130 CMR, § 515.001

Current through Register 1536, December 6, 2024

Section 515.001 - Definition of Terms

The terms listed in 130 CMR 515.001 have the following meanings for purposes of MassHealth, as described in 130 CMR 515.000 through 522.000: MassHealth: Other Division Programs.

Activities of Daily Living (ADLs) - self-care activities including, but not limited to, bathing, grooming, dressing, eating, and toileting.

Affidavit - a written or printed statement of fact sworn to or affirmed before a person having legal authority to administer such an oath.

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.

Annuity - a legal instrument that makes payments for a designated period of time or for life, regardless if the payments are principal, interest, or both.

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

Appeal Representative - a person who

(1) is sufficiently aware of the appellant's circumstances to assume responsibility for the accuracy of the statements made during the appeal process, and who has provided the Office of Medicaid Board of Hearings with written authorization from the appellant to act on the appellant's behalf during the appeal process;

(2) has, under applicable law, authority to act on behalf of an appellant in making decisions related to health care or payment for health care. An appeal representative may include, but is not limited to, a guardian, conservator, executor, administrator, holder of power of attorney, or health-care proxy;

(3) is a licensed attorney who notifies the MassHealth Board of Hearings that he or she represents the appellant in an appeal. This shall also include a non-lawyer supervised by a licensed attorney; or

(4) is an authorized representative meeting the requirements of 130 CMR 501.001: Appeal Representative (1), (2), or (3).

Applicant - a person who completes and submits an application for MassHealth, and is awaiting the decision of eligibility.

Application - seeSenior Application.

Asset Limit - the maximum dollar value of assets that can be owned by, or available to, the applicant, member, or the spouse, which if exceeded, results in ineligibility.

Assets - property including, but not limited to, real estate, personal property, and funds. This term has the same meaning as resources as defined in 42 U.S.C. 1396p(e)(5).

Authorized Representative.

(1) a person or organization designated as the authorized representative of an applicant or member in a completed, signed Authorized Representative Designation Form or similar designation document submitted to the MassHealth agency in which the authorized representative agrees to comply with rules regarding confidentiality in the course of representing the applicant or member, provided that such person or organization must satisfy one of the following criteria:

(a) an authorized representative may be a person or organization appointed by the applicant or member to act responsibly on his or her behalf in connection with the eligibility process and other ongoing communications with the MassHealth agency. Such person or organization shall have the authority to complete and sign an application on the applicant's behalf, select a health plan, complete and sign a renewal form, receive copies of the applicant or member's notices and other communications from the MassHealth agency which may include protected health-care information, personal data, and financial information and unless otherwise specified, act on behalf of the applicant or member in all other matters with the MassHealth agency or the Health Connector;

(b) an authorized representative may be a person acting responsibly on behalf of the applicant or member who is sufficiently aware of such applicant's or member's circumstances to assume responsibility for the accuracy of the statements made on his or her behalf during the eligibility process and in other communications with the MassHealth agency. Such person shall have the authority to complete and sign an application on the applicant's behalf, select a health plan, complete and sign a renewal form, receive copies of the applicant or member's notices and other communications from the MassHealth agency which may include protected health-care information, personal data, and financial information; or

(c) an authorized representative may be a person acting responsibly on behalf of the applicant or member who has, under applicable law, authority to act on behalf of such applicant or member in making decisions related to health care or payment for health care including, but not limited to, a guardian, conservator, executor, administrator, holder of power of attorney, or health-care proxy. The extent of such person's authority to act on behalf of the applicant or member is determined by the applicable law or underlying legal document; and

(2) As a condition of any organization serving as an authorized representative under 130 CMR 515.001: Authorized Representative (1)(a), a provider or staff member or volunteer of such organization must not have a conflict of interest and must affirm that he or she will adhere to 42 CFR part 431, subpart F.

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.

Burial Trust - a trust established by an individual solely for funeral expenses, burial expenses, or both.

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 caregiver 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 collection of written documents and electronic 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.

Citizen - see130 CMR 518.002: U.S. Citizens.

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

Community Resident - a person who lives in a noninstitutional setting in the community.

