101 CMR, § 613.05

Current through Register 1536, December 6, 2024

Section 613.05 - Medical Hardship

(1)Eligibility.

(a)General. A Massachusetts Resident at any Countable Income level may qualify for Medical Hardship if allowable medical expenses exceed a certain percentage of his or her Countable Income as specified in 101 CMR 613.05(1)(c). A determination of Medical Hardship is a one-time determination and not an ongoing eligibility category. An applicant may submit no more than two Medical Hardship applications within a 12-month period.

(b)Countable Income.

1.Gross Earned Income.

a. Gross earned income is the total amount of compensation received for work or services performed without regard to any deductions.

b. Gross earned income for the self-employed is the total amount of business income listed on the most recently filed federal tax return or allowable on a federal tax return.

c. Seasonal income is income derived from an income source that is associated with a particular time of the year. Annual gross income is divided by 12 to obtain a monthly gross income with the following exception: if the Patient has a disabling illness or accident during or after the seasonal employment period that prevents the person's continued or future employment, only current income will be considered in the eligibility determination.

2.Gross Unearned Income.

a. Gross unearned income is the total amount of income that does not directly result from the individual's own labor before any income deductions are made.

b. Unearned income includes, but is not limited to, social security benefits, railroad retirement benefits, pensions, annuities, federal veterans' benefits, interest and dividend income, unemployment benefits, child support, and alimony.

3.Rental Income. Rental income is the total amount of gross income less any deductions listed or allowable on the Patient's most recently filed federal tax return or allowable on a federal tax return.

(c)Percentage of Countable Income. To qualify for Medical Hardship, the applicant's allowable medical expenses exceed a specified percentage of the applicant's Countable Income as follows.

Income Level	Percentage of Countable Income
0 - 205% FPL	10%
205.1 - 305% FPL	15%
305.1 - 405%	20%
405.1 - 605% FPL	30%
>605.1% FPL	40%

(2)Eligibility Determination. An applicant for Medical Hardship must complete a Medical Hardship application and provide required documentation of Countable Income, documentation of Massachusetts residency, proof of identity, and detailed, itemized documentation of medical expenses. The Health Safety Net Office processes applications for Medical Hardship and verifies information contained in the application. Providers must assist the applicant to complete the Medical Hardship application and assemble the required documentation. Once the applicant has completed the application and assembled all of the required documentation, the Provider assisting the applicant must submit the completed application to the Health Safety Net office within five business days. If the Provider assisting the applicant fails to submit the completed application to the Health Safety Net Office within that time frame, the Provider may not undertake a Collection Action against the applicant with respect to any bills that would have been eligible for Medical Hardship payment had the application been submitted and approved. The Health Safety Net Office approves an application for Medical Hardship if the applicant's allowable medical expenses exceed the percentage of Countable Income listed above. If the applicant reports Countable Income less than or equal to 405% of the FPL, the applicant must submit an Application, with all required documentation. The Health Safety Net Office does not approve Medical Hardship applications for individuals reporting Countable Income less than or equal to 405% of the FPL unless the applicant has submitted an Application. The Health Safety Net Office does not make a determination on Medical Hardship applications for individuals reporting Countable Income less than or equal to 405% of the FPL until the Patient has received a determination related to the Application.

(3)Allowable Medical Expenses. The Health Safety Net Office determines the applicant's allowable medical expenses based on review of the submitted documentation. Allowable medical expenses may include only Medical Hardship Family medical bills from any health care Provider that, if paid, would qualify as deductible medical expenses for federal income tax purposes. Allowable medical expenses include paid and unpaid bills for services provided up to 12 months prior to the date of the Medical Hardship application for which the Patient is responsible. If a Patient does not receive an initial medical bill for more than nine months from when the services were provided, the bill may still be considered an allowable medical expense if a Medical Hardship application is submitted within 90 days of the date of the initial medical bill for the service. Allowable medical expenses do not include bills for services incurred while the applicant was a Low Income Patient unless the applicant was a Dental-only Low Income Patient on the date of service. Allowable medical expenses do not include bills for services incurred while the applicant was enrolled in MassHealth or the Premium Assistance Payment Program Operated by the Health Connector. Bills included in an approved Medical Hardship determination cannot be included in a subsequent Medical Hardship application.

(4)Payable Medical Expenses. The Health Safety Net pays only for the services described in 101 CMR 613.03(2) through (4). Other allowable medical expenses are not eligible for Health Safety Net payment.

(5)Medical Hardship Contribution.

(a) The applicant's required contribution is calculated as the specified percentage of Countable Income in 101 CMR 613.05(1)(b) based on the Medical Hardship Family's FPL multiplied by the actual Countable Income less bills not eligible for Health Safety Net payment, for which the applicant will remain responsible.

(b) There is one Medical Hardship contribution for each Medical Hardship determination. If the applicant is determined a Low Income Patient or eligible for MassHealth, the applicant's required contribution will be deferred until the applicant's Low Income Patient status or MassHealth eligibility is ended. If the Health Safety Net Office approves two Medical Hardship applications during a 12-month period, it will prorate the required contribution amounts.

(6)Notification of Determination. The Health Safety Net Office notifies applicants of the determination.

(a) An approval notice explains that the person is eligible for Medical Hardship; includes the dates for which allowable medical expenses may be included; includes the amount of the applicant's Medical Hardship contribution; lists the services that do not qualify as Eligible Services; and includes a contact number for more information. The Office also notifies Providers with bills included in the applicant's allowable medical expenses of the determination and allocates the applicant's contribution to each Provider based on the dates of services and gross charges of services provided to the applicant's Medical Hardship Family.

(b) A denial notice explains that the person is not eligible for Medical Hardship and the reasons for the eligibility denial. Both the Patient and Provider are notified of the denial.

(7)Claims. When the Health Safety Net Office approves a Medical Hardship application, it notifies those Providers whose services were included in the documentation of medical expenses required under 101 CMR 613.05(2). To be eligible for payment for any such service, the Provider must submit a claim to the Health Safety Net Office within 18 months of the date of service. Payment of such claims is subject to all other requirements set forth in 101 CMR 613.00 and other applicable laws and regulations.