The Online Resource for Massachusetts Poverty Law Advocates

MassHealth: Children's Issues Series

Date: 
01/25/2016
Author: 
MLRI

For which MassHealth Program(s) is my child eligible?

See http://aspe.hhs.gov/poverty/index.cfm for the 2015 Federal Poverty Level guidelines.  See http://www.masslegalservices.org/content/new-income-chart-masshealth-open-enrollment-beginning-january-2016 for current Poverty Level Guidelines in MassHealth

*Children who receive TAFDC, Emergency Aid for Elders, Disabled and Children (EAEDC) or Supplemental Security Income (SSI) benefits, are automatically enrolled in MassHealth Standard.

 

MassHealth Program

Family Income % of Federal Poverty Line (FPL)

Other Eligibility Criteria

Qualifies for Early Periodic Screening Diagnosis and Treatment (EPSDT)?

Standard

150% of FPL or less for child age 1-21;

200% of FPL or less for child under age 1

-Family income is not counted for some children clinically eligible for nursing facility care

-Youth in cutody of DCF at age 18 remain eligible regardless of income until age 21

-Citizenship or lawful presence

-May have other insurance

-No disability determination necessary

Yes

Family Assistance

Between 150% and 300%

-Citizenship or lawful presence

-No disability determination necessary

-If access to employer insurance – premium assistance

-If no access to insurance – charged premium for MassHealth

No

CommonHealth

More than 150%

-Citizenship or lawful presence

-May have other insurance

-Must have disability determination

Yes

Limited

150% or less

-No eligible immigration status

No

Children’s Medical Security Plan

No upper income limit but charged full cost over 400% FPL

-No access to other health insurance

-Not eligible for any MassHealth program (except Limited)

No

What is MassHealth Standard?

MassHealth Standard offers a full range of health-care benefits including dental care. Children can receive comprehensive health services from MassHealth Standard if they are United States citizens or immigrants lawfully residing in the U.S., and meet the income criteria. There are no copays or deductibles for children’s coverage in any MassHealth program, and no premiums for children in MassHealth Standard.

What is CommonHealth?

CommonHealth provides comprehensive health services to children with disabilities who are not eligible for MassHealth Standard because they have a family income that is over 150% of the Federal Poverty Line. CommonHealth can be used to supplement health insurance that the family already has. There is no upper income ceiling for CommonHealth eligibility, but families will be charged  monthly premium based on income.  To be eligible a child must have a disability determination from SSA or MassHealth.

What is Family Assistance?

Family Assistance assists children in families who are not eligible for MassHealth Standard or CommonHealth. Family Assistance helps the family pay their share of employer-sponsored insurance premiums for family coverage that includes the children if the insurance is cost effective. 

If employer-sponsored insurance does not include dental, MassHealth will provide children’s dental coverage in addition to premium assistance.

If there is no cost effective employer insurance available, the children are enrolled into MassHealth coverage that is comprehensive but less extensive than MassHealth Standard or CommonHealth, and there is a premium charge. 

Depending on family income, the monthly premium is $12, $20, or $28 per child per month, with caps of $36, $60, and $84 for three or more children (2011).  The children’s premium is waived for any month in which parents are paying a premium for their own coverage in Connector Care.

What is MassHealth Limited?

MassHealth Limited pays for emergency medical services for children who are otherwise eligible for MassHealth Standard but do not have an eligible immigration status. Children eligible for MassHealth Limited will also be eligible for CMSP (see below).

What is MassHealth Premium Assistance?

Premium Assistance is a program that reimburses a family for some or all of the costs of purchasing private insurance coverage that covers an eligible child when private coverage is considered to be “cost-effective” by MassHealth. For children eligible for MassHealth Standard or CommonHealth, Premium Assistance will reimburse all the costs of private coverage and the child will still have full MassHealth benefits as “secondary” coverage. For children eligible for Family Assistance, MassHealth will reimburse only a portion of the costs of private coverage instead of providing full MassHealth coverage, but MassHealth dental benefits will still be covered.  The private coverage must meet minimum standards of cost and coverage in order to be considered cost-effective by MassHealth.

What is the Children’s Medical Security Plan (CMSP)?

