Advocacy Tips for Retaining MassHealth for Older Adults
Learn important advocacy tips for helping older adults in the community retain MassHealth, focusing on eligibility rules, key points to consider during renewal, and managing bank accounts effectively. Discover pathways to eligibility, asset and income counting rules, and considerations for clients aged 65 and older.
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Advocacy Tips for Helping Older Adults in the Community Retain MassHealth Victoria Pulos, Senior Staff Attorney, vpulos@mlri.org Massachusetts Law Reform Institute January 2024 1
MassHealth Eligibility rules change at age 65 Under age 65 (with exceptions) Upper income limit 138% FPL MAGI income counting rules All income in Adjusted Gross Income (AGI) under IRS rules & Also, all SSA insurance-based benefits including nontaxable amounts, (but not SSI), tax exempt interest & certain nontaxable foreign income No asset test Prepopulated renewal form-shows current info & asks what changed HIX Computer System 65 or older (with exceptions) Upper income limit 100% FPL + $20 mo Non-MAGI income & asset counting rules Non-MAGI rules generally follow the same income & asset counting rules as SSI. 42 CFR 435.601 Countable assets can t exceed $2000/$3000 (individual/couple) Renewal form=Application form MA-21 Computer System 2
Key Points If client 65 or older will have income over 100% FPL & assets over $2000/$3000, consider other options at renewal Step 1: assess whether countable income will be more than 100% FPL and/or countable assets over $2000/$3000 Step 2: explore other options at renewal Step 3: include information on the renewal application that will be needed to qualify for other options At renewal, people are eligible until found to be ineligible after MassHealth has explored all pathways to eligibility What are other options at renewal Pathways to MassHealth or other programs with higher income/asset rules Spending down assets (safely) Refer to an experienced elder law attorney for more complex options like trusts https://www.naela.org/findlawyer 3
Bank accounts: income vs. assets Money received is income in the month of receipt, the amount unspent is an asset in the first moment of the following month Example: Balance in your checking account on May 31 is $1000, you receive Pension of $1500 on June 1 Countable assets in your checking account in June: $1000 $1500 Pension is included in June income See, POMS SI 00810.010 (Relationship of Income to Resources) Some unspent income received during COVID-19 is never counted as an asset e.g. Economic Incentive Payments/Stimulus Payments from IRS in 2020-2021 MassHealth recognizes the exemption but has never explained how to identify exempt amounts included in bank balance. EOM 23-18 (July 2023) 4
Other pathways to MassHealth Standard Parent/caretaker relative incl. grandparents raising grandchildren (130 CMR 505.002 & 519.005). Upper income 138% FPL & no asset test + 12-month extended eligibility if working (TMA) Complete the ACA-3 application rather than the SACA-2 HCBS Frail Elder waiver (130 CMR 519.007(B)). Upper income $2829 per mo (2024); spousal income not counted & more generous spousal asset rules(*there are other waivers through DDS, MassRehab and for nursing home residents) Age 60-64 & disabled or age 65 or older, and meet nursing facility level of care as determined by Aging Service Access Point ( ASAP) but able to live in community with supports from HCBS waiver https://www.mass.gov/location-details/aging-services-access-points-asaps-in-massachusetts See, Eligibility Operations Memo 23-24, Applying for HCBS Waivers, (October 2023) PACE(130 C.M.R. 519.007(C)): upper income $2829 (2024); spouse s income and assets not counted Age 55-64 & disabled or age 65 or older, and meet nursing facility level of care & live in PACE service area https://www.mass.gov/program-of-all-inclusive-care-for-the-elderly-pace PCA deduction (130 CMR 520.013(B). You may be eligible for MH Standard if your income is over 100% FPL, you are in need of a Personal Care Attendant (PCA), and- your income without PCA deduction is 133% FPL or less, or your income without the PCA disregard is over 133% FPL, and you meet a deductible. 130 CMR 520.028(E) Deemed SSI: Pickle, DAC. (130 CMR 519.003 and 519.004) 5
