Fill - Free fillable Masshealth Noncustodial Parents Health Insurance March 2013 (Commonwealth of Massachusetts) PDF form

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

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.

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.

The Office’s findings do not include applicants who claimed good cause for not providing the information.

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.

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

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

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

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.”

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.

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

eligible for Medicaid.

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.

The Office notes that nonqualified aliens and aliens with special status may qualify for MassHealth Limited.

130 C.M.R. § 505.001(a)(7).

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.

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

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).

under the federal child support enforcement program.

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

;

(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

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).

Some limited aspects of this program do not fall within Medicaid.

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).

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].”

Medicaid also offers coverage for certain Medicare beneficiaries.

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,

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.

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

MassHealth refers to a noncustodial parent as an “absent parent.”

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?

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.”

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

Supplement B refers to health insurance orders as “medical-support orders.”

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.

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

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.

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.

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

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.

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

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.

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

the eligibility determination process.

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.

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.

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).

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.

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

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.

MassHealth staff informed the Office that the timeframe is 60 days.

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.

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

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.

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.

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 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.

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.

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.

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).

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.

• 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.

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.

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.

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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.

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.

To ﬁll 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

ﬁrst 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)

over

Click here to get to the "Applications and Member Forms" page.

NOTE: Information

entered into this form

cannot be saved, so

be sure to print a copy

of the filled-out form

before closing it.

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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

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

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

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

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

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 / /

Please go to the next page

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.

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 $

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.

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):

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):

Please go to the next page

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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

Signature of applicant or eligibility representative Print name

Please go to the next page

Date

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

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.

Please go to the next page

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.

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.

Please go to the next page

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Masshealth Noncustodial Parents Health Insurance March 2013 (Commonwealth of Massachusetts)

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