§ 9A — MassHealth; beneficiaries; eligibility; payment; information applications

Section 9A. (1) As used in this section and in section nine B, the following words shall have the following meanings:''Beneficiary'', a person who, pursuant to eligibility criteria established by the terms and conditions of a demonstration project and regulations promulgated by the division, is determined to be eligible for medical benefits pursuant to this section.''Demonstration project'', (i) a program of medical benefits approved by the Secretary pursuant to section 1115(a) of the Social Security Act, 42 USC Section 1315(a) or any other federal waiver or demonstration authority; or (ii) a project approved by said secretary for which federal reimbursement is available pursuant to any successor to Title XIX if such project is similar to any such project approved or which would be approved under said section 1115(a), meets their requirements for a demonstration project established by this section and is implemented pursuant to a plan filed with the joint committee on health care and the house and senate committees on ways and means sixty days prior to implementation.''Children's and Seniors' Health Care Assistance Fund'', the fund established by section two FF of chapter twenty-nine intended to wholly support the costs of medical benefits and administration for expansion beneficiaries under the demonstration project and a pilot program of pharmaceutical assistance for the elderly.''Program of health care assistance'', programs of full or partial medical care funded wholly by the commonwealth for which the demonstration project seeks federal reimbursement.''MassHealth'', a program of full or partial medical benefits provided under the demonstration project as authorized by this section.''Medical benefits'', health care services including managed care programs, provided to beneficiaries pursuant to the terms and conditions of a demonstration project and regulations promulgated by the division and including, but not limited to, assistance with premiums and costs sharing and medical insurance purchased for beneficiaries pursuant to section 18 or benefits authorized by 42 U.S.C. section 1396e.(2) The division may, subject to appropriation and the provisions of section nine B, implement MassHealth in accordance with the terms and conditions of a demonstration project, notwithstanding the provisions of any other section of this chapter. MassHealth may provide a program or programs of medical benefits to one or more of the beneficiary categories described in the following clauses:(a) children and adults who, in the absence of a demonstration project, would be otherwise eligible for medical assistance pursuant to section nine;(b) infants to age 1 and pregnant women whose financial eligibility, as determined by the division, does not exceed 200 per cent of the federal poverty level and children and adolescents aged 1 to 20 years, inclusive, whose financial eligibility, as determined by the division, does not exceed 150 per cent of the federal poverty level.(c) children and adolescents, from birth to 18 years, inclusive, whose financial eligibility as determined by the division exceeds 133 per cent but is not more than 300 per cent of the federal poverty level, including such children and adolescents made eligible for medical benefits under this chapter by Title XXI of the Social Security Act.(d) persons aged 21 to 64, inclusive, whose financial eligibility, as determined by the division, does not exceed 133 per cent of the federal poverty level; provided, however, that such persons shall meet such other eligibility criteria that the division and the secretary may establish.(e) persons who are disabled, blind or chronically ill and eligible for benefits under the provisions of sections 16 and 16A.(f) persons receiving, or eligible to receive, unemployment insurance benefits who meet the eligibility requirements established under MassHealth and who, in the absence of a demonstration project, would otherwise qualify for the health insurance program established pursuant to subsection (1) of section fourteen G of chapter one hundred and fifty-one A;[Clause (g) of subsection (2) effective until April 1, 2003. For text effective April 1, 2003, see below.]

(g) persons who are not receiving unemployment insurance benefits and who are not eligible for medical assistance but who are determined by the division to be long-term unemployed, out of the labor force, provided, however, that such persons meet the eligibility requirements established under MassHealth; provided, further, that such eligibility requirements shall not exclude from eligibility persons who are employed intermittently or on a non-regular basis;

[Clause (g) of subsection (2) as amended by 2002, 184, Sec. 95 effective April 1, 2003, provided that the secretary of the United States Department of Health and Human Services has approved an amendment to the demonstration waiver, as approved pursuant to 42 U.S.C. § 1315(a) and authorized by 1996, 203, incorporating the provision of 118E:9A(2)(g), as amended by 2002, 184, Sec. 95. See 2002, 184, Sec. 244. For text effective until April 1, 2003, see above.]

(g) persons who: (i) are recipients of emergency assistance to the elderly, disabled, and children; or (ii) persons who are determined by the commissioner of the department of mental health to be classified as clients of the department of mental health; provided that such persons meet the eligibility requirements established under MassHealth and that their financial eligibility as determined by the division does not exceed 100 per cent of the poverty level.

(h) persons who would be eligible for financial or medical assistance under the foregoing clauses, but for income or resources, except where the terms and conditions of the demonstration project provide for more restrictive or less restrictive eligibility criteria, including the payment of premiums as a condition of eligibility; provided, however, that the division shall not establish disability criteria for applicants or recipients which are more restrictive than the criteria authorized by Title XVI of the Social Security Act, 42 U.S.C. 1381 et seq.

(i) persons who have tested positive for the human immunodeficiency virus whose financial eligibility as determined by the division does not exceed 200 per cent of the federal poverty level.

(j) premium assistance for employer sponsored health insurance for adults whose financial eligibility, as determined by the division, does not exceed 300 per cent of the federal poverty level, are uninsured at the time of application, are not eligible for any other program under this chapter and are not eligible for federal advanced premium tax credits through the health connector because they have access to employer sponsored minimum essential coverage as defined in section 1401 of the Patient Protection and Affordable Care Act, Public Law 111–148, as amended from time to time.

