Section 506.009 - The One-time Deductible(A)Eligibility Requirements. Disabled adults described in 130 CMR 505.004(C)(5)(a) and disabled young adults described in 130 CMR 505.004(E)(3)(a)1. may establish eligibility for MassHealth CommonHealth by meeting a one-time-only deductible. Once a deductible has been met, the person may be assessed a premium in accordance with the premium schedule in 130 CMR 506.011(B)(2). Once the deductible has been met, the person is not required to meet another deductible if there is a lapse in CommonHealth coverage.(B)Definition of the Deductible. The deductible is the total dollar amount of incurred medical expenses that an applicant, whose MassHealth Disabled Adult household income, as described in 130 CMR 506.003, exceeds 133% of the federal poverty level (FPL), must be responsible for before MassHealth eligibility is established.(C)The Deductible Period. The deductible period is a six-month period beginning on the date established in accordance with 130 CMR 505.004(M): Medical Coverage Date.(D)Calculating the Deductible. The amount of the deductible is determined by comparing the MassHealth Disabled Adult household income as described in 130 CMR 506.003 to the MassHealth CommonHealth Monthly Deductible Income Standards provided in the following chart and multiplying the difference by six. THE MASSHEALTH COMMONHEALTH MONTHLY DEDUCTIBLE INCOME STANDARDS |
MassHealth Disabled Adult Household Size | Income Standards 542 |
1 | 670 |
2 | 795 |
3 | 911 |
4 | 1036 |
5 | 1161 |
6 | 1286 |
7 | 1403 |
8 | 1528 |
9 | 1653 |
10 | + 133 for each additional person |
(E)Notification of the Deductible. (1) The applicant who has excess monthly income will be informed they are currently ineligible for MassHealth, but may establish eligibility by meeting the deductible. The applicant will be informed in writing of the following:(a) the deductible amount; and(b) the start and end dates of the deductible period.(2) A person who meets a deductible will be eligible for MassHealth CommonHealth effective with the begin date of the deductible period.(F)Persons Deemed to Have Met a Deductible. The following disabled adults will be considered to have met a deductible: (1) those who were receiving MassHealth on July 1, 1997, as the result of meeting a deductible; and(2) those who were denied eligibility with a deductible before July 1, 1997, but who submit medical bills on or after July 1, 1997, to meet the deductible.(G)Submission of Bills to Meet the Deductible.(1)Criteria. To establish eligibility, the applicant must submit verification of medical or remedial bills whose total equals or exceeds the deductible and that meets the following criteria. (a) The bill must not be subject to further payment by health insurance or other liable third-party coverage, including the Health Safety Net.(b) The bill must be for an allowable medical or remedial expense as provided in 130 CMR 506.009(G)(2). A remedial expense is a nonmedical support service made necessary by the medical condition of any individual in the family group.(c) The bill must be unpaid and a current liability, or, if paid, was paid during the six-month deductible period.(d) The bill may not be for one of the following services:3. weight-training equipment;6. room and board charges for individuals in residential programs.(2)Meeting the Deductible.(a) Bills to meet the deductible are applied in the following order: 1. Medicare and other health insurance premiums credited prospectively for the cost of six months' coverage;2. expenses incurred by any member of the MassHealth Disabled Adult household for necessary medical and remedial-care services that are recognized under state law but are not covered by MassHealth, including guardianship fees and related expenses as defined in 130 CMR 515.001: Definition of Terms, and described in and allowed under 130 CMR 520.026(E)(3): Guardianship Fees and Related Expenses; and3. expenses incurred by any member of the MassHealth Disabled Adult household for necessary medical and remedial-care services that are covered by MassHealth.(b) Premiums for Qualified Health Plans can be applied to meet the deductible as they are incurred.(c) Any bills or portions of bills that are used to meet the deductible are not paid by the MassHealth agency and remain the responsibility of the applicant.Amended by Mass Register Issue 1357, eff. 1/26/2018.Amended by Mass Register Issue 1500, eff. 7/21/2023.