Other Pathways to MH Standard PACE(130 C.M.R. 519.007(C)): upper income $2829 (2024); spouse s income and assets not counted Age 55-64 & disabled or age 65 or older; meet nursing facility level of care; live in PACE service area Find a PACE program & how to apply: https://www.mass.gov/program-of-all-inclusive- care-for-the-elderly-pace PCA deduction (130 CMR 520.013(B). Your income is over 100% FPL, you are in need of a Personal Care Attendant (PCA), and- your income without PCA deduction is 133% FPL or less, or your income without the PCA disregard is over 133% FPL, and you meet a deductible. 130 CMR 520.028(E) Deemed SSI: Pickle, DAC. (130 CMR 519.003 and 519.004) You used to receive SSI, now have Social Security & meet other conditions. 6
The Personal Care Attendant (PCA) deduction 130 CMR 520.013(B) Your income is 133% FPL or less but over 100% FPL You need hands-on help with two or more activities of daily living (ADLs) You complete, sign and return the PCA Supplement Form https://www.mass.gov/doc/personal-care-attendant-supplement-0/download Example: You turned 65; your income is $1300 per month in 2024. You need help getting in and out of bed and bathing. You return the PCA form. See, PCA eligibility criteria at 130 CMR 422 Your PCA deduction is 133% FPL ($1670 per mo. in 2024) less $522 =$1,148 Your countable income is now 100% FPL or less: $1300-1148=$152 per mo. You qualify for Standard, and can now be evaluated by a Personal Care Management agency about how much help you need and how to use the PCA benefit 7
Meeting a deductible if you need a PCA 130 CMR 520.028 The MassHealth Spenddown program is a way seniors can qualify for Standard as medically needy. Needing a PCA is not required, but it lowers the amount of the deductible to make the Spenddown a feasible option. Your income is over 133% FPL without the PCA disregard. Your deductible=((Your monthly gross income less PCA disregard & other allowable disregards) -$522) X 6 months You meet the deductible by submitting proof that bills you paid or incurred for medical & related expenses in the 6-month budget period and older bills that are still actively due equal or exceed the deductible amount You will qualify for Standard for the 6-mo period in which the deductible is met MassHealth will not pay expenses used to meet the deductible 8
Deemed SSI Status: Pickle and DAC People enrolled in SSI are automatically eligible for MH Standard People who lose SSI retain MassHealth for 4 months and then are sent a renewal form to determine if they still qualify. MAOA v Sharp, (1st Cir 1986) People with deemed SSI status are eligible for MH Standard even if their income is over 100% FPL if 1. they lost SSI, 2. now have Social Security Insurance Based benefits (Title II), and 3. would still be eligible for SSI but for receipt of: Title II COLAs added to their Title II SSA income since they lost SSI (PICKLE), or See https://healthlaw.org/wp-content/uploads/2023/12/Pickle-Publication-2024.pdf Title II Disabled Adult Child*benefits on the account of a deceased, disabled or retired parent (DAC). * You must have been disabled before age 22 to be a DAC. You can check whether you had SSI and when you lost it with SSA. MassHealth can also get this info from its data match with SSA. 130 CMR 519.003(Pickle), 519.004 (DAC) There are other deemed SSI statuses for disabled people under 65 including disabled widows DAW 9
Renewing Eligibility for HCBS waivers and PACE 2019 El. Ops. Memo 19-13, PETI for HCBS Waiver Members and 2021 El. Ops. Memo 21-13, Implementation of PETI in PACE) If you were enrolled in HCBS or PACE and are now being renewed, special income rules apply to your continuing eligibility. If you were financially eligible for HCBS or PACE and enrolled, but Your income has increased and is now higher than the upper income limit for new applicants for HCBS or PACE ($2829 per mo in 2024), then The Post-Eligibility Treatment of Income (PETI) Rules apply. Your countable income for continuing eligibility is your gross income less all allowable deductions and, in addition, a deduction of $2829 per month (2024). Example: At renewal, your countable income before the added PETI deduction is now $3000, too high to initially qualify for HCBS/PACE in 2024. Your patient paid amount with the PETI deduction is $3000-2829=$171. You may retain eligibility for HCBS/PACE but will owe a monthly payment of $171 per month to the HCBS/PACE program. 10
