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| Home > Statutes > USA Massachusetts |
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USA Statutes : massachusetts
Title : PART I. ADMINISTRATION OF THE GOVERNMENT
Chapter : TITLE XVII. PUBLIC WELFARE
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Section 1. The following words, as used in this chapter, unless the context otherwise requires, shall have the following meaning:—“Commissioner”, commissioner of veterans’ services.
“Dependent”, the wife, husband, widow, widower, child, mother or father of a veteran, as hereinafter defined, including any person who stood in the relationship of a parent to such veteran for the five years next preceding the commencement of his wartime service; provided, that no child of a veteran who is more than eighteen years of age shall be deemed a dependent, unless such child is attending school for the purpose of completing a regulation high school course or its equivalent, or unless he is mentally or physically unable to support himself, and his disability existed before he attained that age, or unless he is under twenty-three years of age, and is a full-time student at an educational institution which maintains a regular faculty and curriculum and has a regularly organized body of students in attendance at the place where its educational activities are carried on.
“Reside”, to be present within a city or town of the commonwealth, notwithstanding the lack of a present abode, with no present intention of definite and early removal, but not necessarily with the intention of remaining permanently; provided, however, that any such person who enters the commonwealth solely for the purpose of obtaining benefits under this chapter shall not be considered to reside in the commonwealth; and, provided further, that an applicant lacking a present abode shall be required to provide an affidavit stating his identity, his last place of residence and his intention to establish an abode within the city or town in which he applies.
“Institution”, any hospital, sanatorium or wayfarer’s lodge, boarding or rest home, or convalescent or nursing home, for the operation of which a license is required by law, any facility conducted by an agency incorporated under chapter one hundred and eighty or any special act as a charitable corporation and any facility operated by municipal, county, state or federal government.
“Veteran”, any person who (a) is a veteran as defined in clause Forty-third of section seven of chapter four; or (b) meets all the requirements of said clause Forty-third except that instead of performing wartime service as so defined he has served on active duty in the Mexican border service, between June thirteenth, nineteen hundred and sixteen, and February third, nineteen hundred and seventeen; or (c) is entitled to the Civil War, Indian Campaign, Spanish Campaign, or Spanish War Service Medal; or (d) meets all the requirements of said clause Forty-third except that instead of performing ninety days active service, at least one day of which was for wartime service, he has performed active service in the armed forces of the United States at any time between April sixth, nineteen hundred and seventeen and November eleventh, nineteen hundred and eighteen, inclusive; or (e) meets all the requirements of said clause Forty-third, except that instead of performing wartime service as so defined he is entitled to any of the following campaign badges: First Nicaraguan, Haitian, Dominican, Yangtze River, Second Yangtze River, Second Nicaraguan, Vera Cruz, Mexican Service; provided, that in any case the service of such person was credited to Massachusetts, or such person has three years continuous residence in the commonwealth.
“Veterans’ agent” or “Part-time veterans’ agent”, a veteran, as defined in clause Forty-third of section seven of chapter four, appointed under section three to disburse veterans’ benefits in any city or town, or, if no such appointment has been made, the mayor of the city or the selectmen of the town disbursing such benefits; in Boston, the veterans’ benefits and services commissioner.
“Veterans’ benefits”, the benefits provided by this chapter. When used in any statute, ordinance, by-law, rule or regulation, the phrases “state aid”, “military aid”, “soldiers’ relief”, “soldiers’ burial”, or any words or phrases connoting the same, shall mean veterans’ benefits.
Chapter 115: Section 10. Creation; directors; districts; treasurer of district Section 10. The mayors of cities and the selectmen of towns, other than cities and towns which become part of a district as authorized by the second paragraph of this section, shall cause to be established and maintained in their respective cities and towns a department for the purpose of furnishing such information, advice and assistance to veterans and their dependents as may be necessary to enable them to procure the benefits to which they are or may be entitled relative to employment, vocational or other educational opportunities, hospitalization, medical care, pensions, and other veterans’ benefits. Each department so established and maintained shall be known as the department of veterans’ services, and the officer in charge thereof shall be known as the director of veterans’ services. Such director and any assistant or deputy director appointed under this section or section eleven shall be a veteran and shall be appointed in a city by the mayor, with the approval of the city council, and in a town by the selectmen.
Two or more adjoining towns, or two or more adjoining municipalities only one of which is a city, may, in a city by vote of the city council thereof, and in a town by vote of the selectmen thereof, form a district for the purposes set forth in the first paragraph of this section, including the appointment and compensation of a director of veterans’ services, for the enforcement therein of such purposes and of such other provisions of law as it may be his duty to enforce. Any constituent city or town by vote may withdraw from the district at the end of any fiscal year of such city or town if such withdrawal is voted in the manner aforesaid not less than sixty days prior to the end of such fiscal year and notice of such vote is filed with the other municipalities comprising the district.
The director of veterans’ services of each district established under authority of the preceding paragraph shall, under the direction of the district board referred to in section eleven, perform the duties of his office in each of the municipalities comprising his district.
The treasurer of one of the municipalities comprising such district, designated by the district board thereof, shall be treasurer of the district and shall give to the district a bond, with a surety company authorized to transact business in the commonwealth as surety, for the faithful performance of his duties as treasurer of the district in such sum and upon such conditions as said district board may require. The district treasurer shall disburse the money received under the provisions of section eleven upon warrants approved by the district board.
Chapter 115: Section 11. District boards; powers; apportionment of expenses; payment of costs and expenses by district members Section 11. In every district established under authority of section ten there shall be a board composed of the mayor or his designee of such city, if any, as may be included in the district and the chairman of the board of selectmen or its designee of each of the towns, if any, included in said district and the town manager or his designee in a municipality with a town council form of government, if any, included in said district. Said board shall appoint, fix the compensation of, and may remove the director of veterans services of said district. Said board may appoint, fix the salary of, and remove, a deputy or assistant to such director, if in the opinion of said board such an officer is necessary.
Said board may determine the expenses of said director and deputy or assistant and of the department under the charge of said director, and may apportion said expenses among the several municipalities comprising such district on the basis of the taxable valuation of said municipalities as last established by the general court as a basis of apportionment for state and county taxes, or on the basis of the population of each municipality in such district based on the most recent federal census, or by any other means determined by a unanimous vote of said board to be fair and equitable to each community. Said board shall promptly thereafter notify the treasurers of said municipalities of such apportionment. Every city or town treasurer so notified shall, annually in December, certify the amount of such apportionment to the board of assessors of his municipality, who shall include such amount in the tax levy of the following year.
Upon order of the district board the city or town treasurer of each of the constituent members of the district shall from time to time pay to the district treasurer a sum or sums not exceeding, in the aggregate, the amount certified by the board as its respective share of the costs and expenses of the district. In case a city or town becomes a member of a district at a time when it is too late to permit an assessment as provided by sections ten to fourteen, inclusive, such city or town may appropriate and pay to the district treasurer an amount representing its proportionate share of the expense of the district for the period ending December thirty-first in the year in which such city or town becomes a member of the district.
Chapter 115: Section 12. Advisory boards; duties; rules and regulations Section 12. In each city, and in each town not included in a district established under section ten, and in each such district, there may be in the department of veterans’ services an unpaid advisory board to be appointed, in cities by the mayor, in towns by the board of selectmen, and in districts by the district board. Said advisory board shall render such assistance to the director of veterans’ services of the municipality or district relative to the provisions of this chapter, except as to sections one to nine, inclusive, as said director may request. The commissioner is hereby authorized and directed to formulate and publish rules and regulations establishing in a general manner the types of persons, with respect to their occupations, professions and special skills, who may be appointed to such unpaid advisory boards. Every such advisory board shall consist of not less than five nor more than fifteen residents of the city, town or district, as the case may be.
Chapter 115: Section 13. Duties of departments Section 13. Said departments shall acquire and have on hand copies of current booklets and other printed matter pertaining to the statutory rights of veterans provided under state and federal laws. They may call at any time upon any department, board, division or commission of the commonwealth for such assistance as may be necessary in carrying out their functions. They shall also work in close coordination with existing federal agencies established for the aid of such veterans, and they shall enlist the support of hospitals within their respective communities or districts for carrying out the purposes of sections ten to fourteen, inclusive.
Chapter 115: Section 14. Control and direction of commissioner; separate and independent location Section 14. Departments established and maintained under sections ten to fourteen, inclusive, shall be under the general direction of the commissioner, and they shall be physically located independently of, and separate and apart from, any other public or private agency, board, bureau, social agency or society, except a department or agency disbursing aid or relief or veterans’ benefits under this chapter.
Chapter 115: Section 15. Audit of accounts of districts Section 15. The director of accounts in the department of corporations and taxation shall cause an audit to be made annually of the accounts of all districts organized under the authority of section ten and for such purpose he, and his duly accredited agents, shall have access to all necessary papers, books and records. The expenses incurred for said audits shall be paid primarily by the commonwealth. Said director shall apportion the cost of each audit among the several municipalities comprising the district on the basis of the taxable valuation of said municipalities as last established by the general court for state and county taxes, and submit the amounts of each apportionment to the state treasurer, who shall issue his warrant requiring the assessors of the cities and towns which comprise the district to assess a tax to the amount so apportioned, and such amount shall be collected and paid to the state treasurer as provided by section twenty of chapter fifty-nine.
veterans’ services Section 2. The commissioner shall assist and advise veterans’ agents in the performance of their duties, investigate, so far as the interests of the commonwealth require, all payments of veterans’ benefits, prepare papers and expedite the adjudication of claims, assist claimants in proving their cases, keep a record of work done in his office, and make an annual report.
He shall establish the form of application to be used by applicants for veterans’ benefits, may require the annexation thereto of official records of the veteran’s induction, enlistment, service or discharge, or attested copies of the same, and shall from time to time provide each city and town with blank application forms prepared by him. He shall adopt such regulations as he may deem necessary to insure the proper administration of the provisions of this chapter, and he may issue and promulgate directives for the guidance of all persons concerned with veterans’ benefits or with matters before the Veterans’ Administration of the United States government.
The commissioner shall decide all controversies between towns relative to the residence of applicants for veterans’ benefits and, subject to the approval of the attorney general, his decisions shall be final. He shall decide any controversies between any applicant and a veterans’ agent or part-time veterans’ agent relative to the validity or amount of a claim for such benefits. Any claimant veterans’ agent or part-time veterans’ agent aggrieved by a decision of the commissioner shall have a right to appeal the decision, after due notice, to the division of administrative law appeals established within the executive office of administration and finance pursuant to section four H of chapter seven, hereinafter in this section referred to as “the division”. Any person aggrieved by a decision of the commissioner or by the failure of a city or town to render adequate veterans’ benefits or to approve or reject an application for veterans’ benefits within forty-five days of receiving such application, or aggrieved by the withdrawal of such benefits, shall also have a right, after due notice, to appeal to the division. A hearing on such appeal held pursuant to this paragraph shall be conducted at a location convenient to the person appealing and shall be conducted as an adjudicatory proceeding under chapter thirty A. The division shall issue its decision within ninety days after the day of the filing of the appeal, except that when an aggrieved person appeals the rejection of his application for veterans’ benefits or the failure to act on said application or the failure of a city or town to render assistance to meet an emergency or hardship situation, the division shall render and issue its decision within forty-five days after the date of filing of said appeal. Further review of such decision may be had by any party upon application made to the governor and council within ten days after his receipt of notice of the decision. Whether or not an application for further review is made to the governor and council, the decision of the division, or the decision of the governor and council, if an application for further review is made, shall be subject to judicial review in accordance with the provisions of chapter thirty A. The time for commencing such an action for judicial review shall run from the receipt of notice of the decision of the division, or, in the event that an application for further review is made to the governor and council, from the receipt of notice of the decision of the governor and council. In such an action for judicial review, the record shall consist of (a) the entire proceedings before the division of administrative law appeals and, if applicable, the governor and council, or (b) such portions thereof as the commissioner and the parties may stipulate, or (c) a statement of the case agreed to by the commissioner and the parties.
Upon the written request of the mayor of a city or the selectmen of a town, he shall forthwith investigate any matter relating to the administration therein of the provisions of this chapter and the expenses of such an investigation shall be certified by him to the state treasurer who shall collect the same as an additional tax upon such city or town.
He may, with the consent of the governor, appoint, as occasion may require, one or more disinterested persons who shall investigate any claims against the commonwealth for veterans’ benefits, examine any persons to or for whom such benefits have been paid, investigate the reasons for and all matters relating to the granting of such benefits, and shall report their findings to him. The reasonable expenses and compensation of any such disinterested person, if and when approved by the commissioner and allowed by the governor and council, shall be paid by the commonwealth.
He may authorize the payment by a veterans’ agent of such sums as he deems necessary to provide special care in a hospital or at any other place for a veteran of the civil war, his wife or widow. On or before November tenth in the year following any expenditure so authorized, the city or town making the same shall be reimbursed by the commonwealth to the extent of seventy-five per cent of such expenditure.
He may, by a written demand signed by him or by his “duly authorized agent” which term, for the purposes of this paragraph, shall be deemed to include local veterans’ agents appointed pursuant to section three, require the treasurer of a savings bank, institution for savings, national bank, trust company, co-operative bank, benefit association, insurance company, savings and loan association under the supervision of the commissioner of banks, federal savings and loan association, credit union or safe deposit company, to inform him of the amounts at any time deposited with such corporation or association to the credit of a recipient of veterans’ benefits under this chapter, or an applicant therefor, or at any time withdrawn from such corporation or association by such recipient or applicant, or the amounts loaned to such recipient or applicant for the purchase of real property under the terms of a mortgage and the present balance due thereon, and, in like manner, may require the employer of any such recipient or applicant, or of any child of such recipient or applicant living in his household, to inform him of the amount of money at any time paid by such employer to such recipient, applicant or child, and any treasurer or employer who refuses to furnish such information or who wilfully renders false information in reply to such demand shall forfeit fifty dollars to the use of the commonwealth.
He shall be the agent and attorney of and for all departments, boards and commissions of the commonwealth, including the department of correction and the institutions under its control, in all matters before the Veterans’ Administration of the United States government involving any question of federal compensation or pension to which any veteran or dependent under the care or supervision of such departments, boards and commissions may be entitled, and involving any question of reimbursement of the commonwealth for assistance, care, board or hospitalization of any such veteran or dependent. Each such department, board and commission shall notify him, in writing, of all such veterans or dependents who are inmates of any hospital or other institution under the control of such department, board or commission, or otherwise under the supervision of, or in receipt of direct financial assistance from, such department, board or commission. Such notification shall be on forms to be prepared by him and shall contain such information as he may require to enable him to proceed properly in matters of federal compensation or pension for such veterans or dependents, and in matters of reimbursement of the commonwealth for assistance, care, board or hospitalization of such veterans or dependents.
He shall investigate the probabilities of securing such compensation or pension for any such veteran or dependent, and, in furtherance of such investigation, he may require the services of the veterans’ agents of the various cities and towns and of the directors of veterans’ services of the various cities, towns and districts, and shall prosecute claims for such compensation or pension in behalf of any such veteran or dependent from whom he may secure a power of attorney, in accordance with the regulations of the Veterans’ Administration of the United States government. He may co-operate with any responsible veterans’ service agency in the prosecution of such claims in behalf of any such veteran or dependent from whom such agency has secured such power of attorney, and he shall prosecute claims for reimbursement of the commonwealth for assistance, care, board or hospitalization of any such veteran or dependent in cases wherein the federal government is responsible for such reimbursement.
He may, by written notice, order a city or town to pay veterans’ benefits to an applicant on an application approved by the commissioner. If a city or town refuses or does not make such payment within fourteen days from receipt of such notice he shall notify the state treasurer of such refusal or failure and thereafter such benefits shall be paid to the applicant by the commonwealth. If the commonwealth shall be called upon to pay any such benefits on behalf of any such city or town, the total of any such benefits paid in any such calendar year shall be assessed upon such city or town, or deducted from funds that may be due such city or town from the commonwealth.
He shall appoint an advisory committee on women veterans to investigate, foster and promote the interests of women veterans as defined in section seven of chapter four. The committee shall consist of at least eleven members, one of whom shall be the commissioner or his designee, one of whom shall be a person appointed by the governor as an advisor on women’s issues, one of whom shall be the chairman of the Massachusetts commission against discrimination, or his designee, three of whom shall be members of veterans organizations as provided in section eight E of chapter twelve to be appointed by the governor, one of whom shall be a veterans agent to be appointed by the governor, and four of whom shall be women veterans appointed by the commissioner, no fewer than two of whom shall be participants in the Vietnam Veterans Outreach Program of the United States Veterans Administration. Any member shall be eligible for reappointment and shall serve without compensation. The terms of appointment shall be coterminous with the governor. The advisory committee may issue annual reports on their activities.
Section 2A. If the commissioner decides a controversy between an applicant and a veterans’ agent relative to the validity or amount of a claim for veterans’ benefits, as provided in section two, in favor of the applicant, the said veterans’ agent shall, forthwith, make payment to the applicant in accordance with said decision notwithstanding any appeal therefrom by the veterans’ agent. If the governor and council sustain the appeal of said veterans’ agent as to the validity of such claim, payment to the applicant shall thereupon cease and all amounts paid to the applicant shall be reimbursed by the commonwealth in the manner provided in section six. If the governor and council sustain the appeal of said veterans’ agent as to the amount of such claim, payment to the applicant of any amount in excess of the amount approved by the governor and council shall thereupon cease and all amounts paid to the applicant in excess of the amount so approved shall be reimbursed by the commonwealth in the manner provided by said section six.
The decision of the commissioner, in accordance with the provisions of said section two, may be enforced by the superior court on a petition in equity.
Section 2B. There shall be a commission on veterans employment opportunities that shall investigate whether veterans are subjected to employment discrimination on the basis of their status as veterans. The commission shall report its findings and recommendation annually on March 1 to the secretary of veterans affairs. The commission shall consist of 5 persons as follows: the secretary of veterans affairs or his designee, the secretary of economic development or his designee, a member appointed by the speaker of the house of representatives, a member appointed by the president of the senate and a veteran appointed by the Governor.
duties Section 3. The mayor of each city except Boston shall, and the selectmen of each town may, annually in April, appoint a veterans’ agent to act for him or them in the disbursement of veterans’ benefits by such city or town; provided, however, that in each town having a part time veterans’ agent the town clerk shall receive applications and assist applicants for, veterans’ benefits, and shall turn over said applications to the veterans’ agent. Two or more contiguous towns may, by vote of the selectmen, appoint one person to serve as veterans’ agent for such towns and may apportion the payment of compensation among such towns.
Every veterans’ agent shall, from time after the original allowance of any claim for veterans’ benefits, make such investigations of the necessities and qualifications of the claimant as to prevent the payment of any such benefits contrary to any provision of this chapter.
Every such agent shall, within three days after his receipt of an application from or in behalf of a civil war veteran, his wife or widow, for special care, under the provisions of section two, notify the commissioner thereof upon blank forms approved by him; upon his refusal or unreasonable neglect to give such notice, such agent shall be punished by a fine of twenty-five dollars.
Upon the request of any veteran, the veterans’ agent for the city or town in which he resides shall record his discharge or release papers, without charge, in books kept by him for that purpose. Said agent shall keep an index of papers so recorded, and copies thereof, if attested by him, shall be admissible in evidence to the same extent and with the same effect as the originals.
veterans Section 3A. Whenever a veteran shall be required by general or special law to file or exhibit a certificate of discharge from the armed forces of the United States, the filing or exhibition of a photostatic copy of such discharge shall be deemed sufficient to comply with the requirements of such law.
Section 4. Every application for veterans’ benefits shall be in writing, signed by the applicant under the penalties of perjury, and shall contain a statement of the name, age and residence of the applicant and his relationship to the veteran upon whose wartime service his application is based, such information as the commissioner may require relative to the commencement, duration, extent and termination of such veteran’s wartime service, and such other representations, concerning the needs of the applicant and his reasons for applying for such benefits, as the commissioner may require. Every such application shall be filed with the veterans’ agent for the city or town from which such benefits are sought, and such agent shall forthwith transmit the same to the commissioner.
Veterans agents shall complete applications authorized by the department of public welfare for any veteran, widow and dependent applying for veterans benefits or for medical assistance under chapter one hundred and eighteen E if agreed to by an applicant. The veterans agent shall file the application for the veteran if the veteran selects assistance under said chapter one hundred and eighteen E. The application shall be processed through the said department. Said applicant shall be duly advised of his entitlement to veterans benefits or benefits from public assistance.
town; assignment of benefits; dishonorable discharge, etc. Section 5. Veterans’ benefits shall be paid to a veteran or dependent by the city or town wherein he resides; provided, that no benefits shall be paid to a veteran unless he has actually resided within the commonwealth continuously for three years next preceding the date of his application for such benefits, nor to any dependent of a veteran unless he has actually resided within the commonwealth continuously for three years next preceding the date of his application for such benefits, nor unless the veteran of whom he is a dependent has actually resided within the commonwealth continuously for three years next preceding the date of such dependent’s application for such benefits. If the veteran is deceased at the time of the dependent’s application for benefits, and the veteran died while a resident of the commonwealth, the commissioner may, notwithstanding the foregoing proviso, authorize such benefits to such dependent actually residing in the commonwealth at the time of the veteran’s death; provided, however, any veteran who actually resided in the commonwealth at the time of his entry into or continuance in active military or naval service of the United States and the dependents of such veteran shall be eligible for benefits without any waiting period.
Veterans’ benefits shall not be subject to trustee process, and no assignment thereof shall be valid. Only such amount shall be paid to or for any veteran or dependent as may be necessary to afford him sufficient relief or support and such benefits shall not be paid to any person who is able to support himself or who is in receipt of income from any source sufficient for his support. The applicant’s receipt of income from any source in an amount insufficient for his support shall not bar him from receiving veterans’ benefits to supplement the same, if determined necessary by the commissioner. No payment of benefits shall be made for any period of time prior to the date of application; provided, however, that the commissioner, on recommendation of the veterans’ agent of the city or town paying the benefits, may authorize the payment of benefits for not more than sixty days prior to the date of the application if the necessity therefor has been caused by serious accident or illness to the applicant or to one or more dependents of the veteran upon whose service the application is made.
No veterans’ benefits shall be paid to or for any veteran who has been dishonorably discharged from any national soldiers’ or sailors’ home or from a soldiers’ home in this commonwealth, or to or for his dependents, unless the commissioner shall otherwise determine; nor to or for any applicant convicted of a crime, if the veterans’ agent and the commissioner shall so rule; and, unless the commissioner, at his discretion, shall otherwise determine, no veterans’ benefits shall be paid to or for any veteran who neglects to support his dependents nor to or for any dependents of such veteran, nor to or for any veteran or applicant if the necessity therefor is caused by his voluntary idleness or continuous vicious habits nor to or for any dependents of such veteran or applicant; but dependents of a deceased veteran shall not be deemed ineligible to receive such benefits by reason of any negligence of such veteran, when alive, to support them. No veteran who is or shall otherwise be entitled to veterans’ benefits shall lose his right thereto by reason of his absence from the commonwealth while receiving hospital treatment, under orders of the United States Veterans’ Administration, at any hospital located outside the commonwealth, nor shall the right of his dependents thereto be lost while he is actually receiving such hospital treatment by reason of their absence from the commonwealth to accompany him.
No veteran or dependent shall be compelled to receive veterans’ benefits without his consent. He shall receive such benefits at home, or at such other place as the veterans’ agent may deem proper, but he shall not be compelled to receive the same at an infirmary or public institution unless his physical or mental condition so requires, or, if a minor, unless his parents or guardians so elect. The veterans’ agent or the commissioner may require a person to whom veterans’ benefits are granted to pay over his United States pension or compensation to them to be expended for his relief before receiving such benefits. In the event that the necessity for the granting of veterans’ benefits to any veteran or any dependent of a veteran is caused by unemployment, accident or illness of or to such veteran or dependent and monetary remuneration is provided therefor whether by workers’ compensation, accident or health insurance, or otherwise, or by legal responsibility of a tortfeasor liable for financial damages to such veteran or dependent therefor, the veterans’ agent or the commissioner may require such veteran or dependent to assign to him the whole or any portion of the financial proceeds to be realized from such workers’ compensation, accident or health insurance, or otherwise, or the whole or any portion of the financial damages to be recovered from such tortfeasor whether by settlement, arbitration, court action, or otherwise. Such assignment shall operate as a lien on such financial proceeds or financial damages to an amount equivalent to the total expenditures of veterans’ benefits allowed to such veteran or dependent, and said lien may be enforced by petition to the district court within the jurisdiction of which the city or town of payment is located.
