Verification of Eligibility Factors

The MassHealth agency requires verification of eligibility factors including income, residency, citizenship, immigration status, and identity as described in 130 CMR 503.000: Health Care Reform: MassHealth: Universal Eligibility Requirements, 130 CMR 504.000: Health Care Reform: MassHealth: Citizenship and Immigration, and 130 CMR 506.000: Health Care Reform: MassHealth: Financial Requirements. (A) Information Matches. The MassHealth agency initiates information matches with other agencies and information sources as described at 130 CMR 502.004 in the following order, when an application is received in order to verify eligibility: (1) the Federal Data Services Hub, which matches with the Social Security Administration, the Department of Homeland Security, and the Internal Revenue Service; and (2) other federal and state agencies and other informational services. (B) Electronic Data Sources. If electronic data sources are unable to verify or are not reasonably compatible with the attested information, additional documentation will be required from the individual. (C) Request for Information Notice. If additional documentation is required, including corroborative information as described at 130 CMR 502.001(B), a Request for Information Notice will be sent to the applicant listing all requested verifications and the deadline for submission of the requested verifications. (D) Time Standards. The following time standards apply to the verification of eligibility factors. (1) The applicant or member has 90 days from the receipt of the Request for Information Notice to provide all requested verifications. (2) If the applicant or member fails to provide verification of information within 90 days of receipt of the MassHealth agency's request, the MassHealth agency does one of the following. (a) If the required information is available from electronic data sources, the MassHealth agency uses that information to redetermine eligibility. (b) If the required information is not available from electronic data sources, MassHealth coverage is denied or terminated except for individuals described at 130 CMR 502.001(D)(1) through (4). (c) If the required verifications are received within one year from the date of the application or renewal form was received, coverage is reinstated to the first day of the month in which the verifications were received. (d) If the required verifications are not received within one year of receipt of the previous application or renewal form, a new application must be completed. (E) Provisional Eligibility. The MassHealth agency will provide benefits while the applicant provides the MassHealth agency outstanding corroborative information in accordance with 130 CMR 502.003(D)(1), except for individuals described in 130 CMR 502.003(E)(2). Except as further set forth below, the MassHealth agency will accept self-attestation for all eligibility factors other than citizenship and immigration status, and make a provisional eligibility determination as if the applicant had supplied the information. MassHealth applicants can receive only one provisional eligibility approval during a 12-month period, unless the individual is pregnant. MassHealth members are required to enroll in managed care during the provisional eligibility period, if enrollment is otherwise required as described in 130 CMR 508.004: Managed Care Organizations (MCOs). MassHealth members who have been assessed a premium are subject to payment of premiums during the provisional eligibility period. Premium assistance is not awarded during the provisional eligibility period. It is only provided when all corroborative information has been received and the health insurance investigation is complete, as described in 130 CMR 505.000: Health Care Reform: MassHealth: Coverage Types. Provisional eligibility is subject to the following limitations. (1) Coverage Date. (a) Coverage for individuals who have been determined provisionally eligible begins on the first day of the month in which the application was received. (b) If all required verifications are received before the end of the provisional eligibility period, retroactive coverage is provided under 130 CMR 502.006(A)(2). (2) Limitations. Provisional eligibility is subject to the following limitations. (a) Provisional eligibility is not available for adults 21 years of age or older who have not verified all income in their MAGI household, as described at 130 CMR 506.000: Health Care Reform: MassHealth: Financial Requirements, unless the individual is 1. pregnant and has attested MAGI income at or below 200% of the federal poverty level (FPL); 2. 21 through 64 years old and HIV-positive with attested MAGI income at or below 200% of the FPL; or 3. in active treatment for breast or cervical cancer and is younger than 65 years old with attested MAGI income at or below 250% of the FPL. (b) The MassHealth agency will not accept self-attestation of disability. Disability must be verified as described in 130 CMR 505.002(E)(1): Disabled Adults. Eligibility for applicants who apply for benefits based on disability will be determined as if they were not disabled until disability is verified as described in 130 CMR 505.002(E)(1): Disabled Adults. (c) A member’s coverage type will not be redetermined during the provisional eligibility period, except that members granted provisional eligibility who attest to pregnancy will be enrolled in MassHealth Standard. (F) Reasonable Opportunity to Verify Citizenship and Identity or Immigration Status. The MassHealth agency provides applicants and members a reasonable opportunity period to provide satisfactory documentary evidence of citizenship and identity or immigration status if MassHealth’s electronic data matches are unable to verify the applicant’s citizenship or immigration status. (1) Time Standards. The reasonable period begins on, and extends 90 days from, the date on which an applicant or member receives a reasonable opportunity notice. (2) Coverage Start Date. (a) Coverage for individuals who are pregnant and children younger than 19 years old who receive a reasonable-opportunity period will begin as follows. 