130 CMR, § 501.001

Current through Register 1531, September 27, 2024

Section 501.001 - Definition of Terms

The terms listed in 130 CMR 501.001 have the following meanings for the purposes of MassHealth, as described in 130 CMR 501.000 through 508.000. In the event that a definition conflicts with federal law, the federal law supersedes.

Accountable Care Organization (ACO) - an entity that enters into a population-based payment model contract with EOHHS as an accountable care organization, wherein the entity is held financially accountable for the cost and quality of care for an attributed or enrolled member population. ACOs include Accountable Care Partnership Plans, Primary Care ACOs, and MCO-administered ACOs.

Accountable Care Partnership Plan - a type of ACO with which the MassHealth agency contracts under its ACO program to provide, arrange for, and coordinate care and certain other medical services to members on a capitated basis and which is approved by the Massachusetts Division of Insurance as a health-maintenance organization (HMO) and which is organized primarily for the purpose of providing health care services.

Access to Health Insurance - the ability to obtain employer-sponsored health insurance for an uninsured family member where an employer would contribute at least 50% of the premium cost, and the health insurance offered would meet the basic-benefit level.

American Indian or Alaska Native - a person who

(1) is a member of a federally recognized tribe, band, or group as defined in Title 25 of U.S.C.;

(2) is an Eskimo, Aleut, or other Alaska Native enrolled by the Secretary of the Interior, pursuant to the Alaska Native Claims Settlement Act at 43 U.S.C. 1601et seq.; or

(3) has been determined eligible to receive health care services from Indian Health Care Providers as an Indian pursuant to 42 CFR 136.12 or Title V of the Indian Health Care Improvement Act.

Appeal - a written request, by an aggrieved applicant or member, for a fair hearing.

Appeal Representative - an Appeal Representative as defined in 130 CMR 610.004: Definitions.

Applicant - an individual who completes and submits an application for MassHealth.

Application - a request for health benefits that is received by the MassHealth agency and includes all required information and a signature by the applicant or their authorized representative. The application may be submitted at www.MAHealthConnector.org, or the applicant may complete a paper application, complete a telephone application, or apply in person at a MassHealth Enrollment Center (MEC).

Authorized Representative

(1) a person or an organization identified as the authorized representative of an applicant or member in a completed Authorized Representative Designation Form or another form prescribed by the MassHealth agency that has been signed by the authorized representative and, if applicable, the applicant or member and submitted to the MassHealth agency and in which the authorized representative agrees to comply with applicable rules regarding confidentiality and conflicts of interest in the course of representing the applicant or member; provided that such person or organization must be

(a) a person or organization designated by the applicant or member in writing to act responsibly on their behalf in connection with the eligibility process and other ongoing communications with the MassHealth agency;

(b) a person acting responsibly on behalf of the applicant or member and who is sufficiently aware of such applicant's or member's circumstances to assume responsibility for the accuracy of the statements made on their behalf during the eligibility process and in other communications with the MassHealth agency, such as a family member or friend; provided that the applicant or member in this case cannot provide written designation and does not otherwise have an individual who can act on their behalf such as an existing authorized representative, guardian, conservator, personal representative of the estate, holder of power of attorney, or an invoked health care proxy; or

(c) a person who has, under applicable law, authority to act on behalf of the applicant or member in making decisions related to health care or payment for health care including, but not limited to, a guardian, conservator, personal representative of the estate of an applicant or member, holder of power of attorney, or an invoked health care proxy.

(2) An authorized representative will have the authority to complete and sign an application on the applicant's behalf, select a health plan on the applicant's or member's behalf, complete and sign a renewal form on the member's behalf, receive copies of the applicant's or member's notices and other communications from the MassHealth agency (which may include protected health care information, personal data, and financial information), and act on behalf of the applicant or member in all other matters with the MassHealth agency or the Connector, including representing the applicant or member at an appeal provided that, with respect to a person serving as an authorized representative pursuant to 130 CMR 501.001: Authorized Representative (1)(c), authority to act on behalf of the applicant or member is determined by the applicable law or underlying legal document.

