101 CMR 613.04 - Eligible Services to Low Income Patients
(1)
General.
Providers may submit claims for Reimbursable Health Services to Low Income
Patients determined in accordance with the criteria in 101 CMR 613.04. Low
Income Patients may be determined eligible for Health Safety Net - Primary or
Health Safety Net - Secondary, in accordance with 101 CMR 613.04(6). The
following individuals are not eligible for Low Income Patient status:
(a) individuals who have been determined
eligible for any MassHealth program, including any premium assistance program,
but who have failed to enroll; and
(b) individuals whose enrollment in
MassHealth or the Premium Assistance Payment Program Operated by the Health
Connector has been terminated due to failure to pay
premiums.
(2)
Low Income Patient Determination. Except as provided
in 613.04(3) and 613.04(4) an individual must complete and submit an
Application for benefits using the eligibility procedures and requirements
under
130 CMR 502.000:
MassHealth: The Eligibility Process or
130 CMR 516.000:
MassHealth: The Eligibility Process. In order to be determined
a Low Income Patient, an individual must be a Resident of the Commonwealth and
document that the Modified Adjusted Gross Income of his or her MassHealth MAGI
Household is equal to or less than 300% of the FPL, or that the Countable
Income of his or her Medical Hardship Family is less than or equal to 300% of
the FPL that if the individual used a Senior Application as defined in
130 CMR
515.001: Definition of
Terms.
(a)
Determination
Notice. The MassHealth Agency or the Commonwealth Health Insurance
Connector notifies the individual of his or her eligibility determination for
health care coverage or if the individual is a Low Income Patient.
(b)
Verification of
Income. Verification of income is mandatory. Income may be
verified either through electronic data matches or paper verification.
1.
Electronic Data
Matches. MassHealth electronically matches with federal and state
data sources described at
130 CMR
502.004: Matching
Information to verify attested income. The income data received
through an electronic data match is compared to the attested income amount to
determine if the attested amount and the data source amount are reasonably
compatible. If these amounts are reasonably compatible, the attested income is
considered verified for purposes of an eligibility determination. To be
considered reasonably compatible
a. both the
attested income and the income from the data sources must be above the
applicable income standard for the individual; or
b. both the attested income and the income
from the data sources must be below the applicable income standard for the
individual; or
c. the attested
income and the income from the data sources must be within a ten percent range
of each other.
2.
Asset Verification. If the MassHealth agency requests
an asset verification pursuant to
130 CMR 520.000:
MassHealth: Financial Eligibility for an applicant, the
applicant must comply with the guidelines listed in
130 CMR
516.003: Verification of Eligibility
Factors in order to obtain and/or maintain their Health Safety Net
determination.
3.
Paper
Verification. If the attested income and the income from the
electronic data source are not reasonably compatible, or if the electronic data
match is unavailable, paper verification of income is required.
a. Paper verification of monthly earned
income includes, but is not limited to
i.
recent paystubs;
ii. a signed
statement from the employer; or
iii. the most recent federal tax
return.
b. Verification
of monthly unearned income is mandatory and includes, but is not limited to
i. a copy of a recent check or paystub
showing gross income from the source;
ii. a statement from the income source, where
matching is not available; or
iii.
the most recent federal tax return.
c. Verification of gross monthly income may
also include any other reliable evidence of the Patient's earned or unearned
income.
(c)
Verification of Identity. The following are acceptable
proof of identity.
1. The following are
acceptable proof of identity, provided such documentation has a photograph or
other identifying information including, but not limited to, name, age, sex,
race, height, weight, eye color, or address:
a. identity documents listed at
8 CFR §
274a.2(b)(1)(v)(B)(1),
except a driver's license issued by a Canadian government authority;
b. driver's license issued by a state or
territory;
c. school identification
card;
d. U.S. military card or
draft record;
e. identification
card issued by the federal, state, or local government;
f. military dependent's identification card;
or
g. U.S. Coast Guard Merchant
Mariner card;
2. for
children younger than 19 years old, a clinic, doctor, hospital, or school
record, including preschool or day care records;
3. two documents containing consistent
information that corroborates an applicant's identity. Such documents include,
but are not limited to
a. employer
identification cards;
b. high
school and college diplomas (including high school equivalency
diplomas);
c. marriage
certificates;
d. divorce
decrees;
e. property deeds or
titles;
f. a pay stub from a
current employer with the applicant's name and address preprinted, dated within
60 days of the application;
g.
