masshealth

MassHealth

Annette SheaDirector of Disability Policy and Home and

Community Based Waiver OversightExecutive Office of Health and Human

ServicesOffice of Medicaid

• Provide an overview of MassHealth Including benefit plans and eligibility requirements

• Provide an overview of the Home and Community Based Waiver Program for individuals with Mental Retardation• Answer questions

Goal of Today’s Presentation

Examples:MassHealth Coverage Types

• MH Standard

• MH CommonHealth• MH Family Assistance

• MH Basic• MH Essential• MH Limited

• MH Prenatal

• Parents, children,pregnant women,disabled,caretaker relative,seniors

• Disabled adults,disabled children,disabled working adults

• Parents, children, HIV+,families with access to a qualified employers insurance

• EAEDC recipients,DMH recipients• Long term unemployed adults• Emergency services to people, who

under federal law, have an immigration status that limits other services

• Pregnant time limited benefit, Missing information

Person Federal Poverty Level Coverage TypeChildren under 19 years of age 300% Standard/Family Asst.Pregnant women 200% Standard/Family

Asst/LimitedPerson HIV positive 200% Family AssistanceDisabled Adult 133% Standard/CommonHealth/Limited

Disabled Working Adults No Income Limit CommonHealth/LimitedDisabled Child No income limit Standard/CommonHealth/Fam.

Asst/LimitedParents 133% Standard/CommonHealth/Limited Caretaker Relative 133% Standard/LimitedLong-term unemployed with DMH services 100% BasicPeople 65 years of age and older 100% Standard/Essential/Limited EA/EDC- Transitional Assistance 100% Basic

Long Term Unemployed 100% Essential

Women’s Breast & Cervical Cancer 250% Standard

Who is eligible?

Examples of Covered Services

• Inpatient Hospitalization• Outpatient Services• Medical Services• Mental Health and Substance Abuse

Services• Well Child Screenings• Transportation Services• Rx Drugs

Different coverage types allow for different covered services. You should read the MassHealth booklet or call MassHealth Customer Service (1-800-841-2900) for correct information regarding your coverage

Prior Authorization Contact Number

Prior Authorization

1 800 862-8341

or

617 451-7017

Family Size

MassHealth Income Standards

100%Federal Poverty Level




1 Monthly Monthly Monthly Monthly Monthly522 817 980 1087 1103

2 650 1100 1320 1463 14853 775 1384 18404 891 1667 22175 1016 1950 25946 1141 2234 29717 1266 2517 33488 1383 2800 3724

For each additional person add +133 +284 +377

Family Size




300% Federal Poverty Level

400% Federal Poverty Level

Monthly Monthly Monthly Monthly Monthly1 1225 1634 2042 2451 32672 1650 2200 2750 3300 44003 2075 2767 3459 4150 55344 2500 3334 4167 5001 66675 2925 3900 4875 5850 78006 3350 4467 5584 6700 89347 3775 5034 6292 7551 100678 4200 5600 7000 8400 11200

For each additional person add +425 +567 +709 850 1134

Effective 4/2006

Determination:•Social Security Administration;

• Mass. Commission for the Blind;

• Disability Evaluation Service

Disability Evaluation

Completion of Supplement:•When not deemed disabled by either the Social

Security Administration or Mass. Commission for the Blind

Disability Supplement: Must include:

• signed completed form• signed medical release forms

• accurate and current medical information that you had received or are receiving

• information such as, vocational, educational and current daily activities

Immigration StatusMassHealth looks at citizenship and immigration status to determine what coverage type someone may be eligible for.

Citizens (born in the U.S. and naturalized) are eligible for any coverage type that they meet the other categorical requirements for.

Legal Permanent Residents are eligible for any coverage type that they meet the other categorical requirements for with one additional requirement. If entered the country after 8-22-1996, they must have been in this country for at least 5 years to be eligible for standard coverage.

Qualified Aliens are people who entered the country with a certain immigration status. For a listing of these status’s refer to the MassHealth Member Booklet or visit the web site www.mass.gov/masshealth - Current Members Eligibility Regulations section 518.002 (B).