Nothing in this chapter shall be deemed to prohibit the granting of veterans’ benefits by a city or town in excess of the amount authorized or approved by the commissioner in any particular case, or the paying of such benefits as may be necessary to meet the emergency needs of any applicant prior to the date of the approval by the commissioner of the payment of benefits under any such application if the veterans’ agent making such grant or payment forthwith furnishes the commissioner with a written statement of his reasons for taking such action.
All benefits available to dependents of veterans as provided by this chapter shall be extended to the mother of any member of the armed forces of the United States whose death occurred as the result of injury sustained or disease contracted during active service in time of war or insurrection, including active service in the said armed forces under the flag of the United Nations; provided, that such a mother qualifies in her own right as to the requirements of residence notwithstanding the failure of the deceased veteran to so qualify at the time of his death and notwithstanding lack of proof of the actual dependency of such a mother upon such a veteran at the time of his death. Such benefits shall include payment of reasonable medical and hospital expenses in accordance with regulations adopted by the commissioner and directives issued and promulgated by him; provided, that no back benefits shall be paid beyond the date of application.
Effective July first of every year, subject to appropriation, cities and towns shall increase the basic budget of each eligible recipient, before taking into consideration any available income and resources, by a percentage amount equal to the percentage rise in the United States Consumer Price Index for January first of that year over the level of said index for January first of the previous year plus such additional percentage amount as is recommended annually by the commissioner and appropriated by the general court.
The benefits provided herein shall include an amount for fuel in the winter months for eligible veterans and dependents if they pay their own heating costs.
veterans’ benefits Section 5A. In every case where the applicant for or a recipient of benefits under this chapter is a dependent mother or father, as defined in section one, with an interest in one or more parcels of real estate and the fair market value of such interest is more than fifteen hundred dollars, an instrument signed and acknowledged by the veterans’ agent of the town granting such benefits and giving notice of a lien upon each such parcel for all benefits granted and to be granted under this chapter by such town to such mother or father, who shall be named therein, shall, not earlier than three days, Saturdays, Sundays and legal holidays excluded, after a like instrument has been sent by certified mail to such mother or father, be recorded in the records of the county, or of the district, if such county is divided into districts, where each parcel lies, without the payment of any fee for such recording. Every such instrument shall contain a description sufficient to identify each parcel of real estate subject to the lien, and upon recording shall create a lien upon so much of such mother’s or father’s interest as has a fair market value in excess of fifteen hundred dollars, which lien shall be superior to any deed, mortgage, lien or other encumbrance thereafter recorded. Whenever such lien is satisfied or is ordered discharged as hereinafter provided, an instrument signed and acknowledged by such veterans’ agent and reciting such fact shall be given; and upon the recording of such instrument, such lien shall be dissolved.
Such lien shall be enforceable in the superior court for the county where any parcel of the real estate lies by a petition in equity brought by the veterans’ agent against all persons appearing of record to be interested in the real estate subject to such lien, whether as equity owners, mortgagees, lienors, attaching creditors or otherwise. Such petition shall allege the amount claimed under such lien and incorporate a certified copy of the recorded instrument creating such lien. At any time before final decree, the court, of its own motion or upon the suggestion of any party, may issue a precept to any other person appearing to have an interest, directing him to appear on or before a specified day or be forever barred from redeeming from such lien. Proceeds realized through any such enforcement shall be apportioned between the commonwealth and the town granting the benefits in proportion to the amount of their respective contributions thereto, but in no case for more than the amount contributed, without interest. No lien under this section shall be enforceable until after the death of both mother and father, and then only when written permission has been obtained from the commissioner, who, in his discretion, may, if undue hardship might be caused by enforcement, waive enforcement in whole or in part, and order a discharge to the extent waived. If the veterans’ agent neglects or refuses promptly to refer the enforcement of a lien under this section to the commissioner for his approval, or to bring a petition within the period specified by the commissioner, the commissioner shall thereupon bring the petition in his own name; and in such event, all proceeds shall be retained by the commonwealth.
A veterans’ agent, subject to the prior approval of the commissioner, may by an agreement in writing, consent to subordinate any such lien to a mortgage, if in the opinion of the commissioner such mortgage is required for necessary repairs to the real estate subject to such lien.
Such lien shall be dissolved and be unenforceable upon the expiration of twenty years from the date of the recording in the register of deeds of the county wherein said real estate lies.
Any conveyance of real estate by a mother or father within two years before an application for veterans’ benefits, unless for fair market value, shall be deemed to be in avoidance of the provisions of this section and shall make such mother or father ineligible to receive veterans’ benefits.
The provisions of this section shall not be applicable if the applicant for or the recipient of veterans’ benefits is the dependent mother or father of a person who while in the armed forces of the United States during wartime was killed in action or died from service connected disability incurred in wartime service.
veterans’ benefits Section 6. The amounts expended by any city or town for veterans’ benefits, the names of recipients thereof, the amounts paid to or for each applicant, the reasons for granting him such benefits, the names of the veterans on account of whose services the benefits were granted, the names, if any, of the companies, regiments, stations, organizations or vessels in which they respectively enlisted, or to which they were appointed, and in which they last served, and the relationship of each dependent to the veteran on account of whose service the benefits were granted, and such other details as the commissioner may require, shall, within thirty days following the month in which such expenditures were made, be certified to said commissioner on blank forms provided by him, in a manner approved by him, and under the penalties of perjury, by the veterans’ agent and treasurer of such city or town. The commissioner shall examine such certificates, shall allow and endorse thereon such amounts as he finds have been paid and reported in accordance with the provisions of this chapter, and shall transmit the certificates to the comptroller. The commissioner may decide upon the necessity of the amount paid in each case, and may allow any part thereof which he deems proper and lawful. Subject to such decision and allowance, seventy-five per cent of the amounts of veterans’ benefits paid to applicants by the cities and towns wherein they reside, but none of the expenses attending the payment of such benefits, shall be paid by the commonwealth to the several cities and towns on or before November tenth in the year after such expenditures.
Chapter 115: Section 6A. Veteran; definition Section 6A. As used in this section and in sections 6B and 6C, the word “veteran” shall mean a person who has performed wartime service as defined in Clause Forty-third of section 7 of chapter 4 or any person who served on active duty in the armed forces of the United States for a period of at least 180 days and whose last discharge or release from the armed forces of the United States was under other than dishonorable conditions and who is a resident of the commonwealth.
Chapter 115: Section 6B. Annuities for blind, paraplegic or disabled veterans Section 6B. In addition to any other aid to which a veteran is entitled, a veteran who, according to the records of the Veterans’ Administration of the United States government, has suffered permanent impairment of vision of both eyes of the following status: central visual acuity of 5/200 or less in the better eye, with corrective glasses, or central visual acuity of more than 5/200 if there is a field defect in which the peripheral field has contracted to such an extent that the widest diameter of visual field subtends an angular distance no greater than twenty degrees in the better eye, a veteran who is suffering from paraplegia and has permanent paralysis of both legs and lower parts of the body, resulting from traumatic injury to the spinal cord or brain, sustained through enemy action, or accident while in such military or naval service, and a veteran who has permanent paralysis of both legs and lower parts of the body, resulting from malaria, anemia, other forms of disease, tumors or poisoning which may produce signs and symptoms similar to those resulting from traumatic paraplegia and certified by said Veterans’ Administration to be service-connected shall be paid so long as such blindness or permanent paralysis exists, the sum of $1,500 annually in two equal payments on August 1 and February 1. Such payments shall be due and payable from the date of his application. This section shall not include paraplegia resulting from locomotor ataxia and other forms of syphilis of the central nervous system, or chronic alcoholism.
A veteran who has lost both legs or is otherwise determined to be 100 per cent disabled by the Veterans Administration as a result of enemy action or an accident certified by said Veterans’ Administration to be service connected shall be paid the sum of $1,500 annually in two equal payments on August 1 and February 1. Such payments shall be due and payable from the date of his application.
The parents of a deceased member of the armed forces of the United States, whose death occurred as a result of injury sustained or disease contracted during active service in time of war or insurrection or combat, shall be paid the sum of $1,500 annually in two equal payments on August 1 and February 1. Such payments shall be due and payable from the date of said parents’ application.
Chapter 115: Section 6C. Proof of service and disability Section 6C. Evidence of the service and disability mentioned in sections six A and six B shall be furnished to the commissioner of veterans’ services who shall examine the same and upon being satisfied that the service was performed and the veteran has been rendered blind or permanently paralyzed, as defined in section six B shall so certify to the comptroller, whereupon said annuity shall be paid by the commonwealth, subject to appropriation, from the veterans’ services fund.
Chapter 115: Section 7. Veterans’ burial agent; appointment; powers and duties Section 7. In each city, except Boston, and in each town, the veterans’ agent shall be the burial agent; and in Boston, the soldiers’ relief commission shall designate a burial agent who shall be a veteran. He shall, under regulations established by the commissioner, cause properly to be interred the body of any veteran or adult dependent who dies without sufficient means to defray funeral expenses, and the body of any dependent child of a veteran if such veteran and his wife, or his widow, be without sufficient means to defray funeral expenses. If interment of any such body has taken place without the knowledge of the burial agent, application may be made to him within 60 days after the date of death, or after final interment, if the veteran dies in the service, and if upon investigation he shall find that the deceased was within the provisions of this section and the rules of the commissioner, he may certify the same as provided in section eight. The provisions of this section shall not apply to any person who at the time of entering the federal service was a subject or citizen of a neutral country, who had filed his intention to become a citizen of the United States and who afterward withdrew such intention under the act of congress approved July ninth, nineteen hundred and eighteen, nor to any person designated upon his discharge as a conscientious objector. The provisions of this section shall also apply to any person who served as a state guardsman in the military service of the commonwealth between April fifth, nineteen hundred and seventeen, and December twenty-first, nineteen hundred and nineteen, or served in the state guard established during World War II, and was honorably discharged from such service and dies without sufficient means to defray funeral expenses, but shall not apply to any adult dependent or dependent child of such person.
Chapter 115: Section 8. Payment and reimbursement of burial expenses; certificate Section 8. Amounts expended by the burial agent under the provisions of section 7 shall not exceed $2,000 for the funeral and burial of a person under this chapter, provided that the cost of funeral and burial does not exceed $3,000 and there are insufficient resources in the estate of such person to pay for the cost of such funeral and burial. Any resources of such person shall be deducted from the maximum cost of the funeral and burial allowance hereunder and the difference, subject to the limitation set forth in this paragraph, shall be paid by the burial agent. No city or town shall be reimbursed under this section for any amount so expended for a single burial if the total expense of such burial, exclusive of the purchase price of the grave, the cost of the grave opening and the cost of a cement vault liner if one is required by the cemetery regulations, by whomsoever incurred, exceeded $500 for a child under the age of seven or $900 for any other person. The burial shall not be made in a cemetery or burial ground used exclusively for the burial of persons under the provisions of chapter 117 or in any part of a cemetery or burial ground so used. Relatives of the deceased who are unable to bear the expense of burial may be allowed to conduct the funeral. The full amount so expended, the name of the deceased and, if the deceased was a veteran, the regiment, company, station, organization or vessel in which such veteran served, the date of death, place of interment and, if the deceased was a spouse or widow or widower, the name of such veteran’s spouse and date of marriage and, if the deceased was a dependent child, the name of the veteran and such other details as the commissioner may require, shall be certified on oath to said commissioner in such manner as said commissioner may approve, by the burial agent and the treasurer of the city or town expending the amount, within three months after the burial. The commissioner shall endorse upon the certificate the allowance of such amounts as have been paid and reported according to the foregoing provisions and shall transmit the certificate to the comptroller. Seventy-five per cent of the amounts so paid and allowed for burial expenses of veterans or dependents by the cities and towns wherein they reside shall be paid by the commonwealth to the several cities and towns on or before November 10 in the year after the expenditures have been made. Notwithstanding the requirements as to residence as set forth in section 5, the commissioner may authorize the burial agent of a city or town to arrange for the proper interment of the body of an indigent veteran who dies within the commonwealth.
Chapter 115: Section 9. Care of graves of veterans Section 9. The mayor of every city and the selectmen of every town shall appoint a resident of such city or town who shall be a veteran as defined in clause Forty-third of section seven of chapter four, as a veterans’ graves officer, for a term to be determined by the appointing authority; provided, however, that said term shall not exceed five years. It shall be the duty of such veterans’ graves officer to cause every veteran’s grave within such city or town to be suitably kept and cared for. Such care shall include the clearing of weeds and other unseemly growth from said graves; the repairing, replacement and general up-keep of fences around said graves; the raising and repairing of sunken grave stones and markers and other similar services that may be necessary to restore and maintain such graves and their surroundings in an orderly condition. If the cost of such care and maintenance is not paid by private persons, or by the trustees of the cemeteries where any such grave is situated, it shall be paid by the city or town; and cities and towns may appropriate money therefor. Money so appropriated may be expended directly by the city or town or paid over to the trustees or manager of any cemetery where any such grave is situated; but the sum so paid over in any year shall not exceed for each grave the sum charged for the annual care and maintenance of like lots in the same cemetery, or, if no such charge is made in that cemetery, it shall not exceed the sum charged in other cemeteries in the same city or town for like services. In cities and towns where there are cemeteries containing the remains of deceased veterans, such cities and towns shall cause to be placed on such veterans’ graves a flag of the United States on every Memorial day. Upon the approval of the commissioner, compensation for 75 per cent of the cost of such flags, but none of the expenses attending the placement of such flags shall be paid by the commonwealth to the several cities and towns on or before November 10 in the year after such expenditures. In cities and towns where there are cemeteries with mausoleums containing the remains of deceased veterans, each such city or town shall cause to be placed on each mausoleum a suitable plaque with the names of all deceased veterans contained therein, and a flag of the United States shall be suitably placed at each mausoleum on every Memorial day.
entitled Section 1. Any person who (a) is a veteran as defined in clause Forty-third of section seven of chapter four, or (b) meets all the requirements of said clause Forty-third, except that instead of performing wartime service as so defined, has performed not less than ninety days’ active service in any of the campaigns or expeditions enumerated in section two, shall be entitled to out-patient treatment at, admission to, and hospitalization in, the Soldiers’ Home in Massachusetts and the Soldiers’ Home in Holyoke, subject to the provisions of section three.
surgery and urology Section 10. The commandant of the Soldiers’ Home in Massachusetts may establish a program for the training of residents in medicine, surgery, urology and such other specialties and sub-specialties of medicine as he may deem advisable. The persons undergoing such training shall be designated as follows and shall be eligible for training grants from the commonwealth, which grants shall be exempted from the provisions of chapter sixty-two. Recipients of said grants shall not be subject to the provisions of chapter thirty-one and shall not be deemed to be employees of the commonwealth. Approval of said training program by the personnel administrator shall be required in accordance with the provisions of section twenty-eight of chapter seven.
Section 11. The trustees of the Soldiers’ Home in Massachusetts may insure the buildings of the said home and contents thereof in such amounts as they deem sufficient over and above any insurance coverage purchased by the commonwealth.
Section 2. Service referred to in section one shall mean service during any of the following periods, both dates inclusive: — (a) Mexican Border Service, between June nineteenth, nineteen hundred and sixteen and February third, nineteen hundred and seventeen, provided, that such service was in the Massachusetts National Guard; (b) Cuban Pacification Campaign, between October sixth, nineteen hundred and six and April first, nineteen hundred and nine; (c) Nicaraguan Campaign, between August twenty-eighth, nineteen hundred and twelve and October thirtieth, nineteen hundred and twenty-nine; (d) Vera Cruz Expedition, between April twenty-first, nineteen hundred and fourteen and November twenty-sixth, nineteen hundred and fourteen; (e) Dominican Campaigns, between May fourth, nineteen hundred and sixteen and September seventeenth, nineteen hundred and twenty-four; (f) Haitian Campaign, between July ninth, nineteen hundred and fourteen and October thirtieth, nineteen hundred and twenty-nine; (g) China Expeditionary Service, between October thirtieth, nineteen hundred and twenty-nine and June thirtieth, nineteen hundred and thirty; (h) Army of Occupation in Germany, also known as the A.
E.
F.
, between November twelfth, nineteen hundred and eighteen and July eleventh, nineteen hundred and twenty-three; provided, in any case, that proof of service in the campaign, army of occupation or expedition mentioned is made.
Section 3. No person shall be entitled to the treatment, admission or hospitalization referred to in sections one and two, unless at the time of his application for such treatment, admission or hospitalization he has actually resided within the commonwealth continuously for five years next preceding the date of such application. The burden of proof of such residence shall be the responsibility of the veteran.
World War I Section 4. Any person who was recruited in the United States and who served in the military service of Poland while said country was allied with the United States in World War I, between October seventh, nineteen hundred and seventeen, and January thirty-first, nineteen hundred and nineteen, both dates inclusive, shall be entitled to out-patient treatment at, admission to, and hospitalization in the Soldiers’ Home in Massachusetts and the Soldiers’ Home in Holyoke; provided, that he produces information in conformity with the rules and regulations of said Homes, that he has been honorably discharged from said service, and is a citizen of the commonwealth and resides in a city or town therein, or if not such a citizen is a citizen of the United States and resides therein; but no such person shall be treated as an out-patient at, admitted to, or hospitalized in, said Homes if the treatment, admission or hospitalization of any person qualified under the provisions of section one would thereby be postponed or denied.
regulations Section 5. Nothing in this chapter shall be construed to prevent the trustees of the Soldiers’ Home in Massachusetts and the trustees of the Soldiers’ Home in Holyoke from adopting, issuing and promulgating reasonable rules and regulations governing out-patient treatment at, admission to, and hospitalization in, including an increase in any charges, subject to the approval of the secretary of health and human services in said Homes; providing for such treatment, admission and hospitalization for any person qualified under section one except for residence if such person had at some time prior to his application for such treatment, admission or hospitalization, resided in the commonwealth continuously for five years; providing for emergency treatment for any person in need of such treatment by reason of accident or sudden illness, until such person can be transferred to some other institution or place; providing for proper disciplinary action, including discharge from said Homes, of any person whose conduct therein or while a member thereof is deemed to be inimical to the welfare of other members; providing for the exclusion from the respective Homes, either temporarily or permanently, of any person who has received a disciplinary discharge from either Home or from any Veterans’ Administration facility; nor providing for the exclusion from out-patient treatment at, admission to, or hospitalization in, said Homes, of any person whose disability or illness may be diagnosed as neuropsychiatric, neurosurgical or tubercular, or other ailment or condition for the treatment and care of which proper facilities are not available at said Homes.
Section 6. So much of any funds known as “Patients Funds” as represents monies belonging to, or deposited for the benefit of, patients or members who have been discharged or voluntarily departed from, or died at, either of said Homes, which shall have remained unclaimed for more than three years, shall be paid by the commandant or superintendent thereof to the state treasurer to be held subject to be paid to the person establishing a lawful right thereto, with interest at the rate of three per cent per annum from the time when it was so paid to the state treasurer to the time when it is paid by him to such person; provided, that so much of any monies so paid to the state treasurer as may be necessary to reimburse said Home for any sum due for the support of the person by whom, or for whose benefit such money was originally deposited, shall be credited to said Home for that purpose. After six years from the date when any such monies were paid to the state treasurer the same or any balance thereof then remaining in his hands shall be transferred to the trustees of said Home for deposit in its legacy fund or legacy account. Any person, may, however, establish his claim after the expiration of the six years above mentioned and any claim so established shall be paid from the legacy fund or legacy account of said Home. Any person claiming a right to money deposited with the state treasurer or with the trustees under this section may establish the same by a petition to the probate court. A justice of said court, after examining the merits of the claim, may direct the treasurer or the trustees to pay such money to the claimant.
Section 7. If a patient at either of such Homes is discharged therefrom or dies therein while obligated to the commonwealth for support furnished him at such Home and there is in the custody of the superintendent of such Home a bank book representing a deposit account in a bank, as defined in section one of chapter one hundred and sixty-seven, in his name, which is unclaimed during the two-year period following the date of the discharge or death of such patient, the chairman of the board of trustees of such Home may present said bank book to such bank accompanied by an affidavit stating (1) the name of said former patient, (2) the date of admission of said patient to the Home and the date of his discharge therefrom, or his death therein, (3) the amount of money for which the said patient or his estate is obligated to the commonwealth, (4) that said bank book belongs to said patient or his estate, (5) that it has been in the custody of the superintendent and has been unclaimed for more than two years, and demanding payment of all or such portion of the amount represented by said bank book as is not in excess of the amount due to the commonwealth for the support furnished such patient.
Thereupon, such bank shall pay the trustees of such Home the amount so requested in said affidavit and shall endorse such payment upon such bank book, with specific reference to this section and shall return such bank book to such chairman.
Upon receipt of such payment the trustees of such Home shall cause the same to be deposited in its legacy fund or legacy account.
Payment to the board of trustees of such Home, under the provisions of this section, shall discharge the bank of liability to the owner of said property, or any person claiming under him, to the extent of such payments.
Any person claiming an interest in property surrendered to the chairman of the board of trustees of such Home, pursuant to the provisions of this section, and who claims (1) that said property is or was not beneficially owned by said patient, or (2) that said patient is or was not obligated to the commonwealth for support, as set forth in said affidavit, may within seven years following the date upon which such property is surrendered to the trustees, establish such claim by a petition to the probate court which, after determining the merits of the claim, may direct the trustees to pay the whole or any part of the sum claimed to the claimant.
Section 8. The Soldiers’ Homes, after a determination and approval of the trustees of the respective Homes, that it is in the best interest of the patients, may lease, upon such terms and conditions as may be stipulated by said trustees, sufficient land belonging to such Soldiers’ Home for the purpose of constructing thereon chapels for the use of the patients or members of said Home. The lease shall remain in full force and effect so long as a chapel for said patients is maintained thereon and so long as it shall be maintained in a physical condition satisfactory to the superintendent and the trustees of said Home.
The trustees shall select the lessees in each case, and the design and location of each chapel shall be subject to the approval of the trustees.
Nothing contained herein shall be construed to deprive any patient, regardless of his religious belief, of an equal opportunity to worship in accordance with said belief, and adequate facilities for such worship shall be made available to all patients by the superintendent.
Section 9. Domiciliary facilities within the limitation of physical facilities, are hereby authorized for the admission of female veterans at the Soldiers’ Home in Massachusetts. Female veterans seeking admission shall be subject to all requirements, both federal and state, as may presently apply to other veteran applicants and services provided for domiciliary care shall be identical and equal to services provided male veterans.
residents Section 1. There is hereby established within the department of public welfare a program of emergency aid for elderly and disabled residents of the commonwealth found by the department to be eligible for such aid, pursuant to regulations promulgated by said department and subject to appropriation. In promulgating, amending, or rescinding its eligibility regulations from time to time, the department may take into account the amounts available to it for expenditure under this chapter. The department shall by regulation provide that an applicant or recipient who lives with one or more family members who receives assistance pursuant to chapter one hundred and eighteen and who is legally obligated to support such family member shall receive assistance, pursuant to this chapter, which, when combined with the assistance being received by the family member of the applicant or recipient pursuant to chapter one hundred and eighteen, does not exceed the assistance available under chapter one hundred and eighteen to an assistance unit of the same household size as the applicant or recipient and such family member.
Any person (i) who is eligible for assistance under the provisions of this chapter, (ii) who is not maintaining his or her own home, and (iii) who is receiving care in a licensed nursing home, a licensed chronic hospital, a licensed rest home or an approved public medical institution, shall retain the first sixty dollars of monthly income for clothing, personal needs allowance, and leisure time activities. If there is no such income, or if such income is less than sixty dollars, the recipient shall be paid the difference between such income and sixty dollars.
director Section 10. In case of the decease of a poor and indigent person the commonwealth shall pay for the expense of the funeral and burial of such person a sum not exceeding eleven hundred dollars; provided, however, that the total expense of the funeral and burial does not exceed fifteen hundred dollars; and provided, further, that any payment made by the commonwealth shall be reduced by whatever resources may exist in the estate of said person. The funeral director engaged in conducting the funeral and burial of said deceased person shall perform the services and furnish the materials in connection therewith as follows:— removal of body; procuring of death certificate and burial permit; embalming and dressing of body; furnishing suitable burial garment; furnishing suitable casket, bearing metal plate with name of deceased engraved thereon; furnishing outer case of pine wood; furnishing hearse for transporting body of the deceased to a cemetery; furnishing conveyance for transporting to such cemetery the immediate family of the deceased; procuring of a clergyman, of the religion that the deceased professed, to officiate at the funeral; procuring a burial place for the body of the deceased; opening the grave, and obtaining the use of interment devices.
positions; individuals not subject to provisions of section Section 2. No employable person shall be eligible for aid or assistance under this chapter who willfully fails without good cause, as determined by the department, to maintain his registration for work or to accept a referral to or offer of suitable employment. He shall be required to report to the department information with respect to any job to which he has been referred. The department shall, not less frequently than once every three months, request verification from the division of employment and training of an applicant’s record with that agency.
