Masshealth/ Medicaid

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MassHealth is the name given to the Massachusetts Medicaid Program. This section contains information concerning eligibility and services under the MassHealth program, as well as links to important web sites needed for effective advocacy for MassHealth applicants and recipients. The section also contain copies of fair hearing decisions involving the MassHealth program, but we need your help:

Please send us copies of your fair hearing decisions to the attention of Vicky Pulos, MLRI, 40 Court Street, Suite 800, Boston, MA 02108,  vpulos@mlri.org.

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What's in the Blue Envelope for People Turning 65

MassHealth
MassHealth is in the process of renewing eligibility for all its 2.4 million members during the one year period from April 1, 2023 to March 31, 2024. If eligibility can't be renewed through data matching, beneficiaries will be sent a blue envelope with a notice dated April 1, 2023 or later to be…

MassHealth Renewal: What's in the blue envelope for people under 65?

MasHealth
MassHealth is in the process of renewing eligibility for all its 2.4 million members during the one year period from April 1, 2023 to March 31, 2024. If eligibility can't be renewed through data matching, beneficiaries will be sent a blue envelope with a notice dated April 1, 2023 or later to be…

MassHealth Managed Care Options in 2023

Various
On April 1, 2023 MassHealth members subject to mandatory managed care will have a new set of managed care options. These changes do not apply to people 65 or over or Medicare beneficiaries with voluntary managed options in SCO or One Care, or to other MassHealth members with MassHealth secondary to…

CMS directs Medicaid agencies to reinstate duals who were downgraded to Medicare Savings Programs only

CMS
On Mar 7, 2023 CMS issued a notice to all state Medicaid agencies pursuant to an injunction entered against CMS in a nationwide class action called Carr v Becerra filed in federal district court in Connecticut. The class consisted of people who had been determined eligible for Medicaid after…

Pending Bills to Reform MassHealth Estate Recovery

Sen Comerford & Rep Barber
Sen Comerford & Rep Barber are lead sponsors on bills to reform MassHealth Estate Recovery.  A fact sheet about the bills is attached.  An Act Protecting the Homes of Seniors and People with Disabilities on MassHealth H. 1168    S. 726   

A bill to reinstate 3 months retroactive MassHalth Coverage in 2023

MHA & MLRI
Attached is a fact sheet on a bill filed in the 2023 session to restore retroactive MassHealth coverage; MassHealth plans to end this coverage for new applicants 19-64 who are not pregnant when the COVID-19 Public Health Emergency ends expected to be this spring.

MassHealth Behavioral Health for Criminal Justice Involved People

MassHealth
This MassHealth website describes a program to connect "justice-involved" people with  behavioral health services & social supports in the community. "Justice-involved" includes:  • people leaving jail or prison within six months, • people who…

Tips for Communicating with Optum

MLRI
This May 2022 updated memo by MLRI provides contact information for MassHealth's Third Party Administrator for certain Long Term Services and Supports (LTSS), Optum. Optum began making prior authorization decisions for PCA and certain other LTSS services in the summer of 2017. The updated…

MassHealth Managed Care Contracts

MassHealth
At this website MassHealth has posted its contracts with its managed care plans including the MCOs, the ACOs, the Behavioral Health Partnership, and the One Care and SCO plans. When researching the scope of covered services for a beneficiary enrolled in a managed care plan, the contract may have…

CCA One Care Coverage Exceptions for non-covered benefits

Various
In Feb 2022 CCA updated and published its Medical Necessity Guidelines for otherwise NonCovered Services (PDF is attached) & posted it here: https://www.commonwealthcarealliance.org/ma/wp-content/uploads/2023/01/Non-Covered-Benefit-MNG-100_20230124.pdf Thanks to Central West Justice…

March and Nov 2022 Upper Income Limits in MassHealth and Health Connector

MLRI
MassHealth updates its income standards with the current year's poverty level on March 1. Attached are tables from MLRI showing the upper income levels for MassHealth and Health Connector programs, updated to show the cost of living adjustments for 2022 that took effect in MassHealth…

