Office of the Inspector General
Commonwealth of Massachusetts
Glenn A. Cunha
Inspector General
Report Pursuant to Section 182
of Chapter 139 of the Acts of
2012: Assessing MassHealth’s
Identification and Recovery of
Noncustodial Parents’ Health
Insurance
March 1, 2013
Massachusetts Office of the Inspector General
Address:
Room 1311
John McCormack State Office Building
One Ashburton Place
Boston, MA 02108
Phone:
(617) 727-9140
(617) 523-1205 (MCPPO Program)
(800)
322-1323 (confidential 24-hour
hotline)
Internet and Fax:
www.mass.gov/ig
(617) 723-2334 (fax)
Printed on recycled paper.
Table of Contents
Executive Summary....................................................................................................................... i
Introduction....................................................................................................................................1
Background ....................................................................................................................................3
I. The Office of the Inspector General ....................................................................................3
II. The Medicaid Program ........................................................................................................3
A. Federal Regulation ........................................................................................................... 3
B. MassHealth........................................................................................................................ 6
III. The Office’s Review of Information Provided on the MBR .............................................11
A. Overview of the Database ............................................................................................. 11
B. Noncustodial Parent Information ................................................................................. 11
Findings.........................................................................................................................................13
I. MassHealth receives information each month from DOR/CSE regarding
noncustodial parents...........................................................................................................13
II. MassHealth’s TPL vendor also uses MBR information to pursue TPL. ...........................13
III. MassHealth does not pursue potential coverage from a noncustodial parent, even
when there is a health insurance order...............................................................................14
IV. Prior to March 2011, MassHealth did not require applicants to provide complete
information necessary to pursue noncustodial parent health insurance before
making an initial eligibility determination.........................................................................15
V. It is unclear how much Supplement B information MassHealth has required
Medicaid applicants to provide since March 2011. ...........................................................16
VI. The MBR’s Supplement B is confusing and also does not request important
information that would help MassHealth to pursue noncustodial health insurance ..........18
Recommendations........................................................................................................................19
I. In order to obtain the information necessary to pursue TPL coverage, MassHealth
should simplify the language on the MBR and should add new questions .......................19
II. MassHealth should require applicants to answer all the questions on Supplement
B and any other questions related to noncustodial parents’ health insurance....................20
III. MassHealth should expand its efforts to use information obtained from the MBR
to evaluate TPL opportunities involving noncustodial parents..........................................21
A. MassHealth should perform data matching with all possible sources before
making an eligibility determination............................................................................. 21
B. MassHealth should send information from the MBR, including Supplement B, to
DOR/CSE........................................................................................................................ 22
Conclusion ....................................................................................................................................25
Appendix A: MassHealth Medical Benefit Request Form
Appendix B: Supplement B to the Member Benefit Request: Absent-Parent Questions and
Assignment of Rights
Executive Summary
At the direction of the Legislature the past two years, the Office of the Inspector General
(“Office”) has studied the administration of the Massachusetts Medicaid program (“Medicaid”)
by MassHealth, the state entity that runs the program. This year, pursuant to Section 182 of
Chapter 139 of the Acts of 2012, the Office examined: (1) how MassHealth gathers and verifies
information from custodial parents regarding the availability of commercial health insurance
from noncustodial parents; and (2) to what extent MassHealth uses that information to obtain
such health insurance coverage for a Medicaid member (referred to as a third party liability or
“TPL”). These issues are important to the financial well-being of Medicaid because the program
is designed and funded as the payor of last resort, which means that Medicaid is supposed to pay
only when another payor is unavailable. And under federal regulations, MassHealth is required
to take reasonable measures to identify TPL payors for Medicaid health care services, including
commercial health insurance from noncustodial parents of Medicaid members.
The Office studied two scenarios in which MassHealth could access a noncustodial parent’s
health insurance. First, MassHealth could discover that a noncustodial parent was already
providing health insurance to a Medicaid beneficiary and could then require this insurance to pay
the beneficiary’s health care claims. In this scenario, MassHealth’s maximum responsibility
would be to provide “secondary coverage” to the beneficiary to pay for deductibles, copays and
services not covered by the noncustodial parent’s insurance. The Office determined that
MassHealth does have policies and procedures in place for when a Medicaid member is already
covered by a noncustodial parent’s existing health insurance.
Second, in the scenario in which MassHealth learns that the member is not covered by a
noncustodial parent’s policy, MassHealth could, but currently does not, attempt to obtain or
enforce a health insurance support order by referring cases to the Department of Revenue’s Child
Support Enforcement Division (“DOR/CSE”), the Commonwealth’s child support enforcement
unit. MassHealth’s practice is inconsistent with federal and state regulations. Moreover,
MassHealth does not require Medicaid applicants to provide basic noncustodial parent
information, such as address, date of birth, Social Security number, and employer. This also
violates federal Medicaid regulations, and it prevents MassHealth from gathering information
i
that would enhance its ability to obtain or enforce a health insurance support order from a court,
should MassHealth decide to pursue such orders in the future. The Office searched the Medicaid
eligibility database and discovered that, at least prior to May 2011, Medicaid applicants did not
provide much of the noncustodial parent information requested by MassHealth.
1
In short, when
a Medicaid member is not already covered by a noncustodial parent’s health insurance policy,
MassHealth does not collect enough information, does not share with DOR/CSE the information
it does collect, and does not actively attempt to obtain or enforce health insurance support orders.
MassHealth has, however, made some changes designed to gather more noncustodial parent
information. MassHealth is also currently working with DOR/CSE to adopt a set of rules for
determining when it is cost-effective for MassHealth to pursue health insurance support orders
by referring cases to DOR/CSE. The Office applauds those efforts, but notes that MassHealth
has delayed adopting such rules the past few years. MassHealth can help all Medicaid members
by following the federal and state rules that are designed to facilitate MassHealth’s
identifications and recovery of noncustodial parents’ health insurance. In order to obtain the
information needed to identify available health insurance, MassHealth should simplify the
language on its application and expand the questions it asks about noncustodial parents and their
health insurance. Unless good cause exists not to provide information, MassHealth should also
require applicants to answer all of the questions on the application, including supplements,
related to noncustodial parents and their health insurance. The Office will follow up and report
to the Legislature on MassHealth’s progress in addressing the issues raised in this analysis.
1
The Office’s findings do not include applicants who claimed good cause for not providing the information.
ii
Introduction
In Chapter 240 of the Acts of 2004, the Legislature authorized the Office of the Inspector
General (“Office”) to form an Uncompensated Care Pool Audit Unit to oversee and examine the
practices surrounding the health care services provided to the uninsured in hospitals throughout
the Commonwealth. The Legislature funded these health care services through what was then
known as the Uncompensated Care Trust Fund, now the Health Safety Net Trust Fund (“HSN
Trust Fund”). The Office issued its first report pursuant to Chapter 240 in June 2005. That was
the first in a long series of reports the Office has issued regarding various aspects of the services
funded through the HSN Trust Fund.
In July 2012, the Legislature enacted Chapter 139 of the Acts of 2012, part of which directed the
Office to study and review the Massachusetts Medicaid program using funding from the HSN.
1
Section 182 of Chapter 139 states:
SECTION 182. The inspector general shall expend funds from the Health Safety
Net Trust Fund, established in section 36 of chapter 118G of the General Laws, to
conduct a study and review of the Massachusetts Medicaid program. The study
shall include, but not be limited to, a review of the program’s eligibility
requirements, utilization, claims administration and compliance with federal
mandates. The inspector general shall report any preliminary findings to the
secretary of health and human services and the house and senate committees on
ways and means on or before October 30, 2012, and issue a final report on or
before March 1, 2013.
Pursuant to this mandate, the Office reviewed the application process for medical benefits, and in
particular, catalogued the information that MassHealth
2
gathers from custodial parents regarding
the availability of health insurance from noncustodial parents. The Office further reviewed what
steps MassHealth takes to verify this information, as well as whether MassHealth determines if
noncustodial parents are responsible for providing health insurance to dependent children and/or
1
The Legislature enacted a similar provision the previous year (see Section 156 of Chapter 68 of the Acts of 2011),
and the Office issued the following: “Report Pursuant to Section 156 of Chapter 68 of the Acts of 2011: Rates of
Reimbursement to Providers in the MassHealth MCO Program.”
http://www.mass.gov/ig/publications/reports-and-
recommendations/2012/rates-of-reimbursement-masshealth-mco-providers-july-2012.pdf
2
MassHealth is the state agency that administers Massachusetts’ Medicaid program. The “MassHealth” agency is
also called the “Massachusetts Office of Medicaid.” In addition, “MassHealth” is another name for the
Massachusetts Medicaid program. To avoid confusion, whenever practicable throughout this report the Medicaid
program will be referred to as “Medicaid” and the state agency administering the program will be referred to as
“MassHealth.”
1
custodial parents through a court order (a “health insurance order”). To perform this study, the
Office used an eligibility database that it obtained from MassHealth in May 2011, to ascertain
what information applicants provide to MassHealth regarding noncustodial parents and health
insurance orders, and what MassHealth does with that information as part of its eligibility review
process.
As part of its review, the Office also met with, and conducted several follow-up interviews with,
staff from MassHealth and the Massachusetts Department of Revenue (“DOR”). DOR’s Child
Support Enforcement Division (“DOR/CSE”) is the government unit responsible for
administering and supervising the Commonwealth’s child support enforcement efforts. The
Office also interviewed third party liability (“TPL”) specialists from Commonwealth Medicine
of the University of Massachusetts Medical School, the TPL vendor for MassHealth. The Office
conducted additional informational interviews and performed a database review of 158,066
Medicaid recipients. This report contains the Office’s findings and recommendations.
2
Background
I. The Office of the Inspector General
Created in 1981, the Office was the first state inspector general’s office in the country. The
Office’s mission is to prevent and detect fraud, waste and abuse in the expenditure of public
funds. The Office investigates allegations of fraud, waste and abuse at all levels of government;
conducts programmatic reviews to identify systemic vulnerabilities and opportunities for
improvement; and provides assistance to the public and private sectors to help prevent fraud,
waste and abuse in government spending. The Office also offers a wide range of training
programs designed to promote excellence in public procurement and to enhance public
purchasing officials’ ability to operate effectively.
The Office has considerable experience reviewing health care programs that have eligibility,
documentation and verification components and has issued a number of analyses, reports and
recommendations regarding Medicaid oversight, the Health Safety Net, health care reform and
other health care topics. The Office also has expertise in developing fraud-control best practices
for state agencies and municipalities.