No individual shall be considered ineligible for aid or assistance because of failure to comply with the provisions of this section, if such failure is due to illness or disability. In no event shall such failure affect the eligibility of minor children for assistance under this chapter.
No recipients of assistance under chapter one hundred and eighteen A or recipients of assistance with dependent children under age three years, shall be subject to the provisions of this section; provided, however, that in a two parent household, only one parent shall be exempt from the provisions of this section.
Section 3. A person shall not be eligible for assistance under the provisions of this chapter if said person is eligible to receive assistance under chapter one hundred and fifteen or one hundred and eighteen or who would be eligible under chapter one hundred and eighteen but for income or assets, or who is eligible to receive unemployment compensation under chapter one hundred and fifty-one A.
The department shall not consider ex-offenders, persons over the age of forty-five with no recent work history, or persons in residential treatment facilities as eligible solely by virtue of such status.
Section 4. A person who is neither a citizen of the United States nor lawfully admitted for permanent residence or otherwise permanently residing in the United States under color of law shall be ineligible for assistance under the provisions of this chapter.
Section 5. No person dependent on public support shall be placed by the department or by any veteran’s agent, board of health, or other public authority, in any hospital, nursing home, infirmary or institution not operated by the commonwealth which is not licensed as required by chapter one hundred and eleven. Any person violating the provisions of this section shall be punished by a fine of not less than twenty-five or more than one hundred dollars.
they are not entitled Section 6. A person shall be liable in contract to the commonwealth for expenses incurred by it under this chapter for his support to which he was not entitled, and action may be taken by the commonwealth to compel payment at any time within six years after the date when said person last received support or assistance under this chapter or chapter one hundred and eighteen A. The executor or administrator of such person shall likewise be liable for such expenses.
Section 7. The parents of such poor persons, if of sufficient ability, shall be bound to support such poor persons in proportion to their ability; provided, however, that said parents shall not be required to support or contribute to the support of any of their children eighteen years of age or over.
furnish information upon request Section 8. A treasurer of a savings bank, national bank, trust company, co-operative bank, state-chartered or federally-chartered credit union, benefit association, insurance company or safe deposit company authorized to do business in the commonwealth who, upon written request, signed by an officer of the department, unreasonably refuses to inform him of the amount deposited in the corporation or association to the credit of a person named in such request as a charge upon the commonwealth, or as an applicant to the commonwealth for public assistance under chapter one hundred and seventeen A, one hundred and eighteen, one hundred and eighteen A or one hundred and eighteen D, or who willfully renders false information in reply to such request, shall forfeit fifty dollars to the use of the commonwealth. Upon such request, a treasurer, as aforesaid shall furnish the records on deposits and withdrawals during the past five years, concerning any applicant for or recipient of public assistance under chapter one hundred and seventeen A, one hundred and eighteen, one hundred and eighteen A or one hundred and eighteen D to any officer of the department.
expenses Section 9. The department shall provide for the decent burial of all deceased persons who are at the time of death recipients of aid or assistance under this chapter, all deceased persons who, although without means of support at the time of death, did not apply for such aid or assistance; and all unknown persons found dead. It shall also provide for the grave of each such deceased person a suitable marker bearing the name and dates of birth and death of such deceased person, if known, and for the opening of such grave. The expense thereof may be recovered of their kindred, if any, chargeable by law for their support in the manner provided in this chapter; and if the expense of their funeral and burial is not paid by such kindred, an amount not exceeding eleven hundred dollars; provided, however, that the total expense of the funeral and burial does not exceed fifteen hundred dollars; and provided, further, that any payment made by the department shall be reduced by whatever resources may exist in the estate of said person.
Section 1. The following words and phrases as used in this chapter, unless the context otherwise requires, shall have the following meanings:—“Dependent child”, a needy child who has been deprived of parental support or care by reason of the death, continued absence from the home, physical or mental incapacity or the unemployment of a parent, and who is living with his father, mother or other parent in a place of residence maintained by one or more of such relatives as his or their own home and who is under the age of eighteen or who is eighteen and a full-time student in a secondary school or in the equivalent level of vocational or technical training and who may reasonably be expected to complete such program before reaching age nineteen.
“Parent”, shall include, in addition to the father and mother of the dependent child, the following: — stepfather, stepmother, stepbrother, stepsister; any blood relative, including those of the half blood, except cousins who are more distantly related than first cousins; adoptive relative of equal propinquity to the foregoing; and spouses of any such persons.
“Aid to families with dependent children”, money payments with respect to families with a dependent child or children.
“Department”, the department of transitional assistance.
false statement or fraud Section 10. Aid hereunder shall not be subject to trustee process and no assignment thereof shall be valid. No applicant for aid hereunder, who knowingly makes any false statement, or seeks to perpetrate any fraud or deception, in or relative to his application for such aid, shall be granted any aid hereunder upon such application.
aid; payment Section 11. If a parent or dependent child requests care at an institution, as defined in section two of chapter one hundred and eighteen E, the institution furnishing such care may initiate an application on behalf of the parent or dependent child to the department and the department shall accept the application and act thereon. Such institution shall be entitled to notice, hearing and right of appeal in the same manner as an applicant or recipient, as provided in section eight.
Payment for such care shall be made, to the extent allowed by rules and regulations of the Secretary of Health, Education and Welfare, if an applicant dies before approval of his application. Payment for such medical care and hospitalization, including nursing home care, shall be paid, subject to the rules and regulations of the department and the rules and regulations of the Secretary of Health, Education and Welfare, for a reasonable period not to exceed thirty days prior to the date of application on account of said services actually rendered.
Section 2. The department shall aid a parent in properly bringing up, in his or her own home, each dependent child, but no aid shall be granted, under this chapter, for, or on account of, any child unless the said child resides in the commonwealth. Further, the department shall render aid to any pregnant women, who is otherwise eligible, upon medical verification of pregnancy. The aid furnished shall be sufficient to enable such parent to bring up such child or children properly in his or her own home, and shall be in an amount to be determined in accordance with budgetary standards of the department, and shall be granted from the date on which the applicant is determined to be eligible or thirty days from the receipt of a signed and completed application form, whichever is earlier. Such assistance shall be paid by cash or in check and shall be paid semimonthly in advance unless the applicant prefers less frequent payments.
Payment for funeral expenses of any such parent or dependent child in his or her custody may be paid directly to the person furnishing such services. Payment for other services rendered to such parent or dependent child in his or her custody may be paid directly to the person furnishing such services only when such payment is effected to meet an expense which remained unpaid at the time of the death of the parent or his commitment to an institution as a mentally ill person or in a case where such payment is necessary to discharge an obligation incurred by the department in securing such services for such parent or dependent child. Nothing in this chapter shall be construed as authorizing any public official, agent or representative, in carrying out any provision of this chapter, to take charge of any child over the objection of the father or the mother of such child, or of the person standing in loco parentis to such child, except pursuant to a proper court order.
The department may pay a sum not exceeding eleven hundred dollars for the funeral and burial of a recipient provided that cost does not exceed fifteen hundred dollars and there are insufficient resources to pay for the cost of such funeral and burial. Any resources of the recipient shall be deducted from the maximum cost of the funeral and burial allowable hereunder and the difference, subject to the limitation set forth in this paragraph, shall be paid by the department.
Effective July first of every year, subject to appropriation, the department shall increase the total budget of each eligible recipient, before taking into consideration any available income and resources, by a percentage amount equal to the percentage rise in the United States Consumer Price Index for January first of that year over the level of said index for January first of the previous year plus such additional percentage amount as is recommended annually by the department and appropriated by the general court.
Section 2B. Every application for assistance made under this chapter shall be in writing on application forms prescribed by the commissioner and shall include but not be limited to the following; the name, age and residence of the applicant; the name, date and place of birth of each dependent; the social security number of the applicant, the spouse and all dependent children over sixteen years of age; a list of any motor vehicle or trailer owned by the applicant or dependent; wages, salaries, pensions, fees, tips, bonuses and all other sources of income of all such persons; said application form shall include a statement not inconsistent with federal regulations giving consent to the department to investigate all facts related to the applicant’s eligibility for assistance.
The application form prescribed in paragraph one shall contain a statement that it is signed by the applicant under the penalties of perjury.
Section 3. Except as hereinafter provided, the department shall determine what aid is necessary to enable such parent to bring up such child or children. For this purpose, the department shall make an immediate and careful inquiry, including the resources of the family and ability of its other members, if any, to work or otherwise contribute to its support, the existence of relatives able to assist the family and societies or agencies who may be interested therein; shall, in any case involving a missing parent require the applicant or recipient to furnish in writing under the penalties of perjury, complete information within the knowledge of such applicant or recipient pertinent to the location of said missing parent; shall take all lawful means to locate said missing parent; shall take all lawful means which shall include, in appropriate cases, the institution of criminal proceedings, to compel all persons bound to support such parents and such child or children to support them, and to enforce any other legal rights for their benefit; shall encourage all members of the family who are able to work, to secure work; shall help them to find work; and shall secure all necessary aid for such parent and such child or children which can be secured from relatives or organizations; provided, however, that any exemption now or hereinafter permissible under the federal Social Security Act relative to earned income may be allowed; and provided, further, that determination of eligibility be completed within forty-five days of the date of application.
The department shall follow federal regulations relative to search for missing parents, and employment and employment training for certain recipients.
The department shall give first priority in employment placement activities to each parent whose unemployment has caused his or her children to be dependent within the meaning of this chapter and shall insure that all services necessary for such employment are available to said parent within thirty days after initial receipt of benefits under this chapter. Consistent with all applicable state and federal regulations, said parent shall not refuse employment. If such refusal of employment is without good cause, said parent shall be determined ineligible for this program.
A recipient whose youngest dependent is at least six years of age shall be referred to the division of employment and training or shall be enrolled in any vocational training program; provided, however, that a recipient shall not be compelled by the department to be trained or to be employed in domestic service, nor required to accept such employment if such employment would require work between the hours from six o’clock postmeridian of one day and six o’clock antemeridian of the following day. In no case shall a recipient be required to seek or accept employment as a condition for eligibility when a mental or physical disability of a dependent child requires presence at home.
No individual shall be considered ineligible for aid or assistance because of failure to comply with the provisions of this chapter if such failure is due to illness or disability. This section shall not apply to any recipients under chapter one hundred and eighteen A nor to recipients of assistance under this chapter with dependent children under six years of age; provided, however, that in a two parent household, only one parent shall be exempt from the provisions of this section. In no event shall such failure to comply with the provisions of this section affect the eligibility of minor children for assistance under this chapter.
of locating, establishing and enforcing liability of persons obligated to pay support Section 3A. For the purpose of locating, establishing and enforcing the liability of any person who is legally obligated by court order or otherwise to support his spouse or children and who is obligated to pay such support either to the department pursuant to section twenty-one of chapter eighteen or to individuals on whose behalf the department is giving aid in the enforcement of support obligations pursuant to Title IV–D of the Social Security Act, the department shall have access to the following information in accordance with the following conditions and requirements:(a) The department may request from any employer whom the department has reason to believe employs a person described above, information concerning the dates and amounts of compensation paid to such person and the persons’ last known address, social security number, and available health or medical insurance benefits. The department shall not inquire of an employer concerning any such person more than once every four months. Employers shall respond to such requests fully and in writing, but may limit their responses to the period beginning four months before the date of the request. No employer who complies with this section shall be liable in any civil or criminal action or proceeding brought by the employee on account of such compliance. Any employer who, without reasonable cause, fails to comply with such requests or who willfully renders false information in reply to such requests, pursuant to this paragraph, shall be liable for a penalty of one hundred dollars per violation.
(b) The department may request from the department of revenue state income tax information concerning any person described above. The commissioner of the department of revenue, upon written request, shall furnish to the commissioner of the department or his designee, the address, filing status, amounts, nature, and sources of income, including names and addresses of all employers, and the number of dependents reported on the most recent return filed by any individual with respect to whom child support obligations are sought to be established or enforced pursuant to section twenty-one of chapter eighteen or pursuant to the provisions of part D of Title IV of the Social Security Act. Such information shall be available only for the purposes of, and to the extent necessary in establishing and collecting child support obligations from, and locating, individuals owing such obligations.
parents or children from commonwealth; reciprocal agreements Section 4A. Any parent receiving aid under this chapter, or any child for whose bringing up such aid is furnished, may be absent from the commonwealth on visit without having such aid suspended. Such parent, before his departure or the departure of the child from the commonwealth and following return thereto, shall notify the department. The department may provide by rules or regulations for the continuation of such aid during such period as it may deem proper with respect to cases where the suspension of such aid because of absence from the commonwealth would result in undue hardship or be inconsistent with the purposes of this chapter.
The department may also provide by rules and regulations for the payment of aid under this chapter for a parent and child or children who have moved permanently from the commonwealth to another state, so as to continue said aid until such time as may be reasonably necessary for such parent to meet requirements for receiving similar aid from such other state; provided, that after the expiration of a period of three months’ residence in such other state, the amount of such aid shall not exceed the amount of aid that the parent would receive from such other state if eligible therefor; and provided, further, that such aid shall be granted only when reciprocal agreements are in effect between this commonwealth and said state under section fourteen of chapter eighteen.
for eligible families; sliding scale system of fees Section 4B. The department shall continue to provide assistance to families who are otherwise eligible for such assistance under the provisions of section two and who are temporarily making their residence at the New Chardon street shelter in the city of Boston administered by the department of social services. Said department of social services is further authorized and directed to establish a sliding scale system of fees for the provision of temporary housing services at the New Chardon street shelter in said city of Boston. The fee under such system for a family receiving benefits under said section two shall not exceed the food and shelter component for such benefits as established by the department of transitional assistance.
Section 5. The department shall, in addition to its annual report, make such reports to the Secretary of Health, Education and Welfare under the Federal Social Security Act, as amended, as may be necessary to secure to the commonwealth the benefits of said act.
option; waiver Section 9. If an application for aid under this chapter is affected by the eligibility of the applicant to receive benefits under chapter one hundred and fifteen, the applicant shall be entitled to exercise such options and execute such waivers as may be necessary to receive the aid which he seeks.
disabled; state payments supplementary to federal benefits; eligibility, restriction; standard levels Section 1. The department of transitional assistance, in this chapter called the department, shall administer a program of financial assistance for aged and disabled persons who reside within the commonwealth. Such assistance, which shall be called state supplementary payments, shall be based on need and granted in supplementation of benefits granted by the United States government to aged and disabled individuals, under the provisions of title XVI of the federal Social Security Act and amendments thereto, in this chapter called title XVI. Such assistance shall be granted to persons who, on account of age or disability, qualify for supplemental security income granted pursuant to title XVI and may, based on need, be granted to individuals who would, but for their income, be eligible for such supplemental security income.
The department shall establish, subject to the approval of the secretary of the executive office of human services, standard levels for state supplementary payments for the aged and disabled. Such payments may vary by category, by marital status, and by living arrangements to the extent allowed by title XVI and the regulations promulgated thereunder.
No assistance under this section shall be granted to an applicant who, at any time within two years immediately prior to the filing of an application for such assistance, has made an assignment or transfer or who has mortgaged or otherwise encumbered property so as to render himself eligible for such assistance.
No person receiving assistance under this section shall be prohibited from receiving benefits under the federal Food Stamp Act solely because of his status as a recipient of such assistance.
levels; determination; limitation Section 2. Effective July first of every year, the level of any state supplementary payment authorized by section one plus the level of federal supplemental security income in effect at such time shall be increased, subject to appropriation, by a percentage amount equal to the percentage rise in the United States Consumer Price Index for January first of that year over the level of said Index for January first of the previous year plus such additional percentage amount as is recommended annually by the department and appropriated by the general court. In determining said additional percentage amount, consideration shall be given to the goal of reaching, within a reasonable time, a total income level equal to or consistent with the current budget at the intermediate level of living for a retired couple established by the United States Department of Labor, Bureau of Labor Statistics, for the metropolitan Boston area.
If, on January first of any year, the level of any state supplementary payment, taking into account the federal supplemental security income benefits, is equal to or exceeds the annual budget at the intermediate level of living for a retired couple as most recently established by the United States Department of Labor, Bureau of Labor Statistics, for the metropolitan Boston area, or, taking into account variances in category, marital status and living arrangements as established by the department, is not inconsistent with said annual budget, the increase granted on July first next following shall be limited to said percentage rise in said Index.
provisions Section 3. The commissioner of transitional assistance, in this chapter called the commissioner, shall enter into an agreement with the Secretary of the United States Department of Health, Education and Welfare, under which said Secretary shall, on behalf of the commonwealth, administer the program of state supplementary payments authorized by section one. Such agreement shall contain all requirements for and limitations and qualifications on state supplementary payments which title XVI or regulations adopted thereunder make necessary in order to qualify the commonwealth for administration by said Secretary of state supplementary payments. Such agreement may include, but need not be limited to: provision for varying categories of assistance for state supplementation; a maximum of five living arrangements in any one category which may receive differing state supplementary payments; procedures for making payments to said Secretary and limitations on such payments; limits on state supplementary payments for inmates of public institutions or patients in health care facilities; ineligibility for state supplementary payments of certain individuals who are ineligible for supplemental security income; provision for recoupment of overpayments, or payments unlawfully procured, of state supplementary payments and adjustments against future state payments on account of such recoupment, and any other fiscal and quality control provisions deemed advisable by the commissioner; and provision for a hearing before said Secretary or his designee for any person aggrieved by a determination made pursuant to the agreement concerning any state supplementary payment.
federal determination Section 4. An application to the Social Security Administration of the United States Department of Health, Education and Welfare for supplemental security income benefits pursuant to title XVI of the federal Social Security Act shall be deemed an application for state supplementary payment for the category of assistance for which said application is filed. Eligibility for any one category of assistance of an individual or couple shall be determined in accordance with federal law.
Welfare Department; audit Section 5. There shall be advanced from the state treasury to the Secretary of the United States Department of Health, Education and Welfare, prior to the first day of each month, an amount equal to said Secretary’s estimate of state supplementary payments authorized under this chapter for such month. The department shall conduct, once in each fiscal year, an audit of such payments made by said Secretary on behalf of the commonwealth.
Section 6. No disclosure or use of information concerning applicants or recipients of assistance under this chapter shall be made by the department except for purposes directly connected to the administration of this chapter.
funeral and burial costs Section 7. The department shall provide to aged and disabled residents of the commonwealth under this chapter a program of social services as enumerated under section two of chapter eighteen. In addition to the other benefits authorized by this chapter, the department may provide to such recipients grants of assistance in cases of fire, flood, or other disaster. The department may pay a sum not exceeding eleven hundred dollars for the funeral and burial of a recipient provided that cost of funeral and burial does not exceed fifteen hundred dollars and there are insufficient resources to pay for the cost of such funeral and burial. Any resources of the recipient shall be deducted from the maximum cost of the funeral and burial allowable hereunder and the difference, subject to the limitation set forth in this paragraph, shall be paid by the department.
homes Section 7A. The department may provide to any recipient under this chapter who resides in a rest home which has a rate established pursuant to section thirty L of chapter seven a special grant whenever the aid provided under this chapter is insufficient to meet said rate established for such rest home. The department may pay such grant either to the recipient or to the rest home.
Section 8. The department shall promulgate such rules and regulations as are necessary or desirable for the administration of this chapter.
55.
] Chapter 118C: Section 1. Declaration of policy Section 1. In order to extend to employees of instrumentalities, and to the dependents and survivors of such employees, the basic protection accorded to others by the old age and survivors insurance system embodied in the Social Security Act, it is hereby declared to be the policy of the general court, subject to the limitations of this chapter, that such steps be taken as to provide such protection to employees of instrumentalities on as broad a basis as is permitted under the Social Security Act.
Chapter 118C: Section 10. Rights of members of contributory retirement system Section 10. Nothing contained in this chapter shall be construed to affect adversely the rights of any person who is a member of any contributory retirement system established under the provisions of sections one to twenty-eight, inclusive, of chapter thirty-two or under corresponding provisions of earlier laws, with reference to accumulated total deductions or benefits accrued or to be accrued on account of any service rendered by him.
Chapter 118C: Section 2. Definitions Section 2. For the purposes of this chapter—(a) The term “wages” means all remuneration for employment as defined herein, including the cash value of all remuneration paid in any medium other than cash, except that such term shall not include that part of such remuneration which, even if it were for “employment” within the meaning of the Federal Insurance Contributions Act, would not constitute “wages” within the meaning of that act;(b) The term “employment” means any service performed by an employee in the employ of any instrumentality, for such employer, except (1) service which in the absence of an agreement entered into under this chapter would constitute “employment” as defined in the Social Security Act; or (2) service which under the Social Security Act may not be included in an agreement between the commonwealth and the Federal Security Administrator entered into under this chapter;(c) The term “employee” includes an officer of an instrumentality;(d) The term “state agency” means the state board of retirement, as defined in section eighteen of chapter ten;(e) The term “Federal Security Administrator” includes any individual to whom the Federal Security Administrator has delegated any of his functions under the Social Security Act with respect to coverage under such act of employees of states and their political subdivisions;(f) The term “instrumentality” means an authority or agency of the commonwealth or of one or more of its political subdivisions, or of the commonwealth and one or more of its political subdivisions, which is a juristic entity which is legally separate and distinct from the commonwealth or subdivision, and whose employees are not by virtue of their relation to such juristic entity employees of the commonwealth or subdivision;(g) The term “Social Security Act” means the Act of Congress approved August fourteenth, nineteen hundred and thirty-five, chapter five hundred and thirty-one, 49 Stat. 620, cited as the “Social Security Act”, including regulations and requirements issued pursuant thereto, as such act has been and may from time to time be amended; and(h) The term “Federal Insurance Contributions Act” means subchapter A of chapter nine of the Federal Internal Revenue Code.
Chapter 118C: Section 3. Agreement with Federal Security Administrator; extension of benefits; provisions Section 3. (a) The state agency, with the approval of the governor, is hereby authorized to enter on behalf of the commonwealth into an agreement with the Federal Security Administrator, consistent with the terms and provisions of this chapter, for the purpose of extending the benefits of the federal old age and survivors insurance system to employees of instrumentalities, with respect to services specified in such agreement which constitute “employment” as defined in section two. Such agreement may contain such provisions relating to coverage, benefits, contributions, effective date, modification and termination of the agreement, administration and other appropriate provisions as the state agency and the Federal Security Administrator shall agree upon, but, except as may be otherwise required by or under the Social Security Act as to the services to be covered, such agreement shall provide in effect that—(1) Benefits will be provided for employees whose services are covered by the agreement and their dependents and survivors on the same basis as though such services constituted employment within the meaning of Title II of the Social Security Act;(2) The commonwealth will pay to the Secretary of the Treasury, at such time or times as may be prescribed under the Social Security Act, contributions with respect to wages as defined in section two equal to the sum of the taxes which would be imposed by sections fourteen hundred and fourteen hundred and ten of the Federal Insurance Contributions Act if the services covered by the agreement constituted employment within the meaning of that act;(3) Such agreement shall be effective with respect to services in employment covered by the agreement performed after a date specified therein, but in no event may it be effective with respect to any such services performed prior to the first day of the calendar year in which such agreement is entered into, or in which the modification of the agreement making it applicable to such services is entered into; and(4) All services which constitute employment as defined in section two, are performed in the employ of an instrumentality, and are covered by a plan which is in conformity with the terms of the agreement and has been approved by the state agency under section four, shall be covered by the agreement.
(b) Any instrumentality jointly created by the commonwealth and any other state or states is hereby authorized, upon the granting of like authority by such other state or states, (1) to enter into an agreement with the Federal Security Administrator whereby the benefits of the federal old age and survivors insurance system shall be extended to employees of such instrumentality; (2) to require its employees to pay and for that purpose to deduct from their wages contributions equal to the contributions which might be imposed upon them under section four (c) if they were covered by an agreement made pursuant to subsection (a) of this section; and (3) to make payments to the Secretary of the Treasury in accordance with such agreement, including payments from its own funds, and otherwise to comply with such agreements. Such agreement shall, to the extent practicable, be consistent with the terms and provisions of subsection (a) and other provisions of this chapter.
