Masshealth/ Medicaid

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MassHealth is the name given to the Massachusetts Medicaid Program. This section contains information concerning eligibility and services under the MassHealth program, as well as links to important web sites needed for effective advocacy for MassHealth applicants and recipients. The section also contain copies of fair hearing decisions involving the MassHealth program, but we need your help:

Please send us copies of your fair hearing decisions to the attention of Vicky Pulos, MLRI, 40 Court Street, Suite 800, Boston, MA 02108,  vpulos@mlri.org.

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Superior Court DJ on Inadequate MassHealth Notices

Hon. Douglas Wilkins
This is a declaratory judgment decision in two companion cases filed in Suffolk Superior Court, Maas v. Sudders and Hirvi v. Sudders, by 2 private attornies & members of the MA Chapter of the Natl. Assoc. of Elder Lawyers (NAELA). Each case was filed as an affirmative action seeking to…

Continuity of Care in MassHealth Managed Care after March 1, 2018

Office of Medicaid and Others
March 1, 2018 over 1 million members will be moving to new kinds of health plans. This affects individual under age 65 with MassHealth as their only coverage. Individuals should have received notice of the change from MassHealth and their new plans. There are protections in place to try to avoid…

Comments on House 2 MassHealth Amendments Relating to the Pharmacy Program

CHLPI/MLRI
Comments on House 2 MassHealth Amendments Relating to the Pharmacy Program On behalf of the Center for Health Law and Policy Innovation (CHLPI) of Harvard Law School, the Massachusetts Law Reform Institute (MLRI), and the undersigned organizations, we are grateful for the opportunity to provide…

Pharmacy Facts

Office of Medicaid
Attached is very helpful issue of a publication MassHealth regularly distributes to participating pharmacies. The March 15, 2018 issue makes clear that pharmacies may not charge a MassHealth member more than the allowed co-payment if payment is "available from MassHealth" and that payment…

MassHealth Managed Care Changes for 1 million March 1, 2018

Vicky Pulos
Attached is an updated powerpoint describing MassHealth managed care changes in the works for several years now that will affect over 1 million members starting March 1, 2018. The materials provide an overview of what's going on including descriptions of several problem scenarios, possible…

MassHealth Income Guidelines effective March 1, 2018

MLRI. MassHealth
The MLRI Health Income Chart includes the 5% MAGI allowance, plus the $20 income disregard for MassHealth Senior calculations The MassHealth Desk Guide does not include combined figures.

MassHealth Income Guidelines 2017 & 2018

MLRI, MassHealth
Attached are four tables.  The MLRI MassHealth Income Table for March 1 2017.  This table factors in the 5% MAGI income deduction to the various poverty levels.  Effective in MassHealth Mar 1, 2017 to Feb 28, 2018. Updated for Connector Open Enrollment beginning Nov 1,…

MLRI Letter to HWM on H2 proposal to drop 140,000 from MassHealth

Vicky Pulos
In January, 2018 the Governor's budget bill (H2) once again proposed dropping 140,000 nondisabled adults with income over 100% FPL but under 138% FPL from MassHealth leaving them with only potential ConnectorCare coverage. This letter to the Chair of the House Ways and Means Committee describes…

CHIP Flyer

CHAC
Federal funding for the Children's Health Insurance Program expired on September 30, 2017.  Massachusetts and other states are continuing to operate their programs using unexpended prior funding, but this is rapidly running out.  Funding in Massachusetts could be exhausted sometime in…

MassHealth Restructuring Web Page

MassHealth
Bookmark this page for materials on changes in the MassHealth delivery and payment system. It currently includes copies  of the Model contracts with new Accountable Care Organizations that will be providing services starting March 1, 2018 and includes a powerpoint presentation on new behavioral…

MassHealth Managed Care Notices Mailed Nov 13-Dec 22 2017

MassHealth & MLRI
Starting on Nov 13, and continuing through Dec 22, 2017 MassHealth is notifying 1.2 million members enrolled in managed care of new options starting March 1, 2018 including new Accountable Care Organizations. This is the Delivery System Reform Innovation approved in the November 2016 amendment to…

MLRI MassHealth/Connector Income Guidelines for Open Enrollment beginning November 1, 2017

MLRI
Attached is a revised MLRI MassHealth Income Chart, revised to reflect the 2017 FPL levels for the Connector programs. 2017 FPL income guidelines are effective in ConnectorCare during the January through December 2018 enrollment period.  Open Enrollment for 2018, begins on November 1st and runs…

Reference Guide to Federal Medicaid Statutes & Regs

MACPAC
Helpful on-line research tool from the Medicaid and Chip Payment and Access Commission (MACPAC) listing topics/issues with corresponding provision in Medicaid T. XIX and federal regulations. 

