130 CMR, § 502.006

Current through Register 1530, September 13, 2024

Section 502.006 - Coverage Dates

(A)Start Date of Coverage for Applicants. For individuals applying for coverage, the date of coverage for MassHealth is determined by the coverage type for which the applicant may be eligible. 130 CMR 505.000: Health Care Reform: MassHealth: Coverage Types describes the rules for establishing this date, except as specified in 130 CMR 502.003(E)(1), (F)(2), and (H)(2).

(1) The start date of coverage for individuals approved for benefits under provisional eligibility is described at 130 CMR 502.003(E)(1).

(2) The start date of coverage for individuals who do not meet the requirements for provisional eligibility, as described at 130 CMR 502.003(E)(2)(a), is described at 130 CMR 502.006(A)(2)(a) through (d), except individuals described at 130 CMR 502.006(C).

(a) The start date for individuals who are pregnant or younger than 19 years old who submit all required verifications within the 90-day time frame is described in 130 CMR 502.006(A)(2)(a)1. and 2.

1. If covered medical services were received during such period, and the individual would have been eligible at the time services were provided, the start date of coverage is determined upon receipt of the requested verifications and may be retroactive to the first day of the third calendar month before the month of application except as specified in 130 CMR 502.006(C).

2. If covered medical services were not received during such period, or the individual would not have been eligible at the time services were provided, the start date of coverage is determined upon receipt of the requested verifications and coverage begins ten days prior to the date of application, except as specified in 130 CMR 506.006(C).

(b) For individuals not described in 130 CMR 502.006(A)(2)(a) who submit all required verifications within the 90-day time frame, the start date of coverage is determined upon receipt of the requested verifications and coverage begins ten days prior to the date of application, except as specified in 130 CMR 502.006(C).

(c) For individuals who fail to provide verifications of information within 90 days of the receipt of the MassHealth agency's request and the MassHealth agency used information received from electronic data sources to determine eligibility, the start date of coverage is determined upon the agency's eligibility determination and coverage begins as described in 130 CMR 502.006(A)(2)(c)1. and 2.

1. For individuals who are pregnant or younger than 19 years old

a. If covered medical services were received during such period, and the individual would have been eligible at the time services were provided, the start date of coverage is determined upon receipt of information received from electronic data sources and may be retroactive to the first day of the third calendar month before the month of application except as specified in 130 CMR 502.006(C).

b. If covered medical services were not received during such period, or the individual would not have been eligible at the time services were provided, the start date of coverage is determined upon receipt of the information received from electronic data sources and coverage begins ten days prior to the date of application, except as specified in 130 CMR 502.006(C).

2. For all other individuals, coverage will begin ten days prior to the date of application, except as specified in 130 CMR 502.006(C).

(d) For individuals denied for failure to provide verification of requested information who then provide requested verifications or report changes after the denial, the start date of coverage is described in 130 CMR 502.006(A)(2)(d)1. and 2.

1. For individuals who are pregnant or younger than 19 years old

a. If covered medical services were received during such period, and the individual would have been eligible at the time services were provided, the start date of coverage is determined upon receipt of the verifications and may be retroactive to the first day of the third calendar month before the received date of the verifications, except as specified in 130 CMR 502.006(C).

b. If covered medical services were not received during such period, or the individual would not have been eligible at the time services were provided, the start date of coverage is determined upon receipt of the verifications and coverage begins ten days prior to the received date of the verifications, except as specified in 130 CMR 502.006.

2. For all other individuals, coverage will begin ten days prior to the date of receipt of all requested verifications or a reported change, except as specified in 130 CMR 502.003(D)(2)(d) and 502.006(C).

(B)Coverage Dates for Existing Members Who Have a Change in Benefits. The date of coverage for existing members whose MassHealth coverage type changes due to a change in circumstances are described in 130 CMR 502.006(B)(1) through (4).

(1) For existing members who are pregnant or younger than 19 years old, when an eligibility determination results in a more comprehensive benefit, except as described in 502.006(C)

(a) if covered medical services were received during such period, and the individual would have been eligible at the time services were provided, the start date of the new coverage may be retroactive to the first day of the third calendar month prior to

1. the receipt of the requested verifications;

2. the receipt date of the annual renewal;

3. the date of the eligibility determination for reported changes that do not result in request for verification; or

4. the date of the MassHealth agency's eligibility determination due to information in the member's case file;

(b) if covered medical services were not received during such period, or the individual would not have been eligible at the time services were provided, the start date of the new coverage is ten days prior to

1. the receipt of the requested verifications;

2. the receipt date of the annual renewal;

3. the date of the eligibility determination for reported changes that do not result in request for verification; or

4. the date of the MassHealth agency's eligibility determination due to information in the member's case file;

(2) for existing members not described in 130 CMR 502.006(B)(1), when an eligibility determination results in a less comprehensive benefit, the end date of the existing coverage is no sooner than 14 days from the date of the notice unless the MassHealth member files an appeal in a timely manner and requests continued MassHealth benefits pending such an appeal or reinstatement of benefits as described at 130 CMR 610.036: Continuation of Benefits Pending Appeal and the start date of the new coverage is ten days prior to

(a) the receipt of the requested verifications;

(b) the receipt date of the annual renewal;

(c) the date of the eligibility determination for reported changes that do not result in request for verification; or

(d) the date of the MassHealth agency's eligibility determination due to information in the member's case file;

(3) for existing members whose eligibility determination results in a less comprehensive benefit, the end date of the existing coverage is no sooner than 14 days from the date of the notice unless the MassHealth member files an appeal in a timely manner and requests continued MassHealth benefits pending such an appeal or reinstatement of benefits as described at 130 CMR 610.036: Continuation of Benefits Pending Appeal and the start date of the new coverage is ten days prior to

(a) the receipt of the requested verifications;

(b) the receipt date of the annual renewal;

(c) the date of the eligibility determination for reported changes; or

(d) the date of the MassHealth agency's eligibility determination due to information in the member's case file;

(4) for existing members, effective dates for changes in premium payments are described at 130 CMR 506.011(C).

(C)Limitations. MassHealth coverage start dates are subject to the following limitations.

(1) The start date for Medicare premium payments for individuals determined eligible for MassHealth Standard, MassHealth CommonHealth, and MassHealth Medicare Savings Programs is described at 130 CMR 505.002(O), 505.004(L), and 505.007.

(2) The start date for Premium Assistance Payments for individuals eligible for MassHealth Standard, MassHealth CommonHealth, MassHealth Family Assistance, and MassHealth CarePlus is described at 130 CMR 506.012(F)(1)(d).

(D)End Date of Coverage. Except as specified in 130 CMR 502.003(H)(2), MassHealth benefits terminate or downgrade no sooner than 14 days from the date of termination or downgrade notice unless the MassHealth member timely files an appeal and requests continued MassHealth benefits pending such appeal or reinstatement of benefits as described in 130 CMR 610.036: Continuation of Benefits Pending Appeal. MassHealth will extend coverage to the end of the month only for those individuals whose MassHealth eligibility is terminated and who become eligible for the Premium Tax Credit (PTC). If the effective date of the termination is on or before the 15^th of the month, MassHealth coverage will end on the last day of that month. If the effective date of the termination is after the 15^th of the month, MassHealth coverage will end on the last day of the following month.