130 CMR, § 519.007

Current through Register 1536, December 6, 2024

Section 519.007 - Individuals Who Would Be Institutionalized

130 CMR 519.007 describes the eligibility requirements for MassHealth Standard coverage for individuals who would be institutionalized if they were not receiving home- and community-based services.

(A)The Kaileigh Mulligan Program. The Kaileigh Mulligan Program enables severely disabled children younger than 18 years old to remain at home. The income and assets of their parents are not considered in the determination of eligibility.

(1)Eligibility Requirements. Children younger than 18 years old may establish eligibility for the Kaileigh Mulligan Program by meeting the following requirements. They must

(a)

1. meet Title XVI disability standards in accordance with the definition of permanent and total disability for children younger than 18 years old in 130 CMR 515.001: Definition of Terms or have been receiving SSI on August 22, 1996; and

2. continue to meet Title XVI disability standards that were in effect before August 22, 1996;

(b) have $2,000 or less in countable assets;

(c)

1. have a countable income amount of $72.80 or less; or

2. if greater than $72.80, meet a deductible in accordance with 130 CMR 520.028: Eligibility for a Deductible through 520.035: Conclusion of the Deductible Process; and

(d) require a level of care equivalent to that provided in a hospital or nursing facility in accordance with 130 CMR 519.007(A)(3) and (4).

(2)Additional Requirements. The MassHealth agency must have determined

(a) that care provided outside an institution is appropriate; and

(b) that the estimated cost paid by the MassHealth agency would not be more than the estimated cost paid if the child were institutionalized.

(3)Level of Care That Must Be Required in a Hospital. To require the level of care provided in a hospital, the child must have a medical need for the following:

(a) direct administration of at least two discrete skilled-nursing services (as defined in130 CMR 515.001: Definition of Terms) on a daily basis, each of which requires complex nursing procedures, such as administration of intravenous hyperalimentation, changing tracheotomy tubes, assessment or monitoring related to an uncontrolled seizure disorder, assessment or monitoring related to an unstable cardiopulmonary status, or other unstable medical condition;

(b) direct management of the child's medical care by a physician or provided directly by someone who is under the supervision of a physician on at least a weekly basis;

(c) ongoing use of invasive medical technologies or techniques to sustain life (such as ventilation, hyperalimentation, gastrostomy tube feeding), or dialysis, or both; and

(d) at least one of the following:

1. assistance in one or more activities of daily living (ADLs), as defined in130 CMR 515.001: Definition of Terms, beyond what is required at an age-appropriate activity level; or

2. one or more skilled therapeutic services (occupational therapy, physical therapy, or speech and language therapy), provided directly by or under the supervision of a licensed therapist at least five times a week.

(4)Level of Care That must Be Required in a Skilled-nursing Facility. To require the level of care provided in a skilled-nursing facility, the child must be nonambulatory and meet the following requirements.

(a) A child 12 months of age or older must have global developmental skills (as defined in 130 CMR 515.001: Definition of Terms) not exceeding those of a 12-month-old child as indicated by a developmental assessment performed by the child's physician or by another certified professional. In addition, the child's developmental skills level must not be expected to improve.

(b) A child younger than 12 months old must have global developmental skills significantly below an age-appropriate level and such skills must not be expected to progress at an age-appropriate rate as indicated by a developmental assessment performed by the child's physician or by another certified professional.

(c) Regardless of age, the child must also require all of the following:

1. direct administration of at least two discrete skilled nursing services on a daily basis, each of which requires complex nursing procedures as described at 130 CMR 519.007(A)(3);

2. direct management of the child's medical care by a physician or provided directly by someone who is under the supervision of a physician on a monthly basis;

3. assistance in one or more ADLs beyond what is required at an age-appropriate activity level; and

4. any combination of skilled therapeutic services (physical therapy, occupational therapy, speech and language therapy) provided directly by or under the supervision of a licensed therapist at least five times a week.

(5)Premium Assistance for Standard Kaileigh Mulligan. Individuals eligible for MassHealth Standard in 130 CMR 519.007(A) may be eligible for Premium Assistance if they meet the requirements described in 130 CMR 505.002(N): Access to Employer-Sponsored Insurance and Premium Assistance Investigations for Individuals Who are eligible for MassHealth Standard and 506.012: Premium Assistance Payments.