II. The Medicaid Program
The Medicaid program was created in 1965 for the purpose of providing medical assistance to
low-income Americans, particularly children, through a shared state-federal commitment.
Today, Medicaid is an entitlement program that finances medical care, as well as long-term care,
for tens of millions of Americans. Each state administers its own version of Medicaid under
federal and state laws and regulations.
A. Federal Regulation
MassHealth must administer Medicaid consistent with a number of basic federal guidelines that
beneficiaries must meet and mandates with which the state must comply. For example, under
federal law, with limited exceptions, only United States citizens, either natural or naturalized, are
3
eligible for Medicaid.
3
Beneficiaries must meet various eligibility criteria, including income
limits.
1. Payor of last resort
The federal government has determined that Medicaid must be the payor of last resort. This
means that Medicaid must ensure that it is paying only for health care for individuals who have
no other source of reimbursement for their health care, or that Medicaid pays last when other
insurance is present.
With regard to parents and their children’s health care, courts in divorce and paternity cases will
often enter an order, referred to as a health insurance order, requiring one parent to provide
health insurance for the children. For cases in which there is a health insurance order,
MassHealth has an obligation to obtain applicant information that would be useful in identifying
a legally liable third party. 42 C.F.R. § 433.138(b).
2. Third party liability
To carry out the mandate that Medicaid is the payor of last resort, federal regulations require that
MassHealth take “reasonable measures” to determine if there is any other entity that is legally
liable to pay for health care services. 42 C.F.R. § 433.138(a). This legal liability is referred to as
third party liability (“TPL”). Although there are a number of different sources of TPL, the
Office focused on TPL provided by commercial insurance offering health or casualty insurance
to individuals or groups.
To meet the “reasonable measures” standard under federal regulation, MassHealth must:
during the initial application and each redetermination process, obtain from the
applicant or recipient such health insurance information as would be useful in
identifying legally liable third party resources so that the agency may process
claims under the third party liability payment procedures . . . . Health insurance
information may include, but is not limited to, the name of the policy holder, his
or her relationship to the applicant or recipient, the social security number (SSN)
of the policy holder, and the name and address of insurance company and policy
number.
3
The Office notes that nonqualified aliens and aliens with special status may qualify for MassHealth Limited.
130 C.M.R. § 505.001(a)(7).
4
42 C.F.R. § 433.138(b)(1). The applicable federal regulations also specifically require that
MassHealth include in the eligibility case file the custodial or noncustodial parent’s Social
Security number to the extent such information is available. 42 C.F.R. § 433.138(c). The federal
regulations further require MassHealth to use the Social Security number and information
regarding the custodial or noncustodial parents’ employers to determine the availability of TPL.
4
42 C.F.R. § 433.138(d)(1)(i-ii).
3. Assignment of rights and cooperation
Pursuant to federal regulations, an applicant for, or recipient of, Medicaid benefits must assign to
MassHealth his own rights to any medical care support available under a court or administrative
order, his own rights to any third party payments for medical care, and the rights of an individual
for whom he can legally make such an assignment. 42 C.F.R. § 433.145. Consistent with this
requirement, MassHealth must require an individual who assigns any rights to medical support or
payments to cooperate in establishing paternity for a child born out of wedlock, as well as in
obtaining medical support and payments for himself and any other person for whom the
individual can legally assign rights. 42 C.F.R. § 433.147. Specifically, MassHealth may require
the individual to appear at a MassHealth office to provide information or evidence relevant to the
case; appear as a witness at a court or other proceeding; provide information, or attest to lack of
information, under penalty of perjury; pay MassHealth any support or medical care funds
received that are covered by the assignment of rights; and take any other reasonable steps to
assist in establishing paternity and securing medical support and payments, and in identifying
and providing information to assist MassHealth in pursuing any liable third party (such as health
insurance from a noncustodial parent). 42 C.F.R. § 433.147(b).
4. Good cause for refusal to cooperate
MassHealth may waive the requirements regarding cooperation if it determines that there is good
cause for an individual’s refusal to cooperate. 42 C.F.R. § 433.147(c). To do so, MassHealth
must find that cooperation is not in the best interest of a child, consistent with factors considered
4
MassHealth is also required to enter into agreements with other entities to identify additional potential sources of
TPL, such as workers’ compensation and motor vehicle accident coverage. 42 C.F.R. § 433.138(d)(4)(i-ii).
5
under the federal child support enforcement program.
5
42 C.F.R. § 433.147(c)(1). When
MassHealth waives cooperation with establishing paternity, obtaining medical care support and
payments for a child, or identifying and providing information to assist MassHealth in pursuing
liable third parties, such as a noncustodial parent, it must also do so in a manner that is consistent
with the federal child support enforcement program. 42 C.F.R. § 433.147(d).
B. MassHealth
1. Overview of types of MassHealth categories and coverage
MassHealth provides health care coverage for certain individuals who would not otherwise have
such coverage. Although it is partially funded by the federal government, the Commonwealth is
responsible for administering the program. As the administrator, MassHealth must ensure that
the program meets both federal and state mandates. With permission from the federal
government, the Commonwealth may create programs that broaden the safety net for health care
services to include more residents who do not meet all the federal Medicaid standards.
MassHealth currently administers seven different types of Medicaid programs and three
additional non-Medicaid benefit programs. The MassHealth Medicaid programs are:
(1) MassHealth Standard: for families, pregnant women, children, disabled individuals,
and women with breast or cervical cancer;
(2) Prenatal: for pregnant women;
(3) MassHealth CommonHealth: for disabled adults and disabled children who are not
eligible for MassHealth Standard;
(4) MassHealth Family Assistance: for children, certain employed adults, and persons
who are HIV positive who are not eligible for MassHealth Standard or
CommonHealth
6
;
(5) MassHealth Basic: for the long-term unemployed who have income at or below 100
percent of the federal poverty level, and who are receiving services or are on a
waiting list to receive services from the Department of Mental Health (DMH), as
identified by the DMH to MassHealth, or for individuals or members of a couple who
5
Similarly, for an individual who is applying only for himself, MassHealth may waive cooperation if it determines
that cooperation would result in reprisal against, and cause physical or emotional harm to, the individual providing
information or the person who would be receiving Medicaid benefits. 42 C.F.R. § 433.147(c)(2).
6
Some limited aspects of this program do not fall within Medicaid.
6
receive Emergency Aid to the Elderly, Disabled and Children (EAEDC) cash
assistance;
(6) MassHealth Essential: for the long-term unemployed and for disabled long-term
unemployed aliens with special status who have income at or below 100 percent of
the federal poverty level and who are not eligible for MassHealth Basic; and
(7) Limited: for nonqualified aliens and aliens with special status.
130 C.M.R. § 505.001(A).
7
The three additional benefit programs are: the Children’s Medical Security Plan (provides
certain uninsured children and adolescents with primary and preventive medical and dental
coverage), the Healthy Start Program (provides health insurance to low-income, uninsured
pregnant women to improve access to early, comprehensive, and continuous prenatal care to
improve the health of newborns and their mothers), and the Health Safety Net (provides care for
uninsured and underinsured individuals who are otherwise not eligible for MassHealth
programs). MassHealth also assists in the administration of the eligibility process for
Commonwealth Care, a state program that offers affordable health insurance to uninsured
Massachusetts adults who meet certain income and other requirements but do not qualify for
Medicaid.
2. MassHealth eligibility process
MassHealth has promulgated a number of regulations that govern its eligibility process. The
MassHealth regulations require that each “applicant or member must cooperate with the
MassHealth agency in providing information necessary to establish and maintain eligibility, and
must comply with all the rules and regulations of MassHealth, including recovery and obtaining
or maintaining available health insurance.” 130 C.M.R. § 501.010.
An individual provides information to MassHealth by completing the Medical Benefit Request
form (“MBR”). 130 C.M.R. § 502.00 et seq. The MassHealth regulations define a “complete”
MBR as one “that is received by the MassHealth agency and includes all required information
and verifications.” 130 C.M.R. § 501.001. When MassHealth receives an incomplete MBR,
“the MassHealth agency is unable to determine the applicant’s eligibility for [Medicaid].”
7
Medicaid also offers coverage for certain Medicare beneficiaries.
7
130 C.M.R. § 502.001(E)(1). There is, however, a process in place for MassHealth to request
additional information. 130 C.M.R. § 502.001(E)(2). If MassHealth still does not receive the
requisite information and the MBR remains incomplete, MassHealth is required to notify the
applicant that it is unable to determine eligibility for medical benefits. 130 C.M.R. §
502.001(E)(4).
With specific regard to noncustodial parent information, the MassHealth regulations state that:
(B) The applicant or member must fully cooperate with and provide [MassHealth]
with information to help pursue any medical support and source of third-party
payment, including the absent parent,
8
who is legally obligated to pay for care and
services for the applicant or member, or person on whose behalf benefits are
requested, unless he or she can show good reason not to cooperate or provide this
information.
(C) Refusing to comply with the[se] requirements . . . will exclude the applicant
or member from receipt of [Medicaid] benefits unless the applicant or member
demonstrates good cause, . . . or is a pregnant woman . . . .
130 C.M.R. § 503.004. As part of the eligibility determination process, MassHealth’s
regulations permit it to take data from the MBR and match it with information held by other
agencies and information sources. These agencies and information sources may include, but are
not limited to: the Division of Unemployment Assistance, the Department of Public Health's
Bureau of Vital Statistics, the Department of Industrial Accidents, the Department of Veterans'
Services, the Department of Revenue, the Bureau of Special Investigations, the Internal Revenue
Service, the Social Security Administration, the Alien Verification Information System, the
Department of Transitional Assistance, and health insurance carriers. 130 C.M.R. § 502.004.
In addition to its responsibility for obtaining complete information and matching that information
with other sources, MassHealth is responsible for reviewing the accuracy of the information that
it collects. In particular, MassHealth regulations refer to its Quality Control Division, which
“periodically conducts an independent review of eligibility factors in a sampling of case files.”
130 C.M.R. § 501.010(C). The regulations require that all members cooperate with the
representative of MassHealth. This cooperation includes, but is not limited to, a personal
8
MassHealth refers to a noncustodial parent as an “absent parent.”
8
interview and the furnishing of requested information. If the member does not cooperate,
MassHealth may terminate the member’s benefits. 130 C.M.R. § 501.010(C).