census verification containing the applicant's name and address, dated not more
than 12 months before the date of the application;
h. a pension or retirement statement from a
prior employer or pension fund stating the applicant's name and address, dated
within 12 months of the application;
i. tuition or student loan bill containing
the applicant's name and address, dated not more than 12 months before the date
of the application;
j. utility
bill, cell phone bill, credit card bill, doctor's bill, or hospital bill
containing applicant's name and address, dated not more than 60 days before the
date of the application;
k. valid
homeowner's, renter's, or automobile insurance policy with preprinted address,
dated not more than 12 months before the date of the application, or a bill for
such insurance with preprinted address, dated not more than 60 days before the
date of the application;
l. lease
dated not more than 12 months before the date of the application, or home
mortgage identifying applicant and address; or
m. employment verification by means of W-2
forms or other documents bearing the applicant's name and address submitted by
the employer to a government agency as a consequence of
employment;
(d)
Matching Information. The MassHealth Agency initiates
information matches with other agencies and information sources when an
application is received, at annual renewal and periodically, in order to update
or verify eligibility. These agencies and information sources may include, but
are not limited to, the following: the Federal Data Services Hub, the Division
of Unemployment Assistance, Department of Public Health's Bureau of Vital
Statistics, Department of Industrial Accidents, Department of Veterans'
Services, Department of Revenue, Bureau of Special Investigations, Internal
Revenue Service, Social Security Administration, Systematic Alien Verification
for Entitlements, Department of Transitional Assistance, and health insurance
carriers.
(3)
Confidential Services. The Health Safety Net Office's
Application for Health Safety Net Confidential Services may be used for the
following special application types. For these application types, five
percentage points of the current FPL are subtracted from the applicable total
Countable Income to determine the applicant's eligibility for Low Income
Patient status. An individual seeking these services is not required to report
his or her primary address.
(a) Minors
receiving Confidential Services may apply to be determined a Low Income Patient
using their own Countable Income information and using the Office's application
for Health Safety Net Confidential Services. If a minor is determined to be a
Low Income Patient, the Provider may submit claims for Confidential Services
when no other source of funding is available to pay for the services
confidentially. For all other services, Minors are subject to the standard Low
Income Patient determination process. Providers may submit claims for Eligible
Services rendered to these individuals for Confidential Services
only.
(b) An individual who has
been a victim of domestic violence, or who has a reasonable fear of domestic
violence or continued domestic violence, may apply for Low Income Patient
status using his or her own Countable Income information if he or she seeks
medically necessary Eligible Services.
(4)
Presumptive
Determination. An individual may be determined to be a Low Income
Patient for a limited period of time, if on the basis of attested information
submitted to a Provider on the form specified by the Health Safety Net Office,
the Provider determines the individual is presumptively a Low Income Patient.
An individual may not be determined to be a Low Income Patient pursuant to 101
CMR 613.04(4)(b)4. if the individual has already been determined to be a Low
Income Patient pursuant to 101 CMR 613.04(4)(b)4. within the previous 12
months. Notwithstanding 101 CMR 613.04(7)(a), Providers may submit claims for
Reimbursable Health Services provided to individuals with time-limited
presumptive Low Income Patient determinations only for dates of service
beginning on the date on which the Provider makes the presumptive determination
and continuing until the earlier of
(a) the
end of the month following the month in which the Provider made the presumptive
determination if the individual has not submitted a complete Application,
or
(b) the date of the
determination notice described in 101 CMR 613.04(6)(a) related to the
individual's Application.
(5)
Grievance
Process. An individual may request that the Office conduct a
review of a determination of Low Income Patient status, Provider compliance
with the provisions of
101 CMR 613.00, or Medical
Hardship eligibility if exceptional circumstances outside of the individual's
control had a material impact on the Medical Hardship eligibility
determination. The Health Safety Net Office will conduct a review using the
following process.
(a) In order to request a
review, the individual must send a written request to the Office with
supporting documentation.
(b) To
request a review of a determination of Low Income Patient status, the
individual must send the review request within 30 days from the date of the
official notification of the determination.
(c) To request a review of a Medical Hardship
eligibility determination, the individual must send the review request,
including a description of the circumstances outside of the individual's
control that had a material impact on the eligibility determination, within six
months from the date of the official notification of the determination. For all
grievances, the Office may request additional information as necessary from the
grievant, other state agencies, and/or the Provider(s). Additional information
requested from the grievant by the Office must be submitted within 30
days.
(d) The Office will provide
an initial response to the grievant within 30 days of receipt of the grievance
and will issue a written decision and explanation of the reasons for its
decision to the grievant and other relevant parties within a reasonable time
after receipt of all necessary information.
(6)
Low Income Patient
Eligibility Categories.
(a) The
categories of Low Income Patient eligibility for Health Safety Net services
are:
1.
Health Safety Net -
Primary. A Low Income Patient is eligible for Health Safety Net -
Primary if he or she is uninsured and documents MassHealth MAGI Household
income or Medical Hardship Family Countable Income, as described in 101 CMR
613.04(2), between 0% and 300% of the FPL, subject to the following exceptions.
a. Low Income Patients eligible for
enrollment in the Premium Assistance Payment Program Operated by the Health
Connector are not eligible for Health Safety Net -Primary except as provided in
101 CMR 613.04(7)(a) and (b).
b.