(k) persons under the age of 26 years who, on the date of attaining 18 years of age, were enrolled in foster care or in the care and custody of the department of children and families; provided, however, that such persons shall be enrolled to receive benefits under this section without any interruption in coverage; provided further, that the division shall develop and implement a simplified redetermination form for such persons; and provided further, that a beneficiary under this section shall only be required to complete and return such a form if information known to the division is no longer accurate or is materially incomplete.

(3) The division may, consistent with the terms and conditions of the demonstration project, deny MassHealth eligibility to persons who would otherwise qualify for a program of medical benefits pursuant to clause (c) of subsection 2 who were enrolled in a health insurance plan not administered by the state or federal government at any time during the eighteen months prior to applying to MassHealth, and may deny MassHealth eligibility to persons in any or all of eligibility categories as set forth in clauses (a) to (i), inclusive, who: (i) at the time of application, are eligible for health insurance, or (ii) do not meet citizenship or residency requirements established by the division, provided that any person whose residency in the commonwealth was established solely for the purpose of seeking medical benefits shall not be eligible for MassHealth.

(4) The terms and conditions of a demonstration project shall provide that the division may, for any and all beneficiary categories, vary the amount, duration, and scope of medical benefits, establish differing managed care options, and restrict the freedom of beneficiaries to choose health care providers.

(5) Medical benefits provided by MassHealth to school-aged children and adolescents shall, as much as reasonably practical, be provided by school-based clinics.

(6) The division shall not eliminate retroactive eligibility for applicants over the age of sixty-five or for institutionalized applicants or applicants who have been hospitalized for more than twenty days or who have been resident in a nursing home for more than thirty days.

(7) The provisions of Title XIX shall remain applicable to MassHealth except as waived or supplemented by the secretary under the terms and conditions of a demonstration project.

(8) Consistent with the provisions of Title XIX and any waiver authority therein, the division may establish premium and copayment amounts for beneficiaries of MassHealth. Said premiums and copayments may be established on a sliding scale commensurate with beneficiary income levels. The division may waive premiums and copayments upon a finding of substantial financial or medical hardship.

(9) Unless explicitly provided under a demonstration project, nothing in this section shall be construed as requiring direct payment of any kind to any beneficiary. The division may make such direct payment, as it deems necessary, to (i) pay for covered medical benefits received between the date of effective eligibility and, if later, the date of determination of eligibility, (ii) correct errors made by the division, or (iii) comply with a court order; provided, that the division may, in lieu of cash payments, issue to individuals vouchers or other documents certifying that the division will pay a specified amount for health insurance under specified circumstances.

(10) If, during the term of a demonstration project, the division proposes modifications to MassHealth which would require approval by the secretary, the division may implement said modifications upon the secretary's approval, subject to the terms of that approval, and the enactment of authorizing legislation, if required.

(11) The division may implement provisions of a demonstration project through arrangements with other agencies of the commonwealth, including agencies that administered programs of health care assistance prior to implementation of the demonstration project, provided, that the division shall have final authority over all policies and procedures pertaining to the administration of the demonstration project. Such agencies shall furnish any information and data pertaining to MassHealth programs, providers, health insurers and beneficiaries deemed necessary by the commissioner to implement and monitor MassHealth. Upon the termination of the demonstration project, authority ceded to the division for the administration of MassHealth shall revert to such other agencies as provided by law.

(12) The division shall maintain comprehensive information on MassHealth medical benefits and eligibility requirements and shall make applications readily accessible to persons eligible for said benefits at a reasonable number of locations throughout the commonwealth. Said locations shall be equipped to provide all required eligibility information, benefit schedules and limitations, application forms and other information associated with remaining eligible for MassHealth. The division shall, whenever possible, utilize one standard application form and procedure for all MassHealth services and programs. Applicants who do not meet the eligibility requirements of a program for which they apply shall be informed of other programs for which they may qualify and be provided with all necessary forms and information required for such other programs. The division, when arranging for the implementation of programs with other agencies of the commonwealth, shall ensure that such other agencies meet the intent of this paragraph.

(13) Eligibility for and the medical benefits provided by MassHealth shall not give rise to nor be construed as giving rise to enforceable legal rights for any party or an enforceable entitlement to such eligibility or medical benefits other than to the extent that such rights or entitlements exist pursuant to the regulations of the division or the terms and conditions of a demonstration project.

(14) The terms and conditions of a demonstration project shall not establish any rights or entitlements that exceed the rights or entitlements established by Title XIX in the absence of the demonstration project, or impose any obligations upon the commonwealth's administration or financing because of implementation of MassHealth which is in excess of the obligations established by Title XIX for the state Medicaid program in the absence of the demonstration project. The commissioner shall, prior to the initial implementation of MassHealth, certify to the secretary of administration and finance and the house and senate committees on ways and means that no such terms, conditions or obligations have been established by the demonstration project that would violate the provisions of this paragraph.

(15) Pursuant to section 8B of chapter 62C, the office of Medicaid shall provide written statements to residents of the commonwealth for whom creditable coverage is provided and shall provide a separate report verifying those statements to the commissioner of revenue.

(16) The division shall enroll MassHealth members in available employer-sponsored health insurance if that insurance meets the criteria for MassHealth payment of premium assistance and if federal approval will be obtained to ensure federal reimbursement for premium assistance for that insurance.