3. The Medical Benefit Request form (“MBR”)
The MBR is the application for Medicaid, the Children’s Medical Security Plan, Healthy Start
and the Health Safety Net. See Appendix A, Medical Benefit Request form. Completing the
application also allows MassHealth to determine whether the applicant could be eligible for
health insurance premium assistance.
The application is for individuals who live in Massachusetts, who are not on the verge of
entering a nursing home, and who are less than 65 years old. Parents and guardians of children
under the age of 19 may also use the form to apply for services. Either the entire family group
may apply for services, or parents may apply for their children only. Individuals with disabilities
may also use the MBR to apply for services.
The MBR instructs applicants that they must answer “all questions” and complete the entire
application and any applicable supplements correctly. Applicants must also provide proof of
citizenship for any member of the family unit that is applying for Medicaid.
a. MBR questions regarding the noncustodial parent and
Supplement B
Pages four and five of the MBR ask for information regarding health insurance that the applicant
has or for which the applicant may be eligible. The instructions for this section states that health
insurance “can be from . . . an absent parent.” These pages ask for the policyholder’s name,
Social Security number if obtainable, employer name, policyholder contribution to premium
costs, as well as the insurance company name, policy type, policy start date, policy number,
covered services, and names of covered family members.
Page six of the MBR contains the following two questions:
Has any child in the household been adopted by a single parent or has [sic] a parent who
is deceased or unknown?
Does any child in the family have a parent who does not live with you who is not
included in the previous question?
9
If the applicant answers “yes” to either of these questions, the MBR directs the applicant to
complete Supplement B. Supplement B instructs that the applicant “must cooperate with the
Child Support Enforcement Division of the Massachusetts Department of Revenue (DOR) to
establish paternity and enforce a medical-support order, unless you have Good Cause not to
cooperate.”
9
Supplement B describes cooperation as giving “information about the identity,
location, and employment of the absent parent . . . [and taking] any other action necessary to help
DOR in establishing paternity, and establishing, changing, or enforcing a child medical-support
order.” Supplement B asks whether an applicant has “good cause” not to cooperate with efforts
to obtain health insurance from the noncustodial parent, which includes the following situations:
(1) cooperation would lead to serious physical or emotional harm to a family member or his
child, the applicant, or member; (2) adoption of the child is in process; and (3) the child was the
result of sexual abuse or assault. Unless an applicant asserts a good cause claim, the applicant’s
“MassHealth eligibility could be affected” by the failure to cooperate. See Appendix B, MBR
Supplement B.
With regard to the specific information about the noncustodial parent, Supplement B requires the
applicant to provide the name, address, telephone number, Social Security number if obtainable
and one has been issued, date of birth, driver’s license number, gender, and employer’s name and
address. Supplement B also asks whether there is a “medical support(i.e., health insurance)
order in place.
b. The MBR’s signature page
By signing the application, the applicant grants as follows:
I give permission for my current and former employers and health insurers to
release to MassHealth . . . any and all information they have about my health-
insurance coverage and health-insurance coverage for members of my family
group. This includes, but is not limited to, information about policies, premiums,
coinsurance, deductibles, and covered benefits that are, may be, or should have
been available to me or members of my family group.
The applicant also grants MassHealth permission to pursue and collect third-party payments for
medical care and medical support (such as health insurance) from the noncustodial parent of any
child under age 19 who is applying for benefits. The applicant must assert, under the pains and
9
Supplement B refers to health insurance orders as “medical-support orders.”
10
penalties of perjury, that the information on the MBR, as well as on Supplement B, is “correct
and complete” to the best of the applicant’s knowledge.
III. The Office’s Review of Information Provided on the MBR
In light of the provisions of Section 182 requiring a review of MassHealth’s eligibility process
and compliance with federal law, the Office conducted a program integrity review to determine
how applicants were completing the MBR and to understand how MassHealth uses that
information to determine eligibility for Medicaid. This review focused in particular on
information provided regarding noncustodial parents and health insurance orders.
A. Overview of the Database
In May 2011, the Office received what is essentially a “snapshot” of the MA21 computer
database (“MA21”), which is the database that MassHealth uses to determine an applicant’s
eligibility for Medicaid, as well as to maintain applicants’ and members’ eligibility
information.
10
Among other information, MA21 includes eligibility information for every
member on every Medicaid program. The snapshot of the database was designed to allow the
Office to review applicant information at a fixed point in time. The Office also requested
information obtained through the Eligibility Review Form, which MassHealth uses to confirm
continued Medicaid eligibility annually.
The Office notes that the MA21 database has a potential weakness. When MassHealth enters
revised eligibility information on MA21, MassHealth overwrites the previous information, which
is then no longer available on MA21. Thus, historical eligibility information is not maintained.
As a result, changes cannot be tracked and the information contained in the MA21 database may
not be the same information as the applicant initially provided on the MBR.
B. Noncustodial Parent Information
For the purpose of the current review, the Office focused on the noncustodial parent information
that Medicaid members had listed on their MBR forms. The MBR responses show that, as of
10
In order to comply with the Affordable Care Act, MassHealth plans to transition by 2014 to a new system for
determining Medicaid eligibility. The system, called the Health Insurance Exchange/Integrated Eligibility System
(“HIX/IES’), is designed to eventually fully integrate eligibility determinations for a variety of state health and
human services programs. The issues and recommendations set forth in this report are equally relevant to the
current MA21 system and to the new HIX/IES system.
11
May 2011, there were 158,066 Medicaid members (i.e., dependent children and custodial
parents) associated with a noncustodial parent. These Medicaid members did not claim good
cause, and for 10,295 of those members the custodial parent reported that a health insurance
order was already in place. Presumably, the potential for obtaining health insurance coverage
from a noncustodial parent is higher on average for these 10,295 members than for the remaining
147,771 dependent children and custodial parent Medicaid members for whom there was no
good cause claim and no indication that a health insurance order was in place.
The Office notes that obtaining health insurance coverage from a noncustodial parent for a
Medicaid member (referred to as a TPL recovery” or “pursuit of TPL”) is not always possible
even when there is a health insurance order because: (1) some health insurance orders are
conditional, and a change in the circumstances of the noncustodial parent may mitigate the
obligation to provide health insurance; and (2) even when there is an unconditional health
insurance order, a noncustodial parent may not be easy to locate or may not have the resources
necessary to provide health insurance.
12
Findings
The Office found the following regarding MassHealth’s current efforts with TPL and
noncustodial parents:
I. MassHealth receives information each month from DOR/CSE regarding
noncustodial parents.
MassHealth and DOR have, for more than ten years, implemented many policies and procedures
to ensure that the Commonwealth realizes a cost savings when a dependent child on MassHealth
is enrolled in a noncustodial parent’s health insurance. In particular, each month DOR/CSE,
pursuant to federal law and the existing interagency service agreement (“ISA”) between
DOR/CSE and the Executive Office of Health and Human Services, sends an electronic file that
includes its entire caseload (with limited exceptions) to MassHealth’s TPL vendor. The file
includes specific identifying demographic data, household information, noncustodial parent court
order status, enrollment status, and policy information, if available. The TPL vendor, which has
access to large databases of private and public insurance information, uses the DOR/CSE
information to match MassHealth members to noncustodial parents’ insurance.
DOR/CSE stated that the data it sends to MassHealth’s TPL vendor includes information about
families who are or were recipients of Temporary Assistance for Needy Families (“TANF”).
TANF is a program that provides cash assistance, among other benefits, to low-income families.
All TANF recipients are also eligible for MassHealth. The Department of Transitional
Assistance (“DTA”), which administers the TANF program, is required by regulation to refer
TANF recipients who have assigned their rights to child support and health insurance to
DOR/CSE, with some limited exceptions. Because all TANF recipients are also eligible for
MassHealth, applicants complete assignments of rights for both DTA and MassHealth as part of
their TANF application. DOR/CSE establishes and enforces, to the greatest extent possible,
child support and health insurance orders in these cases. It is these cases from which the greatest
cost savings are derived.
II. MassHealth’s TPL vendor also uses MBR information to pursue TPL.
In addition to acting on information it receives from DOR/CSE, MassHealth’s TPL vendor uses
MBR information to pursue TPL, including identifying the existence of health insurance from a
13
noncustodial parent. If the custodial parent’s MBR contains sufficient information about a
noncustodial parent’s health insurance, the TPL vendor verifies with the insurer whether the
noncustodial parent has an active policy, and whether the dependent child(ren) and/or custodial
parent are insured under the policy. When the policy does cover a MassHealth member, the
vendor then identifies the insurer as the primary payor of the member’s future health care claims
and also bills the insurer for any claims that MassHealth already paid.
11
If the MBR does not
disclose adequate information regarding a noncustodial parent’s health insurance, the TPL
vendor conducts monthly data matches with the vendor’s large databases of insurance
information to determine whether the noncustodial parent has health insurance.
The Office is encouraged by the TPL vendor’s utilization of these databases. However, the
vendor’s insurance checks are entirely dependent upon the quality of the information collected
on the MBR regarding the noncustodial parent’s health insurance.
Moreover, there are at least two situations involving noncustodial parents in which MassHealth
typically does not recover TPL: (1) if the noncustodial parent has health insurance but the
dependent child(ren) and/or the custodial parent are not included on the policy; and (2) if the
noncustodial parent does not have health insurance. MassHealth limits its review in these
instances to determining whether members are already covered by a noncustodial parent’s
insurance. MassHealth’s focus is on existing coverage, not on potential coverage.
III. MassHealth does not pursue potential coverage from a noncustodial parent, even
when there is a health insurance order.
Although MassHealth receives information from DOR/CSE and provides information to its TPL
vendor, it does not pursue potential coverage from a noncustodial parent, even when the MBR
discloses the existence of a health insurance order. MassHealth does not request that the
custodial parent follow up with the noncustodial parent, either informally or formally, to ensure
that the noncustodial parent complies with the terms of the order. MassHealth does not contact
the noncustodial parent to inquire about the status of that parent’s health insurance. Most
important, MassHealth does not currently share its MBR information with DOR/CSE, thereby
11
In this situation, MassHealth usually becomes the secondary payor of the member’s health care claims and pays
for most of the member’s health care costs that are not paid by the primary insurer. There are limited circumstances
in which the discovery of a private insurance policy would mean that the member is no longer eligible for
MassHealth.
14
missing opportunities to obtain new, and to enforce existing, health insurance orders against
noncustodial parents. In short, MassHealth does not have policies or procedures in place to try to
make the noncustodial parent obtain coverage for the dependent child(ren) and/or the custodial
parent.
