130 Mass. Reg. 505.004

Current through Register 1520, April 26, 2024

Section 505.004 - MassHealth CommonHealth

(A)Overview.

(1)130 CMR 505.004 contains the categorical requirements and financial standards for MassHealth CommonHealth coverage available to both disabled children and disabled adults, and to disabled working adults.

(2) Persons eligible for MassHealth CommonHealth coverage are eligible for medical benefits as described in 130 CMR 450.105(E): MassHealth CommonHealth.

(B)Disabled Working Adults. Disabled working adults must meet the following requirements:

(1) be 21 through 64 years old (for those 65 years of age or older, see130 CMR 519.012: MassHealth CommonHealth);

(2) be employed at least 40 hours per month, or if employed less than 40 hours per month, have been employed at least 240 hours in the six-month period immediately preceding the month of receipt of the application or MassHealth's eligibility review;

(3) be permanently and totally disabled (except for engagement in substantial gainful activity) as defined in 130 CMR 501.001: Definition of Terms;

(4) be a citizen as described in 130 CMR 504.002: U.S. Citizens or a qualified noncitizen as described in 130 CMR 504.003(A)(1): Qualified Noncitizens;

(5) be ineligible for MassHealth Standard; and

(6) comply with 130 CMR 505.004(J).

(C)Disabled Adults. Disabled adults must meet the following requirements:

(1) be 21 through 64 years old;

(2) be permanently and totally disabled, as defined in 130 CMR 501.001: Definition of Terms;

(3) be ineligible for MassHealth Standard;

(4) be a citizen as described in 130 CMR 504.002: U.S. Citizens or a qualified noncitizen as described in 130 CMR 504.003(A)(1): Qualified Noncitizens;

(5)

(a) meet a one-time-only deductible in accordance with 130 CMR 506.009: The One-time Deductible; or

(b) have modified adjusted gross income of the MassHealth Disabled Adult household that is less than or equal to 200% of the federal poverty level (FPL) and provide verification that they are HIV positive; and

(6) comply with 130 CMR 505.004(J).

(D)Disabled Working Young Adults. Disabled working young adults are eligible for MassHealth CommonHealth if they meet the following requirements:

(1) be permanently and totally disabled (except for engagement in substantial gainful activity), as defined in 130 CMR 501.001: Definition of Terms;

(2) be ineligible for MassHealth Standard;

(3)

(a) be a citizen as described at 130 CMR 504.002: U.S. Citizens or qualified noncitizen as described in 130 CMR 504.003(A)(1): Qualified Noncitizens and be employed at least 40 hours per month, or if employed less than 40 hours per month, have been employed at least 240 hours in the six-month period immediately preceding the month of receipt of the application or MassHealth eligibility review; or

(b) be a nonqualified PRUCOL as described in 130 CMR 504.003(C): Nonqualified Persons Residing under Color of Law (Nonqualified PRUCOLs) with a modified adjusted gross income of the MassHealth Disabled Adult household income that is less than or equal to 150% of the FPL; and

(4) comply with 130 CMR 505.004(J).

(E)Disabled Young Adults. Disabled young adults are eligible for MassHealth CommonHealth if they meet the following requirements:

(1) be permanently and totally disabled, as defined in 130 CMR 501.001: Definition of Terms;

(2) be ineligible for MassHealth Standard;

(3)

(a) be a citizen as described at 130 CMR 504.002: U.S. Citizens or qualified noncitizen as described in 130 CMR 504.003(A)(1): Qualified Noncitizens, and either

1. meet a one-time-only deductible in accordance with 130 CMR 506.009: The One-time Deductible; or

2. have modified adjusted gross income of the MassHealth Disabled Adult house-hold that is less than or equal to 200% of the FPL and provide verification that they are HIV positive; or

(4) comply with 130 CMR 505.004(J).

(F)Disabled 18-year-olds. Disabled 18-year-olds must meet the following requirements:

(1) be ineligible for MassHealth Standard;

(2) be a citizen as described at 130 CMR 504.002: U.S. Citizens or lawfully present immigrant or a nonqualified PRUCOL, as described in 130 CMR 504.003: Immigrants, and either

(a) if not working, be permanently and totally disabled, as defined in 130 CMR 501.001: Definition of Terms; or

(b) if working, be permanently and totally disabled (except for engagement insubstantial gainful activity), as defined in 130 CMR 501.001: Definition of Terms.

(G)Disabled Children Younger than 18 Years Old. Disabled children younger than 18 years old must meet the following requirements:

(1) be permanently and totally disabled, as defined in 130 CMR 501.001: Definition of Terms;

(2) be ineligible for MassHealth Standard; and

(3) be a citizen as described at 130 CMR 504.002: U.S. Citizens, lawfully present immigrant, or a nonqualified PRUCOL, as described in 130 CMR 504.003: Immigrants.