MassHealth Eligibility Review Forms- English & Spanish

MLRI
These forms are used in MassHealth redeterminations.  Do not use for applications.  For under 65 year old only. Not on MassHealth website

Hurricane Evacuees and MassHealth Enrollment

MassHealth
Important information from MassHealth on facilitating MassHealth enrollment for hurricane evacuees. MassHealth has developed procedures to streamline the application process for these hurricane evacuees who apply for MassHealth. Click the "go to website" link to download more…

CMS Emergency Response and Recovery Website

CMS
This CMS website contains information about recent public health emergency declarations which give HHS the authority to modify or waive certain provisions of Medicare and Medicaid to assist states and territories dealing with an emergency situation such as the devestation of this year's…

Oct 20 CMS Comment Deadline on MassHealth 1115 Amendments

vicky pulos
On Sept. 8, 2017, EOHHS submitted a request to CMS to amend the 1115 Waiver to include a wide-ranging set of MassHealth eligibility and benefit cuts. Comments on the proposed changes must be filed with CMS by Oct. 20, 2017. Attached is a Table prepared by MLRI summarizing the July proposal to amend…

Action Alert: September 1 Comment Deadline on Ending Non-emergency transportation in CarePlus & Provisional Income Eligibility for Adults in MassHealth and the HSN

MLRI and others
MassHealth filed a proposal to end provisional income eligibility for adults in MassHealth and the Health Safety Net (except adults who are pregnant, HIV+ or in treatment for breast or cervical cancer) with a target date of October 2017.  This will delay enrollment for adults whose income is…

Advocates' Comments to EOHHS on 1115 Proposal

MLRI and others
In July 2017 EOHHS released for public comment proposed amendments to the MassHealth 1115 demonstration. The proposals among other things would lower the income standard for parents/caretakers and other non-disabled adults, deny MassHealth to non-disabled adults with access to Student Health…

30A Complaint for BOH Failing to Vacate Dismissal

Nancy Lorenz
This is a redacted Complaint seeking judicial review of the Board of Hearings final action denying the appellant's motion to vacate the dismissal of his appeal. The issue was whether he had good cause for his failure to appear. His counsel, Nancy Lorenz of GBLS, reports that the agency agreed to…

Fact sheet & Letters to FY 18 Conference Committee on Last Minute MassHealth Reform Proposals

MLRI, ACT Coalition
On June 20, the Governor asked the conference committee to include a package of reforms in the budget for the fiscal year staring July 1, 2017 including damaging cuts to MassHealth eligibility and benefits.  Attached is a two- page fact sheet with our critical concerns and…

Daley v. Secretary of EOHHS

Gants, C.J.
SJC decision reversing the MassHealth board of hearings  in two cases concerning eligibility for nursing facility care. In both cases the applicants had transferred ownership of their homes to an irrevocable trust. in one case retaining a life estate and in the other retaining the right to use…

Protect Medicaid Website

Center for Public Representation
CPR has established a new website on proposed federal Medicaid cuts, particularly those related to people with disabilities. Here is a link: protectourmedicaid.org  

Preliminary Look at How the House Repeal and Replace Bill Could Affect MassHealth and ConnectorCare

Vicky Pulos
Attached is MLRI's summary of some of the most worrisome features of the initial version of the House bill to repeal and replace key features of the Affordable Care Act (as of March 13, 2017).

Getting Through and Being Heard: Limited English Proficiency and MassHealth

Laura Spark and Vicky Pulos
Attached is the report of a survey of bilingual enrollment assisters and advocates conducted by MLRI on the experience of Limited English Proficient  (LEP) MassHealth applicants and members attempting to communicate with MassHealth by telephone. The survey results identified multiple barriers…

Revised Health Income Guidelines for November 1, 2016 Open Enrollment

MLRI
MLRI's Income Table for MassHealth and Other Health Programs has been updated for the Open Enrollment Period governing the Connector's programs beginning November 1st, 2016. MLRI's Tables shows upper income limits by month and by week including the amount of the standard deduction…

Comments on Proposed Transportation Rules

MLRI and 9 others
Comments filed by MLRI and 9 other provider and consumer advocacy organizations recommending improvements in MassHealth transportation proposed regulations.

Representing Clients in MassHealth Cases

Vicky Pulos
Powerpoint from June 2016 training for legal aid and pro bono lawyers on Reprenting Clients in MassHealth Cases. 

MassHealth Regulations, Operations Memos, Eligibility Memos and Subregulatory Materials

MassHealth
MassHealth maintains a "MassHealth Member Library," which includes regulatory and subregulatory materials, including  the following resources: Member Eligibility Regulations Eligibility Letters Eligibility Operations Memos Coverage Updates Applications Desk…

Senior Medical Benefit Request Form

MassHealth
Link to application form for seniors and those needing long term care on MassHealth website

MassHealth applications and forms

EOHS
Link to applications and forms section of MassHealth website includes application forms and supplements, member book, enrollment guide, adult and child disability supplements, eligibility representative forms etc. All forms in English and Spanish

MLRI Comments on MassHealth Draft Language Access Plan

Vicky Pulos & Teresita Ramos
Attached are MLRI comments on MassHealth's Draft Language Access Plan. The Medicaid agency is required by law to provide meaningful access to its services to individuals who are not proficient in English. A language access plan should asses the language needs of the eligible population and…

Letter to Secretary Opposing Managed Care Lock-In

Vicky Pulos and others
This is a letter signed by legal aid and disability rights organizations to Sec. Sudders opposing the administration's proposal to go to a 12-month lock in for MassHealth beneficiaries who enroll in a Managed Care Organization. 