IV. Prior to March 2011, MassHealth did not require applicants to provide complete
information necessary to pursue noncustodial parent health insurance before
making an initial eligibility determination.
A review of the applicable state regulations, federal regulations, and instructions and questions
on the MBR indicates that (1) a custodial parent applicant must fully complete the MBR in order
to be eligible for Medicaid; and (2) MassHealth must verify the information that the applicant
provides before making an eligibility determination. See 130 C.M.R. § 502.001(E); 130 C.M.R.
§ 503.004(B) and (C); 42 C.F.R. § 433.138(b)(1), (c), and (d)(1); 42 C.F.R. § 433.145(a)(2) and
(3); 42 C.F.R. § 433.147(a) and (b); 42 C.F.R. § 433.148(a); MBR instructions; and Supplement
B to the MBR. The Office asked specifically about MassHealth’s policies and procedures to
verify noncustodial parent information, or to collect such additional information, during the
eligibility determination process. Based on interviews with MassHealth staff and on the Office’s
review of the MA21 snapshot, the Office learned that, prior to March 2011, MassHealth did not
require applicants to fill out Supplement B; signing the form was considered sufficient. In fact,
the MA21 snapshot that this Office reviewed demonstrated that of the 158,066 Medicaid
members (dependent children and custodial parents) who did not claim good cause and who were
associated with a noncustodial parent:
The noncustodial parent’s birthdate was left blank for 67,449 members.
The noncustodial parent’s address was left blank for 100,666 members.
The noncustodial parent’s Social Security number was left blank for
116,339 members.
The noncustodial parent’s employer was left blank for 125,878 members.
The existence of a health insurance order was left blank for 103,757
members.
The Office understands that a Medicaid applicant may not have all of the requested information
at his fingertips, or may not be able to find some of the information at all. MassHealth, however,
has a number of powerful tools at its disposal to find and verify much of this information during
15
the eligibility determination process.
12
The fact that so many items related to noncustodial
parents were not reported on the MBR hampered MassHealth’s ability to identify potential
sources of health insurance. In particular, with so much information missing, MassHealth could
not easily identify those noncustodial parents who had the legal responsibility to provide
coverage to dependent children and custodial parents in the Medicaid program.
As noted above, MassHealth was attempting to recover TPL only from noncustodial parents who
already provide health insurance for the custodial parents and/or their dependent children. One
might therefore observe that, because of MassHealth’s narrow TPL focus, the lack of MBR
information did not make matters worse.
13
But the Office views MassHealth’s limited TPL focus
and its failure to gather MBR information as two indicia of a broader issue: MassHealth is not
following federal regulations that require it to gather certain information (e.g., the names, Social
Security numbers, and employers, if available, of noncustodial parents), and to use that
information to pursue noncustodial parent TPL. See 42 C.F.R. § 433.138(a)-(d).
V. It is unclear how much Supplement B information MassHealth has required
Medicaid applicants to provide since March 2011.
It is evident from the MA21 snapshot that, prior to March 2011, MassHealth did not require
applicants to fill out Supplement B completely in order to be eligible for Medicaid. When the
Office asked MassHealth staff about the large amount of Supplement B information that was
missing, MassHealth staff informed the Office that as long as a Medicaid member signed
Supplement B, that was sufficient. This answer, while inconsistent with several federal and state
regulations, was confirmed by MassHealth staff on multiple occasions. The answer was,
however, entirely consistent with the large amount of missing Supplement B data on the MA21
snapshot.
12
MassHealth’s most powerful tool is to deny eligibility for the custodial parent due to lack of cooperation. Two
caveats should be noted with respect to this tool. First, it applies only to the custodial parent and not to any
dependent children under 19 years old. See 42 C.F.R. § 433.148(b). Second, there is a proposed change to 42
C.F.R. § 433.148(b) that would require states to provide Medicaid coverage and then enforce applicants’ duty to
cooperate, meaning that a custodial parent who failed to cooperate with MassHealth in pursuing TPL would be
enrolled in Medicaid but would be terminated shortly thereafter. See Proposed Rule: 78 Fed. Reg. 4628, 4684
(proposed January 22, 2013) (to be codified at 42 C.F.R. § 433.148).
13
Note that the missing MBR information adversely affects even MassHealth’s narrow TPL focus. MassHealth’s
TPL vendor indicated that when the vendor does not have enough identifying information about the noncustodial
parent, it is more difficult to identify that parent’s health insurance policy, which means that it also more difficult to
discern whether the custodial parent and dependent child(ren) are covered by such a policy.
16
Nevertheless, in March 2011 MassHealth issued “Eligibility Operations Memo 11-02,” which
appears to adopt a policy different from the one MassHealth staff had described in prior
discussions with the Office. Specifically, the memo indicates that if a Medicaid applicant is
supposed to fill out Supplement B but neglects to do so, “MA21 will send a verification notice
with an AP-1 form.” The AP-1 form is a stand-alone form that contains the same information as
the MBR Supplement B.
The memo states the “[f]ailure to complete and return the verification within the required
timeframe
14
will result in denial or termination of benefits for the custodial parent(s).”
Eligibility Operations Memo 11-02, p. 4. If MassHealth is in fact consistently using this
verification tool, MassHealth would be collecting much more noncustodial parent information
than it did before March 2011. In response to the Office’s request, MassHealth staff reviewed
the memo and apprised the Office on the memo’s impact on MassHealth’s procedures for
pursuing TPL from noncustodial parents. According to MassHealth staff, the agency changed its
practices in March 2011 and began requiring applicants who filled out Supplement B to provide
at least the following three pieces of information: (1) the name of the noncustodial parent, (2)
the noncustodial parent’s relationship to the child(ren) and (3) the names of the custodial parent’s
child(ren). If the applicant provides these three pieces of information and signs at the bottom,
MassHealth considers Supplement B to be complete and does not send a verification notice (with
an AP-1 form) to the applicant.
The Office plans to examine MassHealth’s implementation of the AP-1 process. The Office will
follow up on this issue in a future report and has already requested a current MA21 snapshot
from MassHealth to examine the information-gathering process. If they are, that might mean
that MassHealth’s TPL vendor is now able to identify more noncustodial parent health insurance
policies that cover custodial parents and dependent children receiving Medicaid. It would also
mean that if MassHealth and DOR/CSE adopt a policy under which MassHealth provides
noncustodial parent information to DOR/CSE, then DOR/CSE would have more information to
enable it to obtain health insurance orders requiring noncustodial parents to provide health
insurance for custodial parents and dependent children.
14
MassHealth staff informed the Office that the timeframe is 60 days.
17
VI. The MBR’s Supplement B is confusing and also does not request important
information that would help MassHealth to pursue noncustodial health insurance.
There are aspects of the MBR’s Supplement B that are confusing to applicants. Supplement B
requires the applicant to provide the name, address, telephone number, Social Security number,
date of birth, driver’s license number, gender, and employer’s name and address for the
noncustodial parent. But Supplement B does not provide an applicant with a way to respond that
he has seen the requested information but does not know the answer. Rather, applicants who do
not know the requested information, or who do not want to provide certain information, appear
to leave that field blank. This makes it unclear to MassHealth whether the applicant is failing to
cooperate or is unable to provide the answer.
Supplement B also asks whether there is a “medical-support order” [i.e., a health insurance
order] in place and provides “yes” and “no” check boxes, but again there is no option to indicate
that the applicant does not know the answer. And while the term “medical-support order” might
be clear to a lawyer familiar with domestic law, a layperson could easily confuse the meaning of
the term with that of a “health care proxy.” The confusion could be avoided by asking if a court
has ordered the noncustodial parent to provide health insurance for the dependent child(ren) and
asking separately if a court has ordered the noncustodial parent to provide health insurance for
the custodial parent.
Supplement B also does not request some important information that would help MassHealth to
pursue noncustodial health insurance. It does not request the name of the city, town, county,
state and country in which the health insurance order was obtained, or the docket number of the
divorce or paternity case. Supplement B does not inquire whether the noncustodial parent is
currently married, which could provide some insight into that parent’s financial resources.
Moreover, Supplement B does not ask the custodial parent whether the noncustodial parent has
health insurance and, if so, the name of the health insurer, whether the insurance covers the
dependent child(ren) and whether the insurance covers the applicant.
18
Recommendations
Based on the findings above, the Office makes the following recommendations for MassHealth
to strengthen its efforts regarding TPL and noncustodial parents:
I. In order to obtain the information necessary to pursue TPL coverage, MassHealth
should simplify the language on the MBR and should add new questions.
The Office suggests that the MBR use simpler language to explain what it needs. The language
of the MBR mirrors the statutes and regulations too closely, and may create confusion and
ambiguity for applicants. By creating a form that is clear and easier to follow, MassHealth
would obtain more information because applicants would understand better what is required.
And when MassHealth receives more complete information, it is better able to determine
eligibility accurately and ensure that it remains the payor of last resort.
The Office also recommends that MassHealth expand the questions on Supplement B to gather
additional information that would assist MassHealth to identify existing and potential health
insurance from noncustodial parents. For example, Supplement B could include check boxes
that allow the applicant to indicate “I don’t know” for the requested information. The presence
of these boxes would enable an applicant to complete the form in its entirety, rather than leaving
sections blank. During the eligibility determination process, a checked box could trigger the
need for further investigation.
The Office therefore suggests the following changes to the MBR Supplement B, to the extent
allowed by federal law:
Important Supplement B questions should have a check box that allows the
applicant to indicate that he does not know the answer to the question.
Depending on the other responses on Supplement B, MassHealth may need to
follow up with the applicant to obtain additional information.
The term “medical-support order” should either be defined clearly or should
be replaced with questions asking: (1) if a court has ordered the noncustodial
parent to provide health insurance for the dependent child(ren) and (2) if a
court has ordered the noncustodial parent to provide health insurance for the
custodial parent.
Supplement B should include additional questions regarding the health
insurance orders. Docket numbers and other identifying information (such as
case name; the year the case was filed; and the city, town, county, state and
19
country in which the order was obtained) would assist MassHealth, DOR/CSE
and other agencies in determining whether the order exists. This information
is even more important if the applicants are not in the DOR/CSE system.
Supplement B should inquire whether the noncustodial parent is currently
married, which could provide some insight into that parent’s financial
resources.
Supplement B should ask whether the noncustodial parent has health
insurance and, if so, the name of the health insurer, the policy number,
whether the insurance covers the dependent child(ren) and whether the
insurance covers the applicant.