Basic-benefit Level (BBL)

(1) benefits provided under a health insurance plan that include a broad range of medical benefits as defined in the minimum creditable coverage core services requirements in 956 CMR 5.03(1)(a); provided that the annual deductible and the annual maximum out-of-pocket costs under that plan do not exceed the maximum amounts the Massachusetts Health Connector sets for deductibles and out-of-pocket costs in order for a plan to be considered minimum creditable coverage, as set forth at 956 CMR 5.03(2)(b)2. and 3., and 956 CMR 5.03(2)(c), respectively, and as may be illustrated in administrative bulletins published by the Massachusetts Health Connector, and as are in effect on the first day coverage under that plan begins.

(2)Exceptions.

(a) For the avoidance of doubt, instruments including, but not limited to, Health Reimbursement Arrangements, Flexible Spending Arrangements, as described in IRS Pub. 969, or Health Savings Accounts, as described at IRC § 223(c)(2), cannot be used to reduce the health insurance deductible in order to meet the basic-benefit level requirement.

(b) The MassHealth agency reserves the right to set its own annual deductible and maximum out-of-pocket limits. If the MassHealth agency deems it appropriate to set its own annual deductible and maximum out-of-pocket limits, a sub-regulatory bulletin will be issued.

Behavioral Health Contractor - the entity contracted with EOHHS to provide, arrange for, and coordinate behavioral health care and other services to members on a capitated basis.

Blindness - a visual impairment, as defined in Title XVI of the Social Security Act. Generally Blindness means visual acuity with correction of 20/200 or less in the better eye, or a peripheral field of vision contracted to a 10° radius or less, regardless of the visual acuity.

Business Day - any day during which the MassHealth agency's offices are open to serve the public.

Caretaker Relative - an adult who is the primary care giver for a child, is related to the child by blood, adoption, or marriage, or is a spouse or former spouse of one of those relatives, and lives in the same home as that child, provided that neither parent is living in the home.

Case File - the permanent written collection of documents and information required to determine eligibility and to provide benefits to applicants and members.

Certified Application Counselor (CAC) - an individual who is certified by the MassHealth agency and the Connector to provide assistance in completing applications and renewal forms.

Child - a person younger than 19 years old.

Citizen - see130 CMR 504.002: U.S. Citizen.

Commonwealth Health Insurance Connector Authority or Health Connector or Connector -the entity established pursuant to M.G.L. c. 176Q, § 2.

ConnectorCare - the program administered by the Health Connector pursuant to M.G.L. c. 176Q to provide premium assistance payments and point-of-service cost-sharing subsidies to eligible individuals enrolled in health plans.

Couple - two persons who are married to each other according to the laws of the Commonwealth of Massachusetts.

Coverage Date - the date medical coverage begins.

Coverage Type - a scope of medical services, other benefits, or both that is available to members who meet specific eligibility criteria. MassHealth coverage types include the following: MassHealth Standard (Standard), MassHealth CommonHealth (CommonHealth), MassHealth CarePlus (CarePlus), MassHealth Family Assistance (Family Assistance), and MassHealth Limited (Limited). The scope of services or covered benefits for each coverage type is found at 130 CMR 450.105: Coverage Types.

Custodial Parent -

(1) the parent with whom a child's physical custody has been established by a court order or binding separation, divorce, or custody agreement; or

(2) if no such order or agreement exists, the parent with whom the child spends most nights; or

(3) if the child spends an equal number of nights with each parent, it is determined by the Internal Revenue Service (IRS) tax rules.

Day - a calendar day, unless a business day is specified.

Deductible - the total dollar amount of incurred medical expenses that an applicant, whose income exceeds MassHealth income standards, must be responsible for before the applicant is eligible for MassHealth as described at 130 CMR 506.009: The One-time Deductible.

Deductible Period - a specified six-month period within which an applicant for MassHealth, whose income exceeds MassHealth income standards, may become eligible, on the basis of disability, through incurred and/or paid medical expenses of the applicant or any member of the MassHealth Disabled Adult Household as described in 130 CMR 506.009: The One-time Deductible.

Disabled - having a permanent and total disability.

