Current through Register 1531, September 27, 2024
(A)
Overview.
(1)
130
CMR 505.008 contains the categorical
requirements and financial standards for MassHealth CarePlus. This coverage
type provides coverage to adults 21 through 64 years of age.
(2) Persons eligible for MassHealth CarePlus
Direct Coverage are eligible for medical benefits, as described in
130
CMR 450.105(B):
MassHealth CarePlus and 130 CMR 508.000:
Health Care
Reform: MassHealth: Managed Care Requirements and must meet the
following conditions.
(a) The individual is
an adult 21 through 64 years of age.
(b) The individual is a citizen, as described
in 130 CMR 504.002: U.S.
Citizens, or a qualified noncitizen, as described in
130
CMR 504.003(A)(1):
Qualified Noncitizens.
(c) The individual's modified adjusted gross
income of the MassHealth MAGI household is less than or equal to 133% of the
federal poverty level.
(d) The
individual is ineligible for MassHealth Standard.
(e) The adult complies with
130
CMR 505.008(C).
(f) The individual is not enrolled in or
eligible for Medicare Parts A or B.
(B)
Eligibility Requirements for
Certain EAEDC Recipients.
(1)
Eligibility Requirements. Certain EAEDC recipients are
eligible for CarePlus if
(a) the individual is
an adult 21 through 64 years of age;
(b) the individual receives EAEDC cash
assistance; and
(c) the individual
is a citizen, as described in
130
CMR 504.002: U.S. Citizens,
or a qualified noncitizen, as described in
130
CMR 504.003(A)(1):
Qualified Noncitizens.
(2)
Eligibility End
Date. Individuals whose EAEDC cash assistance ends and who are
determined to be potentially eligible for MassHealth continue to receive
medical benefits under MassHealth CarePlus until a determination of
ineligibility is made by the MassHealth agency.
(C)
Use of Potential Health
Insurance Benefits. All applicants and members must use potential
health insurance benefits in accordance with
130
CMR 503.007: Potential Sources of
Health Care and must enroll in health insurance, if available at no
greater cost to the applicant or member than he or she would pay without access
to health insurance, or if purchased by MassHealth in accordance with
130
CMR 505.008(D) or
506.012: Premium
Assistance Payments. Members must access those other health insurance
benefits and must show both their private health insurance card and their
MassHealth card to providers at the time services are provided
(D)
Access to Employer-sponsored
Insurance and Premium Assistance Investigations for Individuals Who Are
Eligible for MassHealth CarePlus.
(1) MassHealth may perform an investigation
to determine if individuals receiving MassHealth CarePlus have
(a) health insurance that MassHealth can help
pay for; or
(b) access to
employer-sponsored insurance that MassHealth wants the individual to enroll and
for which MassHealth will help pay.
1.
Investigations for Individuals Who Are Enrolled in Health
Insurance. If MassHealth determines that the health insurance the
individual is enrolled in meets the criteria at
130
CMR 506.012: Premium Assistance
Payments, the individual is notified in writing that MassHealth will
provide MassHealth CarePlus Premium Assistance Payments as described at
130
CMR 506.012: Premium Assistance
Payments. If MassHealth determines that the health insurance the
individual is enrolled in does not meet the criteria at
130
CMR 506.012: Premium Assistance
Payments, the individual is eligible for MassHealth CarePlus Direct
Coverage.
2.
Investigations for Individuals Who Have Potential Access to
Employer-sponsored Health Insurance. If MassHealth determines the
individual does not have access to employer- sponsored insurance and the
employer is contributing at least 50% of the premium cost and the insurance
meets all other criteria described in
130
CMR 506.012: Premium Assistance
Payments, the individual is notified in writing that they must enroll
in this employer-sponsored coverage. MassHealth will allow the individual up to
60 days to enroll in this coverage. Once enrolled in the health insurance plan,
MassHealth will provide MassHealth CarePlus Premium Assistance Payments as
described in
130
CMR 506.012. Failure to enroll in the
employer-sponsored health insurance plan at the request of MassHealth will
result in loss or denial of eligibility for all individuals.
(2) If MassHealth
determines the individual does not have access to employer-sponsored insurance,
the individual continues to be eligible for MassHealth CarePlus.
(E)
MassHealth
CarePlus Coverage Begin Date.
(1)
The MassHealth CarePlus coverage start date is described at
130
CMR 502.006: Coverage Dates,
except as described at
130
CMR 505.008(E)(2).
(2) Provisional eligibility is described in
130
CMR 502.003(E):
Provisional Eligibility.
(F)
Medically Frail.
If an individual is determined medically frail or is an individual with special
medical needs and has been determined to meet the eligibility criteria for
MassHealth CarePlus as described in
130
CMR 505.008, the individual may elect at any
time to receive MassHealth Standard benefits, as described in
130
CMR 505.002(J). If at any
time after enrolling in MassHealth CarePlus an individual becomes medically
frail or is determined to be medically frail, the individual may elect to
receive MassHealth Standard benefits. The effective date of MassHealth Standard
is the date of the reported change. To be considered medically frail or a
person with special medical needs, an individual must be
(1) an individual with a disabling mental
disorder (including children with serious emotional disturbances and adults
with serious mental illness);
(2)
an individual with a chronic substance use disorder;
(3) an individual with a serious and complex
medical condition;
(4) an
individual with a physical, intellectual, or developmental disability that
significantly impairs their / ability to perform one or more activities of
daily living; or
(5) an individual
with a disability determination based on Social Security criteria.