Supplement B should require applicants with health insurance orders to
provide a copy of the order to MassHealth. The MBR already requires that
applicants send to MassHealth documentary proof of all income, HIV positive
status if applicable, United States citizenship if applicable, immigration cards
if applicable, and an application for a social security number. In keeping with
the requirement that an applicant must provide documentary support for other
information, the MBR should also require an applicant who indicates that
there is a health insurance order to send a copy of the order to MassHealth
with the MBR.
II. MassHealth should require applicants to answer all the questions on Supplement B
and any other questions related to noncustodial parents’ health insurance.
After reviewing the noncustodial parent information in the MA21 snapshot, the Office found
that, prior to March 2011, many applicants did not report even the most basic information about
the noncustodial parent. Applicants failed to report the noncustodial parent’s name, address,
Social Security number, date of birth, employer, or the existence of a health insurance order.
The Office points out that the information requested on the MBR and Supplement B is currently
required by both federal and state regulations. And MassHealth has an obligation under federal
regulations to take reasonable measures to determine the legal liability of third parties who are
liable to pay for health care services. MassHealth also has an obligation under current federal
regulations to ensure that applicants cooperate with the eligibility determination process. Indeed,
MassHealth’s own regulations specifically require a “complete” MBR that “includes all required
information and verifications.” With specific regard to noncustodial parent information,
MassHealth’s regulations require an applicant to provide information to help pursue any health
insurance or other TPL, and state that the failure to do so will exclude the applicant from the
receipt of Medicaid benefits.
20
To fulfill its legal obligations, MassHealth should seek to ascertain this basic information from
the applicant either before determining eligibility or shortly thereafter, depending on whether the
proposed change to 42 C.F.R. § 433.147 is adopted.
15
The Office recommends that MassHealth
investigate how it can obtain this information, and then use this information to assist MassHealth
in making better eligibility determinations and find TPL more quickly, both of which could
improve the Massachusetts Medicaid program.
As noted above, it is unclear whether MassHealth changed its information collection practices
when it issued Eligibility Operations Memo 11-02 in March 2011. The Office plans to study this
issue to further evaluate MassHealth’s efforts to access health insurance from noncustodial
parents who are legally responsible for providing health insurance to Medicaid members.
III. MassHealth should expand its efforts to use information obtained from the MBR to
evaluate TPL opportunities involving noncustodial parents.
A. MassHealth should perform data matching with all possible sources before
making an eligibility determination.
Once MassHealth has obtained a complete MBR, it should use the provided information to
investigate an applicant’s eligibility and identify possible TPL sources, including health
insurance from noncustodial parents. MassHealth’s own regulations permit it to match
information from the MBR with other agencies and information sources to update or verify
eligibility. As noted previously, the regulations list a whole host of agencies and information
sources, including the Division of Unemployment Assistance, the Department of Public Healths
Bureau of Vital Statistics, the Department of Industrial Accidents, the Department of Veterans
Services, the Department of Revenue, the Bureau of Special Investigations, the Internal Revenue
Service, the Social Security Administration, the Alien Verification Information System, the
Department of Transitional Assistance, and health insurance carriers.
15
The Office takes no position as to whether state and federal regulations should require Medicaid applicants to
cooperate with MassHealth’s TPL efforts before initial eligibility is determined. MassHealth should follow the
federal Medicaid regulations and its own regulations. Although the federal regulations may be revised, the existing
and proposed federal regulations allow MassHealth to determine the presence of a health insurance order shortly
after the initial application. Whichever version of the federal regulations applies, MassHealth should work towards
determining whether there is a noncustodial health insurance order shortly after the initial MBR application is made,
and then before all member redeterminations that periodically occur.
21
Similarly, MassHealth should consider using information-gathering tools offered by private
entities, although it would make sense for MassHealth to consider the costs and benefits of such
tools first.
B. MassHealth should send information from the MBR, including Supplement B, to
DOR/CSE.
As mentioned above, DOR/CSE sends information to MassHealth each month regarding its
entire caseload, with limited exceptions. The file includes specific identifying demographic data,
household information, noncustodial parent court order status, enrollment status, and policy
information, if available. MassHealth does not, however, send MBR information to DOR/CSE,
either as part of the eligibility process or after the eligibility determination has been made.
16
The Office inquired as to the policies and procedures that MassHealth follows to pursue TPL
recoveries for Medicaid members who have the right to obtain but who do not have health
insurance coverage from a noncustodial parent. MassHealth responded that it currently has no
such policies or procedures but noted that it was working with DOR/CSE to develop rules for
when MassHealth should share noncustodial parent information with DOR/CSE, which could
then lead to DOR/CSE obtaining coverage for some of those Medicaid members. While
MassHealth has not yet implemented a referral process, the two agencies have made progress,
including analyzing the cost-effectiveness of such a process and preparing a set of business rules
to help determine which cases MassHealth would refer to DOR/CSE.
The Office understands that referrals of specific cases must meet certain threshold requirements
to address concerns with cost-effectiveness. The rationale for defining appropriate referrals is
informed by the Medicaid requirement that pursuit of TPL must be cost-effective.
Considerations in evaluating the cost-effectiveness of different referral types include:
Ensuring that MassHealth refers only those cases with a significant chance of
obtaining health insurance for the custodial parent and/or the dependent
child(ren).
16
The Federal Office of Child Support Enforcement (“FOCSE”) does not require MassHealth to refer all Medicaid
cases involving noncustodial parents to DOR/CSE to obtain and enforce health insurance orders against
noncustodial parents. Instead, FOCSE guidance indicates that MassHealth should refer only those cases which it
deems appropriate based on efficiency and cost-effectiveness criteria. See Guidance on Referral of Medicaid cases
to Title IV-D Child Support Enforcement Agencies, IM-08-03, April 22, 2008.
http://www.acf.hhs.gov/programs/css/resource/guidance-on-referral-of-medicaid-cases-to-title-iv-d-child-support.
22
Avoiding scenarios in which families go on and off Medicaid repeatedly
because the noncustodial parent cannot maintain steady employment. These
scenarios can cause increased administrative costs for MassHealth and
DOR/CSE and can also have adverse health and financial effects on the
families.
The Office also recognizes that there are two categories of MBRs relating to noncustodial
parents. The first category involves an MBR on which the custodial parent has indicated that
there is a health insurance order. When an applicant reports the existence of a health insurance
order, it does not necessarily mean that the dependent is in fact enrolled in the noncustodial
parent’s private health insurance, or that the noncustodial parent even has access to health
insurance. Rather, it presents MassHealth with an important opportunity to verify whether there
is a private alternative to Medicaid and to coordinate with DOR/CSE in those cases in which
there is a noncustodial parent who is not complying with the requirements of a court order.
The second category involves an MBR on which the custodial parent has indicated that there is
no health insurance order.
17
For these situations, the Office recommends that DOR/CSE finalize
their policy so that MassHealth can begin to refer cases to DOR/CSE for initiation of
proceedings with noncustodial parents for medical support when appropriate.
MassHealth should pursue this important policy change expeditiously, although the Office notes
that MassHealth has examined the possibility of sharing its noncustodial parent information with
DOR/CSE since 2009. By not providing DOR/CSE with such information, MassHealth has
missed a significant number of TPL recovery opportunities.
17
Technically, there is a third category of MBRs relating to noncustodial parents specifically, those MBRs on
which the custodial parent has not answered whether there is a health insurance order. MassHealth should eliminate
this category by requiring the custodial parent applicants and members to answer all of the questions about health
insurance orders.
23
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24
Conclusion
The Office’s review indicates that MassHealth and its TPL vendor have policies and procedures
in place when a Medicaid member is already covered by a noncustodial parent’s existing health
insurance. When the member is not covered by a noncustodial parent’s policy either because
the noncustodial parent has no health insurance or because the noncustodial parent has a policy
that does not name the member as a beneficiary MassHealth does not pursue Medicaid TPL
recoveries. This practice is inconsistent with federal and state regulations.
Moreover, at least prior to March 2011 and possibly since then, MassHealth has not required
Medicaid applicants to complete Supplement B (except to sign it). This also violates federal
Medicaid regulations, and it prevents MassHealth from obtaining the information necessary to
pursue TPL for Medicaid members who should be, but who are not, covered by a noncustodial
parent’s health insurance. In addition, the MBR and Supplement B are confusing in certain
places, and they do not request important information that could help MassHealth’s TPL
recovery efforts.
Furthermore, MassHealth misses TPL recovery opportunities because it does not share the
Supplement B information it does receive with DOR/CSE. The flow of information between
these two state agencies travels only in one direction currently from DOR/CSE to MassHealth.
The two agencies are working to remedy this problem by adopting a set of rules to define when it
is cost-effective for MassHealth to pursue health insurance orders. The Office applauds those
efforts, but notes that adopting such rules has been delayed over the past few years and thus
significant opportunities to pursue Medicaid TPL recoveries from noncustodial parents’ health
insurance may have been missed.
The well-being of Medicaid members is inextricably linked to the financial well-being of the
Medicaid program. MassHealth can help all Medicaid members by following the federal and
state rules that are designed to facilitate MassHealth’s use of TPL derived from noncustodial
parents’ health insurance. The Office will follow up and report to the Legislature on
MassHealth’s progress in addressing the issues raised in this analysis.
25
Appendix A: MassHealth Medical Benefit Request Form
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GeGetting Stting Sttarartteded
You can fill out the Medical Benefit Request (MBR) on your computer,
then print it. Or, you can print a blank copy and fill it out by hand.
Make sure you sign and date the MBR on page 7. Then send it with
proof of your income and proof of your U.S. citizenship/national
status and identity to the address listed on the MBR instruction page.
Toll out the MBR on-line, use the mouse to click on the first field
you want to fill out on each page. Type the necessary information, then
press the Tab key to move to the next field, or use the mouse to click on
the next field. To fill a check box, click on the box using the mouse, or tab
to the field, and when the box has a dotted line around it, press the enter
key. If you need to go back to another field, click on that field with your
mouse. To go from one page to the next, tab to “Please go to the next
page.”, and when highlighted, press tab, or use the mouse to click on the
rst field on each page.
After you print the filled-out MBR, YOU MUST click on the “Clear
entire form” button at the bottom of page 7. This will remove all the
information you entered on the MBR so no one can see your personal
information.
