130 CMR, § 505.008

Current through Register 1533, October 25, 2024

Section 505.008 - MassHealth CarePlus

(A)Overview.

(1)130 CMR 505.008 contains the categorical requirements and financial standards for MassHealth CarePlus. This coverage type provides coverage to adults 21 through 64 years of age.

(2) Persons eligible for MassHealth CarePlus Direct Coverage are eligible for medical benefits, as described in 130 CMR 450.105(B): MassHealth CarePlus and 130 CMR 508.000: Health Care Reform: MassHealth: Managed Care Requirements and must meet the following conditions.

(a) The individual is an adult 21 through 64 years of age.

(b) The individual is a citizen, as described in 130 CMR 504.002: U.S. Citizens, or a qualified noncitizen, as described in 130 CMR 504.003(A)(1): Qualified Noncitizens.

(c) The individual's modified adjusted gross income of the MassHealth MAGI household is less than or equal to 133% of the federal poverty level.

(d) The individual is ineligible for MassHealth Standard.

(e) The adult complies with 130 CMR 505.008(C).

(f) The individual is not enrolled in or eligible for Medicare Parts A or B.

(B)Eligibility Requirements for Certain EAEDC Recipients.

(1)Eligibility Requirements. Certain EAEDC recipients are eligible for CarePlus if

(a) the individual is an adult 21 through 64 years of age;

(b) the individual receives EAEDC cash assistance; and

(c) the individual is a citizen, as described in 130 CMR 504.002: U.S. Citizens, or a qualified noncitizen, as described in 130 CMR 504.003(A)(1): Qualified Noncitizens.

(2)Eligibility End Date. Individuals whose EAEDC cash assistance ends and who are determined to be potentially eligible for MassHealth continue to receive medical benefits under MassHealth CarePlus until a determination of ineligibility is made by the MassHealth agency.

(C)Use of Potential Health Insurance Benefits. All applicants and members must use potential health insurance benefits in accordance with 130 CMR 503.007: Potential Sources of Health Care and must enroll in health insurance, if available at no greater cost to the applicant or member than he or she would pay without access to health insurance, or if purchased by MassHealth in accordance with 130 CMR 505.008(D) or 506.012: Premium Assistance Payments. Members must access those other health insurance benefits and must show both their private health insurance card and their MassHealth card to providers at the time services are provided

(D)Access to Employer-sponsored Insurance and Premium Assistance Investigations for Individuals Who Are Eligible for MassHealth CarePlus.

(1) MassHealth may perform an investigation to determine if individuals receiving MassHealth CarePlus have

(a) health insurance that MassHealth can help pay for; or

(b) access to employer-sponsored insurance that MassHealth wants the individual to enroll and for which MassHealth will help pay.

1.Investigations for Individuals Who Are Enrolled in Health Insurance. If MassHealth determines that the health insurance the individual is enrolled in meets the criteria at 130 CMR 506.012: Premium Assistance Payments, the individual is notified in writing that MassHealth will provide MassHealth CarePlus Premium Assistance Payments as described at 130 CMR 506.012: Premium Assistance Payments. If MassHealth determines that the health insurance the individual is enrolled in does not meet the criteria at 130 CMR 506.012: Premium Assistance Payments, the individual is eligible for MassHealth CarePlus Direct Coverage.

2.Investigations for Individuals Who Have Potential Access to Employer-sponsored Health Insurance. If MassHealth determines the individual does not have access to employer- sponsored insurance and the employer is contributing at least 50% of the premium cost and the insurance meets all other criteria described in 130 CMR 506.012: Premium Assistance Payments, the individual is notified in writing that they must enroll in this employer-sponsored coverage. MassHealth will allow the individual up to 60 days to enroll in this coverage. Once enrolled in the health insurance plan, MassHealth will provide MassHealth CarePlus Premium Assistance Payments as described in 130 CMR 506.012. Failure to enroll in the employer-sponsored health insurance plan at the request of MassHealth will result in loss or denial of eligibility for all individuals.

(2) If MassHealth determines the individual does not have access to employer-sponsored insurance, the individual continues to be eligible for MassHealth CarePlus.

(E)MassHealth CarePlus Coverage Begin Date.

(1) The MassHealth CarePlus coverage start date is described at 130 CMR 502.006: Coverage Dates, except as described at 130 CMR 505.008(E)(2).

(2) Provisional eligibility is described in 130 CMR 502.003(E): Provisional Eligibility.

(F)Medically Frail. If an individual is determined medically frail or is an individual with special medical needs and has been determined to meet the eligibility criteria for MassHealth CarePlus as described in 130 CMR 505.008, the individual may elect at any time to receive MassHealth Standard benefits, as described in 130 CMR 505.002(J). If at any time after enrolling in MassHealth CarePlus an individual becomes medically frail or is determined to be medically frail, the individual may elect to receive MassHealth Standard benefits. The effective date of MassHealth Standard is the date of the reported change. To be considered medically frail or a person with special medical needs, an individual must be

(1) an individual with a disabling mental disorder (including children with serious emotional disturbances and adults with serious mental illness);

(2) an individual with a chronic substance use disorder;

(3) an individual with a serious and complex medical condition;

(4) an individual with a physical, intellectual, or developmental disability that significantly impairs their / ability to perform one or more activities of daily living; or

(5) an individual with a disability determination based on Social Security criteria.