Disabled Adult Household - see130 CMR 506.002(C): MassHealth Disabled Adult Household.

Disabled Working Adult -a person who is engaged in substantial gainful activity, but otherwise meets the definition of disabled as defined in Title XVI of the Social Security Act.

Disability Evaluation Services (DES) - a unit that consists of physicians and disability evaluators who determine permanent and total disability of an applicant or member seeking coverage under a MassHealth program for which disability is a criterion using criteria established by the Social Security Administration under Title XVI, and criteria established under state law. This unit may be a part of a state agency or under contract with a state agency.

Duals Demonstration Dual Eligible Individual - for purposes of the Duals Demonstration Program, a MassHealth member must meet all of the following criteria:

(1) be 21 through 64 years of age at the time of enrollment;

(2) be eligible for MassHealth Standard as defined in 130 CMR 450.105(A): MassHealth Standard or MassHealth CommonHealth as defined in 130 CMR 450.105(E): MassHealth CommonHealth;

(3) be enrolled in Medicare Parts A and B, be eligible for Medicare Part D, and have no other health insurance that meets the basic-benefit level as defined in 130 CMR 501.001; and

(4) live in a designated service area of an ICO.

Duals Demonstration Program - the MassHealth state Demonstration to Integrate Care for Duals Demonstration Dual Eligible Individuals.

Eligibility Process - activities conducted for the purposes of determining, redetermining, and maintaining the eligibility of a MassHealth applicant or member.

Fair Hearing - an administrative, adjudicatory proceeding conducted according to 130 CMR 610.000: MassHealth: Fair Hearing Rules to determine the legal rights, duties, benefits, or privileges of applicants and members.

Family Group - a family, couple, or individual.

Federal Poverty Level (FPL) - income standards issued annually in the Federal Register to account for the last calendar year's increase in prices as measured by the Consumer Price Index.

Fee-for-service - a method of paying for medical services provided by any MassHealth participating provider with no limit on provider choice.

Filing Status - an Internal Revenue Service term. The five filing statuses are single, married filing a joint return, married filing a separate return, head of household, and qualifying widow(er) with dependent children. The rate at which income is taxed is determined by the filing status.

Gross Income - the total money earned or unearned, such as wages, salaries, rents, pensions, or interest, received from any source without regard to deductions.

Health Insurance - coverage of health care services by a health insurance company, a hospitalservice corporation, a medical-service corporation, a managed care organization, or Medicare. Coverage of health care services by MassHealth, Health Safety Net (HSN), or Children's Medical Security Plan (CMSP) is not considered health insurance.

Health Safety Net - a source of funding for certain health care under 101 CMR 613.00: Health Safety Net Eligible Services and 101 CMR 614.00: Health Safety Net Payments and Funding.

Hospital-determined Presumptive Eligibility -the MassHealth agency will provide time-limited coverage, in accordance with 130 CMR 502.003(H): Hospital-determined Presumptive Eligibility, for individuals who are determined to be presumptively eligible by a qualified hospital, as defined at 130 CMR 450.110(B).

Incarceration - the confinement in a penal institution of an individual. An individual is not incarcerated if they are on parole, probation, or home release, and do not return to the institution for overnight stays.

Inconsistency Period - the time frame that an individual has to provide verifications needed to determine eligibility for health insurance offered by the Connector.

Integrated Care Organization (ICO) - an organization with a comprehensive network of medical, behavioral health care, and long-term services and supports providers that integrates all components of care, either directly or through subcontracts, and has contracted with the Executive Office of Health and Human Services (EOHHS) and the Centers for Medicare & Medicaid Services (CMS) and been designated as an ICO to provide services to dual eligible individuals under M.G.L. c. 118E. ICOs are responsible for providing enrollees with the full continuum of Medicare- and MassHealth-covered services.

Interpreter - a person who translates for an applicant or member who has limited English proficiency or a hearing impairment.

Lawfully Present Immigrants - see130 CMR 504.003(A): Lawfully Present Immigrants.

Limited English Proficiency - persons who are unable to communicate effectively in English because their primary language is not English and who have not developed fluency in the English language.