Updated Office of Medicaid Guidance on Cuban-Haitian Entrants

Office of Medicaid
This Feb 2022 Eligibility Operations Memo from the Office of Medicaid provides information on how to identify Cuban-Haitian entrants who are "qualifed aliens" eligible for medical benefits on the same terms as US citizens. It updates an earlier June 2020 El Ops Memo to include examples of…

Update on Haitian Entrants

Misc
Feb 2022 UPDATED MassHealth Guidance on Cuban-Haitian Entrants https://www.mass.gov/doc/eom-22-03-eligibility-rules-for-cuban-and-haitian-entrants-0/download  Background Information on Newly Arriving Haitians Recently, hundreds of Haitian families, many with children, have arrived in…

Benefits Included in MassHealth by Coverage Type 2022

MLRI
Attached is a Table prepared by MLRI of the different kinds of services and service providers that are available under the various MassHealth coverage types described in MassHealth eligibility regulations & cross referencing to MassHealth fee for service regulations. It's been updated…

ABCs of Seeking Judicial Review of a MassHealth Board of Hearings Decision

MLRI
Attached is an updated guide on the process of filing a complaint for judicial review of a MassHealth fair hearing decision. Please contact Kate Symmonds (ksymmonds@mlri.org) if you notice any errors or have any tips for other advocates; and please be sure to check the court rules and statutes for…

March & Nov 2021 Update of FPL Tables in MassHealth & Health Connector

MassHealth & MLRI
Attached are updated Tables from MassHealth and MLRI showing the upper income levels for MassHealth and Health Connector programs. It is updated to show the cost of living adjustments for 2021 that take effect in MassHealth programs on March 1, 2021. The Health Connector uses the 2020 federal…

IRS Stimulus Payments Never Treated as Assets

Office of Medicaid
This announcement from MassHealth clarifies that IRS Stimulus payments (also called Economic Incentive Payments or Recovery Rebates) are not income in the month of receipt and unspent funds will not be treated as countable assets for 12 months from receipt and for the duration of the federal public…

EOHHS v. Trocki Medicaid Estate Recovery Decision

Appeals Court
In this Aug 5, 2021 Appeals Court decision, the Court reversed the Superior Court's summary judgment in favor of EOHHS in a Medicaid estate recovery claim under G.L. c. 118E, Sec. 31 in which the claim consisted entirely of capitated monthly payments to a Senior Care Options (SCO) program.…

MassHealth Estate Recovery webinar for assisters & legal aid July 22, 2021

MLRI
MassHealth Estate Recovery A webinar for enrollment assisters & legal aid advocates July 22, 2021, 2-3 pm Recording & slides of July 22 Estate Recovery webinar now available. If you missed the July 22, 2021 Estate Recovery Webinar, the recording is posted here on the…

MassHealth Monthly Copay Caps

MassHealth
MassHealth mailed notices to members about a monthly cap on copayments beginning July 1, 2021 that will reduce the amount of copayments people with multiple prescriptions per month will have to pay.  However, the wording of the notice has led to widespread confusion with many people thinking…

New Brokerage System for MassHealth PT-1 Nonemergency Transportation July 1, 2021

Office of Medicaid
MassHealth members in Standard, CommonHealth and CarePlus are eligible for non-emergency transportation assistance to get to and from their appointments with MassHealth providers if  they cannot use public transportation due to a disability or medical condition or because there…

MassHealth Estate Recovery

Office of Medicaid
MassHealth seeks to recoup the amount of money it has spent paying for services or paying managed care premiums on behalf of MassHealth members age 55 or older from the individual's "probate estate."  It also seeks to recoup the costs of nursing home care from the…

MassHealth estate recovery amended regulations

MLRI
MassHealth proposed changed to its estate recovery regulations in Jan. 2021.  Attached are the comments submitted by MLRI and 13 other organizations urging MassHealth to further expand its undue hardship criteria for waiving estate recovery and improve notice to MassHealth members and their…

1115 Demo amendment comments by 16 organizations

MLRI
In March 2021, MassHealth released for comment proposed amendments to the current 1115 Demonstration to among other things extend the  Medicare Savings Program higher income limits to CommonHealth members without an asset test and to extend the current period of 60 days post-partum…