Chapter 118C: Section 4. Extension of federal benefits to employees; plan; approval; hearing; notice; contribution fund; recovery of delinquent payments Section 4. (a) Each instrumentality is hereby authorized to submit for approval by the state agency a plan for extending the benefits of Title II of the Social Security Act, in conformity with applicable provisions of such act, to employees of such instrumentality. Each such plan and any amendment thereof shall be approved by the state agency if it finds that such plan, or such plan as amended, is in conformity with such requirements as are provided in regulations of the state agency, provided, that no such plan shall be approved unless—(1) It is in conformity with the requirements of the Social Security Act and with the agreement entered into under section three;(2) It provides that all services which constitute employment as defined in section two and are performed in the employ of the instrumentality by employees thereof, shall be covered by the plan;(3) It specifies the source or sources from which the funds necessary to make the payments required by paragraph (1) of subsection (c) and by subsection (d) are expected to be derived, and contains reasonable assurance that such sources will be adequate for such purpose;(4) It provides for such methods of administration of the plan by the instrumentality as are found by the state agency to be necessary for the proper and efficient administration of the plan;(5) It provides that the instrumentality will make such reports, in such form and containing such information, as the state agency may from time to time require, and comply with such provisions as the state agency or the Federal Security Administrator may from time to time find necessary to assure the correctness and verification of such reports; and(6) It authorizes the state agency to terminate the plan in its entirety, in the discretion of the state agency, if it finds that there has been a failure to comply substantially with any provision contained in such plan, such termination to take effect at the expiration of such notice and on such conditions as may be provided by regulations of the state agency, and may be consistent with the provisions of the Social Security Act.
(b) The state agency shall not finally refuse to approve a plan submitted by an instrumentality under subsection (a), and shall not terminate an approved plan, without reasonable notice and opportunity for hearing to the instrumentality affected thereby.
(c)(1) Each instrumentality as to which a plan has been approved under this section shall pay into the contribution fund, with respect to wages at such time or times as the state agency may by regulation prescribe, contributions in the amounts and at the rates specified in the applicable agreement entered into by the state agency under section three.
(2) Each instrumentality required to make payments under paragraph (1) of this subsection is authorized, in consideration of the employee’s retention in, or entry upon, employment, to impose upon each of its employees, as to services which are covered by an approved plan, a contribution with respect to his wages not exceeding the amount of tax which would be imposed by section fourteen hundred of the Federal Insurance Contributions Act if such services constituted employment within the meaning of that act, and to deduct the amount of such contribution from his wages as and when paid. Contributions so collected shall be paid into the contribution fund in partial discharge of the liability of such instrumentality under paragraph (1) of this subsection. Failure to deduct such contribution shall not relieve the employee or employer of liability therefor.
(d) Delinquent payments due under paragraph (1) of subsection (c) may, with interest at the rate of six per cent per annum, be recovered by action in a court of competent jurisdiction against the instrumentality liable therefor, or may, at the request of the state agency, be deducted from any other moneys payable to such instrumentality by any department or agency of the commonwealth.
Chapter 118C: Section 5. Establishment of contribution fund; use; payment to secretary of treasury; custodian; additional appropriations; estimates Section 5. (a) There is hereby established a special fund to be known as the contribution fund. Such fund shall consist of and there shall be deposited in such fund: (1) all contributions, interest and penalties collected under section four; (2) all moneys appropriated thereto under this chapter; (3) any property or securities and earnings thereof acquired through the use of moneys belonging to the fund; (4) interest earned upon any moneys in the fund; and (5) all sums recovered upon the bond of the custodian or otherwise for losses sustained by the fund and all other moneys received for the fund from any other source. All moneys in the fund shall be mingled and undivided. Subject to the provisions of this chapter, the state agency is vested with full power, authority and jurisdiction over the fund, including all moneys and property or securities belonging thereto, and may perform any and all acts, whether or not specifically designated, which are necessary to the administration thereof and are consistent with the provisions of this chapter.
(b) The contribution fund shall be established and held separate and apart from any other funds or money of the commonwealth and shall be used and administered exclusively for the purpose of this chapter. Withdrawals from such fund shall be made only for payment of amounts required to be paid to the Secretary of the Treasury pursuant to an agreement entered into under section three; and refunds of overpayments, not otherwise adjustable, made by an instrumentality.
(c) From the contribution fund the custodian of the fund shall pay to the Secretary of the Treasury such amounts and at such time or times as may be directed by the state agency in accordance with any agreement entered into under section three.
(d) The state treasurer shall be treasurer and custodian of the contribution fund, and shall administer such fund in accordance with the provisions of this chapter and the directions of the state agency, and shall pay all warrants drawn upon it in accordance with the provisions of this section and with such regulations as the state agency may prescribe.
(e)(1) There are hereby authorized to be appropriated annually to the contribution fund, in addition to the contributions collected and paid into the contribution fund under section four, to be available for the purposes of section 5(b) and (c) until expended, such additional sums as are found to be necessary in order to make the payments to the Secretary of the Treasury which the commonwealth is obligated to make pursuant to an agreement entered into under section three.
(2) The state agency shall submit to each regular session of the general court an estimate of the amounts authorized to be appropriated to the contribution fund by paragraph (1) of this subsection for the next appropriation period.
Chapter 118C: Section 6. Expenditure of funds for administrative organization Section 6. For the purposes of establishing the administrative organization necessary for the proper administration of this chapter and for the services of clerical and other assistance and for travel incidental to and preparatory to an agreement between the state agency and the Federal Security Administrator, as herein provided, and for the purpose of further administering the provisions of this chapter for the year beginning January first, nineteen hundred and fifty-two, the state agency may expend such sums as may be appropriated therefor.
Chapter 118C: Section 7. Rules and regulations Section 7. The state agency shall make and publish such rules and regulations, not inconsistent with the provisions of this chapter, as it finds necessary or appropriate to the efficient administration of the functions with which it is charged under this chapter.
Chapter 118C: Section 8. Studies; reports; recommendations Section 8. The state agency shall make studies concerning the problem of old age and survivors insurance protection for employees of the commonwealth and its instrumentalities, and concerning the operation of agreements made and plans approved under this chapter, and shall submit a report to the general court at the beginning of each regular session, covering the administration and operation of this chapter during the preceding calendar year, including recommendations for amendments to this chapter.
Chapter 118C: Section 9. Partial invalidity Section 9. If any provision of this chapter, or the application thereof to any person or circumstance, is held invalid, the remainder of this chapter and the application of such provision to other persons or circumstances shall not be affected thereby.
Section 1. The executive office for health and human services shall be the single state agency responsible for the administration of programs of medical assistance and medical benefits established pursuant to this chapter. All actions of the executive office of health and human services shall be taken by the secretary acting as the single state agency, through the division of medical assistance and the secretary of elder affairs, as appropriate.
women and infants Section 10. The division shall establish a program of medical care and assistance for pregnant women and infants who are not otherwise eligible for medical assistance under this chapter and who lack private health insurance coverage or have a health insurance policy which does not cover all medically necessary care which is covered by the program established by this section. The division shall furnish such medical assistance to each such pregnant woman and infants residing in the commonwealth in accordance with the standards of eligibility established pursuant to section 9A, section 16C or Title XIX; provided, however, that the income eligibility standards shall not be less than one hundred and eighty-five per cent of the non-farm income poverty guidelines as defined by the United States Office of Management and Budget.
The division shall, to the extent permitted by Title XIX, provide for Medicaid in the form of ambulatory care to pregnant women who are presumptively eligible for Medicaid for the period of time prescribed by federal law. The division shall promulgate regulations to implement this section, which shall require health care providers to notify such pregnant women of the need to file an application for Medicaid and which shall set standards to be used by providers in determining presumptive eligibility.
childbirth and postpartum care Section 10A. The division shall provide coverage for prenatal care, childbirth and postpartum care, with a minimum of forty-eight hours of in-patient care following a vaginal delivery and a minimum of ninety-six hours of in-patient care following a caesarean section for a mother and her newly born child. Any decision to shorten such minimum coverages shall be made by the attending physician in consultation with the mother. Any such decision shall be made in accordance with rules and regulations promulgated by the department of public health. Said regulations shall be relative to early discharge, defined as less than forty-eight hours for a vaginal delivery and ninety-six hours for a caesarean delivery and post-delivery care and shall include, but not be limited to, home visits, parent education, assistance and training in breast or bottle feeding and the performance of any necessary and appropriate clinical tests; provided that the first home visit shall be conducted by a registered nurse, physician, or certified nurse midwife; and provided, further, that any subsequent home visit determined to be clinically necessary shall be provided by a licensed health care provider.
For the purposes of this section, attending physician shall include the attending obstetrician, pediatrician, or certified nurse midwife attending the mother and newly born child.
screening tests Section 10B. The division shall provide coverage for the cost of a newborn hearing screening test to be performed before the newborn infant is discharged from the hospital or birthing center to the care of the parent or guardian or as provided by regulations of the department of public health. Nothing contained in this section shall be construed to abrogate any obligation to provide coverage for a hearing screening test or any other hearing screening test or audiological diagnostic procedure pursuant to any law or regulation of the commonwealth or of the United States or under the terms or provisions of any policy, contract or certificate.
youths; funding; types of services; eligibility; program reports; no entitlement Section 10F. (a) There is hereby established a program of managed care to provide primary and preventive health care services for uninsured dependent and adopted youths from birth through age eighteen; provided, however, that only said youths who are ineligible for medical benefits pursuant to this chapter shall be eligible for the services defined in this section. Said program shall be administered by the division subject to appropriation from the Children’s and Seniors’ Health Care Assistance Fund established pursuant to the provisions of section 2FF of chapter 29 and other appropriated funds. The comptroller shall transfer amounts appropriated from the General Fund or any other fiscal resource of the commonwealth designated for health care services provided to said youths from birth to age 12, inclusive, to said Children’s and Seniors’ Health Care Assistance Fund. Services available from the program shall include the following:-(1) preventive pediatric care in a participating doctor’s office, community health center, health maintenance organization or school-based clinic, including not less than one well-child visit a year, immunizations, tuberculin testing, hematocrit, hemoglobin and other appropriate blood testing, urinalysis, and routine tests to screen for lead poisoning, and such services as are periodically recommended by the American Academy of Pediatrics; provided that services provided by a participating independent laboratory for diagnostic laboratory tests shall be reimbursed by said program;(2) unlimited sick visits in a participating doctor’s office, community health center, health maintenance organization, school-based clinic or a patient’s home;(3) first-aid treatment and follow up care, including the changing or removal of casts, burn dressings or structures, in a participating doctor’s office, community health center, health maintenance organization or school-based clinic;(4) the provision of smoking prevention educational information and materials to the parent, guardian or person with whom an enrollee resides.
(b) Services made optionally available under said program may include the following:(1) prescription drugs up to $200 per year; provided, however, that enrollees shall be responsible for a copayment of $3 for each interchangeable drug prescription and $4 for each brand name drug prescription; provided, further, that the division may authorize a higher prescription benefit level for any person enrolled in said program for which said higher benefit will prevent hospitalization.
(2) urgent care visits in the outpatient department of a participating hospital when an enrollee’s primary care practitioner is not available to provide such services, and emergency care in the outpatient department or emergency department of a participating hospital of up to $1,000 per year, including related laboratory and diagnostic radiology services for said urgent and emergency care, provided that rates of reimbursement for such urgent care and emergency services are negotiated by participating hospitals with the department or its designated vendor;(3) outpatient surgery and anesthesia which is medically necessary for the treatment of inguinal hernia and ear tubes, but not including the professional component for related radiology or pathology services; provided that rates of reimbursement for such urgent care and emergency services are negotiated by participating hospitals with the division or its designated vendor;(4) annual and medically necessary eye examinations;(5) medically necessary outpatient mental health services not to exceed 13 visits per year; provided, however, an additional 7 outpatient visits may be approved by the division when clinically necessary according to program guidelines; provided further, that no such mental health services shall be provided by the division that would substitute for mental health services required pursuant to chapter 71B;(6) dental health services, including preventive dental care; provided, however, that no funds shall be expended for cosmetic or surgical dentistry;(7) durable medical equipment up to $200 per year; provided, however, the division may authorize up to $500 per year to prevent unnecessary hospitalization for children with chronic medical conditions, so-called, when clinically necessary according to program guidelines; and(8) auditory screening.
(c) The division shall establish cost-containment measures designed to ensure that only medically necessary services are reimbursed by said program. Should costs of said program exceed the appropriated funds, the division shall limit enrollment rather than reducing benefits.
(d) The cost of said program shall be funded in part by premiums contributed by enrollees according to the following eligibility categories: households ineligible for medical benefits pursuant to chapter 118E earning less than 150 per cent of the federal poverty level shall not be responsible for contributing to program premium costs; households earning between 150 and 200 per cent of the federal poverty level, inclusive, shall contribute not less than 20 per cent and not more than 30 per cent of the monthly premium cost according to a sliding scale established by the division; provided, that additional contributions shall not be required for any enrollee after the third enrollee in such a household; households earning between 200 and 400 per cent of the federal poverty level shall pay a monthly premium of $45.
32, provided that premium amounts in this category may be adjusted from time to time by the division; provided, that enrollees in households earning more than 400 per cent of the federal poverty level shall pay the full premium cost of said program. Household earnings may be defined on the basis of gross earnings, or on an adjusted basis according to criteria deemed appropriate by the division. The department shall base premium costs on an actuarially sound methodology.
(e) Notwithstanding the premium contribution requirements established by this section, no enrollee shall be exempt from the co-payment requirements established herein or by the division. Said co-payments shall be designed to encourage the cost-effective and cost conscious use of said services.
(f) The division shall promulgate regulations necessary to implement the requirements of this section and shall maximize federal financial participation for state expenditures made on behalf of program enrollees.
(g) The division shall report quarterly to the house and senate committees on ways and means and to the joint committee on health care on enrollment demographics, claims expenditures and the annualized costs of said program. The division shall file notice with said committees and the secretary of the executive office of administration not less than thirty days before modifying program benefits and eligibility standards that are intended to ensure that program costs are limited to the funds appropriated therefore.
(h) The program established by this section shall not give rise to enforceable legal rights in any party or an enforceable entitlement to the services funded herein and nothing stated herein shall be construed as giving rise to such enforceable legal rights or such enforceable entitlement.
Section 11. The division shall, within the limits of the funds which have been appropriated for the purposes of this chapter, cooperate with the appropriate federal authorities in the administration of Title XIX, under which federal funds are available to the commonwealth for Medicaid, and accept for the commonwealth any benefits thereof. The state treasurer shall be the custodian of such funds allocated to the commonwealth.
contracts Section 12. In administering the medical assistance programs established under this chapter, the division shall formulate such methods, policies, procedures, standards and criteria, except medical standards and criteria, as may be necessary for the proper and efficient operation of those programs in a manner consistent with simplicity of administration and the best interests of recipients.
The division may enter into any types of contracts with providers of medical services as the division deems necessary to carry out the provisions of this chapter, including, but not limited to, selective contracts, volume purchase contracts, preferred provider contracts and managed care contracts; provided, that such contracts are reviewed by the division of health care finance and policy and the executive office of administration and finance. The division may negotiate the rate of reimbursement to the provider under any such contract, and any such negotiated rate shall not be subject to the provisions of section thirty-two of chapter six A.
The division may take such further action, consistent with law and within the limits of available funds appropriated for the purposes of this chapter, as may be necessary for carrying out the purposes of this program in conformity with all requirements governing the availability of federal financial participation to the commonwealth under said Title XIX, including said provisions relative to notice and reimbursement, a uniform system of records and accounts to be kept by the regional or local offices and the manner and form of making reports to the division. Without limiting the generality of the foregoing, the division may withhold provider payments to ensure sufficient funds will be available to satisfy any amounts that may become due from a provider, upon notification to the provider of the amount subject to such withholding and the reasons therefor, or where otherwise required or permitted under federal law.
The division may adopt, promulgate, amend and rescind rules and regulations suitable or necessary to carry out the provisions of this chapter and said Title XIX and any amendments thereto, and as interpreted from time to time by the Secretary.
Such rules and regulations shall include provisions requiring providers of long term care services intending to withdraw from the medical assistance programs established by this chapter to provide for the continuing care or appropriate relocation of the medical assistance recipients residing in their facilities.
The division may require any long term care provider expressing its intention to withdraw from said programs whose facility is able to meet the standards for participation in said programs to enter into a standard provider contract with the division under which the provider continues to provide services only to those patients residing in its facility at the time the provider announces its intention to withdraw who are eligible for medical assistance or who become eligible for medical assistance during the term of the contract. Such rules and regulations shall also provide that any such provider who has withdrawn from said programs may not participate in said programs for a period of time, not exceeding five years, specified in said regulations.
Such rules and regulations shall also provide that any long term care provider whose facility is unable to meet the standards for participation in said programs shall continue to provide care to the medical assistance recipients residing in its facility until the provider has arranged for the complete relocation of all the medical assistance recipients residing in its facility in accordance with such rules and regulations and with the regulations of the department of public health.
Any provider who violates the provisions of this section by failing to provide care to a medical assistance recipient residing in its facility shall be subject to a fine of one thousand dollars for each violation.
As a method of providing medical assistance to recipients, the division is authorized to contract with any fiscal agent, institution, health insurer, health maintenance organization, health plan, management service or consultant firm consistent with the requirements of 42 CFR Part 434 to administer all or part of the services and benefits available under this chapter; or, to establish a health maintenance organization; provided, that said health maintenance organization shall be operated in accordance with applicable federal and state law.
Notwithstanding any general or special law to the contrary, no health plan offered by, or under a contract with, the division under section 9D or part (a)(26) of 42 USC section 1396d shall constitute the business of insurance and no such plan shall be subject to chapters 175 to 176O, inclusive. Nothing in this paragraph shall affect the legal status or obligations under such insurance laws of any entity otherwise constituting or conducting the business of insurance for any other purpose.
Section 13. The commissioner shall review, and approve or disapprove, any change in Title XIX rates or Title XIX rate methodology proposed by the division of health care finance and policy established by chapter one hundred and eighteen G, which shall be called the “division” only for purposes of this section. The commissioner shall review such proposed rate changes for consistency with agency policy and federal requirements, and within the level of funding available as authorized by the general appropriation act prior to the certification of such rates by the division; provided, that the commissioner shall not disapprove a rate increase solely based on the availability of funding if the federal health care financing administration provides written documentation that federal reimbursement would be denied as a result of said disapproval and said documentation is submitted to the house and senate committees on ways and means. The commissioner shall, when disapproving a rate increase, submit the reasons for disapproval to the division together with any recommendations for changes. Such disapproval and recommendations, if any, shall be submitted after the commissioner is notified that the division intends to propose a rate increase for any class of provider under Title XIX; but in no event later than the date of the public hearing held by the division regarding such rate change; provided, that no rates shall take effect without the approval of the commissioner. The division and the commissioner shall provide documentation on the reasons for increases in any class of approved rates that exceed the medical component of the consumer price index to the house and senate committees on ways and means. The division shall supply the commissioner with all statistical information necessary to carry out his duties under this section. Notwithstanding the foregoing, the commissioner shall not review, approve, or disapprove any such rate set pursuant to chapter twenty-three of the acts of nineteen hundred and eighty-eight. If projected payments from rates necessary to conform to applicable requirements of Title XIX are estimated by the commissioner to exceed the amount of funding appropriated for such purpose in the general appropriation act in any fiscal year, the division and the commissioner shall jointly prepare and submit to the Governor a proposal for the minimum amount of supplemental funding necessary to satisfy the requirements of the under Title XIX state plan.
Section 13A. For hospital fiscal years beginning on or after October first, nineteen hundred and ninety-seven, rates and terms of payment established by the division with non-acute hospitals for services rendered to patients entitled to medical assistance under this chapter shall be established by contract between the division and such hospitals, unless otherwise required by law. Prior to said October first, for those non-acute hospitals whose rates and terms of payment have not been established by contract with the division, said rates and terms of payment shall be based on the system of reimbursement in effect immediately prior to the effective date of this section. This section shall not be construed preventing said division and a non-acute hospital from agreeing to such a contract prior to such date. Any medical necessity and administratively necessary determinations the division may establish for non-acute hospitals shall be based on the screening criteria and procedures applied by peer review organizations as are duly authorized under the Social Security Act.
For any hospital fiscal year subsequent to nineteen hundred and ninety-eight, the division of medical assistance may elect, solely at its discretion, that public payor-dependent non-acute hospitals shall be subject to the provisions of the preceding paragraph; provided, that reimbursement so established by said section shall include an administratively necessary day adjustment for any patient that a public payor-dependent non-acute hospital is unable to place in a more appropriate facility based on said screening criteria and procedures; provided further that the terms of payment for any such patient shall reflect the reasonable costs of any such hospital in providing care to recipients of medical care and assistance; and provided further, that reimbursement so established shall reflect the reasonable costs of treating a disproportionate share of public payor patients.
For any hospital fiscal year commencing on or after October 1, 2003, the division shall not classify any ventilator dependent patients in a public payor-dependent non-acute hospital as an administratively necessary day patient, unless a physician member of the hospital’s utilization review committee finds and certifies that the medical services required by the patient are actually available in a non-hospital facility located within a 25 mile radius of the patient’s principle residence and that the patient will receive safe and effective care. The division shall not make any decision or take any action as to the continuing necessity of hospital care in a public payor-dependent non-acute hospital which is inconsistent with the hospital utilization review committee findings. The division shall pay public payor-dependent non-acute hospitals at the full hospital inpatient per diem rate for services provided to such ventilator dependent patients entitled to medical assistance and the ventilator dependent patients shall not be subject to administratively necessary day rates.
Section 14. Pursuant to the second paragraph of section twelve, the division shall enter into negotiated rate contracts with nursing homes that recognize the acquisition cost, or portion thereof which exceeds the allowable basis under relevant regulations of the division of health care finance and policy, as the allowable basis of fixed assets where there has been a change of ownership effective on or after January first, nineteen hundred and eighty-seven, provided that:(a) (i) the new owner has received a determination letter from the Internal Revenue Service that it is an organization described in section 501(c)(3) of the Internal Revenue Code of 1986; and(ii) the new owner is a nonprofit hospital within the commonwealth licensed by the department of public health, or is a nonprofit organization affiliated with a nonprofit hospital which is organized and operated for the benefit of, to perform one or more functions of, or to carry out one or more of the purposes of the nonprofit hospital it is affiliated with, including operation of freestanding nursing homes licensed by the department of public health; and(iii) the new owner demonstrates that on average not less than eighty-five percent of its patient population is a recipient of medical assistance under this chapter; and(iv) the new owner demonstrates that in the nonprofit hospital it operates it has an average of administratively necessary patient days that is fifty percent of the regional average of administratively necessary patient days as calculated by the division; and(v) the new owner demonstrates that in the nonprofit hospital it operates that on average it has not less than eighty percent occupancy of medical or surgical beds; and(vi) the change of ownership did not occur between a person or organization which is associated or affiliated with or has control of or is controlled by the new owner or is related to the new owner or any director, trustee, partner, shareholder or administrator of the new owner by common ownership or control or in a manner specified in section 267(b) and (c) of the Internal Revenue Code of 1986; and(vii) the change of ownership was made for reasonable consideration; and(viii) the change in ownership was a bona fide transfer of all powers and indicia of ownership; and(ix) the change of ownership manifested an intent to sell the assets of the facility rather than implement a method of financing, or refinancing; and(x) the department of public health certifies the need for additional beds for publicly-assisted residents in the geographical area; and(xi) such geographical area is reasonably isolated which isolation creates difficulties in obtaining access to nursing home care; and(xii) the new owner obtains at least two independent appraisals of the property; and(xiii) the division and the department of public health have determined that the transaction is necessary to ensure the safety of patients as evidenced by current or anticipated delicensure or decertification proceeding against the current owner; provided however, that the provisions of clauses (xii) and (xiii) of paragraph (a) shall only apply to nursing homes acquired after July first, nineteen hundred and ninety; or(b) (i) the new owner acquired the facility from an acute care hospital to operate the nursing home pursuant to relief granted to the acute care hospital by the acute care hospital conversion board pursuant to section one hundred and one of chapter six A; and(ii) the acute care hospital conversion board approves the new owner’s acquisition cost; and(iii) the new owner demonstrates that on average, not less than eighty-five percent of its patient population is receiving medical assistance under this chapter.
If the division is unable to calculate regional averages for administratively necessary patient days pursuant to clause (a)(iv) of this section, the new owner shall be able to receive the acquisition cost, or the portion thereof which exceeds the allowable basis under relevant regulations of the division of health care finance and policy, as the allowable basis of the fixed assets as a result of a change of ownership if the new owner otherwise complies with clauses (i) to (iii), inclusive, and clauses (v) to (xiii), inclusive of paragraph (a).
to acute care and chronic disease or rehabilitation hospitals Section 14A. The division shall treat admissions to acute care hospitals and chronic disease or rehabilitation hospitals as equivalent for purposes of reimbursing nursing homes to reserve beds for medical assistance recipients during brief absences from nursing homes by such recipients to obtain hospital care.