Lump-sum Payment - a one-time only payment that represents either a windfall payment, or the accumulation of recurring countable income, such as retroactive unemployment compensation or federal veterans' retirement benefits. Payments such as gifts, inheritances, and personal injury awards, to the extent that they are not included in modified adjusted gross income, are not considered lump-sum payments.

Managed Care - a system of primary care and other medical services that are provided and coordinated by a MassHealth managed care provider, a SCO, an ICO, or the behavioral health contractor in accordance with the provisions of 130 CMR 450.117: Managed Care and 130 CMR 508.000: MassHealth: Managed Care Requirements.

Managed Care Organization (MCO) - any entity with which the MassHealth agency contracts under its MCO program to provide, arrange for, and coordinate care and certain other medical services to members on a capitated basis, and is approved by the Massachusetts Division of Insurance as a health maintenance organization (HMO) and is organized primarily for the purpose of providing health care services.

MassHealth Agency - the Executive Office of Health and Human Services in accordance with the provisions of M.G.L. c. 118E.

MassHealth MAGI Household - see130 CMR 506.002(B): MassHealth MAGI Household Composition.

MassHealth Managed Care Provider - an MCO, Accountable Care Partnership Plan, Primary Care ACO, or the Primary Care Clinician Plan.

MCO-administered ACO - a type of ACO with which the MassHealth agency contracts under its ACO program and is administered through an MCO.

Medical Benefits - payment for health insurance or medical services provided to a MassHealth member.

Member - an individual determined by the MassHealth agency to be eligible for MassHealth.

Modified Adjusted Gross Income (MAGI) - modified adjusted gross income as defined in section 36(B)(d)(2) of the Internal Revenue Code with the following exceptions:

(1) an amount received as a lump sum only counts as income in the month received;

(2) scholarships, awards, or fellowship grants used for education purposes, and not for living expenses, are excluded from income;

(3) certain taxable income received by American Indians and Alaska Natives is excluded from income as described in 42 CFR § 435.603(e).

Navigator - an individual who is certified by the Health Connector, to assist an applicant with electronic and paper applications to establish eligibility and enroll in coverage through the Health Connector. In addition, a navigator provides outreach and education about insurance options offered through the Health Connector.

Nonqualified Individuals Lawfully Present - see130 CMR 504.003(A)(3): Nonqualified Individuals Lawfully Present.

Nonqualified Person Residing under Color of Law (Nonqualified PRUCOLs) - see130 CMR 504.003(C): Nonqualified Persons Residing under Color of Law (Nonqualified PRUCOLs).

One-adult-with-one-child Policy - a health insurance policy that covers a family consisting of one adult and one child.

Other Noncitizen - see130 CMR 504.003(D): Other Noncitizens.

Parent of a Child Younger than 19 Years Old - natural, adoptive, or stepmother or stepfather of a child.

Permanent and Total Disability - a disability as defined under Title XVI of the Social Security Act or under applicable state laws.

(1)For Adults 18 Years of Age or Older.

(a) The condition of an individual, 18 years of age or older, who is unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment that

1. can be expected to result in death; or

2. has lasted or can be expected to last for a continuous period of not less than 12 months.

(b) For purposes of 130 CMR 501.001: Permanent and Total Disability, an individual 18 years of age or older is determined to be disabled only if their physical or mental impairments are of such severity that the individual is not only unable to do their previous work, but cannot, considering age, education, and work experience, engage in any other kind of substantial gainful work that exists in the national economy, regardless of whether such work exists in the immediate area in which the individual lives, whether a specific job vacancy exists, or whether the individual would be hired if they applied for work. "Work that exists in the national economy" means work that exists in significant numbers, either in the region where such an individual lives or in several regions of the country.

(2)For Children Younger than 18 Years Old. The condition of an individual younger than 18 years old who has any medically determinable physical or mental impairment, or combination of impairments, of comparable severity to an impairment or combination of impairments that disables an adult, or are of such severity that the child is unable to engage in age-appropriate activities, as defined in Title XVI of the Social Security Act as in effect on July 1, 1996.