Competent Medical Authority - a physician or psychiatrist licensed by any state, a psychologist licensed by the Commonwealth of Massachusetts, or both.

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

Countable Income - the types of income that are considered in the determination of eligibility.

Countable-income Amount - gross income less certain business expenses and income deductions.

Couple - two persons 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 Limited (Limited), MassHealth Family Assistance (Family Assistance), MassHealth Senior Buy-in (Senior Buy-in), and MassHealth Buy-in (Buy-in). The scope of services or covered benefits for each coverage type is found at 130 CMR 450.105: Coverage Types.

Curing of a Transfer - the return, following the transfer for less than fair-market value of a portion of, or the full uncompensated value of, a resource to the individual.

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 520.028: Eligibility for a Deductible.

Deductible Period - a specified six-month period within which an applicant for MassHealth, whose income exceeds MassHealth income standards, may become eligible, through incurred and/or paid medical expenses equaling or exceeding the deductible of the applicant or the spouse.

Disability Determination Unit - a unit that consists of physicians and disability evaluators who determine permanent and total disability 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.

Disabled - having a permanent and total disability.

Eligibility Process - activities conducted for the purpose 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.

Fair-market Value - an estimate of the value of a resource if sold at the prevailing price. For transferred resources, the fair market value is based on the prevailing price at the time of transfer.

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.

Global Developmental Skills - a child's average developmental skill level, taking into account the physical, psychological, motor, intellectual, emotional, communicative, and social aspects of the child's functional capabilities.

Grantor - an individual or spouse who creates a trust.

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

Guardian - an individual or entity appointed as guardian by the probate and family court under the provisions of M.G.L. c. 201.

Guardianship Fees and Related Expenses - fees for guardianship services and incurred expenses that are essential to enable an incompetent applicant or member to gain access to or consent to medical treatment.

Health Insurance - coverage of health-care services by a health-insurance company, a hospital-service corporation, a medical-services 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 (HSN) - 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.

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

Income Deductions - specified deductions, as described in 130 CMR 520.011: Standard Income Deductions through 130 CMR 520.014: Long-term-care Earned-income Deductions, that may be made from the gross income of an applicant or member.

Incompetent Applicant or Member - an applicant or member who has been adjudicated as incompetent and in need of a guardian by the probate and family court under the provisions of M.G.L. c. 201.

Institution (Medical) - a public or private facility providing acute, chronic, or long-term care, unless otherwise defined within 130 CMR 515.000 through 130 CMR 522.000: Other Division Programs. This includes acute inpatient hospitals, licensed nursing facilities, state schools, intermediate-care facilities for the mentally retarded, public or private institutions for mental diseases, freestanding hospices, and chronic-disease and rehabilitation hospitals.

Institutionalization - placement of an individual in one or more medical institutions, where placement lasts or is expected to last for a continuous period of at least 30 days.

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

Irrevocable Trust - a trust that cannot be in any way revoked by the grantor.

Jointly Held Resources - resources that are owned by an individual in common with another person or persons in a joint tenancy, tenancy-in-common, or similar arrangement.

Lawfully Present Immigrants - see130 CMR 518.003(A): Lawfully Present Immigrants.

Life Estate - a life estate is established when all of the remainder legal interest in a property is transferred to another, while the legal interest for life rights to use, occupy, or obtain income or profits from the property is retained.

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

Look-back Period - a period of consecutive months that the MassHealth agency may review for transfers of resources to determine if a period of ineligibility for payment of nursing-facility services should be imposed.

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.

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

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

Member - a person determined by the MassHealth agency to be eligible for MassHealth.

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 518.003(A)(3): Nonqualified Individuals Lawfully Present.

Nonqualified Person Residing under Color of Law (nonqualified PRUCOL) - see130 CMR 518.003(C): Nonqualified Persons Residing under Color of Law (nonqualified PRUCOLs).

Nursing-facility Resident - an individual who is a resident of a nursing facility, is a resident in any institution, including an intermediate-care facility for the mentally retarded (ICF/MR), for whom payment is based on a level of care equivalent to that received in a nursing facility, is in an acute hospital awaiting placement in a nursing facility, or lives in the community and would be institutionalized without community-based services provided in accordance with 130 CMR 519.007(B): Home- and Community Based Services Waiver.

