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MassHealth Annette Shea Director of Disability Policy and Home and Community Based Waiver Oversight Executive Office of Health and Human Services Office.

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Presentation on theme: "MassHealth Annette Shea Director of Disability Policy and Home and Community Based Waiver Oversight Executive Office of Health and Human Services Office."— Presentation transcript:

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2 MassHealth Annette Shea Director of Disability Policy and Home and Community Based Waiver Oversight Executive Office of Health and Human Services Office of Medicaid

3 Provide an overview of MassHealth Including benefit plans and eligibility requirements Provide an overview of the Home and Community Based Waiver Program for individuals with Mental Retardation Answer questions Goal of Today’s Presentation

4 Examples:MassHealth Coverage Types MH Standard MH CommonHealth MH Family Assistance MH Basic MH Essential MH Limited MH Prenatal Parents, children,pregnant women,disabled,caretaker relative,seniors Disabled adults,disabled children,disabled working adults Parents, children, HIV+,families with access to a qualified employers insurance EAEDC recipients,DMH recipients Long term unemployed adults Emergency services to people, who under federal law, have an immigration status that limits other services Pregnant time limited benefit, Missing information

5 Person Federal Poverty Level Coverage Type Children under 19 years of age 300% Standard/Family Asst. Pregnant women 200% Standard/Family Asst/Limited Person HIV positive 200% Family Assistance Disabled Adult 133% Standard/CommonHealth/Limited Disabled Working Adults No Income Limit CommonHealth/Limited Disabled Child No income limit Standard/CommonHealth/Fam. Asst/Limited Parents 133% Standard/CommonHealth/Limited Caretaker Relative 133% Standard/Limited Long-term unemployed with DMH services 100% Basic People 65 years of age and older 100% Standard/Essential/Limited EA/EDC- Transitional Assistance 100% Basic Long Term Unemployed 100% Essential Women’s Breast & Cervical Cancer 250% Standard Who is eligible?

6 Examples of Covered Services Inpatient Hospitalization Outpatient Services Medical Services Mental Health and Substance Abuse Services Well Child Screenings Transportation Services Rx Drugs  Different coverage types allow for different covered services. You should read the MassHealth booklet or call MassHealth Customer Service ( ) for correct information regarding your coverage

7 Prior Authorization Contact Number Prior Authorization or

8 Effective 4/2006

9 Determination: Social Security Administration; Mass. Commission for the Blind; Disability Evaluation Service Disability Evaluation Completion of Supplement: When not deemed disabled by either the Social Security Administration or Mass. Commission for the Blind Disability Supplement: Must include: signed completed form signed medical release forms accurate and current medical information that you had received or are receiving information such as, vocational, educational and current daily activities

10 Immigration Status MassHealth looks at citizenship and immigration status to determine what coverage type someone may be eligible for. Citizens (born in the U.S. and naturalized) are eligible for any coverage type that they meet the other categorical requirements for. Legal Permanent Residents are eligible for any coverage type that they meet the other categorical requirements for with one additional requirement. If entered the country after , they must have been in this country for at least 5 years to be eligible for standard coverage. Qualified Aliens are people who entered the country with a certain immigration status. For a listing of these status’s refer to the MassHealth Member Booklet or visit the web site - Current Members Eligibility Regulations section (B).

11 Immigration Status StatusImmigration Status Potential Coverage Type CitizenNot applicable (As of 7/1/06 need to show proof) All coverage types Except Limited Qualified AliensLPR, entered the country before 8/22/1996 or after and satisfied 5 yr bar All coverage types except Limited Protected AliensEligible for Medicaid or CommonHealth or applied for LTC as of June 30,1997 MassHealth Standard or CommonHealth Special Status AlienLPR, or other recognized status which the individual entered the U. S. after 8/22/1996 subject to 5 yr bar Limited/ Potential for Essential (6/1/04)-Adults Under 65 Disability Over 65 Immigration Status Children under 19 Potential/ Family Assistance, Commonhealth, Limited Non-Qualified AlienVisitors visa, no statusLimited Only

12 MassHealth Coverage Types for People with Disabilities Any Massachusetts resident under 65 with a disability is eligible for MassHealth. Coverage type is based on income. Sliding scale premiums may apply. MassHealth Standard financial eligibility is income up to 133% of the federal poverty level (FPL). –Sliding scale premiums applies to those with monthly household income above 114% FPL –Also, those individuals enrolled on the home and community based waiver with income up to 300% SSI FBR are consider MH Standard members MassHealth CommonHealth for children and adults has no income limit and no asset test. –Income-based sliding scale premiums apply –One-time needs test applies to non-working adults with disabilities with monthly income over 133% FPL

13 Appeals Every member has the right to an appeal a decision made by the Division The appeal must be filed in a timely manner. The form to appeal is on the back of the division’s notice. Or a member may obtain a “Request for a Fair Hearing” form. Some members may be entitled to aid pending until their appeal is heard. Mail your appeal request form to the Board of Hearings at 2 Boylston St., Boston, MA or fax to (617) Questions about a notice or how to ask for an appeal should be directed to a MassHealth Enrollment center at