The Governor’s FY2017 Budget Proposal for MassHealth (Medicaid) and Health Reform Programs

Mass. Medicaid Policy Institute (MMPI)
The Governor’s FY2017 Budget Proposal for MassHealth (Medicaid) and Health Reform Programs The Massachusetts Medicaid Policy Institute (MMPI), a program of the Blue Cross Blue Shield of Massachusetts Foundation, is pleased to share a new budget brief, The Governor’s FY2017 Budget Proposal…

MassHealth Income Guidelines March 2016

MLRI
Here are the March 1, 2016 MassHealth Income Guidelines.  Two files attached: MLRI MassHealth Income Guidelines MassHealth FPL-Desk Guide

2016 MassHealth Orthodontia Settlement

Misc
A group of orthodontist & their patients sued MassHealth for having unduly restrictive medical necessity criteria for approving braces for children & youth under age 21. The case resulted in a settlement changing MassHealth policies. Attached is a copy of a Jan 2016 transmittal letter making…

MassHealth: Children's Issues Series

MLRI
For which MassHealth Program(s) is my child eligible? See https://aspe.hhs.gov/poverty-guidelines 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…

New FPL Guidelines for Open Enrollment 2015-16

MLRI
Attached are the updated Federal Poverty Standards for the Connector Programs (Connector Care and Qualified Health Plans) for the Open Enrollment period beginning November 1st .  The actual effective date for eligibility purposes is January 1st, but enrollment for January starts in…

"Workaround" for Disabled Adults with MAGI over 133% FPL

Vicky Pulos
This memo summarizes the circumstances in which the new eligibility and enrollment system will not be able to make an accurate determination for certain disabled adults, and a "workaround" is in place to eventually make the correct determination.  

Applied Behavior Analysis for MassHealth members under age 21

MLRI
Applied Behavior Analysis for MassHealth members under age 21.  ABA providers can apply to MassHealth to enroll as a provider and get prior authorization to provide services NOW. Also, for children and young adults (under 21) enrolled in private insurance with the Partnership for their…

Update on People Losing Health Coverage

Vicky Pulos MLRI
This updated April 10, 2015 Table shows the two different groups of people who had health coverage end recently or will be getting MassHealth termination notices soon.  Both groups need to reapply for coverage but they have different deadlines and different remedies if they miss their…

Alert for Legal Immigrants Getting Connector Denials, April 2015

Vicky Pulos
Please help us identify lawfully present immigrants who were incorrectly denied benefits by the Connector & received only MassHealth Limited or Health Safety Net from MassHealth.    Attached is an alert for affected immigrants including information about how to get legal…

Alert to legal aid offices and social service providers about MassHealth terminations and the availability of MassHealth Renewal Extensions

Vicky Pulos, MLRI
It is not too late for renewing MassHealth members who receive termination notices to reapply and reinstate their coverage back to the date it ended, and you can help What happened? Almost 300,000 MassHealth renewal notices were mailed in January and February giving 500,000 MassHealth members…

2015 MassHealth Income Standards

Office of Medicaid
MassHealth updated its income standards to reflect updated 2015 federal poverty levels on March 1. MLRI is currently working on our version of the 2015 income standards which we will be posting soon. 

Enrollment Dashboard for 2015 Open Enrollment

Connector and Office of Medicaid
2015 Open Enrollment started on Nov. 15, 2014 and ended on Feb. 23, 2015. It was the time in which people could freely purchase non-group health insurance on their own and also coincided with a new eligibility and enrollment system for MassHealth & the Connector going live and with various forms…

MassHealt-Connector Cover Sheet -revised Feb 2015

Office of Medicaid
The following link is for a revised cover sheet to be used when faxing or mailing information to MassHealth or the Connector. A separate cover sheet should be printed out for each use (not photocopied) to assure that the bar code works properly.  Using these cover sheets should improve the…

Sample MassHealth Renewal-Related Notices

Office of Medicaid
In 2015, the Office of Medicaid began renewing MassHealth eligibility for 1.2 million members under age 65 who are subject to the new MAGI methodology and have not had their eligibility renewed since October 2013. The first wave of 500,000 members have already been notified to submit a new…

MassHealth Renewals Process for 2015

Office of Medicaid
In this set of powerpoint slides posted on the MassHealth Training Forum website, MassHealth lays out its process for renewing eligibility for 1.2 million current MassHealth members starting in Feb. 2015.

E-fax Numbers for MassHealth Updated Jan. 2015

MassHealth
MassHealth is using a new fax number for submitting applications and verifications (except for Long Term Care).  Attached is MassHealth's Tip Sheet on Where to Send Applications and Verifications  

Getting MAGI Right: A Primer on Differences that Apply to Medicaid and CHIP

Tricia Brooks, Georgetown Health Policy Institute
Another helpful resource explaining the MAGI income methodology now being used in Massachusetts for most people under 65 in MassHealth and for people seeking subsidized insurance through the Connector