In the event that a nursing facility resident who is age 22 years or under and is a MassHealth recipient leaves the nursing facility for non-medical reasons, the facility shall preserve his bed for a period of up to 10 calendar days per year and the division shall pay to preserve his bed in the facility for a period of up to 10 calendar days per year.
managed care; personal expenses Section 15. The division shall provide Medicaid benefits for such medical care or services as Title XIX and regulations adopted thereunder by the secretary require. The division may provide Medicaid benefits for such additional medical care or services as Title XIX and said regulations permit.
The amount, duration and scope of the aforesaid care and services shall be determined by the rules and regulations of the division, provided such rules and regulations are consistent with the provisions of this chapter and Title XIX. Such rules and regulations may include appropriate limitations on care and services based on such criteria as medical necessity or utilization control procedures.
The division shall develop regulations and procedures requiring a recipient of medical assistance under this chapter to participate in a program of managed care, upon determination by the department, pursuant to the provisions of 42 USC 1396n(a), subject to appeal by the recipient, that said recipient has demonstrated a pattern of excessive or inappropriate utilization of a covered benefit.
Any person who is eligible for assistance under the provisions of this chapter who is not maintaining his or her own home and who is receiving care in a licensed nursing home, a licensed chronic hospital, a licensed rest home, an approved public medical institution, or a public psychiatric institution shall retain the first sixty dollars of monthly income for clothing, personal needs allowance, and leisure time activities. If there is no such income, or if such income is less than sixty dollars, the recipient shall be paid, in advance, the difference between such income and sixty dollars.
The division shall provide by regulation that personal laundry costs shall not be charged to the amount retained by or paid to the recipient pursuant to this section. Personal laundry costs shall be reimbursed through rates paid to such institutions.
assistance program for disabled residents; assistance program for chronically ill or disabled persons forced to leave employment or substantially reduce work hours Section 16. The division shall establish a program of primary and supplemental medical care and assistance for certain disabled residents of the commonwealth including persons who are blind who are not eligible for medical assistance pursuant to Title XIX of the federal Social Security Act. The benefits of such program shall be available to all such persons (1) who are not covered for medical costs relative to their disability by an employer’s group health insurance plan, (2) who are not eligible for medical assistance under any work incentive programs with federal participation, and (3) who, if not engaged in substantial gainful activity, would meet all eligibility requirements for supplemental security income under the provisions of Title XVI of said Social Security Act at the time of application for said program of medical care and assistance. Subsequent to their enrollment in said program, such disabled residents may continue in enrollment in said program notwithstanding the fact that they no longer meet the financial requirements of said Title XVI in accordance with income requirements established by the division. The cost of such program shall be funded, in part, by premium contributions, co-payments, and deductibles contributed by enrollees according to a sliding scale schedule designed by the division.
The division shall further establish a program of assistance for persons forced to leave employment due to the onset or worsening of a severe and chronic disability or illness or whose access to employer sponsored health insurance is jeopardized by a substantial reduction in work hours as a result of such disability or illness. The benefits of such program shall provide for assistance in paying health insurance premiums offered through a group plan of health insurance sponsored by the employer for those persons whose continuing disability or illness would likely result in their becoming eligible for benefits under this chapter; provided that the cost of such benefits shall be paid, in part, by payments from such persons according to a sliding fee schedule established by the division.
projected to exceed available appropriations; notice Section 16A1/2. The commissioner shall notify the house and senate committees on ways and means and the secretary of administration and finance whenever costs incurred for any program of medical care authorized by sections 9A, 16 and 16A are projected to exceed available appropriations for the current fiscal year or for costs authorized for expenditure for prior fiscal years. Such notice shall be filed within five business days of the commissioner’s determination of such projection. Any such notice shall be accompanied by the following information: (a) an explanation of the reasons for any such deficiency or insufficient authorization for prior year expenditures; (b) revised total expenditure projections for any such items of appropriation that shall update the budget neutrality plan required pursuant to section 9B; (c) revised member month caseload assumptions for any such program of medical care that is projected to incur such a deficiency; (d) revised per member per month cost assumptions for any such program of medical care that is projected to incur such a deficiency; and (e) a description of all cost control measures, including quantification of the savings therefrom, that the division would propose to implement to prevent or ameliorate any such deficiency.
disabled children Section 16A. The division shall establish a program of medical care and assistance for certain disabled children of the commonwealth, including children who are blind. The benefits of such program shall be available to children who are not eligible for medical assistance programs with federal financial participation and who would meet the disability requirements for supplemental security income under the provisions of Title XVI of the Social Security Act. The cost of such program shall be funded, in part, by premium contributions, co-payments and deductibles according to a sliding scale schedule designed by the division.
benefits; costs; eligibility Section 16C. (1) There is hereby established the child health insurance program, which shall provide medical assistance or medical benefits to infants, children and adolescents to age 18, inclusive, whose financial eligibility as determined by the division does not exceed 200 per cent of the federal poverty level, pursuant to and in conformity with the provisions of Title XXI, the terms and conditions of the demonstration project authorized by section 9A of this chapter, or a combination thereof.
(2) Medical benefits under said program shall be available to all such infants, children and adolescents qualifying for enrollment in said program pursuant to clauses (b) and (c) of subsection (2) of said section 9A. To the extent authorized by federal law or by the terms and conditions of the demonstration project authorized pursuant to said section 9A, the division is hereby authorized to grant presumptive eligibility for up to 60 days to children and adolescents applying for enrollment in said program. The division may deny eligibility for medical benefits under said program pursuant to the provisions of subsection (3) of said section 9A.
(3) The amount, duration and scope of medical benefits provided under said program for eligible beneficiaries whose financial eligibility, as determined by the division exceeds 133 per cent of the federal poverty level but does not exceed 200 per cent of the federal poverty level, shall be established by the division; provided however, that medical benefits provided under said program shall be both consistent with the benefit levels required under the provisions of said Title XXI and comparable to the benefit levels offered under private insurance plans, shall include early and periodic screening, diagnostic and preventive services and shall include other medical services to the extent that such services are covered medical benefits under said plan.
(4) The costs of said program may be offset by copayments and deductibles to the extent permitted by Title XXI. The division shall require the payment of premiums by households eligible for said program whose household income as determined by said division exceeds 150 per cent of the federal poverty level. Such premiums shall be deposited in the Children’s and Seniors’ Health Care Assistance Fund established pursuant to the provisions of section 2FF of chapter 29. The failure to pay premiums for more than two consecutive months shall constitute grounds for terminating a household’s eligibility to participate in said program of benefits; provided, however, that the commissioner of medical assistance may allow continued participation in said program despite such nonpayment of premiums or otherwise waive the payment of any or all premiums for any particular household in the event that such payment of premiums constitutes an extreme financial hardship for such household.
(5) Eligibility for and the medical benefits provided under said program shall not give rise nor be construed as giving rise to enforceable legal rights for any party or an enforceable entitlement to such eligibility or medical benefits other than to the extent that such rights or entitlements exist pursuant to the regulations of the division, the terms and conditions of the demonstration project established in said section 9A or this section. The provisions of this section shall not establish any rights or entitlements that exceed the rights or entitlements established by Title XIX in the absence of this program, or impose any obligations upon the commonwealth’s administration or financing because of implementation of said program would exceed obligations established by Title XIX.
under color of law; benefits Section 16D. (1) Eligibility for benefits for aliens pursuant to this chapter shall be determined without regard to the availability of federal funding for such benefits or to the provisions of sections 401, 402 or 403 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996.
(2) A person who is not a citizen of the United States but who is either a qualified alien within the meaning of section 431 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 or is otherwise permanently residing in the United States under color of law may receive different benefits unless such person: (i) is residing in a nursing facility, as defined by 42 U.
S.
C. section 1396, as of June 30, 1997; (ii) was receiving services or benefits pursuant to this chapter as of June 30, 1997; (iii) had an application for long-term care services pending on July 1, 1997; or (iv) is eligible for federally reimbursed services or benefits; provided, however, that services or benefits other than emergency services shall not be provided to undocumented aliens unless required by federal law.
(3) Benefits for aliens under this section shall not be provided to persons age 19 or older; but the benefits shall not be terminated for persons described in clauses (i), (ii), (iii) and (iv) of subsection (2).
(4) Before termination of eligibility under the authority of subsection (3), the division shall review eligibility to assure that all federally eligible aliens are identified and their costs of coverage reimbursed by the federal Medicaid program to the greatest extent possible consistent with federal law.
(5) The division shall review all claims for services to aliens to assure that all emergency services are reimbursed by the federal Medicaid program to the greatest extent possible consistent with federal law, including coverage for chronic medical conditions, which, if left untreated, could reasonably be expected to place the persons’ health in serious jeopardy, cause serious impairment to bodily functions or cause serious dysfunction of any bodily organ or part.
(6) Notwithstanding subsection (3), if appropriations permit, the division shall determine eligibility in accordance with subsection (1) and (2).
Section 17. Multiple source drugs listed in the Massachusetts list of interchangeable drug products established pursuant to the provisions of section thirteen of chapter seventeen of the General Laws and regulations adopted thereunder shall not be reimbursable except for the “Massachusetts maximum allowable cost”, as defined by regulations of the department, unless the division grants prior authorization based upon the provision of written documentation by the practitioner to the division that satisfactorily demonstrates that a recipient’s medical condition requires the use of a nongeneric drug and unless the practitioner writes on the face of the prescription in his or her own handwriting the words “brand name medically necessary” under the words “no substitution” in a manner consistent with applicable state law; provided that a pharmacist dispensing in accordance with this section shall be exempt from the provisions of the fourth paragraph of section twelve D of chapter one hundred and twelve.
for emergency medical conditions Section 17A. (a) As used in this section, the following words shall have the following meanings:“Attending physician”, the emergency physician or consultant physician who actively treats the emergency medical condition of a beneficiary at an emergency facility.
“Beneficiary”, a recipient of medical assistance or medical benefits pursuant to this chapter who is treated in an emergency facility for an emergency medical condition.
“Emergency medical condition”, a medical condition, whether physical or mental, manifesting itself by symptoms of sufficient severity, including severe pain, that the absence of prompt medical attention could reasonably be expected by a prudent layperson who possesses an average knowledge of health and medicine, to result in placing the health of a beneficiary or another person in serious jeopardy, serious impairment to body function, or serious dysfunction of any body organ or part, or, with respect to a pregnant woman, as further defined in section 1867(e)(1)(B) of the Social Security Act, 42 U.
S.
C. section 1395dd(e)(1)(B).
“Stabilization for discharge”, an emergency medical condition shall be deemed to be stabilized for purposes of discharging a beneficiary, other than for the purpose of transfer from one facility to another facility, when the attending physician has determined that, within reasonable clinical confidence, the beneficiary has reached the point where further care, including diagnostic work-up or treatment, or both, could be reasonably performed on an outpatient basis or a later scheduled inpatient basis if the beneficiary is given a reasonable plan for appropriate follow-up care and discharge instructions, or as further defined in section 1867(e)(3)(A) of the Social Security Act, 42 U.
S.
C. section 1395dd(e)(3)(A). Stabilization for discharge does not require final resolution of the emergency medical condition.
“Stabilization for transfer”, an emergency medical condition shall be deemed to be stabilized for transfer if a beneficiary can be transferred from one facility to a second facility and the attending physician has determined, within reasonable clinical confidence, that the beneficiary is expected to leave the hospital and be received at a second facility with no material deterioration in his condition, or as further defined in section 1867(c) and (e)(4) of the Social Security Act, 42 U.
S.
C. section 1395dd(c) and (e)(4). Stabilization for transfer does not require final resolution of the emergency medical condition.
(b) Any program of medical assistance or medical benefits for which the division is the primary payor shall cover emergency services provided to a beneficiary for emergency medical conditions. After the beneficiary has been stabilized for discharge or transfer, the division or its designee may require a hospital emergency department to contact the physician on-call designated by the division or its designee for authorization of post-stabilization services to be provided. The hospital emergency department shall take all reasonable steps to initiate contact with the division or its designee within 30 minutes of stabilization. Such authorization shall be deemed granted if the division or its designee has not responded to said call within 30 minutes. Notwithstanding the foregoing provision, if the attending physician and said on-call physician do not agree on what constitutes appropriate medical treatment, the opinion of the attending physician shall prevail and such treatment shall be considered appropriate treatment for an emergency medical condition, if such treatment is consistent with generally accepted principles of professional medical practice and is a covered benefit under said program of medical assistance or medical benefits. Consistent with the foregoing, the division or its designee may enter into contracts with hospitals or emergency physician groups, or both, for the provision of emergency services.
(c) The division or its designee may require a beneficiary to contact the division or its designee or the primary care physician of the beneficiary within 48 hours of receiving such emergency services, but notification already given to said division, designee, or primary care physician by the attending physician shall satisfy the requirements of this subsection.
(d) Nothing in this section shall be construed to limit retrospective utilization review activities by the division or its designee with respect to screening, stabilization and post-stabilization services for the purposes of assessing quality, utilization patterns and coding and billing practices, but such activities shall not result in retroactive changes to treatment or reimbursement decisions previously made in accordance with this section. In conducting said utilization review activities, the division or its designee shall comply with section 12 of chapter 176O and all applicable state and federal confidentiality provisions.
(e) The division or its designee shall clearly state in its brochures, contracts, policy manuals and all printed materials that beneficiaries shall have the option of calling the local pre-hospital emergency medical service system by dialing the emergency telephone access number 911, or its local equivalent, whenever a beneficiary is confronted with an emergency medical condition which in the judgment of a prudent layperson would require pre-hospital emergency services. No beneficiary shall in any way be discouraged from using the local pre-hospital emergency medical service system, the 911 telephone number, or the local equivalent, or be denied coverage for medical and transportation expenses incurred as a result of such emergency medical condition.
eligible for assistance Section 18. The division may purchase on behalf of any person eligible for medical assistance under this chapter medical insurance furnished in accordance with the provisions of chapter one hundred and seventy-five, one hundred and seventy-six A, one hundred and seventy-six B or one hundred and seventy-six G, provided that such medical insurance, in conjunction with any supplemental coverage that may be available to such person by the division under this chapter, would enable such person to obtain medical care and services comparable to those afforded any other similar eligible person under this chapter, at no greater cost to such person or the division. The third party liability unit of the division is hereby authorized to establish services and procedures which seek to maximize and coordinate the utilization of health care benefits provided under any such purchase of medical insurance for such person.
rules and regulations; posttreatment examinations Section 19. The division shall establish methods of approving services to be performed as a prerequisite to extending medical assistance. Said methods of prior approval may include, but need not be limited to: (1) in the case of restorative dentistry, or dentures, examination of proposed recipients or of diagnostic information regarding proposed recipients by dental consultants of the department; (2) in the case of orthodontic services, procedures which assure that medical assistance will be provided only for severe handicapping malocclusions; and (3) in the case of transportation to obtain medical care, a statement from the attending physician certifying that such transportation is necessary due to a physical disability.
Assistance under this chapter for nursing services for persons twenty years of age or under may be available only after a medical review team under the supervision or with the approval of the department of public health, in cooperation with the division and the departments of mental health and mental retardation, approves such services for such persons. The department of public health, in cooperation with the division and such other departments, shall promulgate rules and regulations for such services, and any person or facility offering such services shall receive prior certification from the department of public health.
The division shall establish methods of random posttreatment examination of recipients of medical care or services under this chapter in order to assure that the care or services for which the division is billed were actually performed as described.
Section 2. All powers and duties established pursuant to this chapter shall be exercised by the secretary of health and human services, through the division of medical assistance and the secretary of elder affairs, as appropriate.
Section 20. An application or reapplication by an individual for medical assistance shall be made to the division on forms prepared by the division. Such forms shall include but not be limited to the following:—the name, address and social security number of the applicant and the name, address and social security number of any member of the family sixteen years of age and older, the total income from wages, salaries, pensions, fees, tips, bonuses and all other sources of income of all such persons, the ownership and description of any motor vehicle or boat, or trailer, or similar assets readily convertible into cash owned by any member of the family. Such form shall require that the applicant provide information to determine his or her eligibility for medical assistance under penalty of perjury.
An institution furnishing services under this chapter shall have the right to make such application on behalf of an individual only if, and to the extent, provided by regulations of the division.
applicant; agreement Section 21. Upon receipt of such application, the division shall make full inquiry concerning the eligibility of the applicant, his or her need for medical assistance and his or her resources and income, if any, and, shall make its decision: (1) within ninety days after receipt of such application for applicants who apply for medical assistance on the basis of a disability; and (2) within forty-five days after receipt of such application for all other persons. At the time of such initial decision, and in the event of any subsequent decision, the applicant or recipient shall be notified in writing of such decision and shall be informed of the reason therefor and of his right to appeal and of the method by which he may appeal under this chapter.
The division may enter into an agreement with the secretary, or with any government or private agency, whereby the secretary or agency shall determine on behalf of the division the eligibility for medical assistance under this chapter of all or certain applicants for such assistance.
institutionalized spouse Section 21A. (a) In determining the eligibility for medical assistance of an institutionalized spouse, the division shall comply with all the requirements set forth in 42 U.
S.
C. 1396r–5, including, but not limited to, the following:(1) Upon a determination of eligibility for medical assistance of an institutionalized spouse, the division shall send notification to both spouses.
(2) The notice shall include, but shall not be limited to, the following:(i) the type and amount of all countable assets;(ii) the amount of the community spouse monthly income allowance, as defined in 42 U.
S.
C. 1396 r–5(d)(2);(iii) the amount of any family allowances described in 42 U.
S.
C. 1396 r–5(d)(1)(C);(iv) the minimum monthly maintenance needs allowance of the community spouse, as defined in 42 U.
S.
C. 1396r–5(d)(3);(v) the community spouse resource allowance and its method of computation;(vi) the right to a fair hearing concerning ownership or availability of income or resources, and the determination of the community spouse monthly income allowance or community spouse resource allowance, and the right to a decision within ninety days of a timely request for a fair hearing;(vii) a citation to this section and to any applicable regulation of the division of medical assistance; and(viii) the following language:—“The community spouse (that is, the spouse of the institutionalized person) may have the right to retain a larger share of the combined spousal resources if the income of the community spouse falls below his or her minimum monthly maintenance needs allowance. It will be necessary to request a hearing in order to establish whether the community spouse has a right to retain a larger share of assets; at the hearing, it will be necessary to show that the income of the community spouse is less than the minimum monthly maintenance needs allowance, and that the community spouse needs additional resources to generate enough income to bring the actual income up to the minimum monthly maintenance needs allowance.
”(b)(1) Upon the request by the institutionalized spouse, the community spouse, or a representative acting on behalf of either spouse for an assessment of assets not made in connection with an application for medical assistance, the division shall send notification to the spouse making the request.
(2) The notice shall include, but shall not be limited to, the following:(i) the type and amount of all countable assets;(ii) the right to a fair hearing concerning ownership or availability of income or resources, and the determination of the community spouse monthly income allowance or community spouse resource allowance at the time Medicaid eligibility is determined, and the right to a decision within ninety days of a timely request for a fair hearing;(iii) a citation to this section of the General Laws and to any applicable regulation of the division of medical assistance; and(iv) the following language:“The community spouse (that is, the spouse of the institutionalized person) may have the right to retain a larger share of the combined spousal resources, depending on his or her monthly income and monthly needs. Further information regarding the right of the community spouse to the spousal resources will be provided at the time that the Medicaid eligibility of the institutionalized spouse is determined.
”(c) In making determinations under this section, the division shall revise the community spouse resource allowance as permitted or required by federal law. Either spouse shall have the right to request a fair hearing at which, if it is shown that the income of the community spouse is less than the minimum monthly maintenance needs allowance of the community spouse, the referee shall revise the community spouse resource allowance, using methods permitted or required by federal law, to a level sufficient to generate the shortfall in income. The division shall calculate interest income on the investment of the community spouse resource allowance using the rates reported in the Bank Rate Monitor Index on the date of the hearing.
subrogation Section 22. As used in this section, the following words shall have the following meanings:—“Claimant”, any person who suffers any loss from property damage, accident, illness, injury or otherwise for which monies may be provided by liability insurance, workers’ compensation, or any other third party.
“Third party”, any individual, agency, program, entity or insurer, including but not limited to the claimant’s own insurer, that is or may be liable to pay monies on account of the claimant’s loss.
“Date of the loss”, the date on which the property damage, accident, illness, injury, or other incident occurs.
When any claimant or the claimant’s heirs, estate, or legal representative receives payment from a liability or workers’ compensation insurer or any other third party, the claimant or the claimant’s heirs, estate, or legal representative shall repay to the department of transitional assistance and the division the total of all public assistance benefits, both financial and medical, provided by said agencies on or after the date of the loss to or on behalf of the claimant, the claimant’s spouse or children, and any other individual the claimant is required by law to support; provided, however, that on the date of the loss the claimant was already eligible for medical assistance benefits, the claimant or the claimant’s heirs, estate or legal representative shall repay only medical assistance required and any increase in financial assistance that occurred as a result of the accident, illness, injury, or other incident.
The application for and receipt of benefits recoverable under this section shall, after notice to the third party, operate as a lien to secure repayment against monies which may be provided by said third party up to the amount of such benefits. Notwithstanding the foregoing, the department of transitional assistance and the division may also perfect their right to a lien against any monies which may come into possession of the claimant’s attorney by giving notice to said attorney.
If the monies available for repayment are insufficient to satisfy in full any competing claims of both the department of transitional assistance and the division, the department and the division shall each be entitled to its respective pro rata share of such monies as are available.
Any person receiving public assistance benefits recoverable under this section shall assign to the commonwealth an amount equal to the benefits so provided from the proceeds of any such claim against the third party.
A claimant shall, within ten calendar days, notify the division in writing upon commencement of a civil action or other proceeding to establish the liability of any third party or to collect monies payable under accident, liability, or health insurance, workers’ compensation, or from any other third party or source.
The commonwealth shall be subrogated to a claimant’s entire cause of action or right to proceed against any third party and to a claimant’s claim for monies to the extent of assistance provided under chapters one hundred and seventeen, one hundred and eighteen, or one hundred and eighteen E. The commonwealth shall also have a separate and independent cause of action to recover, from any third party, assistance provided to a claimant under said chapters, which cause of action shall be in addition to other causes of action. The commonwealth may, by attorneys employed or selected by it, commence a civil action or other proceeding to establish the liability of any third party or to collect such moneys, or may intervene as of right in any civil action commenced by a claimant against a third party. No third party shall require written authorization from the claimant before honoring the commonwealth’s rights under this section.
Failure of a claimant without good cause to provide notice as required under this section or to provide such further information deemed necessary by the division to pursue its rights under this section shall be grounds for termination of benefits.
Notwithstanding any general or special law or rule or regulation to the contrary, all insurers doing business in the commonwealth, shall provide information requested by the department of transitional assistance and the division of medical assistance for use by those agencies for the purpose of recovering public assistance benefits under this section and section 5G of chapter 18.
garnishment of wages Section 23. As used in this section, health care insurer, health insurer and health insurance shall include, but not be limited to, any health insurance company, health maintenance organization, group or nongroup health plan, self-insured plan, or any other private or public program, plan, or entity that provides, arranges, or pays for any health, accident, or sickness benefits.
Notwithstanding the provisions of any general or special law, rule or regulation to the contrary, the division shall be subrogated to the rights of any recipient of medical assistance under this chapter and may take any and all actions available to such recipient to secure benefits under any policy issued by any health care insurer that is or may be liable to pay for covered services obtained by a recipient of medical assistance to the extent of any medical benefits provided by the division on behalf of the recipient or his or her dependents. No health care insurer shall require written authorization from the recipient before honoring the division’s rights under this section. A health care insurer shall reimburse the division for any medical benefits provided by the division on behalf of a recipient of medical assistance, and shall not reduce the amount of the total reimbursement by any division payment, provided that any part of the total that is a reimbursement for a division payment shall not exceed the amount actually paid by the division.
A recipient of medical assistance or any person legally obligated to support and have actual or legal custody of a recipient of medical assistance shall inform the division of any health insurance available to such recipient upon initial application and redetermination for eligibility for assistance and shall make known the nature and extent of any health insurance coverage to any person or institution that provides medical benefits to the recipient or his or her dependent.
No policy for health insurance for health care delivery administered, issued or renewed in the commonwealth shall contain any provision denying or reducing benefits to a person who is eligible for or who is receiving medical assistance under this chapter.
A provider of medical assistance under this chapter shall determine whether any recipient for whom it provides medical care or services which are or may be eligible for reimbursement pursuant to this chapter is a subscriber or beneficiary of a health insurance plan. The division is the payor of last resort, and accordingly a provider shall request payment for medical care or services it provides from a health insurer which is or may be liable for the medical care or services so provided, before payment is requested from the division.