Low Income Patients subject to the Student Health Program requirements of
M.G.L. c. 15A, § 18 are not eligible for Health Safety Net -
Primary.
2.
Health Safety Net - Secondary. A Low Income Patient is
eligible for Health Safety Net - Secondary if he or she has other primary
health insurance and documents MassHealth MAGI Household income or Medical
Hardship Family Countable Income, as described in 101 CMR 613.04(2), between 0
and 300% of the FPL, subject to the following exceptions.
a. Effective 101 days after the Medical
Coverage Date, Low Income Patients eligible for the Premium Assistance Payment
Program Operated by the Health Connector are eligible only for dental services
not otherwise covered by the Premium Assistance Payment Program Operated by the
Health Connector.
b. Low Income
Patients enrolled in MassHealth Standard, MassHealth CarePlus, MassHealth
Common Health, and MassHealth Family Assistance excluding MassHealth Family
Assistance - Children are eligible only for Adult Dental Services provided at a
Community Health Center, Hospital Licensed Health Center, or Satellite
Clinic.
c. Low Income Patients
enrolled in a qualifying Student Health Plan are eligible for Health Safety Net
- Secondary.
(b)
Other
Requirements.
1.
Affordable Insurance. An individual with MassHealth
MAGI Household income or Medical Hardship Family Countable Income, as described
in 101 CMR 613.04(2), less than or equal to 300% of the FPL, and for whom
insurance is deemed affordable as defined in
956 CMR 6.00:
Determining Affordability for the Individual Mandate, is not
eligible for Health Safety Net - Primary. If such an individual's employer
offers employer-sponsored insurance, he or she is not eligible for Health
Safety Net - Primary except during the employer's waiting period before the
employer-sponsored insurance becomes effective.
2.
Pending Disability
Determination. Providers may submit claims for individuals whose
MassHealth eligibility status is pending due to a MassHealth disability
determination. If the individual is determined eligible for MassHealth, the
Provider must void Health Safety Net claims for the individual and submit
claims for services to MassHealth.
3.
Health Safety Net -
Partial. A Low Income Patient eligible for either Health Safety
Net - Primary or Health Safety Net - Secondary who documents MassHealth MAGI
Household income or Medical Hardship Family Countable Income, as described in
101 CMR 613.04(2), greater than 150% and less than or equal to 300% of the FPL
is considered Health Safety Net - Partial and must meet the Health Safety Net -
Partial deductible described in 101 CMR
613.04(8)(c).
(7)
Eligibility
Period.
(a) Except as specified
in 101 CMR 613.04(5)(b), providers may submit claims for Reimbursable Health
Services effective on the Medical Coverage Date until the Patient's eligibility
is terminated.
(b) For Low Income
Patients eligible for the Premium Assistance Payment Program Operated by the
Health Connector:
1. Providers may submit
claims for Reimbursable Health Services for the period beginning on the
Patient's Medical Coverage Date and ending 100 days after the Patient's Medical
Coverage Date.
2. Effective 101
days after the Patient's Medical Coverage Date, providers may submit claims
only for dental services not otherwise covered by the Premium Assistance
Payment Program Operated by the Health Connector until the Patient's
eligibility is terminated.
(c) Low Income Patient status is effective
for a maximum of one year from the date of determination, subject to periodic
redetermination and verification that the Patient's MassHealth MAGI Household
income or Medical Hardship Family Countable Income, as described in
101
CMR 613.04(2), or insurance
status has not changed to such an extent that the Patient no longer meets
eligibility requirements.
(8)
Low Income Patient
Responsibilities.
(a)
Cost Sharing Requirements. Low Income Patients are
responsible for paying copayments in accordance with
101
CMR 613.04(8)(b) and
deductibles in accordance with
101
CMR 613.04(8)(c).
(b)
Low Income Patient Copayment
Requirements. Low Income Patients are responsible for copayments
for pharmacy services.
1. The copayments for
pharmacy services are
a. $1 for each
prescription and refill for each generic drug in the following drug classes:
antihyperglycemics, antihypertensives, and antihyperlipidemics;
b. $3.65 for each prescription and refill for
other generic drugs; and
c. $3.65
for each prescription and refill for brand-name drugs.
2. There are no copayments for services
provided to Low Income Patients who are
a.
younger than 21 years old; or
b.
pregnant or in the postpartum period that extends through the last day of the
12th calendar month following the month in which
their pregnancy ends (for example, if the individual gave birth on May
15th, the individual is exempt from the copayment
requirement until June 1st of the next
year).
3. There is an
annual maximum of $250 per Patient on pharmacy copayments.
4. Notwithstanding
101
CMR 613.04(8)(b)1. through
3., Low Income Patients are not responsible for the making copayments for
pharmacy services during the period May 1, 2023, through March 31,
2024.