(H)Determination of Disability. Disability is established by

(1) certification of legal blindness by the Massachusetts Commission for the Blind (MCB);

(2) a determination of disability by the SSA; or

(3) a determination of disability by the Disability Evaluation Services (DES).

(I)MassHealth CommonHealth Premium. Disabled adults, disabled working adults, disabled young adults, and disabled children who meet the requirements of 130 CMR 505.004 may be assessed a premium in accordance with the premium schedule provided in 130 CMR 506.011(B)(2). No premium is assessed during a deductible period.

(J)Use of Potential Health Insurance Benefits. Applicants and members must use potential health insurance benefits, in accordance with 130 CMR 503.007: Potential Sources of Health Care, and must enroll in health insurance, including Medicare, if available at no greater cost to the applicant or member than they would pay without access to health insurance, or if purchased by the MassHealth agency in accordance with 130 CMR 505.002(O), and 130 CMR 506.012: Premium Assistance Payments. Members must access those other health insurance benefits and must show their private health insurance card and their MassHealth card to providers at the time services are provided.

(K)Access to Employer-sponsored Health Insurance and Premium-assistance Investigations for Individuals Who Are Eligible for MassHealth CommonHealth.

(1) MassHealth may perform an investigation to determine if individuals receiving MassHealth CommonHealth

(a) have health insurance that MassHealth may help pay for; or

(b) have access to employer-sponsored health insurance in which MassHealth wants the individual to enroll and for which MassHealth will help pay.

(2) The individual receives MassHealth CommonHealth while MassHealth investigates the insurance.

(a)Investigations for Individuals Who Are Enrolled in Health Insurance.

1. If MassHealth determines that the health insurance that the individual is enrolled in meets the criteria at 130 CMR 506.012: Premium Assistance Payments, the individual is notified in writing that MassHealth will provide MassHealth CommonHealth Premium Assistance as described at 130 CMR 506.012: Premium Assistance Payments.

2. If MassHealth determines that the health insurance that the individual is enrolled in does not meet the criteria at 130 CMR 506.012: Premium Assistance Payments, the individual continues to be eligible for MassHealth CommonHealth.

(b)Investigations for Individuals Who Have Potential Access to Employer-sponsored Health Insurance.

1. If MassHealth determines that the individual has access to employer-sponsored Health insurance, the employer is contributing at least 50% of the premium cost, and the insurance meets all other criteria described in 130 CMR 506.012: Premium Assistance Payments, the individual is notified in writing that they must enroll in this employer-sponsored coverage. MassHealth allows the individual up to 60 days to enroll in this coverage. Once enrolled in this health insurance plan, MassHealth provides premium assistance payments as described in 130 CMR 506.012: Premium Assistance Payments. Failure to enroll in the employer- sponsored health insurance plan at the request of MassHealth will result in the loss or denial of eligibility for all individuals unless the individual is younger than 19 years old, the individual is 19 through 20 years old, and has household income less than or equal to 150% of the federal poverty level, or is pregnant.

2. If MassHealth determines the individual does not have access to employer-sponsored health insurance, the individual continues to be eligible for MassHealth CommonHealth.

(L)Medicare Premium Payment.

(1) The MassHealth agency, in accordance with the Medicare Savings Program as described in 130 CMR 519: Medicare Savings Program (MSP) - Qualified Medicare Beneficiaries (QMB) and 519.011: Medicare Saving Program (MSP) - Specified Low Income Medicare Beneficiaries and Qualifying Individuals also pays the cost of the monthly Medicare Part B premium on behalf of members who meet the requirements of 130 CMR 505.004 and who have modified adjusted gross income of the MassHealth Disabled Adult household that is less than or equal to 135% of the FPL.

(2) The coverage described in 130 CMR 505.004(L)(1) begins on the first day of the month following the date of the MassHealth eligibility determination and may be retroactive up to three months prior to the date the application was received by MassHealth.

(M)Medical Coverage Date.

(1) The medical coverage date for MassHealth CommonHealth is described at 130 CMR 502.006: Coverage Dates, except as described at 130 CMR 505.004(M)(2) and (3).

(2) Persons described in 130 CMR 505.004(C) who have been notified by the MassHealth agency that they must meet a one-time deductible have their medical coverage date established in accordance with 130 CMR 506.009(E): Notification of the Deductible.

(3) Provisional eligibility is described in 130 CMR 502.003(E): Provisional Eligibility.

(N)Extended CommonHealth Coverage. MassHealth CommonHealth members (described in 130 CMR 505.004(B)) who terminate their employment, continue to be eligible for MassHealth CommonHealth for up to three calendar months after termination of employment provided they continue to make timely payments of monthly premiums.

(O)Postpartum Coverage. For people who are pregnant, MassHealth will provide postpartum care for 12 months following the termination of a pregnancy plus an additional period extending to the end of the month in which the 12-month period ends.