(B)Home- and Community-based Services Waiver-frail Elder.

(1)Clinical and Age Requirements. The Home- and Community-based Services Waiver allows an applicant or member who is certified by the MassHealth agency or its agent to be in need of nursing-facility services to receive certain waiver services at home if they

(a) are 60 years of age or older and, if younger than 65 years old, is permanently and totally disabled in accordance with Title XVI standards; and

(b) would be institutionalized in a nursing facility, unless he or she receives one or more of the services administered by the Executive Office of Elder Affairs under the Home- and Community-based Services Waiver-frail Elder authorized under § 1915(c)of the Social Security Act.

(2)Eligibility Requirements. In determining eligibility for MassHealth Standard and for waiver services, the MassHealth agency determines income eligibility based solely on the applicant's or member's income regardless of their marital status. The applicant or member must

(a) meet the requirements of 130 CMR 519.007(B)(1)(a) and (b);

(b) have a countable-income amount less than or equal to 300% of the federal benefitrate (FBR) for an individual; and

(c) have countable assets of $2,000 for an individual and, for a married couple if the initial Waiver eligibility determination was on or after January 1, 2014, have assets that are less than or equal to the standards at 130 CMR 520.016(B): Treatment of a Married Couple's Assets When One Spouse Is Institutionalized; and

(d) have not transferred resources for less than fair market value as described at130 CMR 520.018: Transfer of Resources Regardless of the Transfer Date and 520.019: Transfer of Resources Occurring on or after August 11, 1993.

(3)Financial Standards Not Met. Individuals whose income, assets, or both exceed the standards set forth in 130 CMR 519.007(B)(2) may establish eligibility for MassHealth Standard by reducing their assets in accordance with 130 CMR 520.004: Asset Reduction,by meeting a deductible as described at 130 CMR 520.028 through 520.035, or by both.

(C)Program of All-inclusive Care for the Elderly (PACE).

(1)Overview. The PACE program is a comprehensive health program that is designed to keep frail, older individuals who are certified eligible for nursing facility services living in the community.

(a) A complete range of health care services is provided by one designated community-based program with all medical and social services coordinated by a team of health professionals.

(b) The MassHealth agency administers the program in Massachusetts as the Elder Service Plan (ESP).

(c) Persons enrolled in PACE have services delivered through managed care

1. in day-health centers;

2. at home; and

3. in specialty or inpatient settings, if needed.

(2)Eligibility Requirements. In determining PACE eligibility, the MassHealth agency counts the income and assets of only the applicant or member regardless of their marital status. The applicant or member must meet all of the following criteria:

(a) be 55 years of age or older;

(b) meet Title XVI disability standards if 55 through 64 years of age;

(c) be certified by the MassHealth agency or its agent to be in need of nursing facility services;

(d) live in a designated service area;

(e) have medical services provided in a specified community-based PACE program;

(f) have countable assets whose total value does not exceed $2,000 or, if assets exceed these standards, reduce assets in accordance with 130 CMR 520.004: Asset Reduction; and

(g) have a countable-income amount less than or equal to 300% of the federal benefitrate (FBR) for an individual.

(3)Income Standards Not Met. Individuals whose income exceeds the standards set forth in 130 CMR 519.007(C)(2) may establish eligibility for MassHealth Standard by meeting a deductible as described at 130 CMR 520.028 through 520.035.

(D)Home- and Community-based Services Waivers for Persons with an Intellectual Disability.

(1)Intensive Supports Waiver.

(a)Clinical and Age Requirements. The Intensive Supports Home- and Community-based Services Waiver for Persons with an Intellectual Disability allows an applicant or member who is certified by the MassHealth agency or its agent to be in need of inpatient care at an intermediate-care facility for the intellectually disabled to receive residential habilitation and other specified waiver services if they meet all of the following criteria:

1. have an intellectual disability/developmental disability in accordance with Department of Developmental Services standards;

2. need one or more of the services administered by the Department of Developmental Services under the Intensive Supports Home- and Community-based Services Waiver authorized under § 1915(c) of the Social Security Act;

3. need 24/7 support either in a 24-hour supervised residential setting or in the family home as provided under the Intensive Supports Waiver

4. are 22 years of age or older and, if younger than 65 years old, is totally and permanently disabled in accordance with Title XVI standards.