Fill out form
Print blank form
Medical Benet Request
Instructions
Commonwealth of Massachusetts
EOHHS
www.mass.gov/masshealth
Please read these instructions before you fill out the application.
Dear Applicant:
This is your application for MassHealth, the Children’s Medical Security Plan (CMSP), Healthy Start, and the Health Safety Net*.
MassHealth gives health-care coverage and helps pay for health-insurance premiums for families, children, and individuals. The kind of
coverage you get depends on your family size, income, and other circumstances. After your application is filled out and reviewed, MassHealth will
give you the most complete coverage that you qualify for.
This application is also used to apply for Commonwealth Care. Commonwealth Care is a program administered by the Commonwealth Health
Insurance Connector Authority (“the Health Connector”) for certain adults who are not eligible for MassHealth. Commonwealth Care helps pay
for health-insurance premiums for health plans that are approved by the Health Connector. For more information, see pages 3 and 21 in the
MassHealth Member Booklet.
This application is for people who live in Massachusetts, are not living in or about to go into a nursing home, and are under age 65. This
application may also be used by people of any age who are parents of children under age 19, or who are adult relatives living with and taking
care of children under age 19 when neither parent is living in the home, or who are disabled and work 40 or more hours a month or are
currently working and have worked at least 240 hours in the six months immediately before the month of the MassHealth application. If this
application is not for you, call MassHealth Customer Service at 1-800-841-2900 (TTY: 1-800-497-4648 for people who are deaf, hard of hearing,
or speech disabled).
Please list only one family group on an application. A family group can be parents, stepparents, or adoptive parents of any age and any of their
children under age 19 who are all living together. If no parents are living at home, a family group may be siblings under age 19, or children
under age 19 and an adult related by blood, adoption, or marriage, or a spouse or former spouse of one of those relatives who are all living
together. A family group can also be an individual or a married couple who are living together with no children under the age of 19. If more
than one family group lives in your home, each family group must fill out a separate application. MassHealth will send all eligibility notices to
the person who is your “head of household, and to your eligibility representative, if you have one.
Please read the attached MassHealth Member Booklet carefully before you fill out the application. Keep the booklet. It may answer questions you
have later.
When you fill out the application, be sure to:
Answer all questions, and fill out all sections and any supplements that apply to you and your family.
Sign and date the application. The head of household, all applicants aged 18 or older, and all parents of any age who have children
living with them must sign.
Send proof of all income, like a copy of one recent pay stub. (You do not have to send proof of social security or SSI income.)
Send proof of your HIV-positive status only if you want to see if you are eligible for MassHealth because you are HIV positive.
Send proof of U.S. citizenship/national status and proof of identity, like U.S. passports or U.S. naturalization papers. You can also prove
U.S. citizenship with a U.S. birth certificate or a U.S. hospital birth record. You can also prove identity with a driver’s license, some other
form of government-issued identity card, or a school identification card. We may be able to prove your identity through the Massachusetts
Registry of Motor Vehicles records if you have a Massachusetts driver’s license or a Massachusetts ID card. Once you give MassHealth
proof of your U.S. citizenship/national status and identity, you will not have to give us this proof again. You must give us proof of identity
for all family members who are applying. Seniors and disabled persons who get or can get Medicare or Supplemental Security
Income (SSI), or disabled persons who get Social Security Disability (SSDI) do not have to give proof of their U.S. citizenship/
national status and identity. A child born to a mother who was getting MassHealth on the date of the child’s birth does not have to give
proof of U.S. citizenship/national status and identity. (See pages 28-29 in the MassHealth Member Booklet for complete information about
acceptable proofs.)
Send a copy of both sides of all immigration cards (or other documents that show immigration status) for every family member who is not
a U.S. citizen/national and who is applying for MassHealth or Commonwealth Care, except for MassHealth Limited, CMSP, Healthy Start, or
the Health Safety Net. (See Supplement C.)
Give us a social security number (SSN) or proof that you have applied for an SSN for every family member who is applying for MassHealth
or Commonwealth Care. However, you do not need to give us an SSN or proof you applied for an SSN to get MassHealth Limited, CMSP,
Healthy Start, or the Health Safety Net.
* Information you provide on this application will be used to determine low-income patient status for provider payments from
the Health Safety Net.
MBR-1 (Rev. 01/13)
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NOTE: Information
entered into this form
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Sign and date the application after you fill it out. Send the application and all other needed papers to:
MassHealth Enrollment Center
Central Processing Unit
P.O. Box 290794
Charlestown, MA 02129-0214
The information you give us is kept confidential, as required by state and federal laws. If you want us to share information about
your MassHealth eligibility (including copies of notices we send you) with someone other than your eligibility representative, if
you have one, please call MassHealth to get a MassHealth Permission to Share Information Form.
When lling out this application, please remember the following.
Make sure you fill out the application correctly and completely. If we need to contact you to get more information because we do not
understand what you entered on the application, it will take us longer to decide if you are eligible or not for health benefits.
Make sure on pages 2 through 4 of the application in the sections “Working Income,“Nonworking Income,” and “College Student” that
each family member who has income and/or is aged 19 or older fills out each of these sections correctly.
Please remember when filling out the “Health Insurance” section on pages 4 and 5, that:
• Part A is for listing the health insurance you have now, and Part B is for health insurance you may be eligible for; and
• you will not be eligible for Commonwealth Care if you have or can get insurance from a government insurance program including, but
not limited to:
- Medicare;
- TRICARE (dependents of the military);
- Medical Security Program (through the Division of Unemployment Assistance); or
- student health insurance from a Massachusetts school.
Make sure on page 6 of the application in the section “Injury, Illness, Disability, or Accommodation” that you answer “yes” or “no” to all of
the questions. Do not leave any answer blank.
If you answer “yes” to either question on page 6 of the application in the section “Absent Parent, then you must fill out Supplement B
according to the instructions for Supplement B. If the other parent of the child is living in the same household as the child but does not
want to apply for MassHealth, make sure to list that parent on page 1 of the application in the section “Other Family Members.
If you have any questions about this application or the information you need to send, please call MassHealth Customer Service at
1-800-841-2900 (TTY: 1-800-497-4648 for people who are deaf, hard of hearing, or speech disabled).
When we get your filled-out, signed, and dated application, we will review it. If more information is needed, we will write or call you. Once we
get all needed information, we will make a decision about your eligibility. We will send you a written notice about this decision. If
you are determined eligible for MassHealth, show this notice right away to any health-care provider if you already paid for medical services that
would be covered by MassHealth during your eligibility period. If the health-care provider determines that MassHealth will pay for these services,
the provider will refund what you paid.
To start filling out this application, please turn to page 1 of this application.
Remember, you must read, sign, and date page 7 after you have filled out the application.
Please go to the next page
Click here to fill out the form.
PRG
This is an application for MassHealth, the Children’s Medical Security Plan (CMSP), Healthy Start, Commonwealth Care, and the Health Safety
Net. You do not have to be a U.S. citizen/national to get these benefits. Please print clearly. Please answer all questions and fill out all sections and any
supplements that apply to you and your family. If you need more space to finish any section on this form, please use a separate sheet of paper (include
your name and social security number), and attach it to this form.
Head of Household
HOH
1. Last name First name MI Street address City State Zip
Mailing address (if dierent from street address or if living in a shelter) homeless
City State Zip
Is this person applying?
yes
no If yes, is this person a U.S. citizen/national?
yes
no
Social security number*
Date of birth / /
Gender M F Spoken language choice Written language choice
Work: ( )
Race (optional)
Ethnicity (optional) E-mail
Other Family Members
List all other members of your family group. Do not repeat head of household information in this section.
See instruction page for description of a family group.
2. Last name First name MI
Is this person applying?
yes
no If yes, is this person a U.S. citizen/national?
yes
no
Social security number*
Date of birth / /
Gender M F Spoken language choice Written language choice
Race (optional)
Ethnicity (optional) Relationship to head of household
3. Last name First name MI
Is this person applying?
yes
no If yes, is this person a U.S. citizen/national?
yes
no
Social security number*
Date of birth / /
Gender M F Spoken language choice Written language choice
Race (optional)
Ethnicity (optional) Relationship to head of household
4. Last name First name MI
Is this person applying?
yes
no If yes, is this person a U.S. citizen/national?
yes
no
Social security number*
Date of birth / /
Gender M F Spoken language choice Written language choice
Race (optional)
Ethnicity (optional) Relationship to head of household
Medical Benet
Request
For ofce use only
Date received:
Commonwealth of Massachusetts
EOHHS
www.mass.gov/masshealth
C
I
C
I
C
I
C
I
Telephone numbers Home: ( ) Cell: ( )
*Required, if one has been issued and this person is applying for MassHealth or Commonwealth Care, except for MassHealth Limited, CMSP, Healthy Start,
or the Health Safety Net.
Pregnancy
Are you or any family member pregnant? yes no Name:
Are you or this person pregnant with:
1 baby? twins? triplets? If more, how many?
___________
Due date / /
1
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MBR-1 (Rev. 01/13)
This form is valid only if it has not been changed in any way, other than by entering
the information requested.
IMPORTANT: Please do not leave this information on your computer screen where
unauthorized persons may be able to read confidential personal information.
To fill out this form on your computer screen, use the mouse to click in the first
form field (last name), type your entry, then press the Tab key to go to the next
field.
Type all nine digits without
hyphens or spaces.
mm/dd/yy
Area code and phone number (without parentheses, spaces, or hyphens).
Residency (You must ll out this section.)
MAR
Are you and all members of your household who are applying for benefits living in Massachusetts with the intention to stay? yes no
If no, list the names of the members of your household (including yourself)* who are applying and who are not residents of Massachusetts and who intend
to leave.
*Do not include infants born in Massachusetts who have not left the state.
General instructions for lling out the Working Income, Nonworking Income, AND College Student sections
Each family member who has income and/or is aged 19 or older must fill out all sections on this page through page 4.
Working Income (You must ll out this section.)
EIN
1. Name
Is this person currently working or seasonally employed? (You must answer this question.)
yes no
If yes, fill out the Employer Information section below.
If no, answer the next two questions below. You do not have to fill out the “Employer Information” section below.
Has this person worked in the last 12 months before the date of application?
yes no
If yes, how much did this person earn in the last 12 months before taxes and deductions? Note: If you answered yes” to this question,
you MUST enter a dollar amount on this line. $ If no, go to the next section (Nonworking Income).