Immigration StatusStatus Immigration

Status

Potential Coverage Type

Citizen Not applicable (As of 7/1/06 need to show proof)

All coverage types

Except Limited

Qualified Aliens LPR, entered the country before 8/22/1996 or after and satisfied 5 yr bar

All coverage types except Limited

Protected Aliens Eligible for Medicaid or CommonHealth or applied for LTC as of June 30,1997

MassHealth Standard or CommonHealth

Special Status Alien LPR, or other recognized status which the individual entered the U. S. after 8/22/1996 subject to 5 yr bar

Limited/ Potential for Essential (6/1/04)-Adults

Under 65 Disability

Over 65 Immigration Status

Children under 19 Potential/ Family Assistance, Commonhealth, Limited

Non-Qualified Alien Visitors visa, no status Limited Only

MassHealth Coverage Types for People with Disabilities

• Any Massachusetts resident under 65 with a disability is eligible for MassHealth. Coverage type is based on income. Sliding scale premiums may apply.

• MassHealth Standard financial eligibility is income up to 133% of the federal poverty level (FPL).– Sliding scale premiums applies to those with monthly household

income above 114% FPL– Also, those individuals enrolled on the home and community

based waiver with income up to 300% SSI FBR are consider MH Standard members

• MassHealth CommonHealth for children and adults has no income limit and no asset test.– Income-based sliding scale premiums apply– One-time needs test applies to non-working adults with

disabilities with monthly income over 133% FPL

Appeals•Every member has the right to an appeal a decision made by the Division

•The appeal must be filed in a timely manner.

•The form to appeal is on the back of the division’s notice.

•Or a member may obtain a “Request for a Fair Hearing” form.

•Some members may be entitled to aid pending until their appeal is heard.

•Mail your appeal request form to the Board of Hearings at 2 Boylston St., Boston, MA 02116 or fax to (617) 210-5820.

•Questions about a notice or how to ask for an appeal should be directed to a MassHealth Enrollment center at 1-888-665-9993.

Hardship Waiver of Premiums

How will Health Care Reform affect MassHealth Coverage?

• Family Assistance for children expanded to 300% FPL via SCHIP expansion

• Increases enrollment caps for the Family Assistance/HIV, CommonHealth, and Essential Programs

• Restores optional benefits to 2002 levels and expands MassHealth services

• Creates a Two Year Tobacco Cessation Program for MassHealth members of any age

• Increases the Insurance Partnership program eligibility to 300% FPL

• Prohibits changes to disability eligibility criteria

Health Care Reform

Dental Services Vision Services Chiropractor Services Orthotics Prosthetics Certain 24 hour substance abuse

treatment services Acute hospital inpatient

administratively necessary days Tobacco Cessation Services for

Members of Any Age

www.mass.gov/masshealth/dentists

Federal Deficit Reduction Act 2005(DRA)

• President Bush signed into law February 8, 2005 the (DRA) in an effort to control federal spending

• All states are required to comply with new (DRA) provisions

• The (DRA) impacts MassHealth by: requiring citizenship and identity documentation

changing MassHealth regulations for long term care applicants

DRA Citizenship and Identity Requirements

• Effective July 1, 2006 acceptable documentation of U.S. Citizenship/National status will be required.

(MassHealth can no longer accept self-declaration) • New applicants and current MassHealth members

will be required to verify citizenship and identity on or after July 1, 2006

Documented immigrants will continue to verify their immigration status

Medicare/SSI beneficiaries are exempt from verification process (citizenship has already been verified)

MassHealth Applications & Member Booklets

Applications come in English and SpanishAvailable at MEC 1-888-665-9993Member booklets available in 8 languagesCambodian, Chinese, Haitian Creole, Laotian,

Portuguese, Russian, Spanish, and Vietnamese

Booklets can be obtained by calling the MassHealth Customer Service line, 1-800-841-2900

MassHealth Applications: Who needs to apply?