(b)Eligibility Requirements. In determining eligibility for MassHealth Standard and for these waiver services, the MassHealth agency determines income eligibility based solely on the applicant's or member's income regardless of their marital status. The applicant or member must meet all of the following criteria:

1. meet the requirements of 130 CMR 519.007(D)(1)(a);

2. have countable income that is less than or equal to 300% of the federal benefitrate (FBR) for an individual;

3. have countable assets of $2,000 or less for an individual and, for a married couple if the initial Waiver eligibility determination was on or after January 1, 2014, have assets that are less than or equal to the standards at 130 CMR 520.016(B):Treatment of a Married Couple's Assets When One Spouse Is Institutionalized; and

4. have not transferred resources for less than fair market value, as described in130 CMR 520.018: Transfer of Resources Regardless of Date of Transfer and 520.019: Transfer of Resources Occurring on or after August 11, 1993.

(c)Financial Eligibility Standards Not Met. Individuals whose income, assets, or both exceed the standards set forth in 130 CMR 519.007(D)(1)(b) may establish eligibility for MassHealth Standard by reducing their assets in accordance with 130 CMR 520.004: Asset Reduction, by meeting a deductible as described in 130 CMR 520.028 through 520.035, or by both.

(d)Enrollment Limits. Enrollment in the Intensive Supports Home- and Community-based Services Waiver for Persons with an Intellectual Disability is subject to a limit on the total number of waiver participants. The number of participants who can be enrolled in the waiver may be limited in a manner determined by the MassHealth agency.

(2)Community Living Waiver.

(a)Clinical and Age Requirements. The Community Living Home- and Community-based Services Waiver for Persons with an Intellectual Disability allows an applicant or member who is certified by the MassHealth agency or its agent to be in need of inpatient care at an intermediate-care facility for the intellectually disabled to receive certain waiver services, other than residential habilitation, at home or in the community provided they

1. have an intellectual disability/developmental disability in accordance with Department of Developmental Services standards;

2. need one or more of the services administered by the Department of Developmental Services under the Community Living Home- and Community-based Services Waiver authorized under § 1915(c) of the Social Security Act;

3. need one or more of the services provided only under the Community Living Waiver; and

4. are 22 years of age or older and, if younger than 65 years old, is totally and permanently disabled in accordance with Title XVI standards.

1. meet the requirements of 130 CMR 519.007(D)(2)(a);

2. have countable income that is less than or equal to 300% of the federal benefitrate (FBR) for an individual;

(c)Financial Eligibility Standards Not Met. Individuals whose income, assets, or both exceed the standards set forth in 130 CMR 519.007(D)(2)(b) may establish eligibility for MassHealth Standard by reducing their assets in accordance with 130 CMR 520.004: Asset Reduction, by meeting a deductible as described in 130 CMR 520.028 through 520.035, or by both.

(d)Enrollment Limits. Enrollment in the Community Living Home- and Community-based Services Waiver for Persons with an Intellectual Disability is subject to a limit on the total number of waiver participants. The number of participants who can be enrolled in the waiver may be limited in a manner determined by the MassHealth agency.

(3)Adult Supports Waiver.

(a)Clinical and Age Requirements. The Adult Supports Home- and Community-based Services Waiver for Persons with an Intellectual Disability allows an applicant or member who is certified by the MassHealth agency or its agent to be in need of inpatient care at an intermediate-care facility for the intellectually disabled to receive certain waiver services, other than residential habilitation, at home or in the community provided they

1. have an intellectual disability/developmental disability in accordance with Department of Developmental Services standards;

2. need one or more of the services administered by the Department of Developmental Services under the Adult Supports Home- and Community-based Services Waiver authorized under § 1915(c) of the Social Security Act; and

3. are 22 years of age or older and, if younger than 65 years old, is totally and permanently disabled in accordance with Title XVI standards.

