers who work together to provide members with coordinated healthcare services. The doctors and other healthcare providers contractually agree to follow certain federal and state requirements about how they provide services. MCO enrollees select a primary care physician to provide basic healthcare and make any necessary specialist referrals. MassHealth pays the MCO a capitation payment, the amount of which is based on a rating category assigned by the Executive Office of Health and Human Services, for each member enrolled in the MCO’s managed care plan. Rating categories are based on risk factors for each member, such as whether the member needs facility-based care (e.g., a skilled nursing facility) or behavioral health treatment.
Transformed Medicaid Statistical Information System
The Transformed Medicaid Statistical Information System (T-MSIS) is a database maintained by the federal Centers for Medicare and Medicaid Services. T-MSIS contains Medicaid data from all 50 states, the District of Columbia, and the United States territories to maintain an accurate, up-to-date, and complete data set, containing eligibility, enrollment, and healthcare service claims data about Medicaid members. The Centers for Medicare and Medicaid Services use this data to manage Medicaid programs and aid in the detection of fraud, waste, and abuse.
Public Assistance Reporting Information System
MassHealth is part of the Public Assistance Reporting Information System (PARIS), which is the product of a partnership between the United States government and its states, the District of Columbia, and Puerto Rico. PARIS provides a free service quarterly that states, the District of Columbia, and Puerto Rico can use to cross-reference their public assistance program records to identify any data matches (i.e., recipients who also receive benefits from other states, the District of Columbia, or Puerto Rico).
To participate in PARIS and share information about Medicaid members and their healthcare use, states, the District of Columbia, and Puerto Rico must enter into a contract with the United States Department of Health and Human Services (HHS), called an Interstate Data Matching by State Public Assistance Agency Memorandum of Understanding. Every quarter, each state, the District of Columbia, and Puerto Rico may provide data to PARIS from the following assistance programs to identify data matches: Temporary Assistance for Needy Families, Medicaid, Workers’ Compensation (a federally funded program that administers disability compensation for workers who are injured on the job), Child Care (which provides childcare financial assistance to states and territories for low-income families), and the Supplemental Nutrition Assistance Program. HHS’s Administration for Children and Families oversees PARIS, facilitates the quarterly cross-referencing service, and disseminates information about data matches to the involved states, the District of Columbia, or Puerto Rico.
MassHealth’s Residency Requirements and Verification Process
Section 517.002 of Title 130 of the Code of Massachusetts Regulations (CMR) states, “As a condition of eligibility, an applicant or member must be a resident of the Commonwealth of Massachusetts.”
According to 130 CMR 517.002, “The individual’s residency is considered verified if the individual has attested to Massachusetts residency and the residency has been confirmed by electronic data matching with federal or state agencies or information services.”
MassHealth may also require documentation to validate residency with, for example, a utility bill dated within the past 60 days, driver’s license, a copy of a lease or rental agreement, or an affidavit written and signed by the member stating that they are a Massachusetts resident.
According to 130 CMR 517.002(F)(10), MassHealth allows applicants and members to self-declare their residency. However, this regulation mandates that MassHealth verify an applicant’s declared residency if it identifies conflicting or contradictory information regarding the applicant’s or member’s declared place of residence, such as through a PARIS data match.
Under Section 155.335 of Title 45 of the Code of Federal Regulations, MassHealth must annually redetermine members’ eligibility. According to 130 CMR 502.007(C)(1), members whose continued eligibility can be redetermined based on electronic data matches will have their eligibility automatically renewed. The programs MassHealth uses for redetermining eligibility include PARIS, the National Change of Address database,2 and Accurint, a software product from LexisNexis designed to conduct online research of addresses that MassHealth obtained from members. If MassHealth discovers new or conflicting information in these data matches, it sends a request for information letter to the member to verify that they are still eligible. Members who receive a request for information letter have 45 days to respond with verification documents, such as a driver’s license, utility bill, or rental agreement, which verifies that the member still resides in Massachusetts. If the member does not respond, they may have their coverage terminated or they may be moved to a fee-for-service model, where MassHealth pays each provider for services received by a member after the member receives those services.
Families First Coronavirus Response Act
Congress enacted the Families First Coronavirus Response Act on March 18, 2020. This Act allowed Massachusetts, and other states that meet certain criteria, to receive a 6.2% increase in its federal Medicaid match rate, which is the portion of the MassHealth program that is funded by the federal government. This Act also requires Medicaid programs to meet a maintenance of eligibility requirement, which means that Medicaid programs must keep current members continuously enrolled until the end of the month in which the public health emergency ends, unless there are changes in circumstances (e.g., a change in residency) that make members ineligible for their current coverage.
| Date published: | June 28, 2023 |
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