(c)
Health Safety Net - Partial Deductibles.
1.
Annual
Deductible. For Health Safety Net - Partial Low Income Patients
with MassHealth MAGI Household income or Medical Hardship Family Countable
Income greater than 150% and less than or equal to 300% of the FPL, there is an
annual deductible if all members of the PBFG have an FPL above 150%. If any
member of the PBFG has an FPL equal to or below 150% there is no deductible for
any member of the PBFG. The annual deductible is equal to the greater of
a. the lowest cost Premium Assistance Payment
Program Operated by the Health Connector premium, adjusted for the size of the
PBFG proportionally to the MassHealth FPL income standards, as of the beginning
of the calendar year; or
b. 40% of
the difference between the lowest MassHealth MAGI Household income or Medical
Hardship Family Countable Income, as described in
101
CMR 613.04(2), in the
applicant's Premium Billing Family Group (PBFG) and 200% of the
FPL.
2.
Applying the Deductible. The Patient is responsible
for payment for all services provided up to this deductible amount. Once the
Patient has incurred the deductible, a Provider may submit claims for
Reimbursable Health Services in excess of the deductible. There is only one
deductible per PBFG per approval period. The deductible is not applied to
pharmacy services. Copayments are not considered expenses to be included in the
deductible amount.
3.
Deductible Tracking. The annual deductible is applied
to all Reimbursable Health Services provided to a Low Income Patient or PBFG
member during the Eligibility Period. Each PBFG member must be determined a Low
Income Patient in order for his or her expenses for Reimbursable Health
Services to be applied to the deductible. The Provider must track the Patient's
Reimbursable Health Services expenses until the Patient meets the deductible.
If more than one PBFG member is determined to be a Low Income Patient, or if
the Patient or PBFG members receive services from more than one Provider, it is
the Patient's responsibility to track the deductible and provide documentation
to the Provider that the deductible has been reached.
4.
Acute Hospitals.
The Patient must incur expenses for Reimbursable Health Services in excess of
the annual deductible before the Provider may submit a claim for Reimbursable
Health Services. Once the Patient has incurred the deductible, the Provider may
submit a claim for the remaining balance of Reimbursable Health Service
expenses. The Acute Hospital may require a deposit and/or a payment plan in
accordance with
101
CMR 613.08(1)(g).
5.
Community Health Centers and
Hospital Licensed Health Centers.
a. Health Safety Net - Partial Low Income
Patients receiving Reimbursable Health Services from Community Health Centers
are responsible for 20% of the Health Safety Net payment for each visit, to be
applied to the amount of the Patient's annual deductible until the Patient
meets his or her deductible. Health Safety Net - Partial Low Income Patients
receiving Reimbursable Health Services from Hospital Licensed Health Centers,
Satellite Clinics, and school-based health centers are responsible for either
20% of the Health Safety Net payment for each visit or the full amount of the
service, as specified by the Provider. If the Provider specifies that a Health
Safety Net - Partial Low Income Patient is responsible for 20% of the payment
amount, the Provider may submit a claim for the remaining balance of each
eligible service.
b. If a Hospital
Licensed Health Center, Satellite Clinic, or school-based health center that
provides Reimbursable Health Services specifies that any Health Safety Net -
Partial Low Income Patient is responsible for only 20% of the payment amount,
it must offer this option to all Health Safety Net - Partial Low Income
Patients receiving Reimbursable Health Services at the location.
c. The Health Safety Net Office may require a
Community Health Center to report when a Patient's deductible has been met or
any other information regarding the Patient's deductible in a manner specified
by the Health Safety Net Office.
(d)
Assignment of Third-party
Payments. A Low Income Patient must assign to the MassHealth
Agency his or her rights to third-party payments for medical benefits provided
under the Health Safety Net and must fully cooperate with and provide the
MassHealth Agency with information to help pursue any source of third-party
payment. A Low Income Patient must inform the Health Safety Net Office or
MassHealth when he or she is involved in an accident or suffers from an illness
or injury, or other loss that has resulted or may result in a lawsuit or
insurance claim, other than a medical insurance claim. The Low Income Patient
must
1. file an insurance claim for
compensation, if available;
2.
assign to the MassHealth Agency or its agent, the right to recover an amount
equal to the Health Safety Net benefits provided from the proceeds of any claim
or other proceeding against a third party;
3. provide information about the claim or any
other proceeding and cooperate fully with the MassHealth Agency, unless the
MassHealth Agency determines that cooperation would not be in the best
interests of, or would result in serious harm or emotional impairment to, the
Low Income Patient;
4. notify the
Health Safety Net Office or MassHealth in writing within ten days of filing any
claim, civil action or other proceeding; and
5. repay the Health Safety Net Office from
the money received from a third party for all Health Safety Net services
provided on or after the date of the accident or other incident. If the Low
Income Patient is involved in an accident or other incident after becoming
Health Safety Net eligible, repayment will be limited to Health Safety Net
Eligible Services provided as a result of the accident or
incident.