Other Noncitizens - see130 CMR 518.003(D): Other Noncitizens.

Patient-paid Amount - the amount that a member in a long-term-care facility must contribute to the cost of care under the laws of the Commonwealth of Massachusetts.

Period of Ineligibility - the period of time during which the MassHealth agency denies or withholds payment for nursing-facility services because the individual has transferred resources for less than fair market value.

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

(1)For Adults and 18-year-olds.

(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 515.001: Permanent and Total Disability, an individual 18 years of age or older is determined to be disabled only if his or her physical or mental impairments are of such severity that the individual is not only unable to do his or her 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 he or she 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, that causes marked and severe functional limitations, as defined in Title XVI of the Social Security Act, and can be expected to cause death or can be expected to last for a continuous period of not less than 12 months. Disability for children eligible for MassHealth CommonHealth under 130 CMR 519.012(B): Certain Institutionalized Immigrant Children is determined in accordance with the definition for permanent and total disability for children younger than 18 years old in 130 CMR 501.001: Definition of Terms.

Personal Needs Allowance (PNA) - the designated portion of monthly income that a person in long-term care is allowed to retain for personal expenses. In some instances, the MassHealth agency pays all or a portion of the PNA to the member. The PNA must not be used for payment of any item included in the daily rate at the long-term-care facility.

Personal Needs Allowance (PNA) Account - an account administered by a long-term-care facility on behalf of a member. Regulations regarding the administration of PNA accounts are contained in 130 CMR 456.601: Personal Needs Allowance Account through 456.615: Annual Accounting to the Division of PNA Balance.

Pooled Trust - Effective until sixty days after the end of the maintenance of effort and continuous eligibility provisions of Section 6008 of the Families First Coronavirus Response Act (Public Law No. 116-127), a trust that meets all the following criteria as determined by the MassHealth agency.

(1) The trust was created by a nonprofit organization.

(2) A separate account is maintained for each beneficiary of the trust, but the assets of the trust are pooled for investment and management purposes.

(3) The account in a pooled trust was created for the sole benefit of the individual by the individual, the individual's parents or grandparents, or by a legal guardian or court acting on behalf of the individual.

(4) The trust provides that the Commonwealth of Massachusetts will receive amounts remaining in the account upon the death of the individual up to the amount paid by the MassHealth agency for services to the individual. The trust may retain reasonable and appropriate amounts as determined by the MassHealth agency.

(5) The individual was disabled at the time his or her account in the pool was created.

Effective 60 days after the end of the maintenance of effort and continuous eligibility provisions of Section 6008 of the Families First Coronavirus Response Act (Public Law No. 116-127), a trust that meets all the following criteria as determined by the MassHealth agency:

(1) The trust was created by a nonprofit organization.

(2) A separate account is maintained for each beneficiary of the trust, but the assets of the trust are pooled for investment and management purposes.

(4) The trust provides that the Commonwealth of Massachusetts will receive amounts remaining in the account upon the death of the individual and, if applicable, early termination of the account up to the amount paid by the MassHealth agency for services to the individual. The trust may retain reasonable and appropriate amounts as determined by the MassHealth agency.

(5) The individual was disabled at the time his or her account in the pool was created and funded.

(6) The trust must include provisions that the trustee will promptly provide written notice of the death of the individual, proposed early termination or transfer of the account, and trust accountings to the MassHealth agency or its designee.

Premium Tax Credit - 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.

Promissory Note - a written promise to pay another.

Protected Noncitizens - see130 CMR 518.003(B): Protected Noncitizens.

Qualified Health Plan (QHP) - a health plan licensed under M.G.L. chs. 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.

Qualified Noncitizens - see130 CMR 518.003(A)(1): Qualified Noncitizens.

Qualified Noncitizens Barred - see130 CMR 518.003(A)(2): Qualified Noncitizens Barred.

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

Reapplication - the MassHealth agency's reopening of the application process when the application has been denied pursuant to 130 CMR 516.001(D): Receipt of Corroborative Information.