CMSP provides primary and preventive medical and behavioral outpatient services to children who are not eligible for other MassHealth programs (because they are not citizens or lawfully present immigrants or because their family income is too high) and do not have access to any other health insurance. There are copays in CMSP, and also premium charges for children in families with income over 200% of poverty that increase to full cost when family income is over 400% of poverty. Families below 400% of poverty will also be eligible for full or partial Health Safety Net reimbursement at acute hospitals and health centers.

What is Early and Periodic Screening Diagnosis and Treatment (EPSDT)?

Children under the age of 21 (this include 19 and 20 year olds treated as adults for purposes of eligibility) who are determined eligible for MassHealth Standard or CommonHealth are also eligible for Early and Periodic Screening, Diagnosis and Treatment (“EPSDT”) services, which include all medically necessary services covered by Medicaid law.

MassHealth will pay for any medically necessary treatment that is provided for the eligible child by a qualified professional. If a service is not already covered by MassHealth, the prescribing healthcare provider can ask MassHealth for prior approval (“PA”) to determine if the service is medically necessary. MassHealth pays for the service if prior approval is given.

Through EPSDT MassHealth provides enhanced home and community based behavioral health services to children with serious mental illness under the Children’s Behavioral Health Initiative (CBHI). CBHI added 6 new behavioral health services including two new services, in-home therapy and mobile crisis intervention, which are also available to children and youth under age 21 in MassHealth Family Assistance, Basic and Essential.

For more information, see, Children’s Issue Series: Access to Home-Based Mental Health Services, http://www.masslegalservices.org/content/access-home-based-mental-health...

What is a “disability determination”?

MassHealth determines whether a child has a disability under the standards that were used to determine a childhood disability under the federal SSI program prior to its amendment in 1996. A medical review team gathers medical records and other relevant information from sources identified by the family in a questionnaire called the MassHealth Child Disability Supplement. A disability determination may take up to 90 days.  While awaiting a disability determination for CommonHealth, an uninsured child with family income over 150% of poverty may be enrolled in Family Assistance if family income is less than 300% of poverty or CMSP if family income is over 300% of poverty. No separate determination by MassHealth is needed for a child on SSI. 

How do I apply for MassHealth, CMSP, or CommonHealth for my child?

  1. You must fill out the Massachusetts Application for Health and Dental Coverage and Help Paying Costs (ACA-3) form. You can get the ACA-3 form in a several ways.
  1. Fill out the ACA-3   form
    • You will need to include all household members on the application. Tell us about all the household members who live with you. If you file taxes, we need to know about everyone on your tax return. You do not need to file taxes to get MassHealth.
    • Be sure to answer all questions on the application.

Navigators and Certified Application Counselors can help you apply for MassHealth.

These trained individuals can help you from application through enrollment and answer your questions. To find a Navigator or Certified Application Counselor organization near you, go to www.betterMAhealthconnector.org/get-help.

You can submit your completed application in any of the following ways.

If you mail your application at the post office, make sure to ask for a return receipt. This way you have proof that MassHealth got your application.

◆   The date MassHealth gets your application affects the date that MassHealth can pay for medical services if you are found eligible.

◆   Do not send more than one copy of your application. An application review can take up to 45 days. The extra paperwork will delay review.

◆   Keep a copy of everything you send for your records.

Call the MassHealth Customer Service Center at 1-800-841-2900 and apply over the phone (TTY:  1-800-497-4648).

If a family who has completed an ACA-3 form wants MassHealth to determine whether a child has a disability in order to be eligible for CommonHealth, the family should answer the questions on the MBR indicating that the child has a disability.  If the family is over-income for MassHealth Standard, they should then be sent a  MassHealth Child Disability Supplement along with Medical Release Forms that must be completed, signed and returned. The Disability Supplement and Medical Releases are now returned directly to the U. of Mass. Disability Evaluation Services at P.O.Box 2796, Worcester, MA 01613-2796. The Disability Supplment is available online at http://www.mass.gov/eohhs/docs/masshealth/appforms/mads-child.pdf (English) and http://www.mass.gov/eohhs/docs/masshealth/appforms/mads-child-spanish.pdf (Spanish)

How does a family appeal a denial of eligibility for MassHealth coverage?

