130 CMR, § 502.007

Current through Register 1536, December 6, 2024

Section 502.007 - Continuing Eligibility

(A)Annual Renewals. The MassHealth agency reviews eligibility once every 12 months. Eligibility may also be reviewed as a result of a member's change in circumstances, or a change in MassHealth eligibility rules, or as a result of a member's failure to provide verification within requested time frames. The MassHealth agency updates eligibility based on information received as a result of such review. The MassHealth agency reviews eligibility

(1) by information matching with other agencies, health insurance carriers, and information sources;

(2) through a written update of the member's circumstances on a prescribed form;

(3) through an update of the member's circumstances in person, by telephone, or on the MAHealthConnector.org account; or

(4) based on information in the member's case file.

(B)Eligibility Determinations. The MassHealth agency determines, as a result of this review, if

(1) the member continues to be eligible for the current coverage type;

(2) the member's current circumstances require a change in coverage type, premium payment, or premium assistance payment; or

(3) the member is no longer eligible for MassHealth.

(C)Eligibility Reviews. MassHealth reviews eligibility in the following ways.

(1)Automatic Renewal. Households whose continued eligibility can be determined based on electronic data matches with federal and state agencies will have their eligibility automatically renewed.

(a) If the data match results in no change in benefits or in a more comprehensive benefit for all members of the household, the MassHealth agency will notify the head of household that eligibility has been reviewed using the automatic renewal process.

(b) In addition, if the member's coverage type changes to a more comprehensive benefit, the member will be sent a notice informing him or her of the start date for the new coverage. The start date of the new coverage is described at 130 CMR 502.006, except that premium assistance payments under MassHealth Family Assistance begin in the month of the MassHealth agency's eligibility determination or in the month that the insurance deduction begins, whichever is later in accordance with 130 CMR 506.012(F)(1)(d).

(2)Prepopulated Renewal Application. Households whose continued eligibility cannot be determined based on electronic data matches with federal and state agencies and households whose eligibility would change to a less comprehensive benefit for at least one member of the household as a result of the data matches will be required to complete a prepopulated renewal application.

(a) The MassHealth agency will notify the head of household of the need to complete the renewal application.

(b) The head of household will be given 45 days from the date of the request to return the paper prepopulated renewal application, log onto their MAHealthConnector.org account to complete the renewal application online, or call the MassHealth agency to complete the renewal application telephonically.

1. If the renewal application is completed within 45 days, eligibility will be determined using the information provided by the individual with verification confirmed through electronic data matches if available. If verification through electronic data match is unsuccessful, the MassHealth agency will request required verifications as described in 130 CMR 502.003 and the individual continues to receive benefits pending verification.

2. If the renewal application is not completed within 45 days, the MassHealth agency will

a. use information received from electronic sources, if available, and redetermine eligibility; or

b. if information is not available from electronic sources, terminate MassHealth coverage as described at 130 CMR 502.006(B).

3. If the individual submits the prepopulated renewal application within 90 days of the termination date, as described in 130 CMR 502.007(C)(2)(b)2., and is determined eligible for a MassHealth benefit, the date of coverage for MassHealth is determined by the coverage type for which the individual is now eligible, in accordance with 130 CMR 502.006(A). The begin date of MassHealth coverage may be retroactive to the date of the termination if the individual requests retroactive coverage and has incurred covered medical services since the date of the termination.

4. If the prepopulated renewal application is returned, but the required verifications are not submitted with the form, a second 90-day period starts on the date that the prepopulated form is returned.

5. If the prepopulated renewal application is not submitted within 90 days of the previous termination date, a new application is required.

(c) If the member's coverage type changes, the start date for the new coverage type is determined as follows.

1. If the member's coverage type changes, the start date for the new coverage type is effective as described in 130 CMR 502.006(A).

2. However, premium assistance payments under MassHealth Family Assistance begin in the month of the MassHealth agency's eligibility determination or in the month the insurance begins, whichever is later in accordance with 130 CMR 506.012(F)(1)(d).

(3)Periodic Data Matches. The MassHealth agency matches files of MassHealth members with other agencies and information sources as described in 130 CMR 502.004 to update or verify eligibility.

(a) If the electronic data match indicates a change in circumstances that would result in potential reduction or termination of benefits, the MassHealth agency will notify the member of the information that was received through the data match and require the member to respond within 30 days of the date of the notice.

1. If the member responds within 30 days and confirms the data is correct, eligibility will be determined using the confirmed data from the electronic data match.

2. If the member responds within 30 days and provides new information, eligibility will be determined using the information provided by the member. Additional verification from the member will be required.

3. If the member does not respond within 30 days, eligibility will be determined using available information received from the electronic data sources. If information necessary for eligibility determination is not available from electronic data sources, MassHealth coverage will be terminated.

(b) If the electronic data match indicates a change in circumstances that would result in an increase or no change in benefits, the MassHealth agency will automatically update the case using the information received from the electronic data match and redetermine eligibility. If the member's coverage type changes to a more comprehensive benefit, the member will be sent a notice informing them of the start date for the new benefit. The effective date of the more comprehensive benefit is determined in accordance with 130 CMR 502.006(A).