1. meet the requirements of 130 CMR 519.007(D)(3)(a);

2. have countable income that is less than or equal to 300% of the federal benefitrate (FBR) for an individual;

(c)Financial Eligibility Standards Not Met. Individuals whose income, assets, or both exceed the standards set forth in 130 CMR 519.007(D)(3)(b) may establish eligibility for MassHealth Standard by reducing their assets in accordance with 130 CMR 520.004: Asset Reduction, by meeting a deductible as described in 130 CMR 520.028 through 520.035, or by both.

(d)Enrollment Limits. Enrollment in the Adult Supports Home- and Community-based Services Waiver for Persons with an Intellectual Disability is subject to a limit on the total number of waiver participants. The number of participants who can be enrolled in the waiver may be limited in a manner determined by the MassHealth agency.

(E)Home- and Community-based Services Waiver for Young Children with Autism.

(1)Clinical Requirements. The Home- and Community-based Services Waiver allows an applicant or member who is certified by the MassHealth agency or its agent to be in need of inpatient care at an intermediate-care facility for the intellectually disabled to receive certain waiver services at home or in the community provided they

(a) have a confirmed diagnosis of an autism spectrum disorder (which includes autistic disorder, pervasive developmental disorder-not otherwise specified (PDD-NOS), Rhett'ssyndrome, childhood disintegrative disorder, and Asperger's syndrome);

(b) would be institutionalized in an intermediate-care facility for the intellectually disabled unless they receive one or more of the services administered by the Department of Developmental Services under the Home- and Community-based Services Waiver authorized under § 1915(c) of the Social Security Act; and

(c) are able to be safely served in the community.

(2)Eligibility Requirements and Limitations.

(a) The applicant or member must be younger than nine years old.

(b) The child must be eligible for MassHealth Standard in accordance with 130 CMR 505.002(B)(1): Children Younger than One Year Old and (2): Children One through 18 Years of Age.

(c) Assets are not considered in the eligibility determination.

(d) The number of children who can be enrolled in this waiver may be limited in a manner determined by the MassHealth agency or its agent.

(F)Home- and Community-based Services Waiver for Persons with Traumatic Brain Injury.

(1)Clinical and Age Requirements. The Home- and Community-based Services Waiver for Persons with Traumatic Brain Injury allows an applicant or member who is certified by the MassHealth agency or its agent to be in need of nursing facility services or chronic or rehabilitation hospital services to receive specified waiver services in the home or community if they

(a) are 18 years of age or older and, if younger than 65 years old, is totally and permanently disabled in accordance with Title XVI standards;

(b) have traumatic brain injury, as defined in Massachusetts Rehabilitation Commission (MRC) regulations at 107 CMR 12.02: Meaning of Terms in 107 CMR 12.00;

(c) need one or more of the services administered by MRC under the Home- and Community-based Services Waiver authorized under § 1915(c) of the Social Security Act; and

(d) are able to be safely served in the community.

(a) meet the requirements of 130 CMR 519.007(F)(1);

(b) have a countable income amount that is less than or equal to 300 percent of the federal benefit rate (FBR) for an individual;

(c) have countable assets of $2,000 or less for an individual and, for a married couple if the initial Waiver eligibility determination was on or after January 1, 2014, have assets that are less than or equal to the standards at 130 CMR 520.016(B): Treatment of a Married Couple's Assets When One Spouse Is Institutionalized; and

(d) have not transferred resources for less than fair market value, as described in130 CMR 520.018: Transfer of Resources Regardless of Date of Transfer and 520.019: Transfer of Resources Occurring on or after August 11, 1993.

(3)Enrollment Limits. Enrollment in this waiver is subject to a limit on the total number of waiver participants. The number of participants who can be enrolled in this waiver maybe limited in a manner determined by the MassHealth agency or its agent.

(G)Home- and Community-based Services Waivers for Persons with Acquired Brain Injury.

(1)Residential Habilitation Waiver for Persons with Acquired Brain Injury.