MassHealth should make a decision within 45 days of receiving a completed application form or within 90 days if a disability determination is required.  The decision will be mailed to the head of household. If someone is denied eligibility, the notice will briefly explain why. The notice will also explain the right to appeal the decision within 30 days of the date of the notice and include a request for fair hearing form that can be used to file an appeal. Appeals should be faxed (and/or mailed) to the MassHealth Board of Hearings --not to the MassHealth Enrollment Center.

In the case of a notice terminating someone’s continuing eligibility for MassHealth, benefits will continue pending appeal IF the family files the appeal before the closing date or within 10 days of the date of mailing of the notice whichever is later.

It is usually helpful to call MassHealth to get a better understanding of the reason for the denial. If the denial was based on incomplete, inaccurate or out of date information, supplying correct information may resolve the matter. If not, a family may want to consult with a legal advocate for representation at the hearing or advise preparing for the hearing. Information on legal services programs is available at www.masslegalhelp.org

The hearing may be in person at the MassHealth Enrollment Center or may be conducted by telephone. An impartial hearing officer will hear why MassHealth made its decision, why the family thinks the decision was wrong, and will decide whether MassHealth  followed its regulations based on the information presented at the hearing. If the hearing officerdecides in favor of the person who appeals, MassHealth must take corrective action to reinstate eligibility.

How does a family appeal a denial of specific MassHealth services?

For some services, a medical provider must ask for “prior authorization” from MassHealth or, in some cases, from a Managed Care Organization (MCO) or the Behavioral Health Partnership. If a request for prior authorization is denied, the family will receive a denial notice that explains why they are not eligible for the services. The notice should explain why the services are not medically necessary, and explain  appeal rights.  If the denial was from an MCO or the Partnership, the first level of appeal is to the MCO or Partnership. Upon receiving this notice, the family should file an appeal immediately. If they are appealing a termination or reduction of ongoing services and file within ten days from the date the denial notice was mailed services will be continued  until the appeal is decided.

Appeals from a decision by the MCO or the Partnership will first go to an internal review at the MCO or the Partnership. If the internal review is not favorable, the family can then request a fair hearing before a MassHealth Hearing Officer. For information on Massachusetts Behavioral Health Partnership (MBHP) appeals see: http://www.masslegalhelp.org/mental-health/mbhp-appeals

For information on the appeals process of one of the MassHealth Managed Care Organizations, consult the Member Book the family was sent at enrollment, check the plan’s website or call the plan. 

The family should also talk to the health care provider who requested prior authorization and see if he or she can supply any additional information showing why the service is necessary. This information may convince MassHealth or the MCO or Partnership to approve the service prior to the hearing, or, if not, it will be needed to show the hearing officer why the service was necessary.  A family may also want to call legal services to obtain an advocate to represent them at the hearing or to advise them on how to prepare for the hearing. 

When is a service medically necessary?

For most denials of specific services to a child, the issue at the hearing will be medical necessity criteria. As defined by 130 CMR §450.124 a service is medically necessary if:

  • It is reasonably calculated to prevent, diagnose, prevent the worsening of, alleviate, correct, or cure conditions in the member that endanger life, cause suffering or pain, cause physical deformity or malfunction, threaten to cause or to aggravate a handicap, or result in illness or infirmity; and
  • There is no other medical service or site of service, comparable in effect, available, and suitable for the member requesting the service, that is more conservative or less costly to MassHealth.

In addition MassHealth has published regulations and other guidance on when it considers certain specific services to be medically necessary Most of this information is on the MassHealth website at www.mass.gov/masshealth.

Medical evidence, expert witnesses, and written testimony can be presented at the hearing. A family may be represented by a lawyer or other advocate at the hearing. For a list of legal services offices, see  www.masslegalservices.org/findlegalaid  A decision should  be mailed within 90 days of the hearing request.

For information from other sources:

Massachusetts Family Voices: http://massfamilyvoices.org/publications/MassHealth_Overview.pdf



This Q&A was edited by the Massachusetts Law Reform Institute (MLRI)  as part of the Children’s Issues Series, http://www.masslegalservices.org/content/childrens-issues-index


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