Code of Massachusetts Regulations
130 CMR - DIVISION OF MEDICAL ASSISTANCE
Title 130 CMR 501.000 - Health Care Reform: MassHealth: General Policies
Section 501.015 - Reimbursement of Certain Out-of-pocket Medical Expenses
Universal Citation: 130 MA Code of Regs 130.501
Current through Register 1531, September 27, 2024
(A) Eligibility Requirements. The following persons will be entitled to reimbursement for certain medical expenses for which they paid, subject to the provisions of 130 CMR 501.015.
(1) A member who
(a) applied for SSI;
(b) was denied SSI benefits by the Social
Security Administration; and
(c)
had their initial Social Security Administration denial overturned through a
reconsideration process, administrative hearing, appeals counsel review,
federal court review, or reopening under the Social Security Administration
rules on administrative finality.
(2) A member who
(a) applied for TAFDC or
MassHealth;
(b) was denied TAFDC by
the Department of Transitional Assistance, or was denied MassHealth by the
MassHealth agency; and
(c) had
their initial denial overturned by a subsequent decision by DTA, the MassHealth
agency, 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 505.000, 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, the MassHealth agency
may require submission of medical evidence for consideration under the prior
authorization standards. Reimbursement is available even though 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 Social Security Administration
establishing the date of application and the date of application
denial.
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