Employer Information Employer name
Employer address, and telephone number
Type of work (Check all that apply.)
full-time day labor part-time seasonal yearly wage: $
self-employed sheltered workshop yearly wage: $
Number of hours per week Weekly pay before deductions $ Date began getting this amount of pay / /
Is health insurance oered that would cover doctors’ visits and hospitalizations?
yes no
(Answer yes even if you cannot get it now, chose not to sign up for it, or dropped insurance that was available.)
If you answered no to the above question, was health insurance oered in the last six months?
yes no
Send proof of income, like a copy of one recent pay stub. If self-employed, see the MassHealth Member Booklet for information about the needed proof.
2. Name
Is this person currently working or seasonally employed? (You must answer this question.)
yes no
If yes, fill out the Employer Information section below.
If no, answer the next two questions below. You do not have to fill out the “Employer Information” section below.
Has this person worked in the last 12 months before the date of application?
yes no
If yes, how much did this person earn in the last 12 months before taxes and deductions? Note: If you answered yes” to this question,
you MUST enter a dollar amount on this line. $ If no, go to the next section (Nonworking Income).
Employer Information Employer name
Employer address, and telephone number
Type of work (Check all that apply.)
full-time day labor part-time seasonal yearly wage: $
self-employed sheltered workshop yearly wage: $
Number of hours per week Weekly pay before deductions $ Date began getting this amount of pay / /
Is health insurance oered that would cover doctors’ visits and hospitalizations?
yes no
(Answer yes even if you cannot get it now, chose not to sign up for it, or dropped insurance that was available.)
If you answered no to the above question, was health insurance oered in the last six months?
yes no
Send proof of income, like a copy of one recent pay stub. If self-employed, see the MassHealth Member Booklet for information about the needed proof.
2
Please go to the next page
Nonworking Income (You must ll out this section.)
Rental Income Do you or any family member get rental income? (You must answer this question.) yes no
REN
If yes, enter the monthly amount of rental income (before taxes and deductions) on this line. $
Name of person getting rental income
If no, go to the next section (Unemployment Benets).
Send proof of rental income.
Unemployment Benets Are you or any family member getting an unemployment check? (You must answer this question.) yes no
UIN
If yes, fill out this section and answer all questions. Send proof of unemployment benefits.
If no, go to the next section (Other Nonworking Income).
Name of person getting unemployment benefits
yes no
If yes, in the 12 months before this person became unemployed, did this person work for an employer in Massachusetts?
Is this check from the Commonwealth of Massachusetts?
yes no
(Do not include federal employers, like the U.S. Postal Service.)
Enter the monthly amount of unemployment benefits (before taxes and deductions). $
Name of person getting unemployment benefits
yes no
If yes, in the 12 months before this person became unemployed, did this person work for an employer in Massachusetts?
Is this check from the Commonwealth of Massachusetts?
yes no
(Do not include federal employers, like the U.S. Postal Service.)
Enter the monthly amount of unemployment benefits (before taxes and deductions). $
Other Nonworking Income Do you or any family member have any other income? (You must answer this question.) yes no
UIN
If yes, fill out this section.
If no, go to the next section (College Student).
Please describe the source of the income (where it comes from) for each family member. If anyone has more than one source, list on separate lines.
Send proof. Some types of other income are: (You do not have to send proof of social security or SSI income.)
• alimony • dividends or interest • social security veterans’ benets (federal, state, or city)
• annuities • pensions • SSI • workers compensation
• child support • retirement • trusts • other (Please describe below.)
Name
Type of income (all that apply from list above)
Source (where the income comes from) Monthly amount before taxes $
Name Type of income (all that apply from list above)
Source (where the income comes from) Monthly amount before taxes $
Name Type of income (all that apply from list above)
Source (where the income comes from) Monthly amount before taxes $
3
Please go to the next page
STU
HIN
College Student (You must ll out this section.)
Are you or any family member a college student? (You must answer this question.) yes no
If yes, fill out this section and answer all questions.
If no, go to the next section (Health Insurance You Have Now and Subsidized Health Insurance You May Be Eligible For).
1. Name of college student
Is this person eligible for health insurance from college?
yes no
Is this person a college student in Massachusetts with at least 75% of a full-time schedule?
yes no
(Note: If you are not sure that this person has 75% of a full-time schedule, contact the school to find out if the number of credits the student is taking would
require the student to get the health insurance the school oers to students.)
If yes, is this student planning to get health-insurance coverage from the school, but is waiting for coverage to start?
yes no
If yes, what is the date that the school health-insurance coverage starts? ____ / ____ / ____
2. Name of college student
Is this person eligible for health insurance from college?
yes no
Is this person a college student in Massachusetts with at least 75% of a full-time schedule?
yes no
(Note: If you are not sure that this person has 75% of a full-time schedule, contact the school to find out if the number of credits the student is taking would
require the student to get the health insurance the school oers to students.)
If yes, is this student planning to get health-insurance coverage from the school, but is waiting for coverage to start?
yes no
If yes, what is the date that the school health-insurance coverage starts? ____ / ____ / ____
Health Insurance You Have Now and Subsidized Health Insurance You May Be Eligible For
Even if you or any family member have other health insurance, MassHealth may be able to help you pay your premiums. Health insurance can be from an
employer, an absent parent, a union, a school, Medicare, or Medicare supplemental insurance, like Medex. All applicants must fill out the health insurance
section. Do not include MassHealth or any health plan you enrolled in through Commonwealth Care when answering the questions below.
Do you or any family member get Medicare benefits?
yes no
If yes, name(s):
Claim number(s):
Do you or any family member have health insurance other than Medicare?
yes no
If yes, fill out both Part A below and Part B on the next page.
If no, fill out Part B on the next page.
Part A: Health Insurance You Have Now
Policyholder name 1. Date of birth / /
Social security number* Insurance company name
Policy type (Check one.) individual couple (two adults) dual (one adult, one child) family Policy start date ____ / ____ / ____
Policy number Group number (if known)
Employer or union name
Policyholder contribution to premium costs (Complete one.) $ per week
$ per quarter $ per month
Insurance type (Check one.)
employer or union subsidized (employer or union pays some or all of the insurance cost) TRICARE
other federal or state subsidized (government pays some or all of the insurance cost) student health insurance through school
nonsubsidized, like self-employment or COBRA (policyholder pays total insurance cost) Medical Security Program
Names of covered family members
Insurance coverage (Check all that apply.) doctors’ visits and hospitalizations catastrophic only vision only pharmacy only dental only
If you have long-term-care insurance, send a copy of the policy.
4
Please go to the next page
* Required, if obtainable and one has been issued, whether or not this person is applying.
SIA
NAT
Policyholder name 2. Date of birth / /
Social security number* Insurance company name
Policy type (Check one.) individual couple (two adults) dual (one adult, one child) family Policy start date ____ / ____ / ____
Policy number Group number (if known)
Employer or union name
Policyholder contribution to premium costs (Complete one.) $ per week
$ per quarter $ per month
Insurance type (Check one.)
employer or union subsidized (employer or union pays some or all of the insurance cost) TRICARE
other federal or state subsidized (government pays some or all of the insurance cost) student health insurance through school
nonsubsidized, like self-employment or COBRA (policyholder pays total insurance cost) Medical Security Program
Names of covered family members
Insurance coverage (Check all that apply.)
doctors’ visits and hospitalizations catastrophic only vision only pharmacy only dental only
If you have long-term-care insurance, send a copy of the policy.
* Required, if obtainable and one has been issued, whether or not this person is applying.
Part B: Subsidized Health Insurance You May Be Eligible For
Are you or any member of your family in one of the uniformed services? yes no
If yes, fill out the section below. (The uniformed services are the Army, Navy, Air Force, Marine Corps, Coast Guard, Public Health Services, National
Oceanic and Atmospheric Administration, and the National Guard or Reserves.)
1. Name:
Active Duty?
yes no Retiree? yes no Reserves? yes no Medal of Honor? yes no
2. Name:
Active Duty?
yes no Retiree? yes no Reserves? yes no Medal of Honor? yes no
Have you or any member of your family served in the U.S. military or can you be considered a dependent of someone who has served in the U.S. military?
Yes, I have served. Name:
Yes, I am a dependent of someone who has served. Name:
No, I am neither a veteran nor a dependent.
American Indian/Alaska Native
Certain American Indians and Alaska Natives may not have to pay MassHealth premiums and copays.
Are you or any member of your family who is applying a federally recognized American Indian or Alaska Native who is eligible to receive or has received
services from an Indian health-care provider or from a non-Indian health-care provider through referral from an Indian health-care provider?
yes no
If yes, name of person(s):
5
Please go to the next page
QAC
General instructions for lling out the Injury, Illness, Disability, or Accommodation, Absent Parent,
and U.S. Citizenship/National Status and Immigration Status sections below
The HIV section is optional. You must answer all questions in each of the three sections after the HIV section.
HIV Information (optional)
HIV
MassHealth may give benefits to people who are HIV positive who might not otherwise be eligible.
Do you or any family member who is HIV positive want to apply for these benefits?
yes no
If yes, fill out this section.
Send proof of income, U.S. citizenship/national status and identity, or qualified alien status to see if you can get benefits for up to 60 days while we wait for
you to send us proof of your HIV-positive status. For more information, see the MassHealth Member Booklet.
Name(s):
Injury, Illness, Disability, or Accommodation
Do you or any family member have an injury, illness, or disability (including a disabling mental-health condition) that has lasted or is expected to last for at
least 12 months? (If legally blind, answer yes.)
yes no
Do you or any family member need health care because of an accident or injury?
yes no
Do you or any family member applying for MassHealth require a reasonable accommodation because of a disability or injury?
yes no
If you answered yes to any of these three questions, you must fill out Supplement A (the blue sheet).
Absent Parent
Has any child in the household been adopted by a single parent or has a parent who is deceased or unknown? yes no
Does any child in the family have a parent who does not live with you who is not included in the previous question?
yes no
If you answered yes to either of these questions, you must fill out Supplement B (the yellow sheet).
U.S. Citizenship/National Status and Immigration Status
The U.S. citizenship/national status of parents does not aect the eligibility of their children.
U.S. Citizens
For applicants born in Massachusetts who want help getting proof of their U.S. citizenship, please fill out Supplement D (the red sheet).
For applicants born outside Massachusetts who want help getting proof of their U.S. citizenship, MassHealth may be able to help you. Please call
MassHealth Customer Service at 1-800-841-2900 (TTY: 1-800-497-4648 for people who are deaf, hard of hearing, or speech disabled).
