Financial eligibility




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130 CMR: DIVISION OF MEDICAL ASSISTANCE

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Trans. by E.L. 213

Rev. 01/01/14

MASSHEALTH

FINANCIAL ELIGIBILITY

Chapter 520

Page 520.000

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TABLE OF CONTENTS
Section
520.001: Introduction to General Financial Requirements

520.002: Financial Responsibility

520.003: Asset Limit

520.004: Asset Reduction

520.005: Ownership of Assets

520.006: Inaccessible Assets

520.007: Countable Assets

520.008: Noncountable Assets

520.009: Countable-Income Amount

520.010: Business Expenses

520.011: Standard Income Deductions

520.012: Community Earned Income Deductions

520.013: Community Unearned Income Deductions

520.014: Long-Term-Care Earned Income Deductions

520.015: Noncountable Income

520.016: Long-Term Care: Treatment of Assets

520.017: Right to Appeal the Asset Allowance or Minimum Monthly Maintenance Needs Allowance

520.018: Transfer of Resources Regardless of Date of Transfer

520.019: Transfer of Resources Occurring on or after August 11, 1993

(130 CMR 520.020 Reserved)

520.021: Treatment of Trusts

520.022: Trusts or Similar Legal Devices Created before August 11, 1993

520.023: Trusts or Similar Legal Devices Created on or after August 11, 1993

520.024: General Trust Rules

520.025: Long-Term-Care Income Standard

520.026: Long-Term-Care General Income Deductions

520.027: Long-Term-Care Deductible

520.028: Eligibility for a Deductible

520.029: The Deductible Period

520.030: Calculating the Deductible

520.031: Notification of Potential Eligibility

520.032: Submission of Bills to Meet the Deductible

520.033: Verification of Medical Expenses

520.034: Interim Changes

520.035: Conclusion of the Deductible Process

520.036: Copayments Required by the MassHealth Agency

520.037: Copayment and Cost Sharing Requirement Exclusions

520.038: Services Subject to Copayments

520.039: Members Unable to Pay Copayment

520.040: Maximum Cost Sharing



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Trans. by E.L. 213

Rev. 01/01/14

MASSHEALTH

FINANCIAL ELIGIBILITY

Chapter 520

Page 520.001

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520.001: Introduction to General Financial Requirements
(A) 130 CMR 520.000 describes the rules governing financial eligibility for MassHealth. 130 CMR 520.000 is based on financial responsibility, countable income, and countable assets.
(B) The methods for the calculation of the countable income amount, the deductible, and the income standards used in the determination of eligibility are also explained in 130 CMR 520.000.
520.002: Financial Responsibility
(A) Community Residents.

(1) Spouses Living Together. In the determination of eligibility for MassHealth, the total countable income amount and countable assets of the individual and the spouse who are living together are compared to an income standard and asset limit, unless one spouse is covered by MassHealth under a home- and community-based services waiver, as described in 130 CMR 519.007(B): Home- and Community-Based Services Waiver-Frail Elder.

(2) Spouses Living Apart. When spouses live apart for reasons other than admission to a medical institution, their assets and income are considered mutually available only through the end of the calendar month of separation.
(B) Residents of Medical Institutions.

(1) Spouses Living Together. When spouses live in the same long-term-care facility, the income and assets are not mutually available.

(2) One Spouse Institutionalized.

(a) If only one spouse is a resident of a medical institution who is expected to remain in the facility for 30 days or more, the community spouse's income is not counted in the determination of eligibility for the institutionalized spouse. The institutionalized spouse may provide for the maintenance needs of the community spouse in accordance with 130 CMR 520.026(B).

(b) The countable assets of both spouses must be evaluated and a spousal share established in accordance with 130 CMR 520.016(B).

(3) Institutionalized Child. When a child under age 18 lives in a medical institution, the income and assets of the parents are considered available only through the end of the calendar month of separation.