(e) Patients
are obligated to return money to the Health Safety Net Office, and the Health
Safety Net Office may recover such sums directly from a Patient, only to the
extent that the Patient has received payment from a third party for the medical
care paid by the Health Safety Net or to the extent specified in
101
CMR
613.06(5).
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
(1) General. Providers may submit claims for Reimbursable Health Services to Low Income Patients determined in accordance with the criteria in 101 CMR 613.04. Low Income Patients may be determined eligible for Health Safety Net - Primary or Health Safety Net - Secondary, in accordance with 101 CMR 613.04(6). The following individuals are not eligible for Low Income Patient status:
(a) individuals who have been determined eligible for any MassHealth program, including any premium assistance program, but who have failed to enroll; and
(b) individuals whose enrollment in MassHealth or the Premium Assistance Payment Program Operated by the Health Connector has been terminated due to failure to pay premiums.
(2) Low Income Patient Determination. Except as provided in 613.04(3) and 613.04(4) an individual must complete and submit an Application for benefits using the eligibility procedures and requirements under 130 CMR 502.000: MassHealth : The Eligibility Process or 130 CMR 516.000: MassHealth : The Eligibility Process. In order to be determined a Low Income Patient , an individual must be a Resident of the Commonwealth and document that the Modified Adjusted Gross Income of his or her MassHealth MAGI Household is equal to or less than 300% of the FPL, or that the Countable Income of his or her Medical Hardship Family is less than or equal to 300% of the FPL that if the individual used a Senior Application as defined in 130 CMR 515.001: Definition of Terms.
(a) Determination Notice. The MassHealth Agency or the Commonwealth Health Insurance Connector notifies the individual of his or her eligibility determination for health care coverage or if the individual is a Low Income Patient .
(b) Verification of Income. Verification of income is mandatory. Income may be verified either through electronic data matches or paper verification.
1. Electronic Data Matches. MassHealth electronically matches with federal and state data sources described at 130 CMR 502.004: Matching Information to verify attested income. The income data received through an electronic data match is compared to the attested income amount to determine if the attested amount and the data source amount are reasonably compatible. If these amounts are reasonably compatible, the attested income is considered verified for purposes of an eligibility determination. To be considered reasonably compatible
a. both the attested income and the income from the data sources must be above the applicable income standard for the individual; or
b. both the attested income and the income from the data sources must be below the applicable income standard for the individual; or
c. the attested income and the income from the data sources must be within a ten percent range of each other.
2. Asset Verification. If the MassHealth agency requests an asset verification pursuant to 130 CMR 520.000: MassHealth : Financial Eligibility for an applicant, the applicant must comply with the guidelines listed in 130 CMR 516.003: Verification of Eligibility Factors in order to obtain and/or maintain their Health Safety Net determination.
3. Paper Verification. If the attested income and the income from the electronic data source are not reasonably compatible, or if the electronic data match is unavailable, paper verification of income is required.
a. Paper verification of monthly earned income includes, but is not limited to
i. recent paystubs;
ii. a signed statement from the employer; or
iii. the most recent federal tax return.
b. Verification of monthly unearned income is mandatory and includes, but is not limited to
i. a copy of a recent check or paystub showing gross income from the source;
ii. a statement from the income source, where matching is not available; or
iii. the most recent federal tax return.
c. Verification of gross monthly income may also include any other reliable evidence of the Patient 's earned or unearned income.
(c) Verification of Identity. The following are acceptable proof of identity.