14 Hardship Waiver of Premiums

15 How will Health Care Reform affect MassHealth Coverage? Family Assistance for children expanded to 300% FPL via SCHIP expansion Increases enrollment caps for the Family Assistance/HIV, CommonHealth, and Essential Programs Restores optional benefits to 2002 levels and expands MassHealth services Creates a Two Year Tobacco Cessation Program for MassHealth members of any age Increases the Insurance Partnership program eligibility to 300% FPL Prohibits changes to disability eligibility criteria

16 Health Care Reform Dental Services Vision Services Chiropractor Services Orthotics Prosthetics Certain 24 hour substance abuse treatment services Acute hospital inpatient administratively necessary days Tobacco Cessation Services for Members of Any Age

17 Federal Deficit Reduction Act 2005 (DRA) President Bush signed into law February 8, 2005 the (DRA) in an effort to control federal spending All states are required to comply with new (DRA) provisions The (DRA) impacts MassHealth by: requiring citizenship and identity documentation changing MassHealth regulations for long term care applicants

18 DRA Citizenship and Identity Requirements Effective July 1, 2006 acceptable documentation of U.S. Citizenship/National status will be required. (MassHealth can no longer accept self-declaration) New applicants and current MassHealth members will be required to verify citizenship and identity on or after July 1, 2006  Documented immigrants will continue to verify their immigration status  Medicare/SSI beneficiaries are exempt from verification process (citizenship has already been verified)

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20 MassHealth Applications & Member Booklets Applications come in English and Spanish Available at MEC Member booklets available in 8 languages Cambodian, Chinese, Haitian Creole, Laotian, Portuguese, Russian, Spanish, and Vietnamese Booklets can be obtained by calling the MassHealth Customer Service line,

21 MassHealth Applications: Who needs to apply? SSI recipients do not need to apply for MassHealth benefits. As an SSI recipient they are automatically enrolled SSDI recipients do need to submit an application to MassHealth in order to be enrolled and receive MassHealth benefits –When someone is transitioning from SSI benefits they will receive written notification from MassHealth requesting the member submit an application if interested

22 MASSHEALTH ENROLLMENT CENTER 300 OCEAN AVE, SUITE BRIDGE STREET REVERE, MA SPRINGFIELD, MA FAX: FAX: TTY: TTY: MASSHEALTH ENROLLMENT CENTER 21 SPRING ST, SUITE EAST ST. TAUNTON, MA TEWKSBURY, MA FAX: FAX: TTY: TTY: NEW APPLICATIONS Central Processing Unit P.O.Box Charlestown, Ma MASSHEALTH APPLICATION STATUS OR MEMBER ELIGIBILITY For More Information MassHealth Enrollment Centers

23 Home and Community Based Service Waivers The HCBSW program was established by Section 2176 of the Omnibus Budget Reconciliation Act of 1981 and was incorporated into the Social Security Act at Section 1915 (c). Under the HCBSW program states can elect to furnish under Medicaid as an alternative to institutional care a broad array of services (excluding room and board) that are not otherwise covered under the Medicaid program.

24 MRDD Waiver More than 11,000 DMR-supported adults utilize this waiver annually as a community alternative to an Intermediate Care Facility for the Mentally Retarded Critical services provided through this waiver include: –Residential Supports –Employment Supports –Respite –Individual and Family Supports –Transportation All Waiver enrollees also have access to Medicaid state plan services

25 Eligibility for Waiver Individuals at an ICF-MR level of care Income (earned or unearned) at or below 300% of SSI FBR (approximately 200% of the federal poverty level) Individual assets at or below $2000

26 MassHealth categories of assistance and waiver enrollment In order to be enrolled onto the waiver the recipient needs to determined to be eligible using “traditional Medicaid” rules –Those enrolled in MassHealth categories which do not ask for asset information are not automatically eligible. In order to be enrolled onto the waiver the individual must be re- determine using a long-term care application and traditional rules. –SSI recipients would automatically be eligible

27 Employment and MassHealth Can someone with a disability work and receive MassHealth benefits? YES Individuals with disabilities who work at least 40 hours or more each month and have income above 133% FPL are eligible for CommonHealth. The benefit package is the same as MH Standard (with the exception of a long- term nursing facility benefit). Sliding scale premiums apply based on income. If an individual with a disability has periods of employment and unemployment, would they lose benefits? Not necessarily When an individual has a change in status they should notify the MassHealth Enrollment Center (MEC). During unemployment if a person’s unearned income is at or below 133% of FPL then they should not experience an interruption in benefits. If the individual’s unearned income exceeds 133% of the FPL then they may be subject to a one-time spend down in order to maintain benefits. If an individual is receiving benefits as a CommonHealth Working member and they experience an interruption in employment they are eligible to maintain their CommonHealth enrollment up to 90 days as long as they continue to pay their monthly premium.

28 Employment and Waiver Enrollment Could someone work and be enrolled on the home and community based waiver? –Yes. If the person’s income continues to meet the income criteria (300% SSI FBR = approximately 200% FPL) for the waiver and their individual countable assets are at or below $2000 then they are eligible. If there is a question about a particular case then there may be revenue staff assigned to assist.

29 Contact information Annette Shea Director of Disability Policy and Home and Community Based Waiver Oversight Executive Office of Health and Human Services Office of Medicaid


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