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Trans. by E.L. 213

Rev. 01/01/14

MASSHEALTH

FINANCIAL ELIGIBILITY

Chapter 520

Page 520.003

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520.003: Asset Limit
(A) The total value of countable assets owned by or available to individuals applying for or receiving MassHealth Standard, Family Assistance, or Limited may not exceed the following limits:

(1) for an individual — $2,000; and

(2) for a couple living together in the community where there is financial responsibility according to 130 CMR 520.002(A)(1) — $3,000.
(B) The total value of countable assets owned by or available to individuals applying for or receiving MassHealth Senior Buy-In, as described in 130 CMR 519.010: MassHealth Senior Buy-In, or MassHealth Buy-In, as described in 130 CMR 519.011: MassHealth Buy-In, may not exceed the following limits:

(1) for an individual — in calendar year 2011, $6,680 and, in calendar year 2012, $6,940; and

(2) for a couple living together in the community where there is financial responsibility according to 130 CMR 520.002(A)(1) — in calendar year 2011, $10,290 and, in calendar year 2012, $10,410.
(C) The treatment of a married couple's assets when one spouse is institutionalized is described in 130 CMR 520.016(B).
520.004: Asset Reduction
(A) Criteria.

(1) An applicant whose countable assets exceed the asset limit of MassHealth Standard, Family Assistance, or Limited may be eligible for MassHealth

(a) as of the date the applicant reduces his or her excess assets to the allowable asset limit without violating the transfer of resource provisions for nursing-facility residents at 130 CMR 520.019(F); or

(b) as of the date, described in 130 CMR 520.004(C), the applicant incurs medical bills that equal the amount of the excess assets and reduces the assets to the allowable asset limit within 30 days after the date of the notification of excess assets.

(2) In addition, the applicant must be otherwise eligible for MassHealth.
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Trans. by E.L. 213

Rev. 01/01/14

MASSHEALTH

FINANCIAL ELIGIBILITY

Chapter 520

Page 520.005 (1 of 2)

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(B) Evaluating Medical Bills. The MassHealth agency does not pay that portion of the medical bills equal to the amount of excess assets. Bills used to establish eligibility

(1) cannot be incurred before the first day of the third month prior to the date of application as described at 130 CMR 516.002: Date of Application; and

(2) must not be the same bills or the same portions of the bills that are used to meet a deductible based on income.


(C) Date of Eligibility. The date of eligibility for otherwise eligible individuals described at 130 CMR 520.004(A)(1)(b) is the date that his or her incurred allowable medical expenses equaled or exceeded the amount of his or her excess assets.

(1) If after eligibility has been established, an individual submits an allowable bill with a medical service date that precedes the date established under 130 CMR 520.004(C), the MassHealth agency readjusts the date of eligibility.

(2) In no event will the first day of eligibility be earlier than the first day of the third month before the date of the application, if permitted by the coverage type.
(D) Verification. The MassHealth agency requires the applicant to verify that he or she incurred the necessary amount of medical bills and that his or her excess assets were reduced to the allowable asset limit within required timeframes.
520.005: Ownership of Assets
(A) General. Assets owned exclusively by an applicant or member and the spouse are counted in their entirety when determining eligibility for MassHealth, except when assessing assets in accordance with 130 CMR 520.016.
(B) Joint Ownership of Assets, Other Than Bank Accounts. Any asset, other than a joint bank account, jointly owned by two or more individuals, is presumed to be owned in equal shares and counted proportionately unless a different distribution of ownership is verified or unless assets are being assessed in accordance with 130 CMR 520.016. When such a different distribution of ownership is verified, the MassHealth agency attributes the countable value of the assets to the applicant or member or the spouse in proportion to the ownership interest.
(C) Joint Bank Accounts.

(1) Bank accounts are defined at 130 CMR 520.007(B)(1).

(2) When the applicant or member is a joint owner of a bank account, the entire amount on deposit is considered available to the applicant or member, except when assessing assets in accordance with 130 CMR 520.016.

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Trans. by E.L. 213

Rev. 01/01/14

MASSHEALTH

FINANCIAL ELIGIBILITY

Chapter 520

Page 520.005 (2 of 2)

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(3) If the applicant or member claims partial ownership of the funds in the joint account, he or she must verify the amount owned by each joint depositor. When such a partial ownership is verified, the countable value of the assets is attributed to each owner in proportion to the ownership interest.