1. The following are acceptable proof of identity, provided such documentation has a photograph or other identifying information including, but not limited to, name, age, sex, race, height, weight, eye color, or address:
a. identity documents listed at 8 CFR § 274a.2(b)(1)(v)(B)(1), except a driver's license issued by a Canadian government authority;
b. driver's license issued by a state or territory;
c. school identification card;
d. U.S. military card or draft record;
e. identification card issued by the federal, state, or local government;
f. military dependent's identification card; or
g. U.S. Coast Guard Merchant Mariner card;
2. for children younger than 19 years old, a clinic, doctor, hospital, or school record, including preschool or day care records;
3. two documents containing consistent information that corroborates an applicant's identity. Such documents include, but are not limited to
a. employer identification cards;
b. high school and college diplomas (including high school equivalency diplomas);
c. marriage certificates;
d. divorce decrees;
e. property deeds or titles;
f. a pay stub from a current employer with the applicant's name and address preprinted, dated within 60 days of the application ;
g. census verification containing the applicant's name and address, dated not more than 12 months before the date of the application ;
h. a pension or retirement statement from a prior employer or pension fund stating the applicant's name and address, dated within 12 months of the application ;
i. tuition or student loan bill containing the applicant's name and address, dated not more than 12 months before the date of the application ;
j. utility bill, cell phone bill, credit card bill, doctor's bill, or hospital bill containing applicant's name and address, dated not more than 60 days before the date of the application ;
k. valid homeowner's, renter's, or automobile insurance policy with preprinted address, dated not more than 12 months before the date of the application , or a bill for such insurance with preprinted address, dated not more than 60 days before the date of the application ;
l. lease dated not more than 12 months before the date of the application , or home mortgage identifying applicant and address; or
m. employment verification by means of W-2 forms or other documents bearing the applicant's name and address submitted by the employer to a government agency as a consequence of employment;
(d) Matching Information. The MassHealth Agency initiates information matches with other agencies and information sources when an application is received, at annual renewal and periodically, in order to update or verify eligibility. These agencies and information sources may include, but are not limited to, the following: the Federal Data Services Hub, the Division of Unemployment Assistance, Department of Public Health's Bureau of Vital Statistics, Department of Industrial Accidents, Department of Veterans' Services, Department of Revenue, Bureau of Special Investigations, Internal Revenue Service, Social Security Administration, Systematic Alien Verification for Entitlements, Department of Transitional Assistance, and health insurance carriers.
(3) Confidential Services . The Health Safety Net Office's Application for Health Safety Net Confidential Services may be used for the following special application types. For these application types, five percentage points of the current FPL are subtracted from the applicable total Countable Income to determine the applicant's eligibility for Low Income Patient status. An individual seeking these services is not required to report his or her primary address.
(a) Minors receiving Confidential Services may apply to be determined a Low Income Patient using their own Countable Income information and using the Office's application for Health Safety Net Confidential Services. If a minor is determined to be a Low Income Patient, the Provider may submit claims for Confidential Services when no other source of funding is available to pay for the services confidentially. For all other services, Minors are subject to the standard Low Income Patient determination process. Providers may submit claims for Eligible Services rendered to these individuals for Confidential Services only.
(b) An individual who has been a victim of domestic violence, or who has a reasonable fear of domestic violence or continued domestic violence, may apply for Low Income Patient status using his or her own Countable Income information if he or she seeks medically necessary Eligible Services.
(4) Presumptive Determination. An individual may be determined to be a Low Income Patient for a limited period of time, if on the basis of attested information submitted to a Provider on the form specified by the Health Safety Net Office, the Provider determines the individual is presumptively a Low Income Patient. An individual may not be determined to be a Low Income Patient pursuant to 101 CMR 613.04(4)(b)4. if the individual has already been determined to be a Low Income Patient pursuant to 101 CMR 613.04(4)(b)4. within the previous 12 months. Notwithstanding 101 CMR 613.04(7)(a), Providers may submit claims for Reimbursable Health Services provided to individuals with time-limited presumptive Low Income Patient determinations only for dates of service beginning on the date on which the Provider makes the presumptive determination and continuing until the earlier of
(a) the end of the month following the month in which the Provider made the presumptive determination if the individual has not submitted a complete Application , or
(b) the date of the determination notice described in 101 CMR 613.04(6)(a) related to the individual's Application .
(5) Grievance Process. An individual may request that the Office conduct a review of a determination of Low Income Patient status, Provider compliance with the provisions of 101 CMR 613.00, or Medical Hardship eligibility if exceptional circumstances outside of the individual's control had a material impact on the Medical Hardship eligibility determination. The Health Safety Net Office will conduct a review using the following process.
(a) In order to request a review, the individual must send a written request to the Office with supporting documentation.
(b) To request a review of a determination of Low Income Patient status, the individual must send the review request within 30 days from the date of the official notification of the determination.
(c) To request a review of a Medical Hardship eligibility determination, the individual must send the review request, including a description of the circumstances outside of the individual's control that had a material impact on the eligibility determination, within six months from the date of the official notification of the determination. For all grievances, the Office may request additional information as necessary from the grievant, other state agencies, and/or the Provider(s). Additional information requested from the grievant by the Office must be submitted within 30 days.
(d) The Office will provide an initial response to the grievant within 30 days of receipt of the grievance and will issue a written decision and explanation of the reasons for its decision to the grievant and other relevant parties within a reasonable time after receipt of all necessary information.
(6) Low Income Patient Eligibility Categories.
(a) The categories of Low Income Patient eligibility for Health Safety Net services are:
1. Health Safety Net - Primary. A Low Income Patient is eligible for Health Safety Net - Primary if he or she is uninsured and documents MassHealth MAGI Household income or Medical Hardship Family Countable Income , as described in 101 CMR 613.04(2), between 0% and 300% of the FPL, subject to the following exceptions.
a. Low Income Patients eligible for enrollment in the Premium Assistance Payment Program Operated by the Health Connector are not eligible for Health Safety Net -Primary except as provided in 101 CMR 613.04(7)(a) and (b).
b. Low Income Patients subject to the Student Health Program requirements of M.G.L. c. 15A, § 18 are not eligible for Health Safety Net - Primary.