(a)Clinical and Age Requirements. The Residential Habilitation Waiver for Persons with Acquired Brain Injury, as authorized under § 1915(c) of the Social Security Act, allows an applicant or member who is certified by the MassHealth agency or its agent to be in need of nursing facility services or chronic disease or rehabilitation hospital services to receive residential habilitation and other specified waiver services in a provider-operated 24-hour supervised residential setting if they meet all of the following criteria:

1. are 22 years of age or older and, if younger than 65 years old, is totally and permanently disabled in accordance with Title XVI standards;

2. acquired, after reaching 22 years of age, a brain injury including, without limitation, brain injuries caused by external force, but not including Alzheimer's disease and similar neuro-degenerative diseases, the primary manifestation of which is dementia;

3. are an inpatient in a nursing facility or chronic disease or rehabilitation hospital with a continuous length of stay of 90 or more days at the time of application for the waiver;

4. need a residential support service available under the Residential Habilitation Waiver;

5. are able to be safely served in the community within the terms of the Residential Habilitation Waiver.

(b)Eligibility Requirements. In determining eligibility for MassHealth Standard and for these waiver services, the MassHealth agency determines income eligibility based solely on the applicant's or member's income regardless of his or her marital status. The applicant or member must

1. meet the requirements of 130 CMR 519.007(G)(1)(a);

2. have countable income that is less than or equal to 300% of the federal benefitrate (FBR) for an individual;

3. have countable assets of $2,000 or less for an individual and, for a married couple if the initial Waiver eligibility determination was on or after January 1, 2014,have assets that are less than or equal to the standards at 130 CMR 520.016(B): Treatment of a Married Couple's Assets When One Spouse Is Institutionalized; and

4. not have transferred resources for less than fair market value, as described in130 CMR 520.018: Transfer of Resources Regardless of Date of Transfer and 520.019: Transfer of Resources Occurring on or after August 11, 1993.

(c)Enrollment Limits. Enrollment in the Residential Habilitation Waiver is subject to a limit on the total number of waiver participants. The number of participants who can be enrolled in this waiver may be limited in a manner determined by the MassHealth agency.

(d)Waiver Services. Eligible members who are enrolled as waiver participants in the Residential Habilitation Waiver are eligible for the waiver services described in130 CMR 630.405(A): Acquired Brain Injury with Residential Rehabilitation (ABI-RH) Waiver.

(2)Non-residential Habilitation Waiver for Persons with Acquired Brain Injury.

(a)Clinical and Age Requirements. The Non-residential Habilitation Waiver for Persons with Acquired Brain Injury, as authorized under § 1915(c) of the Social Security Act, allows an applicant or member who is certified by the MassHealth agency or its agent to be in need of nursing facility services or chronic disease or rehabilitation hospital services to receive specified waiver services, other than residential support services, in the home or community if they meet all of the following criteria:

1. are 22 years of age or older and, if younger than 65 years old, is totally and permanently disabled in accordance with Title XVI standards;

3. are an inpatient in a nursing facility or chronic disease or rehabilitation hospital with a continuous length of stay of 90 or more days at the time of application for the waiver;

4. need one or more of the services under the Non-residential Habilitation Waiver; and

5. are able to be safely served in the community within the terms of the Non-residential Habilitation Waiver.

(b)Eligibility Requirements. In determining eligibility for MassHealth Standard and for these waiver services, the MassHealth agency determines income eligibility based solely on the applicant's or member's income regardless of his or her marital status. The applicant or member must

1. meet the requirements of 130 CMR 519.007(G)(2)(a);

2. have countable income that is less than or equal to 300% of the federal benefitrate (FBR) for an individual;

(c)Enrollment Limits. Enrollment in the Non-residential Habilitation Waiver is subject to a limit on the total number of waiver participants. The number of participants who can be enrolled in this waiver may be limited in a manner determined by the MassHealth agency.

(d)Waiver Services. Eligible members who are enrolled as waiver participants in the Non-residential Habilitation Waiver are eligible for the waiver service described in130 CMR 630.405(B): Acquired Brain Injury Non-residential Habilitation (ABI-N)Waiver.

(H)Money Follows the Person Home- and Community-based Services Waivers.

(1)Money Follows the Person (MFP) Residential Supports Waiver.