(4) The applicant or member may transfer the funds owned by him or her into an account that accurately reflects his or her ownership interest. The MassHealth agency does not consider such a transfer of assets to make oneself eligible for MassHealth if the transfer is completed within 30 days after written notification by the MassHealth agency of this requirement, except in the case of a community spouse as described at 130 CMR 520.016 who is allowed 90 days to make the transfer.
(D) Verifications. Individual or joint ownership of any countable asset must be verified by a written document providing reasonable evidence of ownership. The MassHealth agency determines whether a verification is acceptable in accordance with 130 CMR 520.007(B)(3) and 130 CMR 520.005(D). Acceptable verification includes, but is not limited to, the following:

(1) a title;

(2) a purchase contract;

(3) documents establishing ownership of joint bank accounts that demonstrate the following:

(a) the origin of the funds in a joint bank account, who opened the account, or whose money was used to open the account;

(b) federal and state tax records as to which joint account holders pay the tax on interest credited to the account as income;

(c) records of who makes deposits and withdrawals and, if appropriate, how withdrawn funds are spent;

(d) any evidence of written or oral agreements made between the parties at the time of the creation of the account;

(e) evidence of age, relationship, physical or mental condition, or place of residence of the co-holders when the applicant or member states that he or she does not own the account but is listed as a co holder solely as a convenience to the other co holder to conduct bank transactions on his or her behalf; and

(f) why the applicant or member is listed on the account;

(4) certification of ownership;

(5) financial-institution records indicating the establishment of an account that accurately reflect the ownership interest of funds from the joint account;

(6) other documentation that indicates ownership, asset value, and restrictions on access;

(7) a notarized affidavit, sworn to under penalty of perjury, signed by all owners of the asset, and attesting to the distribution of ownership; or

(8) the self-declaration of the individual who is applying solely for MassHealth Buy-In,

as described at 130 CMR 519.011(B): MassHealth Buy-In for Qualifying Individuals. The MassHealth agency may, at its discretion, request additional verification.


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Trans. by E.L. 213

Rev. 01/01/14

MASSHEALTH

FINANCIAL ELIGIBILITY

Chapter 520

Page 520.006

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520.006: Inaccessible Assets
(A) Definition. An inaccessible asset is an asset to which the applicant or member has no legal access. The MassHealth agency does not count an inaccessible asset when determining eligibility for MassHealth for the period that it is inaccessible or is deemed to be inaccessible under 130 CMR 520.006.
(B) Examples of Inaccessible Assets. Inaccessible assets include, but are not limited to

(1) property, the ownership of which is the subject of legal proceedings (for example, probate and divorce suits); and

(2) the cash surrender value of life insurance policies when the policy has been assigned to the issuing company for adjustment.
(C) Date of Accessibility. The MassHealth agency considers accessible to the applicant or member all assets to which the applicant or member is legally entitled

(1) from the date of application or acquisition, whichever is later, if the applicant or member does not meet the conditions of 130 CMR 520.006(C)(2)(a) or (b); or

(2) from the period beginning six months after the date of application or acquisition, whichever is later, if

(a) the applicant or member cannot competently represent his or her interests, has no guardian or conservator capable of representing his or her interests, and the authorized representative (which may include a provider) of such applicant or member is making a good-faith effort to secure the appointment of a competent guardian or conservator; or

(b) the sole trustee of a Medicaid Qualifying Trust, under 130 CMR 520.022(B), is one whose whereabouts are unknown or who is incapable of competently fulfilling his or her fiduciary duties, and the applicant or member, directly or through an authorized representative (which may include a provider), is making a good-faith effort to contact the missing trustee or to secure the appointment of a competent trustee.
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Trans. by E.L. 213

Rev. 01/01/14

MASSHEALTH

FINANCIAL ELIGIBILITY

Chapter 520

Page 520.007 (1 of 9)

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520.007: Countable Assets
Countable assets are all assets that must be included in the determination of eligibility. Countable assets include assets to which the applicant or member or his or her spouse would be entitled whether or not these assets are actually received when failure to receive such assets results from the action or inaction of the applicant, member, spouse, or person acting on his or her behalf. In determining whether or not failure to receive such assets is reasonably considered to result from such action or inaction, the MassHealth agency considers the specific circumstances involved. The applicant or member and the spouse must verify the total value of countable assets. However, if he or she is applying solely for MassHealth Buy-In, as described at 130 CMR 519.011(B): MassHealth Buy-In for Qualifying Individuals, verification is required only upon request by the MassHealth agency. 130 CMR 520.007 also contains the verification requirements for certain assets. The assets that the MassHealth agency considers include, but are not limited to, the following.
(A) Cash.