1. If covered medical services were received during such period, and the individual would have been eligible at the time services were provided, the start date of coverage is determined upon receipt of the application and may be retroactive to the first day of the third calendar month before the month of application except as specified in 130 CMR 502.006(C). 2. If covered medical services were not received during such period, or the individual would not have been eligible at the time services were provided, the start date of coverage is determined upon receipt of the application and coverage begins on the first day of the month in which the application was received , except as specified in 130 CMR 502.006(C). (b) Coverage for all other individuals who receive a reasonable-opportunity period begins on the first day of the month in which the application was received. (c) If satisfactory documentary evidence of citizenship and identity or immigration status is received before the end of the reasonable-opportunity period, retroactive coverage is provided in accordance with 130 CMR 502.006(A)(2). (G) Reasonable Opportunity Extension. Applicants or members who have made a good faith effort to resolve inconsistencies or obtain verification of immigration status may receive a 90-day extension. Requests for a reasonable opportunity extension must be made before the expiration of the verification time period. (H) Hospital-determined Presumptive Eligibility. (1) Presumptive Eligibility Determinations. A qualified hospital may make presumptive eligibility determinations for its patients in accordance with 130 CMR 450.110: Hospital- determined Presumptive Eligibility. Presumptive eligibility will be determined based on attested information. The MassHealth agency will use estimated gross household income rather than MassHealth MAGI to assess whether the financial requirements described below have been met. The qualified hospital may determine presumptive eligibility for the following: (a) MassHealth Standard if the individual appears to meet categorical and financial requirements in 130 CMR 505.002: MassHealth Standard and the individual is 1. a child younger than one year old; 2. a child one through 18 years old; 3. a young adult 19 through 20 years old; 4. pregnant; 5. a parent or caretaker relative; 6. an individual with breast or cervical cancer; 7. an individual who is HIV positive; or 8. an independent foster care adolescent up to 26 years old; (b) MassHealth CarePlus if the individual appears to meet categorical and financial requirements in 130 CMR 505.008: MassHealth CarePlus and the individual is an adult 21 through 64 years old; (c) MassHealth Family Assistance if the individual appears to meet categorical and financial requirements in 130 CMR 505.005(C): Eligibility Requirements for Children and Young Adults Who Are Nonqualified PRUCOLs with Modified Adjusted Gross Income of the MassHealth MAGI Household at or below 150% of the Federal Poverty Level or 130 CMR 505.005(E): Eligibility Requirement for HIV-Positive Individuals Who Are Citizens or Qualified Noncitizens with Modified Adjusted Gross Income of the MassHealth MAGI Household Greater than 133 and Less than or Equal to 200% of the Federal Poverty Level and is 1. a child or a young adult who is a nonqualified PRUCOL as described in 130 CMR 504.003(C): Nonqualified Persons Residing under Color of Law (Nonqualified PRUCOLs); or 2. an individual who is HIV positive; or (d) MassHealth CommonHealth if the individual appears to meet categorical and financial requirements in 130 CMR 505.004: MassHealth CommonHealth for disabled children younger than 20 years old. (2) Coverage Start Date. Benefits provided through the hospital presumptive eligibility process will begin on the date that the hospital determines presumptive eligibility and will continue until (a) the end of the month following the month in which the hospital determined presumptive eligibility, if the individual has not submitted a complete application as described in 130 CMR 502.001 by that date; or (b) an eligibility determination is made based upon the individual’s submission of a complete application as described in 130 CMR 502.001, if the complete application was submitted before the end of the month following the month of the hospital-presumptive eligibility determination. (3) Premium Assessment. Individuals who are determined eligible through hospital- determined presumptive eligibility will not be assessed a premium. Premium assistance is not awarded during the presumptive eligibility period. (4) Continued Eligibility. The individual must submit a complete application as described in 130 CMR 502.001 to determine continued eligibility for MassHealth. (I) Verification Exceptions for Special Circumstances. Except with respect to the verification of citizenship and immigration status, the MassHealth agency will permit, on a case-by-case basis, self-attestation of individuals for all eligibility criteria when documentation does not exist at the time of application or renewal, or is not reasonably available, such as in the case of individuals who are homeless or have experienced domestic violence or a natural disaster.