Purpose

(A) MassHealth Determinations. (1) 130 CMR 610.000 sets out the process for requesting and participating in a fair hearing that allows dissatisfied applicants, members, or nursing facility residents to have administrative review of certain actions or inactions on the part of the MassHealth agency and of determinations by a MassHealth managed care contractor. (2) Such actions include, but are not limited to, determinations of eligibility for MassHealth Standard, MassHealth CommonHealth, MassHealth Family Assistance, MassHealth Limited, MassHealth Senior Buy-In, MassHealth Buy-In, MassHealth CarePlus, MassHealth Small Business Employee Premium Assistance, Children’s Medical Security Plan , Refugee Resettlement Program, low-income subsidies under Medicare Part D (as set forth in the Medicare Prescription Drug and Improvement and Modernization Act of 2003, as described in federal regulations 42 CFR Part 423, Subpart P), and requests for services that require prior authorization. (B) Other Determinations. 130 CMR 610.000 also contains rules for nursing facility residents who want to appeal a discharge, transfer, or failure to readmit initiated by a nursing facility 130 CMR 610.000 contains provisions for individuals seeking an appeal of federally mandated Preadmission Screening and Resident Review (PASRR) determinations.