Person with Breast or Cervical Cancer - an individual who has submitted verification that they have breast or cervical cancer.

Person who is HIV Positive - a person who has submitted verification that they have tested positive for the human immunodeficiency virus (HIV).

Premium - a charge for payment to the MassHealth agency that may be assessed to members of MassHealth Standard, MassHealth CommonHealth, MassHealth Family Assistance, or the Children's Medical Security Plan (CMSP).

Premium Assistance Payment - an amount contributed by the MassHealth agency toward the cost of health insurance coverage for certain MassHealth members who meet the criteria in 130 CMR 506.012: Premium Assistance Payments.

Premium Billing Family Group (PBFG) - a group of persons who live together.

(1) The group can be an individual, a couple who are two persons married to each other according to the rules of the Commonwealth of Massachusetts, or a family.

(2) Two parents are members of the same premium billing family group if they are mutually responsible for one or more children who live with them.

(3) A family making up a PBFG may consist of

(a) a child or children younger than 19 years old, any of their children, and their parents. A child who is absent from the home to attend school is considered as living in the home;

(b) siblings younger than 19 years old and any of their children who live together even if no adult parent or caretaker relative is living in the home; or

(c) a child or children younger than 19 years old, any of their children, and their caretaker relative when no parent is living in the home.

Premium Tax Credit (PTC) - payment made pursuant to 26 U.S.C. § 36B on behalf of an eligible individual to reduce the costs of a health benefit plan premium to the individual.

Primary Care ACO - a type of ACO with which the MassHealth agency contracts under its ACO program.

Primary Care Clinician (PCC) Plan - a managed care option administered by the MassHealth agency through which enrolled members receive primary care and other medical services. See 130 CMR 450.118: Primary Care Clinician (PCC) Plan.

Protected Noncitizens - see130 CMR 504.003(B): Protected Noncitizens.

Provisional Eligibility - approval for MassHealth benefits when an applicant's certain self-attested circumstances show eligibility for MassHealth benefits but further verification is required for continued eligibility. (See130 CMR 502.003: Verification of Eligibility Factors.)

Qualified Noncitizens - see130 CMR 504.003(A)(1): Qualified Noncitizens.

Qualified Noncitizens Barred - see130 CMR 504.003(A)(2): Qualified Noncitizens Barred.

Quality Control - a system of continuing review to measure the accuracy of eligibility decisions.

Qualified Health Plan (QHP) - a health plan licensed under M.G.L. c. 175, 176A, 176B, or 176G that has received the Commonwealth Health Insurance Connector's Seal of Approval as meeting the criteria under 45 CFR § 155.1000 and is offered through the Health Connector in accordance with the provisions of 45 CFR § 155.1010.

Redetermination - a review of a member's circumstances to establish whether they remain eligible for benefits.

Senior Care Organization (SCO) - an organization that participates in MassHealth under a contract with the MassHealth agency and the Centers for Medicare & Medicaid Services to provide a comprehensive network of medical, health care, and social service providers that integrates all components of care, either directly or through subcontracts. SCOs are responsible for providing enrollees with the full continuum of Medicare- and MassHealth-covered services.

Sibling - natural (full or half-blood), adoptive, or stepbrother or stepsister.

Spouse - a person married to the applicant or member according to the laws of the Commonwealth of Massachusetts.

Substantial Gainful Activity - generally, employment that provides a set amount of gross earnings as determined by the Social Security Administration (SSA) under Title XVI of the Social Security Act.

Tax Dependent - a qualifying child or qualifying relative, other than the taxpayer or spouse, who entitles the taxpayer to claim a dependency exemption. An individual who files a return but is claimed as a dependent by someone else is still a tax dependent.

Tax Filer - any individual, including their spouse if married filing jointly, who intends to file a federal tax return for the year in which a member of the tax household is seeking or receives benefits and who claims an exemption for themselves. An individual who files a return but is claimed as a dependent by someone else is still a tax dependent.

Tax Household - all members who are claimed on the tax return, including the tax filer(s) and all dependents.

Third Party - any person, entity, or program that is or may be responsible to pay all or part of the expenditures for medical benefits.