(a)Clinical and Age Requirements. The MFP Residential Supports Waiver, as authorized under § 1915(c) of the Social Security Act, allows an applicant or member who is certified by the MassHealth agency or its agent to be in need of nursing facility services, chronic disease or rehabilitation hospital services, or, for participants 18 through 21 years of age or 65 years of age or older, psychiatric hospital services to receive residential support services and other specified waiver services in a 24-hour supervised residential setting if they meet all of the following criteria:

1. are 18 years of age or older and, if younger than 65 years old, is totally and permanently disabled in accordance with Title XVI standards;

2. are an inpatient in a nursing facility, chronic disease or rehabilitation hospital, or, for participants 18 through 21 years of age or 65 years of age or older, psychiatrichospital with a continuous length of stay of 90 or more days, excluding rehabilitation days;

3. must have received MassHealth benefits for inpatient services, and be MassHealth eligible at least the day before discharge;

4. must be assessed to need residential habilitation, assisted living services, or shared living 24-hour supports services within the terms of the MFP Residential Supports Waiver;

5. are able to be safely served in the community within the terms of the MFP Residential Supports Waiver; and

6. are transitioning to the community setting from a facility, moving to a qualified residence, such as a home owned or leased by the applicant or a family member, an apartment with an individual lease, or a community-based residential setting in which no more than four unrelated individuals reside.

(b)Eligibility Requirements. In determining eligibility for MassHealth Standard and for these waiver services, the MassHealth agency determines income eligibility based solely on the applicant or member regardless of his or her marital status. The applicant or member must

1. meet the requirements of 130 CMR 519.007(H)(1)(a);

2. have countable income that is less than or equal to 300% of the federal benefitrate (FBR) for an individual;

3. have countable assets of $2,000 or less for an individual and, for a married couple if the initial Waiver eligibility determination was on or after January 1, 2014, have assets that are less than or equal to the standards at 130 CMR 520.016(B): Treatment of a Married Couple's Assets When One Spouse Is Institutionalized; and

(c)Enrollment Limits. Enrollment in the MFP Residential Supports Waiver is subject to a limit on the total number of waiver participants. The number of participants who can be enrolled in this waiver may be limited in a manner determined by the MassHealth agency.

(d)Waiver Services. Eligible members who are enrolled as waiver participants in the MFP Residential Supports Waiver are eligible for the waiver services described in130 CMR 630.405(C): Moving Forward Residential Supports (MFP-RS) Waiver.

(2)Money Follows the Person (MFP) Community Living Waiver.

(a)Clinical and Age Requirements. The MFP Community Living Waiver, as authorized under § 1915(c) of the Social Security Act, allows an applicant or member who is certified by the MassHealth agency or its agent to be in need of nursing facility services, chronic disease or rehabilitation hospital services, or, for participants 18 through 21 years of age or 65 years of age or older, psychiatric hospital services to receive specified waiver services, other than residential support services in the home or community, if they meet all of the following criteria:

1. are 18 years of age or older and, if younger than 65 years old, are totally and permanently disabled in accordance with Title XVI standards;

3. must have received MassHealth benefits for inpatient services, and be MassHealth eligible at least the day before discharge;

4. needs one or more of the services under the MFP Community Living Waiver;

5. are able to be safely served in the community within the terms of the MFP Community Living Waiver; and

(b)Eligibility Requirements. In determining eligibility for MassHealth Standard and for these waiver services, the MassHealth agency determines income eligibility based solely on the applicant's or member's income regardless of his or her marital status. The applicant or member must

1. meet the requirements of 130 CMR 519.007(H)(2)(a);

2. have countable income that is less than or equal to 300% of the federal benefitrate (FBR) for an individual;

3. have countable assets of $2,000 or less for an individual and, for a married couple if the initial Waiver eligibility determination was on or after January 1, 2014, have assets that are less than or equal to the standards at 130 CMR 520.016(B): Treatment of a Married Couple's Assets When One Spouse Is Institutionalized; and

(c)Enrollment Limits. Enrollment in the MFP Community Living Waiver is subject to a limit on the total number of waiver participants. The number of participants who can been rolled in this waiver may be limited in a manner determined by the MassHealth agency.

(d)Waiver Services. Eligible members who are enrolled as waiver participants in the MFP Community Living Waiver are eligible for the waiver services described in 130 CMR 630.405(D): Moving Forward Plan Community Living (MFP-CL) Waiver.