Payment by the division under the medical assistance programs established by this chapter shall constitute payment in full; subsequent to any such payment a provider may not recover from any health insurer an amount greater than the amount so paid by the division for any service for which the division is to be the payor of last resort.
Notwithstanding the provisions of any general or special law or rule or regulation to the contrary, all holders of health insurance information, including, but not limited to, health insurers doing business in the commonwealth, all private and public entities who employ individuals in the commonwealth, and all agencies of the commonwealth, shall provide sufficient information to the division, or in the case of said agencies, shall make other arrangements mutually satisfactory to both agencies, to enable the division: (a) to identify whether any of the following persons are or could be beneficiaries under any policy of insurance in the commonwealth: (1) persons applying for or receiving medical assistance or benefits under this chapter or health services through an agency under the executive office of health and human services, (2) persons for whom hospitals and community health centers claim payments from the uncompensated care pool under chapter 118G; and (b) to determine the cost, scope, and terms of said policy of insurance. All public and private entities who employ individuals in the commonwealth shall provide, when requested by any employee applying for or receiving benefits provided by the division, written information to the employee describing the availability of health insurance, if any, provided by or through the employer. The failure of an employer to provide an employee with the information shall not be grounds for denial of benefits by the division.
The division may, after notice and opportunity for hearing, garnish the wages, salary, or other employment income of, and shall, with the assistance of the department of revenue pursuant to section 3 of chapter 62D, withhold amounts from state tax refunds to, any person who: (a) is required by court or administrative order to provide coverage of the costs of health services to a child who is eligible for medical assistance under this chapter; (b) has received payment from a third party for the costs of such services to such child; but, (c) has not used such payments to reimburse either the other parent or guardian of such child or the provider of such services, to the extent necessary to reimburse the division for expenditures for such costs.
information; penalty Section 23A. A treasurer of a savings bank, national bank, trust company, cooperative bank, benefit association, insurance company or safe deposit company authorized to do business in the commonwealth who, upon written request signed by an authorized employee or agent of the division, unreasonably refuses to inform such employee or agent of the amount deposited in the corporation or association to the credit of a person named in such request as a charge upon the commonwealth, or as an applicant to the commonwealth for medical assistance under this chapter, or who willfully renders false information in reply to such request, shall forfeit fifty dollars to the use of the commonwealth. Upon such request, a treasurer, as aforesaid, shall furnish the records on deposits and withdrawals during the past five years concerning any applicant for or recipient of medical assistance under this chapter to any authorized employee or agent of the division.
Section 25. For purposes of determining an individual’s eligibility for Medicaid, the following income and resources shall be exempt and shall neither be taken into consideration nor, except as permitted under Title XIX, required to be applied toward the payment or part payment of Medicaid benefits:(1) Monthly income in an amount not exceeding the level of the minimum dollar amount required under Title XIX;(2) ownership of one’s residence, including furniture, which is essential and appropriate to the needs of the household except as permitted by section 1902(a)(10)(C) of Title XIX. In the case of an applicant or recipient for whom a medical determination has been made, after notice and opportunity for an appeal and hearing, that he or she cannot reasonably be expected to return to live in the residence, the residence will be considered a countable asset unless:(A) the division determines that counting the residence as an asset would cause undue hardship; or(B) any one of the following persons continue or would continue to reside therein: (i) the applicant or recipient’s spouse; or (ii) a child of the applicant or recipient who is under twenty-one years of age or who is blind or permanently disabled; or (iii) a sibling of the applicant or recipient who has an equity interest in the home and who was residing there for a period of at least one year immediately before the date of the applicant’s admission to the medical institution; or (iv) a son or daughter of the applicant or recipient who was residing in the applicant or recipient’s home for a period of at least two years immediately before the date of the applicant’s admission to the medical institution, and who establishes to the satisfaction of the division that he or she provided care to the applicant which permitted the applicant to reside at the home rather than in an institution; or(C) the applicant or recipient has obtained long term care insurance whose coverage meets the requirements of 211 C.
M.
R. 65.
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In the case of an applicant or recipient for whom such a medical determination has been made under this subsection, the division shall continue to consider the residence as a noncountable asset for a period of not less than three months following such medical determination in order that the applicant or recipient may make funds available for his or her medical needs based on his or her equity interest in such residence.
(3) personal property in an amount not exceeding the minimum resource amount required under Title XIX;(4) cemetery plots purchased for the use of the applicant or recipient;(5) funds not to exceed the minimum amount required under Title XIX deposited in a trust account and so reserved for the payment of funeral and burial expenses of the applicant or recipient including, but not limited to, the purchase of a plot, the opening of the grave, the fee for religious services, and the monument inscription; the cash surrender value of burial insurance, so called, or prepaid irrevocable burial contracts, so called.
In any case where the monthly income of an applicant or recipient is in excess of the exemptions allowed, the applicant or recipient, if otherwise eligible for Medicaid under this chapter, shall be liable to pay to the provider of medical care or service an amount which shall be equal to the excess income for a period of six consecutive months, which includes the period when such service was provided.
In determining responsibility of any individual for any medicaid applicant or recipient, such responsibility shall be limited to a person for his spouse and parents for children under the age of eighteen. The income and assets of any Medicaid applicant or recipient under eighteen years of age who lives with his or her parent shall be deemed to include the income and assets of the parent of such applicant or recipient. The income and assets of any Medicaid applicant or recipient under eighteen years of age who does not live with his or her parents shall include only the income and assets that are actually contributed to the applicant or recipient by the parent.
Notwithstanding the first paragraph of this section, the division may require medicaid recipients to pay enrollment fees, premiums, deductibles, coinsurance, copayments or similar cost-sharing charges as participants in managed care plans implemented by the division, so long as any waivers of Title XIX provisions regarding recipient cost-sharing are obtained from the secretary in conjunction with any other federal approvals and waivers necessary to implement these managed care plans. In the absence of managed care plans, the division shall require, to the extent permitted by federal law, that recipients, if eligible for such benefits, be liable for a copayment of up to $3 toward the purchase of each pharmaceutical product, including prescription drugs and over-the-counter drugs, and to require the copayment of $3 for the use of emergency room services in acute care hospitals for the treatment of nonemergency conditions. The division may also require, to the extent permitted by federal law, that recipients be liable for a co-payment of up to $3 for all other covered services with the exception of mental health and substance abuse services. The division shall establish a per member out-of-pocket cap for all co-payments.
Nothing in this chapter shall preclude the division from using asset standards in determining the financial eligibility for any benefit; but the division shall submit to the house and senate committees on ways and means and the joint committee on health care a report of changes in asset standards within 30 days of implementation, and shall submit 4 quarterly reports, beginning 3 months after any new asset standards are implemented, detailing the effect the standards on the number of people applying for or terminated from MassHealth.
Section 26. The division shall issue a numbered identification card to persons receiving medical assistance under this chapter. Such card shall bear the date of issue and shall be presented to providers as verification of eligibility for medical assistance. The division shall establish by rules and regulations such procedures as may be necessary for the purpose of recalling identification on termination of eligibility.
Section 27. If an individual has become eligible under this chapter, eligibility shall be reconsidered or redetermined:(a) When required on the basis of information the division has obtained previously about anticipated changes in the individual’s situation.
(b) Promptly within thirty days, after a report is obtained from any source which indicates that changes in the individual’s circumstances may affect the amount of assistance to which he or she is entitled or may make him or her ineligible.
(c) Periodically, but at least once in every six months.
(d) If any recipient shall by gift, inheritance, or other manner acquire additional assets during any twelve month interval following determination of his or her eligibility, the recipient shall immediately report such acquisition to the division which shall immediately make a reevaluation of such recipient’s eligibility.
value; period of ineligibility Section 28. In determining the eligibility of an institutionalized individual, as defined by Title XIX, the division shall impose a period of ineligibility, consistent with said Title XIX, against any such individual if said individual or his spouse disposes of resources for less than fair market value. In determining the eligibility of a non-institutionalized individual, as defined in said Title XIX, the division may impose a period of ineligibility as permitted by said Title XIX.
Section 29. Whenever an individual who is receiving medical assistance under this chapter transfers an interest in real or personal property, such individual shall notify the division. Such notice shall include, at a minimum, the individual’s name, social security number or, if different, medical assistance identification number, the date of transfer and the dollar value, if any, paid or received by the individual receiving benefits under this chapter.
Section 30. When the division determines that an applicant is eligible for Medicaid, it shall pay for eligible care and services furnished on or after the date of application. Payment shall be made to the provider, institution or insurance entity supplying medical services. The date of application for Medicaid of an individual who has applied for financial assistance under the provisions of chapter one hundred and eighteen A or section one hundred and thirty-one of chapter six, shall be deemed to be the date of application for such financial assistance, whether or not such financial assistance is granted. If consistent with Title XIX of the federal Social Security Act and the regulations established thereunder, the division shall pay for eligible care and services furnished to an eligible applicant during the three months immediately prior to the month in which the applicant filed his or her application; provided, however, that, at the time such care or services are furnished to such individual, that individual upon application would have been eligible for Medicaid pursuant to this chapter.
Section 31. (a) This subsection shall apply to estates of individuals dying prior to April first, nineteen hundred and ninety-five. There shall be no adjustment or recovery of medical assistance correctly paid except as follows:(1) Recovery from the Permanently Institutionalized: From the estate of an individual, regardless of age, who was an inpatient in a nursing facility or other medical institution when he or she received such assistance. Recovery of such assistance shall be limited to assistance provided on or after March twenty-second, nineteen hundred and ninety-one.
(2) Recovery from Persons Age 65 and Over: From the estate of an individual who was sixty-five years of age or older when such individual received such assistance. Any recovery may be made only after the death of the surviving spouse, if any, and only at a time when such individual has no surviving child who is under age twenty-one or is blind or permanently and totally disabled. The division shall waive recovery where it would result in undue hardship, as defined by the division in its regulations.
(b) This subsection shall apply to estates of individuals dying on or after April first, nineteen hundred and ninety-five. There shall be no adjustments or recovery of medical assistance correctly paid except as follows:(1) Recovery from the Permanently Institutionalized: From the estate of an individual, regardless of age, who was an inpatient in a nursing facility or other medical institution when he or she received such assistance. Recovery of such assistance shall be limited to assistance provided on or after March twenty-second, nineteen hundred and ninety-one.
(2) Recovery from Persons Age 65 and Over: From the estate of an individual who was sixty-five years of age or older when he or she received such assistance.
(3) Recovery from Persons Age 55 and Over for Post-October 1, 1993 Medicaid: From the estate of an individual who was fifty-five years of age or older when he or she received such assistance, where such assistance was for services provided on or after October first, nineteen hundred and ninety-three.
Any recovery may be made only after the death of the surviving spouse, if any, and only at a time when he or she has no surviving child who is under age twenty-one or is blind or permanently and totally disabled. The division shall waive recovery if such recovery would work an undue hardship, as defined by the division in its regulations.
(c) For purposes of this section, “estate” shall mean all real and personal property and other assets includable in the decedent’s probate estate under the General Laws.
(d) The division is also authorized during an individual’s lifetime to recover all assistance correctly provided on or after April 1, 1995, if property against which the division has a lien or encumbrance under section 34 is sold. No lien or encumbrance shall be valid against any bona fide purchaser for value or take priority against any subsequent mortgagee for value unless and until it is recorded in the registry of deeds where the property lies.
Repayment shall not be required under this subsection while any of the following relatives lawfully resides in the property: (1) a sibling who had been residing in the property for at least one year immediately prior to the individual being admitted to a nursing facility or other medical institution; or (2) a child who (i) had been residing in the property for at least two years immediately prior to the parent being admitted to a nursing facility or other medical institution; and (ii) establishes to the satisfaction of the division that he provided care which permitted the parent to reside at home during that two year period rather than in an institution; and (iii) has lawfully resided in the property on a continuous basis while the parent has been in the medical institution.
If repayment is not yet required because a relative specified above is still lawfully residing in the property and the individual wishes to sell the property, the purchaser shall take possession subject to the lien or the division shall release the lien if the individual agrees to (1) either set aside sufficient assets to satisfy the lien or give bond to the division with sufficient sureties and (2) repay the division as soon as the specified relative is no longer lawfully residing in the property. Notwithstanding the foregoing or any general or special law to the contrary, the division and the parties to the sale may by agreement enter into an alternative resolution of the division’s lien.
This subsection shall not limit the division’s ability to recover from the individual’s estate under subsection (a) or (b) or as otherwise provided under any general or special law.
petition to division; liability of estate beneficiaries; claims against estate; sale or transfer of property subject to lien or claim Section 32. (a) Notwithstanding any provision of law to the contrary, a petition for admission to probate of a decedent’s will or for administration of a decedent’s estate shall include a sworn statement that copies of said petition and death certificate have been sent to the division by certified mail. Within 30 days of a request by the division, an executor or administrator shall complete and send to the division by certified mail a form prescribed by the division and provide such further information as the division may require.
In the event a petitioner fails to send copies of the petition and death certificate to the division and the decedent received medical assistance for which the division is authorized to recover under section thirty-one, any person receiving a distribution of assets from the decedent’s estate shall be liable to the division to the extent of such distribution.
(b) The division may present claims against a decedent’s estate as follows: (1) within four months after approval of the official bond of the executor or administrator, file a written statement of the amount claimed with the registry of probate where the petition was filed and deliver or mail a copy thereof to the executor or administrator. The claim shall be deemed presented upon the filing of the claim in the registry of probate; or (2) within one year after date of death of the decedent, commence an action under the provisions of section 9 of chapter 197.
(c) When presenting its claim by written statement under subsection (b), the division shall also notify the executor or administrator of (1) the circumstances and conditions which must exist for the division to be required to defer recovery under section 31 and (2) the circumstances and conditions which must exist for the division to waive recovery under its regulations for undue hardship.
(d) The executor or administrator shall have 60 days from the date of presentment to mail notice to the division by certified mail of one or more of the following findings: (1) the claim is disallowed in whole or in part, or (2) circumstances and conditions where the division is required to defer recovery under section 31 exist, or (3) circumstances and conditions where the division will waive recovery for undue hardship under its regulations exist. A notice under clause (2) or (3) shall state the specific circumstances and conditions which exist and provide supporting documentation satisfactory to the division. Failure to mail notice under clause (1) shall be deemed an allowance of the claim. Failure to mail notice under clause (2) shall be deemed an admission that the circumstances or conditions where the division is required to defer recovery under section 31 do not exist. Failure to mail notice under clause (3) shall be deemed an admission that the circumstances and conditions for the division to waive recovery for undue hardship under its regulations do not exist.
(e) If the division at any time within the period for presenting claims under subsection (b) amends the amount due, the executor or administrator shall have an additional 60 days to mail notice to the division under clause 1 of subsection (d).
(f) If the division receives a disallowance under clause (1) of subsection (d), the division may commence an action to enforce its claim in a court of competent jurisdiction within 60 days after receipt of said notice of disallowance. If the division receives a notice under clause (2) or (3) of said subsection (d), with which it disagrees, the division may commence an action in a court of competent jurisdiction within 60 days after receipt of said notice. If the division fails to commence an action after receiving a notice under clause (2) of said subsection (d), the division shall defer recovery while the circumstances or conditions specified in said notice continue to exist. If the division fails to commence an action after receiving a notice under clause (3) of said subsection (d), the division shall waive recovery for undue hardship.
(g) Unless otherwise provided in any judgment entered, claims allowed pursuant to this section shall bear interest at the rate provided under section 6B of chapter 231 commencing four months plus 60 days after approval of the official bond of the executor or administrator.
Notwithstanding the foregoing, if the division fails to commence an action after receipt of a notice under clause (2) of subsection (d), interest at the rate provided under section 6B of chapter 231 shall not commence until the circumstances or conditions specified in the notice received by the division under said clause (2) cease to exist. The executor or administrator shall notify the division within 30 calendar days of any change in the circumstances or conditions asserted in said clause (2) notice, and upon request by the division, shall provide updated documentation verifying that the circumstances or conditions continue to exist.
If the division’s claim has been allowed as provided herein and no circumstances and conditions requiring that the division defer recovery under section 31 exist, it may petition the probate court for an order directing the executor or administrator to pay the claim to the extent that funds are available or for such further relief as may be required.
(h) Notice of a petition by an executor or administrator for a license to sell real estate shall be given to the division in any estate where:(1) the division has filed a written statement of claim with the registry of probate as provided in subsection (b); or(2) the division has filed with the registry of probate a notice, as prescribed under subsection (a) of section 9 of chapter 197, that an action has been commenced.
(i) In all cases where:-(1) the division determines it may have a claim against a decedent’s estate;(2) a petition for administration of the decedent’s estate or for admission to probate of the decedent’s will has not been filed; and(3) more than one year has passed from the decedent’s date of death, the division is hereby authorized to designate a public administrator to be appointed and to serve pursuant to chapter 194. Said designation by the division shall include a statement of the amount claimed. This provision shall apply to all estates in which no petition for administration of the decedent’s estate or for admission to probate of the decedent’s will has been filed as of the effective date of this section, regardless of the decedent’s date of death.
(j) If the executor or administrator wishes to sell or transfer any real property against which the division has filed a lien or claim not yet enforceable because circumstances or conditions specified in section 31 continue to exist, the division shall release the lien or claim if the executor or administrator agrees to (1) either set aside sufficient assets to satisfy the lien or claim, or to give bond to the division with sufficient surety or sureties and (2) repay the division as soon as the circumstances or conditions which resulted in the lien or claim not yet being enforceable no longer exist. Notwithstanding the foregoing provision or any general or special law to the contrary, the division and the parties to the sale may by agreement enter into an alternative resolution of the division’s lien or claim.
Section 32A. There is hereby established on the books of the commonwealth a Long-Term Care Trust Fund to which shall be deposited all contributions collected by the division pursuant to section thirty-one. All interest earned on the amount in said trust fund shall be deposited or retained in said trust fund.
Amounts from this trust fund may be expended, subject to appropriation, on care for recipients of long-term care benefits under this chapter or for services otherwise authorized pursuant to this chapter.
for medical assistance paid Section 33. No claim for costs of a nursing facility and other long term care services may be made by the division under section 31 or 32 if the individual receiving medical assistance was permanently institutionalized, had notified the division that he had no intent on returning home, and had on the date of admission to the nursing facility or other medical institution long term care insurance that met the requirements of 211 C.
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Section 34. No lien or encumbrance of any kind except as may be permitted by the Secretary, shall be required from or imposed against the property of any individual prior to his death because of Medicaid benefits paid or to be paid on his behalf except pursuant to the judgment of a court on account of benefits incorrectly paid on behalf of a Medicaid recipient.
The division shall not be required to pay a recording fee for filing a notice of lien or encumbrance or a release or discharge of a lien or encumbrance under this section.
information Section 35. No claim for medical care or services provided for under this chapter shall be reimbursed if any health insurance company, non-profit hospital service corporation, medical service corporation, or other health insurer is liable for such claim under the terms of a group or individual policy providing coverage for such claim to a person eligible for assistance under this chapter. The division shall establish procedures to ensure that no such unauthorized claims are paid, including the soliciting of information regarding alternative health coverage from all applicants and recipients.
Notwithstanding the provisions of any general or special law to the contrary, chronic hospitals and skilled nursing facilities shall seek certification for Title XVIII of the Social Security Act for those services reimbursed under Title XVIII of the Social Security Act.
Notwithstanding any law to the contrary, all health insurers governed by chapters one hundred and seventy-five, one hundred and seventy-six A, one hundred and seventy-six B, one hundred and seventy-six C, one hundred and seventy-six E, one hundred and seventy-six F, and one hundred and seventy-six G, shall provide information to the division which is necessary to carry out the purposes of this section, including the names and addresses of their policyholders or subscribers.
overpayments Section 36. Participation in the medical assistance programs established under this chapter shall be limited to providers of services who have not been convicted of larceny or fraud or any other crime in connection with such services, or the billing therefor and who:(1) indicate their intention to the division to so participate;(2) present evidence, satisfactory to the division, of their qualifications to provide such services;(3) agree to accept, as payment in full, the amounts paid in accordance with the fee schedules provided for under this chapter;(4) agree to comply with all laws, rules and regulations governing the operation of the programs;(5) agree to be responsible for all overpayments owed to the division, including, in the case of transfer of ownership, the overpayments of any and all previous owners.
If any individual or entity has an ownership interest in more than one institutional provider, the division may offset any monetary liability of such individual or entity to the division under this section or otherwise from any amounts the division owes to any such institutional provider. Any individual or entity having an ownership interest in an institutional provider shall be liable to the division for all monetary liabilities of such provider to the division to the extent of such individual’s or entity’s ownership interest. For purposes of this paragraph, an “ownership interest” shall include both direct ownership interests and ownership interests in any entity which has an ownership interest in an institutional provider, and an “institutional provider” shall mean any entity which participates in any medical assistance program under this chapter as a provider of nursing facility services or acute, chronic, or rehabilitation hospital services.
providers; administrative sanctions Section 37. The division shall distribute to all providers a copy of the rules, regulations, standards, and laws governing the medical assistance programs established by this chapter and shall establish administrative sanctions against providers, including, but not limited to, administrative fines, and, suspension or termination from the programs, for any violations of said rules, regulations, standards or laws. The division shall notify the proper professional society and licensing agency of any such violations.
erroneous denials; overpayments; civil collection actions Section 38. Providers shall submit to the division a bill for goods sold and services rendered not later than ninety days after the goods are sold or the services rendered, and the division shall verify no less than ten percent of said bills with the recipient of said goods or services. The division shall require that the provider maintain proof, subject to audit, of the actual delivery to recipients of services and goods for which bills are submitted. The division shall verify the accuracy of bills submitted under this section through the application of statistical sampling methods.
Said bills shall be signed under the penalties of perjury; provided, however, that an institution, as defined in clause (c) of section eight, may, in lieu of this requirement, agree in writing with the commissioner that its books and records will be available for inspection at all reasonable times by the division with respect to services rendered under the medical assistance programs administered by the division. The division may establish regulations which provide exceptions to the ninety day billing limitation. Said regulations shall not permit payment of such bills submitted more than one year after the last day of the month in which the goods are sold or the services are provided.
The division may also promulgate regulations which establish procedures for providers to appeal erroneous denials by the division of a provider’s claim for payment under this chapter. Such procedures may: (1) provide for disposition of such appeal by a board comprised of division personnel with expertise in claims processing; (2) provide for summary disposition of such appeal based on a review of written submissions; and (3) require that such appeals be filed with the division within thirty days, or some other time period specified by the division, after the date that the division notifies the provider of the final denial of the claim for payment. The provider’s right to payment under this chapter shall be extinguished if the provider fails to file an appeal within the time prescribed by the division.
When the division has reason to believe that a provider has received payment to which he is not entitled, the division shall notify the provider of the facts on which it bases its belief, identifying the amount believed to have been overpaid and the reasons therefor, and shall accord the provider a reasonable opportunity to submit additional data and argument to support the provider’s claim for reimbursement. After consideration and review of any such information submitted by the provider, the division shall make a final determination. Any amount determined to have been overpaid shall be recoverable under the provisions of this section unless the provider files a timely claim for an adjudicatory hearing raising a material dispute of fact or law. In such adjudicatory hearing, the burden shall be on the provider to demonstrate his entitlement to the payments denied by the division. After such hearing, the commissioner shall notify the provider of his decision with reasons therefor. The decision of the commissioner shall be final and is enforceable under this section unless stayed pursuant to a court order; provided, however, that the division has given written notice of the entry and filing provisions of this section to the provider prior to any notification from the division that it has reason to believe that the provider has received a payment to which he is not entitled. Said written notice shall state that the entry and filing provisions of this section are applicable only to those claims for which the division notifies the provider, subsequent to the date of said written notice, that payments are in dispute.
If the division’s determination, or an administrative review thereof, has become final and the amount overpaid remains unpaid in full or in part, the commissioner may file with the clerk of the municipal court of the city of Boston, or in the district court in the judicial district where the provider has his principal place of business, a certificate or a copy thereof under official seal, stating: the name and address of the provider, the amount owed to the commonwealth as overpayment and in default, that the time in which administrative or judicial review is permitted has expired without appeal having been taken, or, if a claim has been filed under section fourteen of chapter thirty A, that the division’s determination has not been stayed. Upon such filing of a certificate stating said information, such clerk shall assign a civil docket number to such certificate and enter judgment thereon in the civil docket as in a civil action. Such entry shall include the name of the provider identified in the certificate, the amount of such overpayment in default, and the date such certificate is filed. Such certificate shall be enforceable in the same manner and to the same extent as a judgment entered by a court of competent jurisdiction; provided, however, that the rules of court governing procedures in civil cases after the entry of judgment shall not apply to certificates entered as judgments as provided herein. Retroactive rate adjustments made to the rates of institutional providers pursuant to section thirty-two of chapter six A shall not be subject to the filing and entry dispositions of this section.