(1) Definition. Cash is defined as currency, checks, and bank drafts in the possession of or available to the applicant, member, or spouse.

(2) Verification. The applicant's or member's declaration on the application or redetermination form stating the amount of cash available to him or her is sufficient verification.
(B) Bank Accounts.

(1) Definition. Bank accounts are defined as deposits in a bank, savings and loan institution, credit union, or other financial institution. Bank accounts may be in the form of savings, checking, or trust accounts, term certificates, or other types of accounts.

(2) Determination of Ownership and Accessibility. The MassHealth agency considers funds in a bank account available only to the extent that the applicant or member has both ownership of and access to such funds. The MassHealth agency determines the ownership of and access to the funds in accordance with 130 CMR 520.005 and 520.006.

(3) Verification of Account Balances. The MassHealth agency requires verification of the current balance of each account at application, during eligibility review, and at times of reported change.

(a) Noninstitutionalized individuals excluding the individuals described at 130 CMR 519.007(B): Home- and Community-Based Services Waiver-Frail Elder must verify the amount on deposit by bank books or bank statements that show the bank balance within 45 days of the date of application or the date that the eligibility review is received in a MassHealth Enrollment Center or outreach site.

(b) Nursing-facility residents as described at 130 CMR 515.001: Definition of Terms must verify the amount on deposit by bank books or bank statements that show the current balance and account activity during the look back period.



130 CMR: DIVISION OF MEDICAL ASSISTANCE

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Trans. by E.L. 213

Rev. 01/01/14

MASSHEALTH

FINANCIAL ELIGIBILITY

Chapter 520

Page 520.007 (2 of 9)

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(c) If during an eligibility review the member states either orally or in writing that an account other than a checking account contains a balance of $25 or less, the MassHealth agency does not require verification provided that, in combination with other countable assets, it would not affect continued eligibility.

(d) If lack of either access to or ownership of funds in an account is verified, the MassHealth agency will not consider the funds a countable asset.
(C) Individual Retirement Accounts, Keogh Plans, and Pension Funds.

(1) Individual Retirement Accounts. An Individual Retirement Account (IRA) is a tax-deductible savings account that sets aside money for retirement. Funds in an IRA are counted as an asset in their entirety less the amount of penalty for early withdrawal.

(2) Keogh Plans. A Keogh Plan is a retirement plan established by a self employed individual. A Keogh Plan may be established for the self-employed individual alone or for the self employed individual and his or her employees. If the Keogh Plan was established for the self employed individual alone, the funds in the Plan are counted as an asset in their entirety less the amount of penalty for early withdrawal. If the Keogh Plan was established for employees other than the spouse of the applicant or member, the MassHealth agency does not count the funds as an asset.

(3) Pension Funds. A pension fund is a retirement plan established by an employer to provide benefit payments to employees upon retirement or disability. Pension funds that are being set aside by an individual's current employer are not countable as an asset. Pension funds from an individual's former employer are countable in their entirety less any penalties for withdrawal provided such funds are accessible. (See 130 CMR 520.006.)


(D) Securities. Securities include, but are not limited to, stocks, bonds, options, futures contracts, debentures, mutual funds including money-market mutual funds, and other financial instruments. Tradable securities are valued at the most recent closing bid price, and nontradable securities are valued at current equity value. A security for which there is no market value or that is inaccessible in accordance with 130 CMR 520.006 is noncountable.
(E) Cash Surrender Value of Life Insurance Policies.

(1) The cash-surrender value of a life-insurance policy is the amount of money, if any, that the issuing company has agreed to pay the owner of the policy upon its cancellation. An individual may adjust the cash-surrender value of life insurance to meet the asset limit. The MassHealth agency will consider the cash-surrender-value amount an inaccessible asset during the adjustment period.



130 CMR: DIVISION OF MEDICAL ASSISTANCE

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Trans. by E.L. 213

Rev. 01/01/14

MASSHEALTH
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