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 annually provides access to healthcare services for approximately 2.5 million eligible children, families, seniors, and people with disabilities, all of whom have low or moderate incomes. In fiscal year 2023, MassHealth paid healthcare providers more than $18.1 billion in total, of which approximately 35% was funded by the Commonwealth. Medicaid expenditures represent approximately 35% of the Commonwealth’s total fiscal year 2023 budget. Below is a chart of MassHealth’s 2023 income standards and federal poverty guidelines.
| Family Size | MassHealth Income Limit (Annually) | 100% Federal Poverty Level | 133% Federal Poverty Level | 150% Federal Poverty Level |
|---|---|---|---|---|
| 1 | $6,264 | $14,580 | $19,392 | $21,876 |
| 2 | $7,800 | $19,728 | $26,232 | $29,580 |
| 3 | $9,300 | $24,864 | $33,072 | $37,296 |
| 4 | $10,692 | $30,000 | $39,900 | $45,000 |
| 5 | $12,192 | $35,148 | $46,740 | $52,716 |
| 6 | $13,692 | $40,284 | $53,580 | $60,420 |
| 7 | $15,192 | $45,420 | $60,420 | $68,136 |
| 8 | $16,596 | $50,568 | $67,248 | $75,840 |
Managed Care Program
MassHealth’s Managed Care Program consists of two managed care organizations (MCOs), Tufts Health Together and WellSense Essential MCO, 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, which is a set amount of money for each enrolled person assigned to them, per period of time, whether or not that person seeks care. The amount paid is based on each patient’s average expected healthcare utilization, with payments for patients generally varying by age and health status. 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 US territories to maintain an accurate, up-to-date, and complete dataset, 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.
Medicaid Management Information System and Identity Matches
The Medicaid Management Information System (MMIS) is the claim processing and data warehouse system used by MassHealth. MMIS contains various types of information, such as healthcare information about services provided to MassHealth members and billing submission data, and is used for processing data, verifying eligibility, and running reports that identify medical treatment.
Section 502.007(A)(1) of Title 130 of the Code of Massachusetts Regulations (CMR) states that MassHealth reviews eligibility of members “by information matching with other agencies, health insurance carriers, and information sources.”
In addition, according to 130 CMR 502.004, “the MassHealth agency may initiate information matches with other agencies and information sources when an application is received, at annual renewal, and periodically, in order to update or verify eligibility.”
According to 130 CMR 516.004, these other agencies include the following:
Federal Data Services Hub, the Department 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, Social Security Administration, Systematic Alien Verification for Entitlements, Department of Transitional Assistance, and health insurance carriers.
Members who are eligible for MassHealth coverage are provided a unique 12-digit alphanumeric member identification number (ID) that is generated by MMIS after receiving a transaction (application) from an eligibility system, such as MA-21 or the Health Insurance Exchange.1 When MMIS receives a transaction from an eligibility system, MMIS tries to find a member’s existing ID through match criteria. MMIS automatically performs eight different matches in succession to identify whether a MassHealth member already has a member ID. According to MassHealth’s Current Match Criteria document, the eight matches are as follows:
Match 1
Mass Health Member IDs match . . .
Match 2
First and Last Names Match
Other Agency IDs and Agency Source Match . . .
Match 3
First and Last Names Match
[Social Security Numbers (SSNs)] Match (Primary SSN matches Primary SSN)
[Date of Birth (DOB)] Match . . .
Match 4
First and Last Names Match
SSN’s Match (Primary SSN matches Primary or Other SSNs),
2 out of the 3 DOB components ( YYYY MM DD ) match . . .
Match 5
First Initial of First Names Match
Last Names Match
SSN’s Match (Primary SSN matches Primary or Other SSNs)
DOB Match
Gender Match . . .
Match 6
First 4 Letters of the First Name Match
Last Names Match, Gender Match
2 out of the 3 DOB components ( YYYY MM DD ) match
SSN’s Match (Primary SSN matches Primary or Other SSNs) . . .
Match 7
SSN’s Match (Primary SSN matches Primary or Other SSNs)
Gender Match
AND
[(2 or 3 of the 3 DOB components ( YYYY MM DD) match AND
First 4 Letters of the First Name Match)
OR
(DOB and First Initial of First Name Match)] . . .
Match 8
Final match if no match was found on Matches 1-7.
Matches on First Name, Last Name, DOB, Gender and Zip. [SSN] is not considered.
If a member is not identified in MMIS through the previous eight matches, MMIS uses master data management (MDM) probabilistic-based matching approach, which is another method used to find similarities between two or more member IDs. MDM is a modular system used to perform sophisticated matching that is separate from MMIS, the claims processing system, and the eligibility systems. If the member is not found with an existing ID, MMIS will generate a new member ID.
- Commonwealth residents can apply for health insurance through the Health Insurance Exchange—if applicants are 65 or younger—or the MA-21 system—if applicants are older than 65 and/or require long-term care.
Recovery Process
According to 130 CMR 515.010,
The MassHealth agency has the right to recover payment of medical benefits to which the member was not entitled at the time the benefit was received, regardless of who was responsible and whether or not there was fraudulent intent.
MCOs are paid a fee per person, or per capita, for the coordination of care. If a person has two member IDs, the MCO would receive two capitation payments (based on their two member IDs) but would be coordinating care for only one individual. In these instances, the Commonwealth should recoup the cost of the unnecessary capitation payment that was caused by the multiple member IDs. When multiple IDs are identified through MMIS or MDM, and subsequently linked, there are three components to the recovery cleanup process. The first component involves an automated reconciliation that runs from the middle to end of each month in MMIS, that is constantly paying and recouping capitation payments for members with multiple IDs that are identified and linked. The system automatically looks back three months from the date of linkage to recoup payments made on behalf of inactive and duplicate IDs. The second component involves annual reconciliation reports, which are completed only when requested. The third component relates to the recovery process running on an as-needed basis for member-specific reconciliation for specific time frames.
Manual Ticket Process
In scenarios where the MMIS match approach or the MDM approach do not uncover multiple IDs for the same member, MassHealth can institute a manual ticket process. There are different ways MassHealth can learn of the prevalence of multiple IDs for the same person that the MMIS and/or MDM processes did not catch. For example, MassHealth staff members can detect multiple IDs when processing eligibility transactions originating from other state agencies. Managed care entities will detect multiple IDs and subsequently send MassHealth reports as well. In these cases, MassHealth creates a ticket to have to the IDs linked and start the recoupment process, if necessary.
| Date published: | December 31, 2024 |
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