No physician shall submit a claim for goods or services rendered if said physician is a salaried employee of a hospital and the hospital submits a claim for such goods or services.
penalty Section 39. Any person or institution which knowingly makes a false representation or, contrary to a legal duty to do so, knowingly fails to disclose any material fact to the division or its agents affecting eligibility or level of benefits for the purpose of causing any person, including the person making such representations, to be supported in whole or in part by the commonwealth, or for the purpose of procuring a payment under any medical assistance program administered by the division, shall be punished by a fine of not less than two hundred nor more than five hundred dollars or by imprisonment for not more than one year.
Nothing in this section shall be construed as preventing the institution of criminal proceedings for the violation of any other law of the commonwealth.
providers; penalty Section 40. Any person who furnishes items or services for which payment may be made under this chapter, who: (1) knowingly and willfully makes or causes to be made any false statement or representation of a material fact in any application for any benefit or payment under this chapter; or (2) knowingly and willfully makes or causes to be made any false statement or representation of a material fact for use in determining rights to such benefit or payment; or (3) having knowledge of the occurrence of any event affecting his or her initial or continued right to any such benefit or payment, or the benefit of any other individual in whose behalf he or she has applied for or is receiving such benefit or payment, conceals or fails to disclose such an event with an intent fraudulently to secure such benefit or payment either in a greater amount or quantity than is due or when no such benefit or payment is authorized; or (4) having made application to receive any such benefit or payment for the use and benefit of another and having received it, knowingly and willfully converts such benefits or payment other than for the use and benefit of such person, shall be punished by a fine of not more than ten thousand dollars, or by imprisonment in the state prison for not more than five years or in a jail or house of correction for not more than two and one-half years, or by both such fine and imprisonment.
Any person who does not furnish items of services for which payment may be made under this chapter, who violates any of the provisions of clauses (1) to (4), inclusive, shall be punished by imprisonment in a jail or house of correction for not more than two and one-half years or by a fine of not more than five thousand dollars or by both such fine and imprisonment.
Section 41. Whoever solicits or receives any remuneration, including any bribe or rebate, directly or indirectly, overtly or covertly, in cash or in kind in return for purchasing, leasing, ordering or arranging for or recommending purchasing, leasing, or ordering any good, facility, service, or item for which payment may be made in whole or in part under this chapter, or whoever offers or pays any remuneration, including any bribe or rebate, directly or indirectly, overtly or covertly, in cash or in kind to induce such person to purchase, lease, order, or arrange for or recommend purchasing, leasing, or ordering any good, facility, service, or item for which payment may be made in whole or in part under this chapter shall be punished by a fine of not more than ten thousand dollars, or by imprisonment in the state prison for not more than five years or in a jail or house of correction for not more than two and one-half years, or by both such fine and imprisonment.
This section shall not apply to a discount or other reduction in price obtained by a provider of services or other entity under this chapter if the reduction in price is properly disclosed and appropriately reflected in the costs claimed or charges made by the provider or entity under this chapter or to any amount paid by an employer to an employee, who has a bona fide employment relationship with such employer, for employment in the provision of covered items or services.
Section 42. Whoever knowingly and willfully charges for any service provided to a patient under this chapter, money or other consideration at a rate in excess of the rates established in accordance with this chapter, shall be punished by a fine of not more than ten thousand dollars, or by imprisonment in the state prison for not more than five years or in a jail or house of correction for not more than two and one-half years, or by both such fine and imprisonment.
precondition for admission or continuance; penalty Section 43. Whoever knowingly and willfully charges, solicits, accepts or receives, in addition to any amount otherwise required to be paid under this chapter, any gift, money, donation, or other consideration as a precondition or guarantee of admitting a recipient of services under this chapter whether or not presently certified or otherwise lawfully approved for long term care, to a hospital or nursing facility or to expedite the admission of such recipient or as a requirement for such recipient’s continued stay in such a facility shall be punished by a fine of not more than ten thousand dollars or by imprisonment in the state prison for not more than five years or in a jail or house of correction for not more than two and one-half years or by both such fine and imprisonment.
Section 44. If any person violates the provisions of this chapter, the attorney general or a district attorney may bring a civil action, either in lieu of or in addition to a criminal prosecution, and recover three times the amount of damages sustained including the costs of investigation and litigation. No action shall be brought under this section more than six years after it accrues.
Section 45. Any action brought under this chapter may be filed in the district or superior courts of Suffolk county.
Section 46. The remedies in sections thirty-nine to forty-five, inclusive, are in addition to and do not supersede any other available remedies.
not in compliance with policies and procedures of medical assistance program; proof of clerical or administrative error Section 46A. Any provider making a claim for payment under any medical assistance program administered by the division, which is not submitted in compliance with the billing policies and procedures of said program, shall not be considered in violation of sections 39 to 46, inclusive, for purposes of eligibility pursuant to section 36, upon submission of proof, to the satisfaction of the commissioner, that the submission of the claim was due solely to a clerical or administrative error.
investigation; decision; rehearing; notice Section 47. Any applicant for or recipient of medical assistance, or the legal representative of such applicant or recipient, aggrieved by the failure of the division to grant medical assistance or by the failure of the division to approve or reject an application within the time limits established by section twenty-one or by the withdrawal of such assistance shall have a right to a hearing, after due notice, upon appeal to the division in the manner and form prescribed by the division; provided, however, such appeal is received by the division within thirty days after official notice of the action taken by the division has been received by the applicant or recipient. Such hearing shall be conducted by the commissioner of medical assistance or a referee designated by the commissioner within the board of hearings established under section forty-eight. The commissioner or the designated referee is hereby empowered to subpoena witnesses, administer oaths, take testimony and secure the production of such books, papers, records and documents as may be relevant to such hearings. The decision of the commissioner, or of the designated referee, small be the decision of the division. Such appeals, hearings, and decisions shall be subject to the provisions of section forty-eight.
The division may make such additional investigation as it may deem necessary and shall make such decision as to the granting of medical assistance and the amount of such assistance to be granted as in its opinion is justified and in conformity with the provisions of this chapter. Applicants or recipients affected by such decisions of the division shall, upon request, be given reasonable notice and opportunity for a hearing as provided under this section. The provisions relating to the conduct of hearings and decisions thereon made, as provided in this section, shall be equally applicable in all cases wherein the division acts upon its own motion.
The commissioner, or the referee designated by the commissioner, shall render and issue his or her decision within ninety days after the date of the filing of the appeal by the aggrieved applicant, or legal representative of an applicant. The commissioner, but not his or her designee, may for good cause shown, direct the director of the board of hearings to conduct a rehearing of the appeal. An order for such rehearing shall not be construed as indicating or implying any position by the commissioner on the merits of the appeal. The director shall send seven days’ written notice to all parties, including the date, time and place of such rehearing, which shall be held at a location convenient to the person appealing, and after such rehearing the director may, not later than thirty days after the order for such rehearing, issue a superseding decision.
Section 48. There shall be within the division a board of hearings for the purpose of holding the hearings referred to herein and rendering decisions. Said board shall be under the supervision of a director appointed by the commissioner and shall be independent of all other subdivisions and personnel of the division.
Any person aggrieved by the failure of the division to render adequate medical assistance under any program of medical assistance administered by the division or to approve or reject an application for medical assistance thereunder within forty-five days after receiving such application, or aggrieved by the withdrawal of such assistance, or by coercive or otherwise improper conduct on the part of his or her social worker, shall have a right to a hearing, after due notice, upon appeal to the commissioner.
A hearing held pursuant to this section shall be conducted by a referee designated by the director at a location convenient to the person appealing and shall be conducted as an adjudicatory proceeding under chapter thirty A. The director of the board of hearings shall be responsible for the fair and efficient operation of the board in conformity with state and federal laws and regulations and for the training of referees, scheduling of hearings and the compilation of decisions. Neither the director nor any other employee of the division shall review, interfere with, change or attempt to influence any hearing decision by a referee. A referee may subpoena witnesses, administer oaths, take testimony and secure the production of such books, papers, records and documents as may be relevant to such hearing. The person appealing shall have the opportunity to confront and cross-examine all adverse witnesses and to question or refute any testimony, evidence, materials, or legal arguments. The referee shall base his or her decision solely on the testimony, evidence, materials and legal rules adduced at the hearing. The referee may reopen a hearing for the purpose of considering further testimony, evidence, materials or legal rules before rendering his or her decision and shall, if he or she reopens the hearing, send seven days’ written notice to all parties of the reopening and the reasons therefor, including the date, time and place of the resumed hearing, which shall be held at a location convenient to the person appealing. The decision of the referee shall be the decision of the division.
A referee shall render and issue a decision within ninety days after the date of the filing of the aggrieved person’s appeal, except that when an aggrieved person appeals the rejection of his or her application for medical assistance, or the failure to act on said application, or the failure of the division to render emergency medical assistance, the referee shall render and issue a decision within forty-five days after the date of filing of said appeal. The decision of the division shall be subject to review in accordance with the provisions of chapter thirty A.
When a hearing is requested because of termination or reduction of assistance, involving an issue of fact, or of judgment relating to the individual case, between the agency and the appellant, assistance will be continued during the period of the appeal and through the end of the month in which the final decision on the hearing is reached. If assistance has been terminated prior to timely request for fair hearing, assistance will be reinstated.
Section 49. The use or disclosure of information concerning applicants and recipients shall be limited to purposes directly connected with the administration of the medical assistance programs established under this chapter and the names of applicants and recipients shall not be published.
underwriting of program Section 50. To the extent feasible the division may contract with one or more federal agencies or corporations authorized to do business in the commonwealth, including nonprofit hospital and medical service corporations, to carry out the necessary administrative functions of the medical assistance programs established under this chapter. The division may contract for the underwriting of all or any part of such medical assistance programs with such corporation.
processing and collection procedures; liability in civil actions Section 51. The division, in cooperation with the department of public health and in accordance with the regulations of the secretary, shall establish processes of utilization review for care or services for which medical assistance is available under this chapter.
The division shall establish data processing and collection procedures which will: (1) monitor eligibility of recipients; (2) assure that providers are neither paid twice for the same care or service nor paid in amounts in excess of fee schedules or other applicable limits; and (3) provide the statistical data necessary for effective utilization review.
A medical professional employee of the division, or person providing medical professional counsel or services to the division on a voluntary or paid basis or an employee of a division subcontractor, shall not be liable in a civil action for damages arising out of any act, omission, proceeding or undertaking in the performance, in good-faith, of duties or responsibilities relative to any utilization related activities authorized or established by this chapter or by regulations promulgated by the secretary.
development of new programs Section 52. The division, in cooperation with the department of public health, shall establish and maintain standards and conditions of participation for providers of all medical care and services for which medical assistance is available under this chapter.
The department of public health, in cooperation with the division shall: (1) plan for and stimulate the development of new medical resources and the expansion of existing resources; (2) stimulate and assist providers of health care and services to develop new and improved methods of delivery of services and payment for services; and (3) expand and increase the services of the department of public health to extend and improve, as far as is practicable, the availability and accessibility of the care and services for which medical assistance is available under this chapter to all recipients of medical assistance, and the coordination of these services in such manner that the best interests of the recipients are served.
Section 6. There shall be a medical care advisory committee which shall advise the executive office about health and medical care services. The committee shall have the opportunity to participate in policy development and program administration. The secretary of health and human services shall appoint members to the advisory committee on a rotating and continuous basis in such numbers and for such terms as the secretary of health and human services deems appropriate; provided that the committee shall include board-certified physicians and other representatives of the health professions who are familiar with the medical needs of low-income population groups and with the resources available and required for their care, members of consumers’ groups, including medical assistance recipients, and the commissioner of the department of public welfare.
The executive office shall provide the committee with such staff and technical assistance as is necessary to enable the committee to make effective recommendations, and such financial arrangements as are necessary to make possible the participation of recipient members.
Section 7. In addition to all powers conferred on state agencies, the division or the department of elder affairs, as appropriate shall have the following powers:a. to make, amend, and repeal rules and regulations for the management of its affairs;b. to make contracts and execute all instruments necessary or convenient for carrying out its business;c. to acquire, own, hold, dispose of, and encumber personal property and to lease real property in the exercise of its powers, and the performance of its duties;d. to enter into agreements or transactions with any federal, state, or municipal agency, or other public institution, or with any private individual, partnership, firm, corporation, association, or other entity;e. to charge and collect fees, rentals and other charges as reasonable and necessary for carrying out its business;f. to receive and administer any funds granted, given or bequeathed to its use or for a special purpose as indicated in the gift, grant, or order or decree of a court;g. to do all acts and things necessary or convenient to carry out the powers otherwise granted under this chapter; andh. to review, prior to implementation, any activity or policy of any agency within the executive office of human services involving the delivery of services reimbursable under this chapter, certification or licensure of providers of services under this chapter, or identification of individuals eligible for medical assistance under this chapter.
Section 8. As used in this chapter the following terms and phrases shall, unless the context clearly requires otherwise, have the following meanings:a. “Commissioner”, the commissioner of medical assistance or the secretary of elder affairs, as appropriate.
a1/2. “Department”, the department of elder affairs.
a3/4. “Division”, the division of medical assistance within the executive office of health and human services; but for the purposes of sections 9 to 52, inclusive, a reference to the word “division” shall mean the department of elder affairs, whenever appropriate.
b. “Executive office”, the executive office of health and human services.
b1/2. “Institution”, a licensed hospital, nursing home or public medical institution that meets the requirements of the secretary.
c. “Medicaid”, the jointly funded state and federal medical assistance program established pursuant to Title XIX under section nine of this chapter.
d. “Medical assistance”, payment by the department, or its agent, or any predecessor or successor agency, of all or part of the cost of the medical care and services provided to recipients of any program established under this chapter, but not including benefits provided under section nine A.
d1/2. “Medical benefits”, benefits provided under section nine A.
e. “Person”, any individual who resides in the commonwealth, or any individual residing outside the commonwealth who is deemed to be a resident of the commonwealth under Title XIX.
f. “Provider”, any institution, agency, individual, or other legal entity qualified under the laws of the commonwealth to perform the medical care or services for which medical assistance and medical benefits are available under this chapter.
g. “Public medical institution”, any medical institution supported in whole or in part by public funds, either federal, state or municipal staffed by professional, medical and nursing personnel and providing medical care, in accordance with standards established through licensing or approval by the department of public health.
h. “Reside”, to occupy an established place of abode with no present intention of definite and early removal, but not necessarily with the intention of remaining permanently, but in no event shall the word “reside” be construed more restrictively or less restrictively than as defined by the Secretary under Title XIX.
Confinement of a person in any nursing home, hospital, or other medical institution in the commonwealth shall not, in and of itself, be sufficient evidence to qualify such person as a resident under this chapter.
i. “Secretary”, the Secretary of the United States Department of Health and Human Services, except as that term is used in section two of this chapter.
j. “Title XIX”, Title XIX of the Social Security Act, 42 U.
S.
C. 1396 et seq. or any successor thereto.
k. “Title XXI”, Title XXI of the Social Security Act, 42 USC 1397 et seq. or any successor thereto.
Section 9. There is hereby established, pursuant to and in conformity with the provisions of Title XIX, a program of medical assistance, hereafter referred to in this chapter as Medicaid, for certain residents of the commonwealth.
Medicaid benefits shall be available to all persons eligible for financial assistance under the provisions of chapter one hundred and eighteen and Title IV of the Social Security Act and to all persons who are eligible for supplemental security income payments on account of age, disability or blindness under the provisions of Title XVI of said Social Security Act or for assistance under the provisions of chapter one hundred and eighteen A. Such benefits may also be made available to other persons who would be eligible for financial assistance under any of the foregoing provisions but for income or resources, provided that such persons meet the financial eligibility requirements of Title XIX; provided, further, that said benefits shall be available to otherwise eligible persons seeking admission to and residents of long-term care facilities whose income and resources are insufficient to meet the cost of their medical care as determined by the financial eligibility requirements of said program. Benefits shall be made available to qualifying individuals as described in section 1933 of the Social Security Act (42 U.
S.
C. Sec.
1396u-3). The division may charge premiums to eligible persons as a condition of receiving benefits, to the extent permitted by Title XIX. The division shall establish the premiums based on a sliding scale commensurate with beneficiary income levels.
payment; information applications Section 9A. (1) As used in this section and in section nine B, the following words shall have the following meanings:“Beneficiary”, a person who, pursuant to eligibility criteria established by the terms and conditions of a demonstration project and regulations promulgated by the division, is determined to be eligible for medical benefits pursuant to this section.
“Demonstration project”, (i) a program of medical benefits approved by the Secretary pursuant to section 1115(a) of the Social Security Act, 42 USC Section 1315(a); or (ii) a project approved by said secretary for which federal reimbursement is available pursuant to any successor to Title XIX if such project is similar to any such project approved or which would be approved under said section 1115(a), meets their requirements for a demonstration project established by this section and is implemented pursuant to a plan filed with the joint committee on health care and the house and senate committees on ways and means sixty days prior to implementation.
“Expansion beneficiaries”, beneficiaries whose eligibility for medical benefits is established by clauses (b) to (g), inclusive, or clause (i) of subsection (2) according to the terms and conditions of the demonstration project and who otherwise would not be eligible for medical assistance pursuant to section 9 in the absence of said demonstration project.
“Children’s and Seniors’ Health Care Assistance Fund”, the fund established by section two FF of chapter twenty-nine intended to wholly support the costs of medical benefits and administration for expansion beneficiaries under the demonstration project and a pilot program of pharmaceutical assistance for the elderly.
“Program of health care assistance”, programs of full or partial medical care funded wholly by the commonwealth for which the demonstration project seeks federal reimbursement.
“MassHealth”, a program of full or partial medical benefits provided under the demonstration project as authorized by this section.
“Medical benefits”, health care services including managed care programs, provided to beneficiaries pursuant to the terms and conditions of a demonstration project and regulations promulgated by the division and including, but not limited to, medical insurance purchased for beneficiaries pursuant to section eighteen or benefits authorized by 42 USC 1396e.
“Traditional beneficiaries”, persons whose eligibility for Medicaid would otherwise be established by section nine and the eligibility criteria established by the Medicaid state plan in effect on July first, nineteen hundred and ninety-six in the absence of the demonstration project, including beneficiaries, as of said date, (i) eligible for financial assistance under the provisions of chapter one hundred and eighteen and Title IV of the Social Security Act, 42 USC Section 601 et seq.
, as it may be amended or altered from time to time through the implementation of a waiver or project approved by the secretary; (ii) eligible for supplemental security income payments on account of disability or blindness under the provisions of Title XVI of the Social Security Act, 42 USC Section 1381 et seq.
, or for financial assistance under the provisions of chapter one hundred and eighteen A, except where applicable provisions of Title XIX, if not waived under the demonstration project, would render such persons ineligible for Medicaid; (iii) persons who would be eligible for financial assistance under clause (i) or (ii) but for income or resources and who meet the financial eligibility requirements established by the division under MassHealth; and (iv) persons who are otherwise eligible for Medicaid pursuant to any other eligibility criteria established by the state plan in effect on said July first.
(2) The division may, subject to appropriation and the provisions of section nine B, implement MassHealth in accordance with the terms and conditions of a demonstration project, notwithstanding the provisions of any other section of this chapter. MassHealth may provide a program or programs of medical benefits to one or more of the beneficiary categories described in the following clauses:(a) children and adults who, in the absence of a demonstration project, would be otherwise eligible for medical assistance pursuant to section nine;(b) infants to age one and pregnant women whose financial eligibility as determined by the division does not exceed 200 per cent of the federal poverty level, and children and adolescents aged one to 18 years, inclusive, whose financial eligibility as determined by the division does not exceed 133 per cent of the federal poverty level and who would otherwise not qualify for Medicaid within the definition of traditional beneficiaries;(c) children and adolescents aged one to 18 years, inclusive, whose financial eligibility as determined by the division exceeds 133 per cent of the federal poverty level but is not more than 200 per cent of the federal poverty level, including such children and adolescents made eligible for medical benefits under this chapter by Title XXI of the Social Security Act.
(d) adults 19 to 64, inclusive, whose financial eligibility as determined by the division does not exceed 133 per cent of the federal poverty level and who otherwise would not qualify for Medicaid within the definition of traditional beneficiaries; provided, however, that said adults shall meet such other eligibility criteria that the division and the secretary may establish, including, but not limited to, the presence of dependent children in the household.
(e) persons who are disabled, blind or chronically ill and eligible for benefits under the provisions of sections 16 and 16A.
(f) persons receiving, or eligible to receive, unemployment insurance benefits who meet the eligibility requirements established under MassHealth and who, in the absence of a demonstration project, would otherwise qualify for the health insurance program established pursuant to subsection (1) of section fourteen G of chapter one hundred and fifty-one A;[Clause (g) of subsection (2) effective until April 1, 2003. For text effective April 1, 2003, see below.
] (g) persons who are not receiving unemployment insurance benefits and who are not eligible for medical assistance but who are determined by the division to be long-term unemployed, out of the labor force, provided, however, that such persons meet the eligibility requirements established under MassHealth; provided, further, that such eligibility requirements shall not exclude from eligibility persons who are employed intermittently or on a non-regular basis;[Clause (g) of subsection (2) as amended by 2002, 184, Sec. 95 effective April 1, 2003, provided that the secretary of the United States Department of Health and Human Services has approved an amendment to the demonstration waiver, as approved pursuant to 42 U.
S.
C. § 1315(a) and authorized by 1996, 203, incorporating the provision of 118E:9A(2)(g), as amended by 2002, 184, Sec. 95. See 2002, 184, Sec. 244. For text effective until April 1, 2003, see above.
] (g) persons who: (i) are recipients of emergency assistance to the elderly, disabled, and children; or (ii) persons who are determined by the commissioner of the department of mental health to be classified as clients of the department of mental health; provided that such persons meet the eligibility requirements established under MassHealth and that their financial eligibility as determined by the division does not exceed 100 per cent of the poverty level.
(h) persons who would be eligible for financial or medical assistance under the foregoing clauses, but for income or resources, except where the terms and conditions of the demonstration project provide for more restrictive or less restrictive eligibility criteria, including the payment of premiums as a condition of eligibility.
(i) persons who have tested positive for the human immunodeficiency virus whose financial eligibility as determined by the division does not exceed 133 per cent of the federal poverty level.
(3) The division may, consistent with the terms and conditions of the demonstration project, deny MassHealth eligibility to persons who would otherwise qualify for a program of medical benefits pursuant to clause (c) of subsection 2 who were enrolled in a health insurance plan not administered by the state or federal government at any time during the eighteen months prior to applying to MassHealth, and may deny MassHealth eligibility to persons in any or all of eligibility categories as set forth in clauses (a) to (i), inclusive, who: (i) at the time of application, are eligible for health insurance, or (ii) do not meet citizenship or residency requirements established by the division, provided that any person whose residency in the commonwealth was established solely for the purpose of seeking medical benefits shall not be eligible for MassHealth.
(4) The terms and conditions of the demonstration project shall provide that the division may, for any and all beneficiary categories, vary the amount, duration, and scope of medical benefits, establish differing managed care options, and restrict the freedom of beneficiaries to choose health care providers.
(5) Medical benefits provided by MassHealth to school-aged children and adolescents shall, as much as reasonably practical, be provided by school-based clinics.
(6) Medical benefits provided under this section shall replace medical assistance provided under section nine, except that persons eligible for supplemental security income payments on account of age under the provisions of Title XVI of the Social Security Act, 42 USC Section 1381 et seq.
, and persons who would be eligible for such payments on account of age but for income or resources, shall continue to receive medical assistance under said section nine. The division shall not eliminate the retroactive eligibility period allowed traditional beneficiaries until sixty days after the commissioner has certified to the Secretary of Human Services and the house and senate committees on ways and means that the division has fully implemented its streamlined eligibility process, including a simplified application and an expedited process for applicants in immediate need of services. The division shall not eliminate retroactive eligibility for applicants over the age of sixty-five or for institutionalized applicants or applicants who have been hospitalized for more than twenty days or who have been resident in a nursing home for more than thirty days.
(7) The provisions of Title XIX shall remain applicable to MassHealth except as waived or supplemented by the secretary under the terms and conditions of the demonstration project.
(8) Consistent with the provisions of Title XIX and any waiver authority therein, the division may establish premium and copayment amounts for beneficiaries of MassHealth. Said premiums and copayments may be established on a sliding scale commensurate with beneficiary income levels. The division may waive premiums and copayments upon a finding of substantial financial or medical hardship.