2. Health Safety Net - Secondary. A Low Income Patient is eligible for Health Safety Net - Secondary if he or she has other primary health insurance and documents MassHealth MAGI Household income or Medical Hardship Family Countable Income , as described in 101 CMR 613.04(2), between 0 and 300% of the FPL, subject to the following exceptions.
a. Effective 101 days after the Medical Coverage Date , Low Income Patients eligible for the Premium Assistance Payment Program Operated by the Health Connector are eligible only for dental services not otherwise covered by the Premium Assistance Payment Program Operated by the Health Connector .
b. Low Income Patients enrolled in MassHealth Standard, MassHealth CarePlus, MassHealth Common Health, and MassHealth Family Assistance excluding MassHealth Family Assistance - Children are eligible only for Adult Dental Services provided at a Community Health Center, Hospital Licensed Health Center, or Satellite Clinic.
c. Low Income Patients enrolled in a qualifying Student Health Plan are eligible for Health Safety Net - Secondary.
(b) Other Requirements.
1. Affordable Insurance. An individual with MassHealth MAGI Household income or Medical Hardship Family Countable Income , as described in 101 CMR 613.04(2), less than or equal to 300% of the FPL, and for whom insurance is deemed affordable as defined in 956 CMR 6.00: Determining Affordability for the Individual Mandate, is not eligible for Health Safety Net - Primary. If such an individual's employer offers employer-sponsored insurance, he or she is not eligible for Health Safety Net - Primary except during the employer's waiting period before the employer-sponsored insurance becomes effective.
2. Pending Disability Determination. Providers may submit claims for individuals whose MassHealth eligibility status is pending due to a MassHealth disability determination. If the individual is determined eligible for MassHealth , the Provider must void Health Safety Net claims for the individual and submit claims for services to MassHealth.
3. Health Safety Net - Partial. A Low Income Patient eligible for either Health Safety Net - Primary or Health Safety Net - Secondary who documents MassHealth MAGI Household income or Medical Hardship Family Countable Income , as described in 101 CMR 613.04(2), greater than 150% and less than or equal to 300% of the FPL is considered Health Safety Net - Partial and must meet the Health Safety Net - Partial deductible described in 101 CMR 613.04(8)(c).
(7) Eligibility Period.
(a) Except as specified in 101 CMR 613.04(5)(b), providers may submit claims for Reimbursable Health Services effective on the Medical Coverage Date until the Patient's eligibility is terminated.
(b) For Low Income Patients eligible for the Premium Assistance Payment Program Operated by the Health Connector :
1. Providers may submit claims for Reimbursable Health Services for the period beginning on the Patient's Medical Coverage Date and ending 100 days after the Patient's Medical Coverage Date.
2. Effective 101 days after the Patient 's Medical Coverage Date , providers may submit claims only for dental services not otherwise covered by the Premium Assistance Payment Program Operated by the Health Connector until the Patient's eligibility is terminated.
(c) Low Income Patient status is effective for a maximum of one year from the date of determination, subject to periodic redetermination and verification that the Patient's MassHealth MAGI Household income or Medical Hardship Family Countable Income , as described in 101 CMR 613.04(2), or insurance status has not changed to such an extent that the Patient no longer meets eligibility requirements.
(8) Low Income Patient Responsibilities.
(a) Cost Sharing Requirements. Low Income Patients are responsible for paying copayments in accordance with 101 CMR 613.04(8)(b) and deductibles in accordance with 101 CMR 613.04(8)(c).
(b) Low Income Patient Copayment Requirements. Low Income Patients are responsible for copayments for pharmacy services.
1. The copayments for pharmacy services are
a. $1 for each prescription and refill for each generic drug in the following drug classes: antihyperglycemics, antihypertensives, and antihyperlipidemics;
b. $3.65 for each prescription and refill for other generic drugs; and
c. $3.65 for each prescription and refill for brand-name drugs.
2. There are no copayments for services provided to Low Income Patients who are
a. younger than 21 years old; or
b. pregnant or in the postpartum period that extends through the last day of the 12th calendar month following the month in which their pregnancy ends (for example, if the individual gave birth on May 15th, the individual is exempt from the copayment requirement until June 1st of the next year).
3. There is an annual maximum of $250 per Patient on pharmacy copayments.
4. Notwithstanding 101 CMR 613.04(8)(b)1. through 3., Low Income Patients are not responsible for the making copayments for pharmacy services during the period May 1, 2023, through March 31, 2024.
(c) Health Safety Net - Partial Deductibles.
