101 CMR, § 613.05 - Medical Hardship
(1)
Eligibility.
(a)
General. A Massachusetts Resident at any Countable
Income level may qualify for Medical Hardship if allowable medical expenses
exceed a certain percentage of his or her Countable Income as specified in
101
CMR 613.05(1)(c). A
determination of Medical Hardship is a one-time determination and not an
ongoing eligibility category. An applicant may submit no more than two Medical
Hardship applications within a 12-month period.
(b)
Countable
Income.
1.
Gross
Earned Income.
a. Gross earned
income is the total amount of compensation received for work or services
performed without regard to any deductions.
b. Gross earned income for the self-employed
is the total amount of business income listed on the most recently filed
federal tax return or allowable on a federal tax return.
c. Seasonal income is income derived from an
income source that is associated with a particular time of the year. Annual
gross income is divided by 12 to obtain a monthly gross income with the
following exception: if the Patient has a disabling illness or accident during
or after the seasonal employment period that prevents the person's continued or
future employment, only current income will be considered in the eligibility
determination.
2.
Gross Unearned Income.
a. Gross unearned income is the total amount
of income that does not directly result from the individual's own labor before
any income deductions are made.
b.
Unearned income includes, but is not limited to, social security benefits,
railroad retirement benefits, pensions, annuities, federal veterans' benefits,
interest and dividend income, unemployment benefits, child support, and
alimony.
3.
Rental Income. Rental income is the total amount of
gross income less any deductions listed or allowable on the Patient's most
recently filed federal tax return or allowable on a federal tax
return.
(c)
Percentage of Countable Income. To qualify for Medical
Hardship, the applicant's allowable medical expenses exceed a specified
percentage of the applicant's Countable Income as follows.
|
Income Level |
Percentage of Countable Income |
|
0 - 205% FPL |
10% |
|
205.1 - 305% FPL |
15% |
|
305.1 - 405% |
20% |
|
405.1 - 605% FPL |
30% |
|
>605.1% FPL |
40% |
(2)
Eligibility
Determination. An applicant for Medical Hardship must complete a
Medical Hardship application and provide required documentation of Countable
Income, documentation of Massachusetts residency, proof of identity, and
detailed, itemized documentation of medical expenses. The Health Safety Net
Office processes applications for Medical Hardship and verifies information
contained in the application. Providers must assist the applicant to complete
the Medical Hardship application and assemble the required documentation. Once
the applicant has completed the application and assembled all of the required
documentation, the Provider assisting the applicant must submit the completed
application to the Health Safety Net office within five business days. If the
Provider assisting the applicant fails to submit the completed application to
the Health Safety Net Office within that time frame, the Provider may not
undertake a Collection Action against the applicant with respect to any bills
that would have been eligible for Medical Hardship payment had the application
been submitted and approved. The Health Safety Net Office approves an
application for Medical Hardship if the applicant's allowable medical expenses
exceed the percentage of Countable Income listed above. If the applicant
reports Countable Income less than or equal to 405% of the FPL, the applicant
must submit an Application, with all required documentation. The Health Safety
Net Office does not approve Medical Hardship applications for individuals
reporting Countable Income less than or equal to 405% of the FPL unless the
applicant has submitted an Application. The Health Safety Net Office does not
make a determination on Medical Hardship applications for individuals reporting
Countable Income less than or equal to 405% of the FPL until the Patient has
received a determination related to the Application.
(3)
Allowable Medical
Expenses. The Health Safety Net Office determines the applicant's
allowable medical expenses based on review of the submitted documentation.
Allowable medical expenses may include only Medical Hardship Family medical
bills from any health care Provider that, if paid, would qualify as deductible
medical expenses for federal income tax purposes. Allowable medical expenses
include paid and unpaid bills for services provided up to 12 months prior to
the date of the Medical Hardship application for which the Patient is
responsible. If a Patient does not receive an initial medical bill for more
than nine months from when the services were provided, the bill may still be
considered an allowable medical expense if a Medical Hardship application is
submitted within 90 days of the date of the initial medical bill for the
service. Allowable medical expenses do not include bills for services incurred
while the applicant was a Low Income Patient unless the applicant was a
Dental-only Low Income Patient on the date of service. Allowable medical
expenses do not include bills for services incurred while the applicant was
enrolled in MassHealth or the Premium Assistance Payment Program Operated by
the Health Connector. Bills included in an approved Medical Hardship
determination cannot be included in a subsequent Medical Hardship
application.
(4)
Payable Medical Expenses. The Health Safety Net pays
only for the services described in
101 CMR 613.03(2)
through (4). Other allowable medical expenses
are not eligible for Health Safety Net payment.
(5)
Medical Hardship
Contribution.
(a) The applicant's
required contribution is calculated as the specified percentage of Countable
Income in 101 CMR 613.05(1)(b) based on the Medical Hardship Family's FPL
multiplied by the actual Countable Income less bills not eligible for Health
Safety Net payment, for which the applicant will remain responsible.
(b) There is one Medical Hardship
contribution for each Medical Hardship determination. If the applicant is
determined a Low Income Patient or eligible for MassHealth, the applicant's
required contribution will be deferred until the applicant's Low Income Patient
status or MassHealth eligibility is ended. If the Health Safety Net Office
approves two Medical Hardship applications during a 12-month period, it will
prorate the required contribution amounts.
(6)
Notification of
Determination. The Health Safety Net Office notifies applicants of
the determination.
(a) An approval notice
explains that the person is eligible for Medical Hardship; includes the dates
for which allowable medical expenses may be included; includes the amount of
the applicant's Medical Hardship contribution; lists the services that do not
qualify as Eligible Services; and includes a contact number for more
information. The Office also notifies Providers with bills included in the
applicant's allowable medical expenses of the determination and allocates the
applicant's contribution to each Provider based on the dates of services and
gross charges of services provided to the applicant's Medical Hardship
Family.
(b) A denial notice
explains that the person is not eligible for Medical Hardship and the reasons
for the eligibility denial. Both the Patient and Provider are notified of the
denial.
(7)
Claims. When the Health Safety Net Office approves a
Medical Hardship application, it notifies those Providers whose services were
included in the documentation of medical expenses required under 101 CMR
613.05(2). To be eligible for payment for any such service, the Provider must
submit a claim to the Health Safety Net Office within 18 months of the date of
service. Payment of such claims is subject to all other requirements set forth
in 101 CMR 613.00 and other applicable laws and
regulations.
Notes
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