• SSI recipients do not need to apply for MassHealth benefits. As an SSI recipient they are automatically enrolled

• SSDI recipients do need to submit an application to MassHealth in order to be enrolled and receive MassHealth benefits– When someone is transitioning from SSI

benefits they will receive written notification from MassHealth requesting the member submit an application if interested

MASSHEALTH ENROLLMENT CENTER MASSHEALTH ENROLLMENT CENTER300 OCEAN AVE, SUITE 4000 333 BRIDGE STREETREVERE, MA. 02151 SPRINGFIELD, MA. 011031-800-322-1448 1-800-332-5545781-485-2500 413-785-4100FAX: 781-485-3400 FAX: 413-785-4180TTY: 1-877-668-4499 TTY: 1-800-596-1276

MASSHEALTH ENROLLMENT CENTER MASSHEALTH ENROLLMENT CENTER21 SPRING ST, SUITE 4 367 EAST ST.TAUNTON, MA. 02780 TEWKSBURY, MA. 01876-19571-800-242-1340 1-800-408-1253508-828-4600 978-863-9200FAX: 508-828-4611 FAX: 978-863-9300TTY: 1-800-596-1272 TTY: 1-800-231-5698

NEW APPLICATIONS

Central Processing Unit P.O.Box 290794Charlestown, Ma 02129-0214

•http://www.mass.gov/masshealth

MASSHEALTH APPLICATION STATUS

OR MEMBER ELIGIBILITY

1- 888-665-9993

For More Information

MassHealth Enrollment Centers

Home and Community Based Service Waivers

• The HCBSW program was established by Section 2176 of the Omnibus Budget Reconciliation Act of 1981 and was incorporated into the Social Security Act at Section 1915 (c).

• Under the HCBSW program states can elect to furnish under Medicaid as an alternative to institutional care a broad array of services (excluding room and board) that are not otherwise covered under the Medicaid program.

MRDD Waiver

• More than 11,000 DMR-supported adults utilize this waiver annually as a community alternative to an Intermediate Care Facility for the Mentally Retarded

• Critical services provided through this waiver include:– Residential Supports– Employment Supports– Respite– Individual and Family Supports– Transportation

• All Waiver enrollees also have access to Medicaid state plan services

Eligibility for Waiver

• Individuals at an ICF-MR level of care

• Income (earned or unearned) at or below 300% of SSI FBR (approximately 200% of the federal poverty level)

• Individual assets at or below $2000

MassHealth categories of assistance and waiver enrollment

• In order to be enrolled onto the waiver the recipient needs to determined to be eligible using “traditional Medicaid” rules– Those enrolled in MassHealth categories

which do not ask for asset information are not automatically eligible. In order to be enrolled onto the waiver the individual must be re-determine using a long-term care application and traditional rules.

– SSI recipients would automatically be eligible

Employment and MassHealth• Can someone with a disability work and receive MassHealth benefits? YES

• Individuals with disabilities who work at least 40 hours or more each month and have income above 133% FPL are eligible for CommonHealth. The benefit package is the same as MH Standard (with the exception of a long-term nursing facility benefit). Sliding scale premiums apply based on income.

• If an individual with a disability has periods of employment and unemployment, would they lose benefits? Not necessarily

• When an individual has a change in status they should notify the MassHealth Enrollment Center (MEC).

• During unemployment if a person’s unearned income is at or below 133% of FPL then they should not experience an interruption in benefits. If the individual’s unearned income exceeds 133% of the FPL then they may be subject to a one-time spend down in order to maintain benefits.

• If an individual is receiving benefits as a CommonHealth Working member and they experience an interruption in employment they are eligible to maintain their CommonHealth enrollment up to 90 days as long as they continue to pay their monthly premium.

Employment and Waiver Enrollment

• Could someone work and be enrolled on the home and community based waiver? – Yes. If the person’s income continues to meet

the income criteria (300% SSI FBR = approximately 200% FPL) for the waiver and their individual countable assets are at or below $2000 then they are eligible. If there is a question about a particular case then there may be revenue staff assigned to assist.

Contact information

Annette SheaDirector of Disability Policy and

Home and Community Based Waiver Oversight

Executive Office of Health and Human Services

Office of Medicaid617 573-1751

[email protected]

mailto:[email protected]

masshealth

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