1. Annual Deductible. For Health Safety Net - Partial Low Income Patients with MassHealth MAGI Household income or Medical Hardship Family Countable Income greater than 150% and less than or equal to 300% of the FPL, there is an annual deductible if all members of the PBFG have an FPL above 150%. If any member of the PBFG has an FPL equal to or below 150% there is no deductible for any member of the PBFG. The annual deductible is equal to the greater of
a. the lowest cost Premium Assistance Payment Program Operated by the Health Connector premium, adjusted for the size of the PBFG proportionally to the MassHealth FPL income standards, as of the beginning of the calendar year; or
b. 40% of the difference between the lowest MassHealth MAGI Household income or Medical Hardship Family Countable Income , as described in 101 CMR 613.04(2), in the applicant's Premium Billing Family Group (PBFG) and 200% of the FPL.
2. Applying the Deductible. The Patient is responsible for payment for all services provided up to this deductible amount. Once the Patient has incurred the deductible, a Provider may submit claims for Reimbursable Health Services in excess of the deductible. There is only one deductible per PBFG per approval period. The deductible is not applied to pharmacy services. Copayments are not considered expenses to be included in the deductible amount.
3. Deductible Tracking. The annual deductible is applied to all Reimbursable Health Services provided to a Low Income Patient or PBFG member during the Eligibility Period. Each PBFG member must be determined a Low Income Patient in order for his or her expenses for Reimbursable Health Services to be applied to the deductible. The Provider must track the Patient's Reimbursable Health Services expenses until the Patient meets the deductible. If more than one PBFG member is determined to be a Low Income Patient, or if the Patient or PBFG members receive services from more than one Provider, it is the Patient's responsibility to track the deductible and provide documentation to the Provider that the deductible has been reached.
4. Acute Hospitals. The Patient must incur expenses for Reimbursable Health Services in excess of the annual deductible before the Provider may submit a claim for Reimbursable Health Services . Once the Patient has incurred the deductible, the Provider may submit a claim for the remaining balance of Reimbursable Health Service expenses. The Acute Hospital may require a deposit and/or a payment plan in accordance with 101 CMR 613.08(1)(g).
5. Community Health Centers and Hospital Licensed Health Centers.
a. Health Safety Net - Partial Low Income Patients receiving Reimbursable Health Services from Community Health Centers are responsible for 20% of the Health Safety Net payment for each visit, to be applied to the amount of the Patient's annual deductible until the Patient meets his or her deductible. Health Safety Net - Partial Low Income Patients receiving Reimbursable Health Services from Hospital Licensed Health Centers, Satellite Clinics, and school-based health centers are responsible for either 20% of the Health Safety Net payment for each visit or the full amount of the service, as specified by the Provider. If the Provider specifies that a Health Safety Net - Partial Low Income Patient is responsible for 20% of the payment amount, the Provider may submit a claim for the remaining balance of each eligible service.
b. If a Hospital Licensed Health Center , Satellite Clinic, or school-based health center that provides Reimbursable Health Services specifies that any Health Safety Net - Partial Low Income Patient is responsible for only 20% of the payment amount, it must offer this option to all Health Safety Net - Partial Low Income Patients receiving Reimbursable Health Services at the location.
c. The Health Safety Net Office may require a Community Health Center to report when a Patient's deductible has been met or any other information regarding the Patient's deductible in a manner specified by the Health Safety Net Office.
(d) Assignment of Third-party Payments. A Low Income Patient must assign to the MassHealth Agency his or her rights to third-party payments for medical benefits provided under the Health Safety Net and must fully cooperate with and provide the MassHealth Agency with information to help pursue any source of third-party payment. A Low Income Patient must inform the Health Safety Net Office or MassHealth when he or she is involved in an accident or suffers from an illness or injury, or other loss that has resulted or may result in a lawsuit or insurance claim, other than a medical insurance claim. The Low Income Patient must
1. file an insurance claim for compensation, if available;
2. assign to the MassHealth Agency or its agent, the right to recover an amount equal to the Health Safety Net benefits provided from the proceeds of any claim or other proceeding against a third party;
3. provide information about the claim or any other proceeding and cooperate fully with the MassHealth Agency, unless the MassHealth Agency determines that cooperation would not be in the best interests of, or would result in serious harm or emotional impairment to, the Low Income Patient ;
4. notify the Health Safety Net Office or MassHealth in writing within ten days of filing any claim, civil action or other proceeding; and
5. repay the Health Safety Net Office from the money received from a third party for all Health Safety Net services provided on or after the date of the accident or other incident. If the Low Income Patient is involved in an accident or other incident after becoming Health Safety Net eligible, repayment will be limited to Health Safety Net Eligible Services provided as a result of the accident or incident.
(e) Patients are obligated to return money to the Health Safety Net Office, and the Health Safety Net Office may recover such sums directly from a Patient, only to the extent that the Patient has received payment from a third party for the medical care paid by the Health Safety Net or to the extent specified in 101 CMR 613.06(5).