Redetermination - a review of a member's circumstances to establish whether or not he or she remains eligible for benefits.

Resources - all income and assets owned by the individual or the spouse. For the purposes of determining eligibility, resources include income and assets to which the individual or the spouse is or would be entitled whether or not they are actually received. This term has the same meaning as assets as defined in 42 U.S.C. § 1396p(e)(1).

Reverse Mortgage - a loan on the equity value of a house paid in installments by a lender to the homeowner who is 60 years of age or older.

Revocable Trust - a trust whose terms allow the grantor to take action to regain any of the property or funds in the trust.

Senior Application or Application - the request for health benefits for an individual who is 65 years of age and older, or not living in the community that is received by the MassHealth agency and includes all required information and a signature by the applicant or his or her authorized representative.

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

Skilled-nursing Services - the planning, provision, and evaluation of goal-oriented nursing care that requires specialized knowledge and skills acquired under the established curriculum of a school of nursing approved by a board of registration in nursing. Such services include only those services that must be provided by a registered nurse, a licensed practical nurse, or a licensed vocational nurse.

Special-needs Trust - Effective until sixty days after the end of the maintenance of effort and continuous eligibility provisions of Section 6008 of the Families First Coronavirus Response Act (Public Law No. 116-127), a special-needs trust is one that meets all the following criteria as determined by the MassHealth agency.

(1) The trust was created for a disabled individual younger than 65 years old.

(2) The trust was created for the sole benefit of the individual by the individual's parent, grandparent, legal guardian, or a court.

(3) The trust provides that the Commonwealth of Massachusetts will receive amounts remaining in the account upon the death of the individual up to the amount paid by the MassHealth agency for services to the individual.

(4) When the member has lived in more than one state, the trust must provide that the funds remaining upon the death of the member are distributed to each state in which the member received Medicaid based on each state's proportionate share of the total amount of Medicaid benefits paid by all states on the member's behalf.

(1) The trust was created for a disabled individual younger than 65 years old.

(2)

(a) The trust was created for the sole benefit of the individual, by the individual, on or after December 13, 2016; or

(b) The trust was created for the sole benefit of the individual by the individual's parent, grandparent, legal guardian, conservator, or a court.

(4) When the member has lived in more than one state, the trust must provide that the funds remaining upon the death of the member or early termination of the trust are distributed to each state in which the member received Medicaid based on each state's proportionate share of the total amount of Medicaid benefits paid by all states on the member's behalf.

(5) The trust must include provisions that the trustee will promptly provide written notice of the death of the individual, proposed early termination, and any other changes, such as the appointment of another trustee, as well as accountings or other documents of the administration of the trust to the MassHealth agency or its designee.

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

Stream of Income - income received on a regular basis.

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.

Supplemental Security Income (SSI) Program - a program that provides financial assistance to needy persons who are 65 years of age or older, blind, or disabled. This program is established under Title XVI of the Social Security Act and is administered by the Social Security Administration. Such persons automatically receive MassHealth.

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 his or her 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 him or herself. 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 individual, entity, or program that is or may be responsible to pay all or part of the expenditures for medical benefits.

Trust - a legal device satisfying the requirements of state law that places the legal control of property or funds with a trustee. It also includes, but is not limited to, any legal instrument, device, or arrangement that is similar to a trust, including transfers of property by a grantor to an individual or a legal entity with fiduciary obligations so that the property is held, managed, or administered for the benefit of the grantor or others. Such arrangements include, but are not limited to, escrow accounts, pension funds, and similar devices as managed by an individual or entity with fiduciary obligations.

Trustee - any individual or legal entity that holds or manages a trust.

Uncompensated Value - the difference between the fair market value of the resource or interest in the resource at the time of transfer less any outstanding debts and the actual amount the individual received for the resource. The MassHealth agency uses the uncompensated value in the calculation of the period of ineligibility.

130 CMR, § 515.001

Amended by Mass Register Issue 1443, eff. 5/14/2021.

Amended by Mass Register Issue 1486, eff. 1/6/2023.