Persons who are not U.S. citizens/nationals
If you or any other family member applying for MassHealth or Commonwealth Care fits any of the immigration status codes on Supplement C (the orange
sheet), numbered 1 through 17, you must fill out Supplement C.
If you or any other family member applying for benefits does not fit any of the immigration status codes on Supplement C (the orange sheet), numbered
1 through 17, you or that family member may get only one or more of the following: MassHealth Limited, Healthy Start, CMSP, or the Health Safety Net.
You do not have to fill out Supplement C.
Note: Family members who want to get only one or more of the following: MassHealth Limited, CMSP, Healthy Start, or the Health Safety Net, do not have to
give us a social security number. We will not match their names with any other agency including the Department of Homeland Security (DHS). You do
not need to send proof of their immigration status. But you must list their names below. MassHealth Limited pays for emergency services only. See
the MassHealth Member Booklet for more information.
List below the names of family members who want to get only one or more of the following: MassHealth Limited, Healthy Start, CMSP, or the Health
Safety Net.
Name(s):
Name(s):
6
Please go to the next page
   
Please read this page carefully, then sign and date the bottom of the page.
This is an application for MassHealth, the Children’s Medical Security Plan (CMSP), Healthy Start,
Commonwealth Care, and the Health Safety Net.
I give permission for my current and former employers and health insurers to release to MassHealth, the Commonwealth Health Insurance
Connector Authority (“the Health Connector”), and the Health Safety Net (administered by the Executive Office of Health and Human Services) any
and all information they have about my health-insurance coverage and health-insurance coverage for members of my family group. This includes,
but is not limited to, information about policies, premiums, coinsurance, deductibles, and covered benefits that are, may be, or should have been
available to me or members of my family group.
I understand that MassHealth may enroll me in available employer-sponsored health insurance if that insurance meets the criteria for MassHealth
payment of premium assistance.
I and my spouse understand that our employers may be notified and billed, in accordance with the regulations of the Health Safety Net, with regard to
any services I and my spouse and any of our dependents may get from hospitals or community health centers that are paid for by the Health Safety Net.
If I or any members of my family are found to be eligible for assistance through MassHealth, the Health Connector, or the Health Safety Net, I
give permission to MassHealth, the Health Connector (Commonwealth Care), or the Health Safety Net to get any records or data: (1) to prove any
information given on this application and any supplements, or other information I give once I am a member; (2) to document medical services
claimed or provided; and (3) to support continued eligibility.
I understand that if I am aged 55 or older, MassHealth may be able to get back money from my estate after I die. Under current practice, this does
not apply to Commonwealth Care.
I understand that if I or any members of my family are in an accident, or we are injured in some other way, and get money from a third party
because of that accident or injury, we will need to use that money to repay: (1) MassHealth (for MassHealth, CMSP, and Healthy Start) or the Health
Connector or my current health insurer (for Commonwealth Care) for certain medical services provided (For MassHealth, these certain medical
services are explained in the MassHealth Member Booklet. For Commonwealth Care, these certain medical services must have been provided to me
by my health insurer.); or (2) the Health Safety Net for medical services reimbursed for me and any family members by the Health Safety Net. I also
understand that I must tell MassHealth (for MassHealth, CMSP, and Healthy Start), my health insurer (for Commonwealth Care), or the Health
Safety Net in writing, within 10 calendar days, or as soon as possible, if I file any insurance claim or lawsuit because of an accident or injury to me
or any family members applying for benefits.
I understand that if I or any members of my family are eligible for MassHealth, CMSP, Healthy Start, Commonwealth Care, or the Health Safety
Net, I must tell MassHealth of any changes in my or my family’s income or employment, family size, health-insurance coverage, health-insurance
premiums, and immigration status, or of changes in any other information I gave on this application and any supplements within 10 calendar
days of learning of the change.
I also understand that by signing below, I give permission to MassHealth to go after and collect third-party payments for medical care and medical
support from the parent of any child under age 19 who is applying for benefits.
If I or any members of my family are eligible for MassHealth or CMSP, I understand that I may have to pay a premium set by MassHealth. I also
understand that if I fail to pay the premium, MassHealth may refer my past due balance to the State Intercept Program (SIP). If I am a certain
American Indian or Alaska Native eligible for MassHealth Family Assistance, I may not have to pay any premiums under MassHealth Family Assistance.
If I or any members of my family are eligible for Commonwealth Care, I understand that I may have to pay a premium set by the Health Connector.
I certify that I have read or have had read to me the information on this application, including any supplements and instruction pages attached
to it, and the information in the MassHealth Member Booklet, and that I understand my rights and responsibilities. I further certify under penalty
of perjury that the information on this application and any supplements, including those submitted with this application as well as any other
supplements, forms, or documents that may be submitted to or required by MassHealth, is correct and complete to the best of my knowledge.
If you are acting on behalf of someone in filling out this application and any supplements, the enclosed MassHealth Eligibility Representative
Designation Form must also be filled out and sent back with this application. Your signature on this application and any supplements as an eligibility
representative certifies that the information on this application and any supplements, including those submitted with this application as well as any
other supplements, forms, or documents that may be submitted to or required by MassHealth, is correct and complete to the best of your knowledge.
If you think MassHealth’s decision about whether you are eligible is wrong, you have the right to appeal or file a grievance. If you are denied
benefits, you will get information about how to appeal a MassHealth decision and also how to file a grievance about any Health Safety Net decision.
The head of household, all persons aged 18 or older, and all parents of any age who have children living with them who are applying
for MassHealth, CMSP, Healthy Start, Commonwealth Care, or the Health Safety Net must read this page carefully, and sign and date
below. If you are signing below as an eligibility representative, a filled-out MassHealth Eligibility Representative Designation Form
must also be submitted.
Signature of applicant or eligibility representative Print name Date
X
Signature of applicant or eligibility representative Print name
7
Please go to the next page
Date
X
Clear entire form.
Go to Supplement A
Appendix B: Supplement B to the Member Benefit Request: Absent-
Parent Questions and Assignment of Rights
Supplement B:
Absent-Parent Questions and
Assignment of Rights
EOHHS
Commonwealth of Massachusetts
www.mass.gov/masshealth
Do not fill out this supplement if you answered NO to both of the absent-parent questions on page 6.
Fill out this supplement only if you answered YES to either of the absent-parent questions on page 6.
Please read Part A of Supplement B before you fill out Parts B, C, and D.
You must sign Part E.
Absent Parent
Part A: Cooperation
To get MassHealth for you and a child who is living with you, you must cooperate with the Child Support Enforcement Division of the Massachusetts
Department of Revenue (DOR) to establish paternity and enforce a medical-support order, unless you have Good Cause not to cooperate. You must
also assign your rights for medical support to MassHealth. Cooperation means that you may have to give information about the identity, location, and
employment of the absent parent, appear for appointments with DOR sta and the Court, submit to paternity testing, give information, and take any other
action necessary to help DOR in establishing paternity, and establishing, changing, or enforcing a child medical-support order. “Good Cause is a legal term
that means if you cooperated by giving us information about the absent parent, it would not be in the best interests of the child for any of the reasons listed
in Part C—Good Cause—below. If you think that you have Good Cause for not cooperating, fill out Part C—Good Cause—below, and do not fill out Part D—
Absent-Parent Information—on the next page.
If you do not want to make a Good Cause claim, and you do not cooperate by filling out Part D—Absent-Parent Information—on the next page, your
MassHealth eligibility could be aected.
To get MassHealth only for the child who is living with you and not for yourself, you do not have to cooperate with DOR, assign your rights for medical
support to MassHealth, or give information about the absent parent. Also, if a pregnant family member is applying for benefits for an unborn child, you do
not need to give us information about the absent parent of the unborn child at this time. This means that you do not have to fill out Part B, C, D, or E of this
supplement for that unborn child. Please read the next paragraph about child-support-enforcement services.
Even if you are applying for MassHealth only for the child who is living with you, you can ask for child-support-enforcement services if you want help getting
the absent parent to pay for health insurance or child support for the child. To do this, you can call DOR at 1-800-332-2733, or go to www.mass.gov/dor and
click on “Child Support Enforcement.The child’s MassHealth coverage will not be aected if you choose to ask for these services or not. If you ask for these
services, you will have to cooperate with DOR.
Part B: Names of children who have been adopted by a single parent or have a parent who is deceased or unknown
Please list the name(s) of the child or children who have been adopted by a single parent or have a parent who is deceased or unknown.
Name Name
Name Name
If all of the children in the household are named in this section, go to Part E. Otherwise, go to Part C.
Part C: Good Cause
Is there any reason (Good Cause) not to help us get medical support from an absent parent? yes no
If yes, list the name(s) of the child or children whose absent parent(s) you do not want to give us information about, and check one of the boxes below for
the reason that applies to the child or children.
If no, fill out Part D—Absent-Parent Information—on the next page.
Names:
Cooperation could result in serious physical or emotional harm to a family member or his or her child, or the applicant or member.
Adoption of the child is in process.
The child was a result of sexual abuse or assault.
Names:
Cooperation could result in serious physical or emotional harm to a family member or his or her child, or the applicant or member.
Adoption of the child is in process.
The child was a result of sexual abuse or assault.
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Supplement B:
Absent-Parent Questions and
Assignment of Rights
EOHHS
Commonwealth of Massachusetts
www.mass.gov/masshealth
Absent Parent (cont.)
Part D: Absent Parent Information (if known)
1. Name Social security number* Date of birth / / Gender M F
Address
Telephone number ( ) Is there a medical-support order? yes no
Relationship to child: mother father other: Driver’s license number*
Names of children of this absent parent
Name and address of absent parent’s employer
Name2. Social security number* Date of birth / / Gender M F
Address
Telephone number ( ) Is there a medical-support order? yes no
Relationship to child: mother father other: Driver’s license number*
Names of children of this absent parent
Name and address of absent parent’s employer
*Required, if obtainable and one has been issued.
Part E: Signature
I am the parent with whom the child lives (custodial parent or legal guardian) and I certify under penalty of perjury that the information in this supplement is
correct and complete to the best of my knowledge. I also understand that by signing below I assign my rights and give permission to MassHealth and DOR to
go after medical support from the absent parent (named in Part D) of any child under age 19 who is living with me and applying for MassHealth. I also agree
to cooperate with MassHealth and DOR in this process, as explained in Part A — Cooperation — of this supplement.
X
Signature of custodial parent or guardian** Print name Date
**Required, only if you are applying for yourself and the child who is living with you.
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