1115 Renewal Recommendations on Eligibility & Access

MLRI, HLA and GBLS
MassHealth has operated under a comprehensive 1115 demonstration since 1997 affecting most of its member under age 65. The current Demo period expires in June 2022 and MassHealth  will be submitting a proposal to renew the current 1115 Demonstration for another 5 years in late spring/early…

Comments Opposing Interim Final Rule Restricting COVID-19 Medicaid Protections

MLRI, GBLS, HLA and HCFA; NHeLP and Justice in Aging
Attached are comments written by MLRI, GBLS, HLA and HCFA and endorsed by 11 other Massachusetts organizations opposing an interim final rule (IFR) that would restrict the Medicaid protections enacted by Congress in the Families First Coronavirus Response Act. These comments were submitted…

Court enjoins MassHealth orthodontia changes

Judge Camille Sarrouf Jr.
Dayanne v. Baker, Middlesex Superior Court, No. 2081CV01893 (J. Camille Sarrouf Jr., Order of Dec. 14, 2020) This was a case brought by an organization of orthodontists and 5 children denied orthontic treatment by MassHealth.  On Dec 14, 2020 the Court entered a preliminary injunction…

July 23 MTF Announcement: 1. MassHealth Buy In & 2. Telephonic authorizations

MassHealth
This is an MTF announcement dated July 23, 2020 about two policy updates: 1. Correcting a system error affecting the Jan 1, 2020 expansion of the Medicare Savings Program (Senior Buy-In/Buy-In Programs). and 2. a June 29, 2020 change in policy authorizing applicants and members to complete a…

Filing a Pro Se Appeal from the MassHealth Board of Hearings

MLRI
Attached is a sample complaint appealing from a decision of the MassHealth Board of Hearings and an outline of key steps in filing an appeal with links to information on the Court's websites.  The Court website has information on filing an appeal from the decision of a state agency like…

Superior Court Decision Granting Hardship Waiver in Medicaid Estate Recovery Case

Judge Christine Roach
This was a Medicaid Estate Recovery case in which EOHHS was pursuing a reimbursement claim against the estate of a single parent who died at home leaving her disabled adult son living in the home along with the sister who had moved in after their mother's death. The family home was the only…

New Health Connector Mailing Address

Health Connector
On May 19, 2020 The Health Connector changed its mailing address. The new mailing address is Health Connector Processing Center, P.O. Box 4404, Taunton, MA 02780.  The MassHealth-Health Connector Mail/Fax Cover Sheet has been updated to reflect the new mailing…

MassHealth Training Forum April 2020 Materials

MassHealth & Health Connector
This website contains materials from the April 2020 MassHealth Training Forum --Powerpoint presentations covering the major COVID-19 related changes over the last 2 months including slides from MassHealth addressing the MassHealth termination moratorium; verifying eligibility by self-attestions,…

How MassHealth & the Health Connector Treat New Payments under the CARES ACT

MLRI
This MLRI Table shows how MassHealth and the Health Connector count new payments authorized by the Coronavirus Aid, Relief, and Economic Security (CARES) Act: a one-time tax rebate from the IRS in the amount of $1200 per eligible adult and $500 per qualifying child under 17, extended Unemployment…

MassHealth BOH reverses Dentaquest Denial

Scott Bernard
Favorable BOH decision reversing Dentaquest denial of prior authorization for deep gum and root cleaning. Dentaquest is the third party administrator of the MassHealth dental program. The decision concerns periodontal care for an adult.  Note that on the last page the hearing officer writes:…

2020 Upper Income Levels for MassHealth & Other Health Programs

MLRI and EOHHS
Attached are updated income tables for 2020 showing the upper income limits in MassHealth and Other Health programs. One table is the MassHealth Desk Guide showing the annual and monthly amounts that correspond to different percentages of the federal poverty level used by MassHealth; the 5%…

MassHealth Premium Assistance

MassHealth
Attached is a powerpoint presentation that MassHealth's Premium Assistance Unit presented at the Jan 2020 MassHealth Training Forums. Also attached is a MassHealth memo (still current in Feb 2020) describing & giving examples of how the amount of premium assistance is calculated.

