Mass. Gen. Laws ch. 118E § 25

Current through Chapter 223 of the 2024 Legislative Session

Section 118E:25 - Eligibility for benefits; exemptions; recipient cost sharing

For purposes of determining an individual's eligibility for Medicaid, the following income and resources shall be exempt and shall neither be taken into consideration nor, except as permitted under Title XIX, required to be applied toward the payment or part payment of Medicaid benefits:

(1) Monthly income in an amount not exceeding the level of the minimum dollar amount required under Title XIX;

(2) ownership of one's residence, including furniture, which is essential and appropriate to the needs of the household except as permitted by section 1902(a)(10)(C) of Title XIX. In the case of an applicant or recipient for whom a medical determination has been made, after notice and opportunity for an appeal and hearing, that he or she cannot reasonably be expected to return to live in the residence, the residence will be considered a countable asset unless:

(A) the division determines that counting the residence as an asset would cause undue hardship; or

(B) any one of the following persons continue or would continue to reside therein: (i) the applicant or recipient's spouse; or (ii) a child of the applicant or recipient who is under twenty-one years of age or who is blind or permanently disabled; or (iii) a sibling of the applicant or recipient who has an equity interest in the home and who was residing there for a period of at least one year immediately before the date of the applicant's admission to the medical institution; or (iv) a son or daughter of the applicant or recipient who was residing in the applicant or recipient's home for a period of at least two years immediately before the date of the applicant's admission to the medical institution, and who establishes to the satisfaction of the division that he or she provided care to the applicant which permitted the applicant to reside at the home rather than in an institution; or

(C) the applicant or recipient has obtained long term care insurance whose coverage meets the requirements of 211 C.M.R. 65.00.

In the case of an applicant or recipient for whom such a medical determination has been made under this subsection, the division shall continue to consider the residence as a noncountable asset for a period of not less than three months following such medical determination in order that the applicant or recipient may make funds available for his or her medical needs based on his or her equity interest in such residence.

(3) personal property in an amount not exceeding the minimum resource amount required under Title XIX;

(4) cemetery plots purchased for the use of the applicant or recipient;

(4 1/2) the entire amount of a monthly payment to a veteran or a widowed spouse of a veteran, including pension, aid and attendance and housebound benefits, from the United States Department of Veterans Affairs if the veteran or widowed spouse would not have received such a payment from the United States Department of Veterans Affairs but for unreimbursed medical expense; and

(5) funds not to exceed the minimum amount required under Title XIX deposited in a trust account and so reserved for the payment of funeral and burial expenses of the applicant or recipient including, but not limited to, the purchase of a plot, the opening of the grave, the fee for religious services, and the monument inscription; the cash surrender value of burial insurance, so called, or prepaid irrevocable burial contracts, so called.

In any case where the monthly income of an applicant or recipient is in excess of the exemptions allowed, the applicant or recipient, if otherwise eligible for Medicaid under this chapter, shall be liable to pay to the provider of medical care or service an amount which shall be equal to the excess income for a period of six consecutive months, which includes the period when such service was provided.

In determining responsibility of any individual for any Medicaid applicant or recipient, such responsibility shall be limited to a person for his spouse and parents for children under the age of eighteen. The income and assets of any Medicaid applicant or recipient under eighteen years of age who lives with his or her parent shall be deemed to include the income and assets of the parent of such applicant or recipient. The income and assets of any Medicaid applicant or recipient under eighteen years of age who does not live with his or her parents shall include only the income and assets that are actually contributed to the applicant or recipient by the parent.

Notwithstanding the first paragraph of this section, the division may require medicaid recipients to pay enrollment fees, premiums, deductibles, coinsurance, copayments or similar cost-sharing charges as participants in managed care plans implemented by the division, so long as any waivers of Title XIX provisions regarding recipient cost-sharing are obtained from the secretary in conjunction with any other federal approvals and waivers necessary to implement these managed care plans. In the absence of managed care plans, the division may require, to the extent permitted by federal law, that recipients, if eligible for such benefits, be liable for a copayment of up to $5 toward the purchase of each pharmaceutical product, including prescription drugs and over-the-counter drugs. The division may also require, to the extent permitted by federal law, that recipients be liable for a co-payment of up to $5 for all other covered services with the exception of mental health and substance abuse services. The division shall establish a per member out-of-pocket cap for all co-payments.

Nothing in this chapter shall preclude the division from using asset standards in determining the financial eligibility for any benefit; but the division shall submit to the house and senate committees on ways and means and the joint committee on health care a report of changes in asset standards within 30 days of implementation, and shall submit 4 quarterly reports, beginning 3 months after any new asset standards are implemented, detailing the effect the standards on the number of people applying for or terminated from MassHealth.

Mass. Gen. Laws ch. 118E, § 118E:25

Amended by Acts 2023 , c. 77, § 27, eff. 12/4/2023.

Amended by Acts 2018 , c. 218, § 28, eff. 11/7/2018.

Amended by Acts 2011 , c. 68, § 88, eff. 7/1/2011.

Amended by Acts 2003 , c. 26, §§ 326, 327, 328, eff. 7/1/2003.

Amended by Acts 2002 , c. 184, § 98, eff. 7/1/2002.