Other options at renewal: CommonHealth, Medicare Savings Programs, ConnectorCare Other MassHealth programs CommonHealth working disabled (130 CMR 519.012): employed at least 40 hours per month, no upper income limit but premiums if income over 150%FPL, no asset test New CommonHealth retirement benefit for people 65 or older who had been on CommonHealth for 10 years or more El. Ops. Memo 23-19 (Aug 2023) Medicare Savings Programs (130 CMR 519.010- 519.011): Income not over 190%/210%/225% FPL. No asset test as of Mar 1, 2024. ConnectorCare (956 CMR 12.04): 500%* FPL; no asset test Not enrolled in Medicare & not eligible for premium-free Medicare Pt A or other affordable insurance Income over 100% FPL unless ineligible for MassHealth due to immigration status Upper income was 300% FPL but under 2-year pilot starting in 2024, it is 500% FPL ConnectorCare is affordable private insurance. See, https://www.mahealthconnector.org/ 11
CommonHealth Working Disabled (130 CMR 519.013) Applies to people age 65 and older not eligible for MassHealth Standard Must be disabled as determined by SSA or by MassHealth Disability Evaluation Service Must be employed at least 40 hours per week or 240 hours in past 6 months Employment is not defined in regs but generally means you provide some service for which you receive some compensation. Proof may be a letter from one or more customers or employers of what you do, how many hours you do it & how much you are paid. No upper income limit or asset test Earnings will be counted using MAGI rules Monthly premium payments required if MAGI countable income is over 150% FPL CommonHealth covers all community LTSS but only short-term nursing home stays 12
CommonHealth Retirement Benefit -NEW Approved in 1115 Demonstration in Sept 2022 effective July 2023 New: Eligibility for CommonHealth for disabled adults 65 and older who have been on CommonHealth for 10 years or more. Eligible with no ongoing work requirement Eligibility Operations Memo 23-19 (August 2023) Write CommonHealth on the top of SACA-2 renewal if new benefit applies Continuing unchanged: Eligibility for disabled adults 65 and older working at least 40 hours per month DES will make a disability determination for people 65 or older if needed At renewal, MassHealth beneficiaries will remain in current coverage pending disability determination needed for CommonHealth working disabled 13
Medicare Savings Program 2024 130 CMR 519.010 & 519.011. https://www.mass.gov/info-details/get-help-paying-medicare-costs No asset test eff. March 1, 2024 Payment of Medicare Pt B Premium ($172 per mo) + Medicare Pt A & B cost-sharing (QMB): income limit $ 2405 per mo (2024) Payment of Medicare Pt B Premiums only (SLMB/QI): income limit $2844 per mo.(2024) One page form & no verification of income required but not an application for full MassHealth & HSN only in months eligible for MSP Full SACA-2 required to apply for all available coverage including MSP Added benefits of MSP: avoids Medicare late enrollment penalties, automatically eligible for low-income subsidy for Pt D (drug benefit) 14
Medicare Savings Program Confusion in 2023 MSP upper income level increased 1/1/2023 but MassHealth initially only applied the increase to people using the MSP-only application not the SACA-2 form. In Nov. 2023 MassHealth implemented a retroactive correction for about 10,000 people who didn t get the increase based on use of SACA-2 form, and amended rule to use same income level whatever form is used. 15