MassHealth & Temporary Census Earnings

Vicky Pulos
Temporary census work is currently available but MassHealth members may have concerns that the added income will jeopardize their continued eligibility for MassHealth.  This Q & A for providers & advocates describes how MassHealth treats temporary census earnings for individuals…

Six changes affecting MassHealth on Jan 1, 2020

Vicky Pulos
Six changes affecting MassHealth on Jan 1, 2020: Primary Care Providers Joining New ACOs Jan 1 MassHealth notified 37,000 members whose primary care provider joined a new ACO that they would be assigned to that ACO on Jan. 1, 2020. The list of providers changing plans is…

A Quick and Easy Method of Screening for Medicaid Eligibility under the Pickle Amendment

Gordon Bonnyman
The Pickle Amendment, named after its congressional sponsor and enacted in 1977, requires that an individual is to be deemed a Supplemental Security Income (SSI) recipient (which in most states means automatic Medicaid eligibility) if the individual1 was simultaneously entitled to receive both…

October 2019 Health Update: Open Enrollment & More

Vicky Pulos

A New Opportunity for Seniors and People with Disabilities Enrolled in MassHealth Home & Community Based Waivers & PACE To Maintain Eligibility After an Increase in Income

MLRI
Memo on a new policy on "post-eligibility treatment of income" for people already enrolled in a HCBS who experience an increase in income. Update: October 1, 2019 MassHealth Eligibility Operations Memo, Post-Eligibility Treatment of Income (PETI) for Home- and Community-Based…

August 2019 State Health Update:

vicky pulos
Attached is an update of several health items in the FY 20 state budget, improvements in the state medical child support law,  improvements in the MassHealth/Connector online system, and several positive changes in MassHealth eligibility policies. 

Medicaid revises policy on home health aides & DME in response to advocacy letter

Office of Medicaid; MLRI, HLA, DLC & GBLS
In August 2018 legal advocates wrote to the Medicaid director identifying several ways that current MassHealth regulations and policies on home health aide services and durable medical equipment (DME) are out of compliance with federal Medicaid regulations and harming our clients. We outlined the…

EPSDT & MassHealth

Vicky Pulos
Medicaid's "Early and Periodic Screening, Diagnosis and Treatment" (EPSDT) benefit for children is a powerful tool advocates can use to help children and youth under age 21 enrolled in MassHealth Standard or CommonHealth get the health benefits they need. This memo provides citations…

Request for Fair Hearing Form

EOHHS
Fair Hearing Request Form [FHR-1 (04/19)] A form used by applicants and members who want to ask for a fair hearing. In English and Spanish. https://www.mass.gov/how-to/how-to-appeal-a-masshealth-decisio

MassHealth Brochure: Need help with health care coverage?

MassHealth
Brochure (aca-1) for Massachusetts residents describing MassHealth benefits and explaining how to apply.  Also includes some information about the Health Connector, Children's Medical Security Plan Commonwealth Care and the Health Safety Net. Available in English and Spanish from…

2019 Upper Income Levels for MassHealth & Other Health Programs

MLRI and EOHHS
Attached are updated income tables for 2019 showing the upper income limits in MassHealth and Other Health programs. One Table is the MassHealth Desk Guide showing the annual and monthly amounts that correspond to different percentages of the federal poverty level used by MassHealth; the 5% of FPL…

PCA Time for Task and PCA Operating Standards

Office of Medicaid
Pursuant to a Jan 2019 record request, we obtained a copy of two subregulatory documents developed by MassHealth regarding Personal Care Attendant (PCA) services. Neither document is new, but both are currently in use at least as of Jan 2019. One is the Time for Task Guidelines, dated 11-16-11,…

Superior Court DJ on Inadequate MassHealth Notices

Hon. Douglas Wilkins
This is a declaratory judgment decision in two companion cases filed in Suffolk Superior Court, Maas v. Sudders and Hirvi v. Sudders, by 2 private attornies & members of the MA Chapter of the Natl. Assoc. of Elder Lawyers (NAELA). Each case was filed as an affirmative action seeking to…

Continuity of Care in MassHealth Managed Care after March 1, 2018

Office of Medicaid and Others
March 1, 2018 over 1 million members will be moving to new kinds of health plans. This affects individual under age 65 with MassHealth as their only coverage. Individuals should have received notice of the change from MassHealth and their new plans. There are protections in place to try to avoid…