Reimbursement of Certain Out-of-pocket Medical Expenses

(A) Eligibility Requirements. The following Standard coverage members are entitled to reimbursement for certain medical expenses for which they paid, subject to the provisions of 130 CMR 515.015: (1) an individual who (a) applied for Supplemental Security Income (SSI); (b) was denied SSI benefits by the Social Security Administration (SSA); and (c) had their initial SSA denial overturned through a reconsideration process, administrative hearing, appeals counsel review, federal court review, or reopening under the SSA rules on administrative finality; or (2) an individual who (a) applied for MassHealth; (b) was denied MassHealth; and (c) had their initial denial overturned by a subsequent decision, MassHealth, the fair hearing process, or the judicial review process. (B) Limitations (1) Reimbursement is limited to bills incurred on or after the coverage start date for the applicable coverage type as described in 130 CMR 519.000: MassHealth: Coverage Types and paid between the date of the erroneous eligibility decision and the date on which the member is notified of MassHealth eligibility. The bill must have been paid by the member, the member's spouse, the parent of a member, or a legal guardian. (2) Reimbursement is also limited to amounts actually paid for care or services that would have been covered under MassHealth had eligibility been determined correctly, even if these amounts exceed the MassHealth rate. Before reimbursing a member for care or services that would have required prior authorization, MassHealth may require submission of medical evidence for consideration under the prior-authorization standards. Reimbursement is available even if the medical care or services were furnished by a provider who does not participate in MassHealth. (C) Verification (1) Applicants or members seeking reimbursement must provide MassHealth with (a) a bill for medical services that includes 1. the provider's name; 2. a description of the services provided; and 3. the date the service was provided; and (b) proof of payment of the bill presented, such as a canceled check or receipt. (2) Recipients of SSI must also provide documents from the SSA establishing the date of application and the date of application denial.