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MassHealth Provisional Income Eligibility Change Approved

CMS (the Federal Medicaid Agency) has approved MassHealth's request to stop doing Provisional Income Eligibility for adults.  The 2-page approval letter is attached, the related changes to the waiver documents are posted here:

This request was in MassHealth's first 1115 amendment request submitted in June which also asked to end Non-emergency transportation in CarePlus for all but trips to Substance Use Disorder services. CMS has not yet made a decision on the transportation request or on the more sweeping changes proposed in a second MassHealth 1115 amendment request submitted in September.

What to expect from the change in Provisional Income Eligibility --we haven't yet seen final regulations or operational memos but this is our best guess of what to expect based on the proposed rules and the waiver request itself.

When will changes occur?

MassHealth already published proposed regulations to make this change & now only needs to  file the final version of the regulations to complete the rule-making process. The operational & computer system changes are also near final.  We expect this change will be made soon --possibly as soon as January --stay tuned.

Who will be affected?

This will be a change for most adult applicants under age 65 (including older adults eligible as parents/caretaker relatives of a minor child or as working disabled) who are applying for MassHealth or the Health Safety Net. 

Children under 21, pregnant women, people eligible based on treatment for breast or cervical cancer, people eligible based on being HIV positive will still have the benefits of Provisional Income Eligibility. Nothing should change for adults whose self-declared income makes them eligible for ConnectorCare not MassHealth. 

This change will not affect adults automatically eligible for MassHealth based on receiving SSI, TAFDC or EAEDC. 

People applying for benefits using the senior application form (SACA-2) with both an income and asset test never had the benefit of provisional income eligibility in the first place, so nothing is changing for them either.

What will be different?

Today, when people under 65 apply for health benefits (MassHealth, ConnectorCare, or Health Safety Net), they are asked to declare their income & the computer system (HIX) attempts to verify their income electronically. If income cannot be verified electronically (because there is no data, or the data shows income more than 10% above MassHealth income limits), the system makes an eligibility decision based on the self-declared income and sends the applicant a 90-day deadline to submit documentary proof of income. If no proof is submitted, the system will make a new decision based on the data (if available) or terminate coverage if no data is available. 

Without provisional income eligibility, for most adult applicants who  would be eligible for MassHealth or HSN based on self-declared income but whose income cannot be verified electronically, they will NOT get an eligibility determination based on self-declared income. They will still be sent a notice to supply proof of income by a deadline, BUT, they will now NOT be determined eligible for MassHealth or HSN until the proof is received. If the deadline passes with no proof, the system will make a decision based on the data or if there is no data, the application will be denied. Once income is verified, the coverage will still go back to 10 days prior to the application date. 

In comments submitted to the state and later to CMS, many of us asked MassHealth to make improvements to the way paper documentation can be submitted & processed before making this change.  We understand there may be some improvements in the works but do not yet have any more information.  

What options are there for people who need time to gather proof of income but need care right away?

These won't be options for everyone, but hospitals can still speed up coverage through Hospital Presumptive Eligibility and hospitals and Community Health Centers can still make Health Safety Net Presumptive Determinations. 

How will this change the application process?

People who apply on-line will know right away if proof of income is needed. 

People who apply on paper will not know if proof is needed until their paper application is processed. It may be weeks before the application is processed and the notice asking for proof of income arrives in the mail. After proof is submitted, those documents must be processed before an eligibility decision is made. If eligible, coverage will still go back 10 days prior to the date of application.

Paper applicants should probably submit documentary proof of income along with their application. But, if proof is not available, it's important not to delay an application if past expenses were incurred. Filing the application protects the coverage date if the applicant is later found eligible.


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