1 Community MassHealth for Elders Neil Cronin Massachusetts Law Reform Institute April 13, 2017 What is MassHealth? 1.9 million members $15 billion budget Mostly federal-state Medicaid Also federal-state non- Medicaid Children s Health Ins. Progr. (CHIP) Small number in stateonly program
4 Eligibility Criteria Residence Age Income Assets Citizenship/Immigration Status Medicaid 42 USC 1396 et seq. 42 CFR Part 430 et seq. Federal agency: Centers for Medicare and Medicaid Services (CMS) Federal website: Medicaid.gov 2dry sources: National Health Law Program, healthlaw.org Residence 130 C.M.R. 517.002 -.005 Live in MA with intent to remain Do not need fixed address e.g. homeless 6
7 Age 130 C.M.R. 515.002 65 or older Exception for HCB waiver 60 or older and disabled ( frail elder ) Exception for PACE 55 to 64 if disabled, meeting SSI standard Income 130 C.M.R. 520.009 -.013 Income at or below 100% FPL Earned income wages, self-employment Earned income deductions business expenses, $20/$65/1/2 remaining 8 Income cont. Unearned income SSDI, RR, pensions, annuities, VA, rental, interest, dividends Unearned income deductions $20 Income spenddown every six months 9
10 Assets 130 C.M.R. 520.003 -.008 Assets at or below $2,000 for individual, $3,000 for couple Countable and non-countable assets Ownership of assets Inaccessible assets Verifications Asset spenddown Assets Countable assets include - Cash/liquid assets Bank accounts Retirement and pension accounts Life insurance (cash surrender value) Vehicles Real estate 11 Assets cont. Non-countable assets include Principal residence Retroactive SSI/SSDI Funeral and burial arrangements Certain trusts Other assets not counted by SSI Program First vehicle for personal use 12
13 Citizenship/Immigration Status 130 C.M.R. 518.001 -.002 Eligibility for coverage types depends on citizenship or immigration status See Immigrant and public benefits BBT program MassHealth Standard, Family Assistance or Limited Verification of identity and citizenship or immigration status is required, except Medicare beneficiary or SSI recipient Standard 519.002 Coverage Types 130 C.M.R. 519.001-013 Most comprehensive benefits Elders, institutionalized individuals, HCB waiver members Coverage can start up to three full calendar months prior to application date Pays Medicare premiums, copays and deductibles SSI, EAEDC automatic coverage 14 Coverage Types Other coverage types Pickle Lost SSI due to SS COLA increase SSI/MassHealth no application required CommonHealth 40 hours/mo. work required Senior Buy-In/QMB Buy-In/SLMB Family Assistance MassHealth Limited 15
16 Application Process 130 C.M.R. 516.001-009 Apply in person, online, fax Use form SACA-2 Use form ACA-3 if over 65, working, and applying for CommonHealth CACs, Navigators available to assist Apply for Health Safety Net using MassHealth application Limits on Services 130 C.M.R. 450.204 Service must be medically necessary No more conservative or less costly alternative Specific criteria for specific services Some services require Prior Authorization to determine medical necessity PA decisions made by MassHealth, not your MD PA decisions can be appealed 17 Copayments Limits on Services 130 C.M.R. 450.130 $1 for certain drug classes $3.65 for most generic/brand drugs $3 for non-emergency ER visit Annual copayment caps of $250 for pharmacy, $36 for non-pharmacy services Nursing home residents, hospice patients exempt Medicare pays the lower of MH/LIS copay Providers can t deny service for non-payment 18
Dental Care Limits on Services 130 C.M.R. 420.421 Different coverage for adult and children Preventive services covered for adults Orthodontic, restorative, periodontics excluded Full and partial dentures restored May 2015 Fillings restored March 2014 HSN pays for dental care in certain cases 19 Special Programs 130 C.M.R. 519.007(B) Home and Community Based Waiver HCB Provides expanded range of community-based services Individual must need nursing home level of care Income eligibility up to $2,205 a month Spouse s income not counted Assets up to $2,000 a month 20 Special Programs 130 C.M.R. 519.007 (C) PACE (Program of All-Inclusive Care for the Elderly) Integrated Medicare and Medicaid payments to provide continuum of services Care management centered around adult day health programs Individual must need nursing home level of care 21
22 PACE (cont d) Special Programs Age 55 or older, but must be disabled if age 55 to 64 Income eligibility up to $2,205 a month Assets up to $2,000 a month Senior Care Options Coordinated care for dually eligible elders MassHealth income and resource standards Integrated Medicare/Medicaid payments No frailty requirements Provides broad range of services Care teams including ASAPs for frail enrollees 23 Estate Recovery 130 CMR 515.011 After the member turns 55* At any age while member was permanently in a long-term-care facility Spouse, disabled child of any age or any child under 21, protected against estate recovery while living *state option which Massachusetts currently adopts 24
Appeal Rights 130 C.M.R. s.610.00 et seq. Advance Notice Timelines for appeal 30 days Benefits pending appeal request for hearing must be initiated before action is effective or 10 days from notice, whichever is longer Best practice fax appeal request to BOH Judicial Review Superior Court 30 day limit 25