Reducing Assets Safely The risk: Transfer of asset rule results in denial of payment for nursing home care based on disqualifying transfer within 60 mo. look-back period. 130 CMR 520.019 Transfer is disqualifying if not for fair market value unless it is permissible like transfer to spouse (520.019(D) or the purpose of transfer was for a reason other than qualifying for MassHealth (520.019(F). Safe ways to reduce assets prior to renewal Pay off bills, buy things you need keep receipts Convert countable assets to non-countable assets e.g. open a burial account see MLRI flyer on burial accounts For more complex options like trusts or annuities & to understand any irrevocable transfer or planned giving, refer to an experience elder law attorney Termination notice for excess assets includes notice of asset spenddown 130 CMR 520.004 If you spend down excess assets within 30 days of notification by paying medical bills, you will be reinstated back to date of denial/termination Otherwise you qualify only on the date assets have been spent down to $2000 or less 16
Resources with more information on countable income & assets MAGI MAGI household rules MAGI income rules- 42 CFR 435.603 & 130 CMR 506.000 et seq Beyond the Basics (CBPP) Income Definition for Marketplace and Medicaid Coverage (Aug 2023) https://www.healthreformbeyondthebasics.org/key-facts-income-definitions-for-marketplace-and-medicaid- coverage/ Disabled adult MAGI -130 CMR 506.000 NonMAGI NonMAGI income rules 130 CMR Parts 520 & 519 Non MAGI asset rules 130 CMR 520.000 et seq No more restrictive than SSI 42 CFR 435.601 SSA s Program Operations Manual https://secure.ssa.gov/apps10/poms.nsf/chapterlist!openview&restricttocategory=05 2023 BBT: MassHealth for Older Adults in the Community 17
More retaining eligibility tips At renewal, you can remain eligible pending the disability determination or medical assessment needed to qualify for HCBS Waiver or CommonHealth if -- On SACA-2 renewal, HCBS is checked or disability is checked and earnings reported for CommonHealth. HCBS: El. Ops Memo 23-24 (Oct 2023), or You appeal a termination in time for aid to continue pending appeal. Prior to the hearing (if possible) update the renewal application, and, if needed, complete the disability form or request HCBS assessment Temporary asset waiver during the unwinding of the COVID public health emergency for renewals. El.Ops.Memo 23-23 (Oct 2023): MassHealth will disregard assets accumulated beyond program asset limits for MassHealth members who were enrolled during the [Public Health Emergency]. Those assets will be disregarded until after the redetermination period. CMS Approval 9/5/23; CMCS Info. Bulletin 12/18/23 (pp. 4-5) extending temporary waivers to 12/31/24. Permanent case by case special circumstances exception to verification requirements when documentary proof is not reasonably available. 42 CFR 435.952(c) 18
More tips for reinstating eligibility without a coverage gap after benefits are terminated Temporary post-termination reconsideration with no gap in coverage after termination for procedural reasons if missing info supplied within 90 days of termination & individual is still eligible. Not automatic. Must be requested. El Ops 23-18 (July 2023). Applies to all procedural terminations on or after 4/1/23. CMS Approval extended to 12/31/24. One Care & SCO contracts include a grace period to keep members enrolled after certain reasons for termination. Grace period is for remainder of month in which MassHealth ends plus 60 days (One Care) 30 days (SCO) MassHealth pays for grace period if member reestablishes eligibility 19
Retaining or reinstating benefits by appealing Deadline for eligibility appeals: Appeal received by BOH within 60 days of member s receipt of adverse notice of decision (130 CMR 610.015(B)) Deadline for aid to continue pending appeal: Appeal received by BOH Before the implementation date of the termination or reduction of your benefits. 130 CMR 610.036 (A), or Within 10 days of receipt of notice of the termination or reduction of benefits (receipt presumed to be within 5 days of date of notice but later receipt may be proven) El.Ops.Memo 23-05 Clarification of Aid Pending Rule (Feb 2023) Important rights in appealing a termination or reduction in benefits: Eligibility is based on evidence submitted at hearing (de novo rule) (130 CMR 610.071) 20