(9) Unless explicitly provided under the demonstration project, nothing in this section shall be construed as requiring direct payment of any kind to any beneficiary. The division may make such direct payment, as it deems necessary, to (i) pay for covered medical benefits received between the date of effective eligibility and, if later, the date of determination of eligibility, (ii) correct errors made by the division, or (iii) comply with a court order; provided, that the division may, in lieu of cash payments, issue to individuals vouchers or other documents certifying that the division will pay a specified amount for health insurance under specified circumstances.
(10) If, during the term of the demonstration project, the division proposes modifications to MassHealth which would require approval by the secretary, the division may implement said modifications upon the secretary’s approval, subject to the terms of that approval, and the enactment of authorizing legislation, if required.
(11) The division may implement provisions of the demonstration project through arrangements with other agencies of the commonwealth, including agencies that administered programs of health care assistance for expansion beneficiaries prior to implementation of the demonstration project, provided, that the division shall have final authority over all policies and procedures pertaining to the administration of the demonstration project. Such agencies shall furnish any information and data pertaining to MassHealth programs, providers, health insurers and beneficiaries deemed necessary by the commissioner to implement and monitor MassHealth. Upon the termination of the demonstration project, authority ceded to the division for the administration of MassHealth shall revert to such other agencies as provided by law.
(12) The division shall maintain comprehensive information on MassHealth medical benefits and eligibility requirements and shall make applications readily accessible to persons eligible for said benefits at a reasonable number of locations throughout the commonwealth. Said locations shall be equipped to provide all required eligibility information, benefit schedules and limitations, application forms and other information associated with remaining eligible for MassHealth. The division shall, whenever possible, utilize one standard application form and procedure for all MassHealth services and programs. Applicants who do not meet the eligibility requirements of a program for which they apply shall be informed of other programs for which they may qualify and be provided with all necessary forms and information required for such other programs. The division, when arranging for the implementation of programs with other agencies of the commonwealth, shall ensure that such other agencies meet the intent of this paragraph.
(13) Eligibility for and the medical benefits provided by MassHealth shall not give rise to nor be construed as giving rise to enforceable legal rights for any party or an enforceable entitlement to such eligibility or medical benefits other than to the extent that such rights or entitlements exist pursuant to the regulations of the division or the terms and conditions of the demonstration project.
(14) The terms and conditions of the demonstration project shall not establish any rights or entitlements that exceed the rights or entitlements established by Title XIX in the absence of the demonstration project, or impose any obligations upon the commonwealth’s administration or financing because of implementation of MassHealth which is in excess of the obligations established by Title XIX for the state Medicaid program in the absence of the demonstration project. The commissioner shall, prior to the initial implementation of MassHealth, certify to the secretary of administration and finance and the house and senate committees on ways and means that no such terms, conditions or obligations have been established by the demonstration project that would violate the provisions of this paragraph.
neutrality certification; projected expenditure and revenue reports; beneficiary distinctions Section 9B. (1) In any fiscal year, the participation of the commonwealth in the demonstration project shall be contingent upon a finding of budget neutrality by the commissioner. Said budget neutrality finding shall be certified by establishing: (a) that MassHealth expenditures for expansion beneficiaries are within the amounts appropriated therefor and (b) that revenues credited and other amounts transferred to the Children’s and Seniors’ Health Care Assistance Fund are sufficient by themselves to meet expenditures for expansion beneficiaries in each fiscal year without requiring additional amounts to be appropriated or transferred from the General Fund or from any other fiscal resource of the commonwealth. Said finding shall be separate and apart from any budget neutrality tests required to maintain federal support for the demonstration project.
Said budget neutrality finding shall be based upon the information developed pursuant to subsection (2), as said information is updated pursuant to subsection (3) and as analyzed pursuant to the provisions of subsection (4). Reports containing such information shall be filed by the commissioner with the secretary of administration and finance and the house and senate committees on ways and means as directed by said subsections.
For purposes of this section, the division may establish a methodology for projecting estimates of caseload, expenditures and revenues, in order to distinguish between traditional and expansion beneficiaries, by using proxies and other conventions in order to account for changes in eligibility criteria implemented under the demonstration project that make it difficult to compare caseload, expenditures and revenue estimates under the demonstration project, provided that said methodology is explicitly stated by the division in any report required by this section.
(2) Not less than sixty days prior to the need for an appropriation to implement MassHealth, the division shall file a report that establishes projected base year expenditures for Medicaid and other programs of health care assistance as they were administered prior to the demonstration project and for which federal reimbursement is approved under the demonstration project. In establishing said base year expenditures, the division shall rely upon date-of-service expenditures for the most recently completed fiscal year. Said report shall further include the following information: (a) a five year expenditure projection, for each Medicaid category of assistance and each program of health care assistance that would have been incurred but for the implementation of the demonstration project; provided, however, that said projections are stated on a date-of-service basis and a date-of-payment basis for each state fiscal year for which said report is making projections, and provided, further, that said projections are based on the average rates of inflation and caseload growth in the base year and the preceding two fiscal years; (b) a five year projection of expenditures for each eligibility category qualified to enroll in the demonstration project as identified in subsection (2) of section nine A that shall explicitly distinguish expenditures on behalf of traditional beneficiaries from expenditures on behalf of each category of expansion beneficiary eligible to enroll in the demonstration project; (c) a five year projection of administrative costs that distinguishes one-time start-up costs from on-going costs and compares such costs to the costs that would have been incurred in the absence of the demonstration project; and (d) a five year projection of all revenues anticipated to be credited to the Children’s and Seniors’ Health Care Assistance Fund, including, but not limited to, tax revenues, premium contributions and federal reimbursements. Said report shall explicitly state all assumptions used in making such projections, including, but not limited to, caseload change, utilization rates, payment rates and any other factors that normally affect health care expenditures of the commonwealth. The expenditures stated in said report shall serve as the basis for advising the general court on the appropriations necessary to make MassHealth budget neutral, as defined herein, in each fiscal year and for conducting said annual budget neutrality test. The commissioner shall obtain the concurrence of the comptroller and the revenue commissioner with said revenue projections required by clause (d).
(3) Expenditure and revenue projections required by subsection (2) shall be updated semiannually based on actual expenditures and revenues of the demonstration project. Said updates shall be made available in sufficient time to advise the annual appropriations process for the operating budget of the commonwealth, provided that said updates shall be available no later than the first Wednesday in November for purposes of the governor’s budget recommendations pursuant to section seven H of chapter twenty-nine and by the first Wednesday in March for assisting the general court in making annual appropriations for the demonstration project. Said updates shall identify the reasons for any variations between any such expenditure and revenue projections and actual expenditures and revenues of the demonstration project and the risks, if any, that such variations pose to the budget neutrality of the demonstration project.
(4) The commissioner shall make the budget neutrality finding required by subsection (1) in a letter of certification that shall accompany the semi-annual update required by subsection (3). Said letter shall certify whether expenditures of the demonstration project for expansion beneficiaries exceed the amounts available therefor and whether revenues and appropriations credited to the Children’s and Seniors’ Health Care Assistance Fund are sufficient to fully support the costs of medical benefits for expansion beneficiaries in the current and subsequent fiscal year.
(5) In the event that said budget neutrality finding is unable to be certified pursuant to subsection (1), the commissioner shall notify the secretary that the commonwealth intends to withdraw from participation in the demonstration project within the time required by the Secretary, or ninety days, whichever is longer. Copies of said termination notice shall be submitted to the secretary of administration and finance and the house and senate committees on ways and means and the joint committee on health care. The commissioner may, prior to initiating said termination notice, file with said parties a plan of corrective action intended to produce budget neutrality within a specified time. Said plan may propose adjustments to any aspect of MassHealth, within the terms and conditions of the demonstration project, that the commissioner determines necessary to produce budget neutrality, including, but not limited to, the initiation of applicant waiting lists, eligibility limitations, changes to federal poverty levels, reductions in the amount, scope and duration of medical benefits, adjustments to or the imposition of beneficiary premium, copayment or other cost-sharing requirements, or revisions to provider billing deadlines, rates, payment schedules or other conditions of provider participation. If budget neutrality is not achieved within the time stipulated by the plan of corrective action, the commissioner shall notify said secretary and committees and initiate the termination notice to the secretary. In the event the commonwealth withdraws from participation in the demonstration project, beneficiaries may, subject to the availability of funds therefor, re-enroll in Medicaid or any program of health care assistance for which they would have qualified in the absence of a demonstration project.
(6) Notwithstanding the provisions of any general or special law to the contrary, the budget recommendations filed by the governor with the general court pursuant to section seven H of chapter twenty-nine shall recommend separate items of appropriation for the medical benefits to be provided to traditional beneficiaries and expansion beneficiaries in the next fiscal year. The revenue projections filed with said recommendations shall separately identify the federal reimbursements associated with traditional beneficiaries and expansion beneficiaries in the next fiscal year. Said budget recommendations shall separately identify the amounts projected to be expended for administrative expenses associated with the demonstration project.
(7) The annual appropriation act for each fiscal year shall make separate appropriations for the costs of medical benefits to be provided to traditional beneficiaries and expansion beneficiaries. Amounts appropriated for traditional beneficiaries shall be appropriated from the General Fund against which expenditures for said beneficiaries shall be charged. Amounts appropriated for expansion beneficiaries shall be charged to the General Fund only up to the amount that would otherwise have been appropriated for expansion beneficiaries in the absence of demonstration project as stated in the report required by clause (a) of subsection (2). Any remaining amounts necessary to meet the costs of medical benefits for expansion beneficiaries shall be appropriated from the Children’s and Seniors’ Health Care Assistance Fund.
(8) The division shall establish an allocation method to account separately for the costs of medical benefits incurred by traditional beneficiaries and by expansion beneficiaries. The division shall separately account for all revenues attributable to traditional beneficiaries and expansion beneficiaries, including, but not limited to, the federal reimbursements authorized under the demonstration project for expansion beneficiaries. The comptroller is hereby authorized and directed to establish in the state accounting system a means of identifying such separately identified expenditures and revenues.
(9) The comptroller is hereby authorized and directed to transfer amounts appropriated from the General Fund or any other fiscal resource of the commonwealth for expansion beneficiaries to the Children’s and Seniors’ Health Care Assistance Fund. Federal reimbursement generated by medical benefits provided to expansion beneficiaries shall be credited to said fund and shall be available for subsequent appropriation for said expansion beneficiaries. The comptroller is hereby further authorized and directed to notify the commissioner, the secretary of administration and finance and the house and senate committees on ways and means whenever the revenues and appropriations credited to said fund are projected to be insufficient to meet the actual and projected expenditures incurred on behalf of expansion beneficiaries in the fiscal year of the next fiscal year. The comptroller shall assist the commissioner in preparing the budget neutrality finding required by subsection (1).
definitions; eligibility; expenditures; submission of plans [Text of section effective as provided by 1997, 47, Sec. 36 as amended by 2003, 9, Sec. 37.
] Section 9C. (1) For purposes of this section, the following words shall have the following meanings:—“Eligible employer”, (i) an individual or an unincorporated business that employs one or more residents of the commonwealth, (ii) a corporation, including a foreign corporation, other than a governmental entity, that employs at least one or more residents of the commonwealth, or (iii) a corporation or an unincorporated entity that is exempt from taxation under the provisions of section 501(c) of the Internal Revenue Code of the United States, as amended and in effect for the taxable year; provided however, that to be eligible said employer employs no more than 50 employees and meets the eligibility requirements set forth in this section and in regulations promulgated by the division; and provided, further, that the method of determining the number of employees an employer has and the amount and types subsidies available to an eligible employer based upon employee family status shall be determined by the division.
“Eligible employee”, (i) an employee of an eligible employer; (ii) who resides in the commonwealth; (iii) who has not attained age 65; and (iv) who meets the financial and other eligibility standards set forth in regulations promulgated by the division; provided, however, that the gross family income standard shall not exceed 200 per cent of the federal poverty level.
“Eligible self-employed single individual”, a person with or without dependents (i) who receives any gross income from self-employment; (ii) who resides in the commonwealth; (iii) who has not attained age 65; and (iv) who meets the financial and other eligibility standards set forth in regulations promulgated by the division, provided that the gross family income standard shall not exceed 200 per cent of the federal poverty level.
“Eligible self-employed husband and wife”, a married couple with or without dependents (i) where either spouse receives any gross income from self employment; (ii) where both spouses reside in the commonwealth; (iii) where neither spouse has attained age 65; and (iv) who meets the financial and other eligibility standards set forth in regulations promulgated by the division, provided that the gross family income standard shall not exceed 200 per cent of the federal poverty level.
“Qualified medical insurance”, shall mean “qualified medical insurance”, “qualified individual medical insurance”, “qualified two-person family medical insurance” and “qualified family medical insurance” as defined in regulations promulgated by the commissioner of insurance pursuant to section 3C of chapter 175.
(2) The division may, subject to the provisions of this section, establish an insurance reimbursement program for certain employees and employers for the purpose of reducing or eliminating the amount of contributions or payments made by such employees and employers toward the cost of qualified medical insurance and which shall consist of the following three programs:(A) an employee subsidy program to assist eligible employees with reducing or eliminating their contribution to premiums or other employment-based costs of qualified medical insurance provided by an eligible employer for which said employer pays not less than 50 per cent of said premium or cost; and provided, further, that the amount of said subsidies may vary with the contribution of said employees to the cost of their qualified medical insurance, and with the income of said employees and their families, in accordance with one or more sliding fee schedules set forth in regulations promulgated by the division and may be paid directly to or on behalf of said eligible employees.
(B) a subsidy program to assist the self-employed single individual and the self-employed husband and wife with reducing or eliminating the cost of premiums or other costs of purchasing qualified medical insurance; provided, further, that the amount of said subsidies may vary with the income or insurance costs of said persons and their families in accordance with one or more sliding fee schedules set forth in regulations promulgated by the division and may be paid directly to or on behalf of said persons; and provided further, the division may choose various options in establishing said program, including but not limited to establishing, (i) subsidies for the self employed which may be for an amount which incorporates payments otherwise available to such self-employed individual or spouse under subsection (5); (ii) sliding fee schedules that may incorporate such payments; or (iii) sliding fee schedules which may be otherwise adjusted so that such persons receive overall assistance comparable, but not necessarily identical, in its effect to that received by similarly situated eligible employees under the program established under paragraph (A).
(C) an employer health care incentive program for the purpose of reducing the cost to said employers of providing or maintaining qualified medical insurance for their eligible low-income employees; provided, however, that said eligible employer pays 50 per cent or more of the premium cost of such qualified medical insurance; and provided, further, that the division may limit payments under this program, using a reasonable methodology, in relation to the participation of said employer’s employees in the subsidy program provided for in paragraph (A).
(3) The subsidy programs described in paragraphs (A) and (B) of subsection (2) shall constitute additional medical benefits to expansion beneficiaries in accordance with the terms and conditions of a demonstration project as defined in subsection (1) of section 9A. The division may, subject to the terms and conditions of said demonstration project, include in the demonstration project the program described in paragraph (C) of subsection (2); provided, however, that the division may implement said program if it is not included within said demonstration project.
(4) The amount of payments for each employer under paragraph (C) of subsection (2) shall be as follows: (i) $400 for each eligible employee for whom the eligible employer pays 50 per cent or more of the cost of qualified individual medical insurance; (ii) $800 for each eligible employee for whom the eligible employer pays 50 per cent or more of the cost of qualified two-person family medical insurance, and (iii) $1,000 for each eligible employee for whom the eligible employer pays 50 per cent or more of the cost of qualified family medical insurance; provided that the division may use any reasonable data sources in determining the number of eligible employees of an eligible employer qualifying for such payments under clauses (i), (ii) and (iii).
(5) The amount of payments for each self-employed single individual or each self-employed husband and wife under paragraph (B) of subsection (2) may include the following amounts: (i) $400 for an eligible self-employed single individual if the individual purchases qualified individual medical insurance; (ii) $800 for an eligible self-employed single individual with a dependent child or for an eligible self-employed husband and wife filing a joint return and who have no dependent children, if the individual or husband and wife purchase qualified two-person family medical insurance; or (iii) $1,000 for an eligible self-employed single individual with two or more dependent children, or for an eligible self-employed husband and wife filing a joint return and who have dependent children, if the individual or the husband and wife purchase qualified family medical insurance; provided that the payment shall not exceed the amount of the net premium cost to said self-employed persons of said insurance, and shall be in conformity with the regulations of the division.
(6) The division may require, as a condition for receiving benefits under this section and solely for the purposes of determining the eligibility of any employee, self-employed single individual, or self-employed husband and wife, the consent of any applicant to the disclosure to the division and to the United States Department of Health and Human Services pursuant to subsection (10) of prior year’s tax information and any other information demonstrating the income level of such persons. The division may employ additional eligibility criteria to ensure, where appropriate, that no person or employer receives payments or assistance under more than one category of persons or employers eligible for payment or assistance.
(7) The income and other eligibility requirements for the programs provided under subsection (1) may be modified from time to time to ensure that projected expenditures for such benefits are within the amounts available and within the amounts projected to be available. The division shall set forth in regulations changes in eligibility requirements, including changes necessary to ensure compliance with the budget neutrality requirements of section 9B.
(8) The division may, in lieu of cash payments or otherwise, issue to individuals vouchers or other documents certifying that the division will pay a specified amount for medical insurance under specified circumstances.
(9) If, during the term of the demonstration project as it pertains to programs authorized under this section, the division proposes modifications to the demonstration project which require approval by the Secretary, the division may implement said modifications upon the Secretary’s approval, subject to the terms of that approval, and, if required, the enactment of authorizing legislation.
(10) Data and information obtained by the division pursuant to subsection (6) to determine eligibility under this chapter shall be available for inspection by the Secretary or his delegate for the specific purpose of substantiating expenditures made under this section.
(11) The division may implement the provisions of this section through arrangements with other agencies of the commonwealth, including the department of revenue, as provided in subsection (11) of section 9A.
(12) The provisions of this section shall not give rise to, nor be construed as giving rise to, enforceable legal rights for any party or an enforceable entitlement to benefits other than to the extent that such rights or entitlements exist pursuant to the regulations of the commissioner of insurance and the regulations of the commissioner of revenue under the provisions referenced in subsection (1), the regulations of the division, or the terms and conditions of the demonstration project.
(13) Expenditures under this section shall, subject to appropriation, be funded by the MassHealth insurance reimbursement program account established by subsection (c) of section 18 of chapter 118G. Aggregate expenditures made by the division for said insurance reimbursement program shall not exceed $120,000,000 in any fiscal year, nor exceed $56,000,000 in the fiscal year when said program commences and shall be further subject to the requirements of the budget neutrality plan established by section 9B.
(14) Ninety days prior to implementing one or more of the programs under this section, the division shall provide a plan or plans for implementing said programs to the committee on health care and to the house and senate committee on ways and means. Said programs may be offered separately and implemented at different times, and a plan relative to each program may be submitted separately.
organizations; enrollment choices; advisory committee; report Section 9D. (a) As used in this section, the following words shall have the following meanings:—“Aging services access point” or “ASAP”, any agency designated by the executive office of elder affairs pursuant to section 4B of chapter 19A.
“Capitation”, a set dollar payment per enrollee per month that the division pays to a senior care organization to cover a specified set of services and administrative costs without regard to the actual number of services provided.
“Complex care”, care for an enrollee who is unable to independently perform, without human assistance or cueing, two or more activities of daily living or who is determined to be in need of continuous behavioral health or social services to maintain minimal daily independent functioning. Such care shall address enrollee needs, including any condition or situation that requires coordination of multiple senior care organization services.
“Dually eligible”, any person, aged 65 or older, who is simultaneously qualified for full benefits under Title XIX of the Social Security Act, 42 U.
S.
C 1396 et seq.
, and Title XVIII of the Social Security Act, 42 U.
S.
C 1395 et seq.
“Enrollee”, any dually eligible or MassHealth-only member, aged 65 or older, who is voluntarily enrolled in a senior care organization in accordance with the enrollment criteria as established by the division of medical assistance.
“Geriatric support services coordinator”, a member of a senior care organization primary care team who is employed by an aging services access point, is qualified to conduct and is responsible for arranging, coordinating and authorizing the provision of appropriate community long-term care and social support services.
“MassHealth Senior Care Options”, a program of medical, health and support services covered under Title XIX or Title XVIII of the Social Security Act, provided through senior care organizations. “Medically necessary”, as defined by the division of medical assistance.
“Medicare”, the federal health insurance program for elderly and disabled persons, and persons with kidney failure established pursuant to Title XVIII of the Social Security Act, 42 U.
S.
C 1395 et seq.
“Primary care team”, a team of health and long-term care professionals established by the senior care organization. Primary care teams shall consist of a primary care physician working in conjunction with a nurse practitioner, registered nurse or physician’s assistant, a geriatric support services coordinator, and other professionals designated by the senior care organization.
“Senior care organization” or “SCO”, a comprehensive network of medical, health care and social service providers that integrates all components of care, either directly or through subcontracts. SCOs will be responsible for providing enrollees with the full continuum of Medicare and MassHealth covered services.
(b) Notwithstanding any general or special law to the contrary, the division may, subject to appropriation and the availability of federal financial participation and pursuant to a memorandum of understanding with the federal Health Care Financing Administration, establish a program of medical and long-term care benefits, known as the MassHealth senior care options initiative for Massachusetts residents, aged 65 and over, who are dually eligible or only eligible for benefits under Title XIX of the Social Security Act. The division may contract with entities, to be known as senior care organizations or SCOs, to provide or arrange to provide a comprehensive network of medical, health care and social services that integrates all components of care, either directly or through subcontracts.
(c) The division shall ensure that enrollment in the program is voluntary. No disincentives for selecting a fee-for-service delivery system shall be included as part of any agreement or waiver regarding the program. The division shall ensure that all enrollees in a SCO have the right to disenroll from the program in any month upon submitting a notice of disenrollment to the division or contracted entity. Disenrollment notices received by the division or contracted entity by the twentieth day of the month shall be effective the first day of the following month.
(d) The benefits provided to persons considered eligible to enroll in the SCO shall include those services covered by Medicare Part A and Part B; the amount, duration and scope of Medicaid-covered services shall be at a minimum no more restrictive than the scope of services provided under MassHealth standard coverage, and shall include services covered under the home and community-based services waiver program; and services necessary for the treatment of mental health or substance abuse.
(e)(1) During the first 3 years of the demonstration project, a SCO shall conform to the minimum medical loss ratio as established by the division for its category. At the end of each fiscal year, the SCO shall provide to the division an audited statement of its medical loss ratio for the past year. Two years after the implementation of the SCO demonstration project, the division shall have 6 months to review the data and audited statements and shall have an additional 6 months to implement revised loss ratios. Beginning the fourth year of the demonstration project and upon renewal of the contract with the division, a SCO shall conform to the revised minimum medical loss ratio as established by the division for its category. Beginning the fourth year of the demonstration project and upon renewal of the contract with the division, if a SCO’s audited medical loss ratio is below the minimum as determined by the division for its category, the SCO shall provide additional benefits or services to its enrollees in the following contract year in an amount that would raise its medical loss ratio to the minimum level established by the division for its category, and shall submit a plan to the division detailing how such benefits or services shall be provided to its plan enrollees.
(2) Not later than the end of the first year of operation as a SCO, the division shall require that all SCOs, with whom the division contracts to deliver such services, establish SCO consumer advisory councils. Such councils shall monitor and make recommendations for the SCOs services delivered under this program and shall be represented by members of its enrolled population, or family members or unpaid caregivers of its enrolled population. The chair or his designee of the SCO consumer advisory council shall have a seat on the board of the SCO and a seat on the division of medical assistance’s SCO advisory committee as created under subsection (m).
(3) The division shall educate consumers and their families as to their enrollment choices under MassHealth senior care options and other available alternatives under Medicare and Medicaid. Neither SCOs nor the division shall offer gifts, payments or other inducements to enroll seniors in a SCO. The division shall also perform outreach services to local councils on aging and other related organizations to educate those councils and organizations on the details of the SCO demonstration project, including, but not limited to, providing the councils and organizations with the SCO educational materials listed in paragraph (4).
(4) The division shall deliver to all prospective enrollees SCO educational materials that shall include, but not be limited to: a definition of a SCO and how it functions; enrollment eligibility standards; the location of SCOs; a complete list of their participating providers; the range of available services; consumer rights under Medicare and Medicaid; an assistance worksheet for determining health care options under MassHealth senior care options, Medicare and Medicaid; and quality of care measurements reported to the division.
(5) The SCO shall be required to evaluate all its enrollees to determine if an enrollee has complex care needs within 30 days of initial enrollment, as well as on an annual basis, or as requested by the enrollee’s primary care physician, or as requested by the enrollee or his authorized representative. If it is determined that an enrollee has complex care needs, the enrollee may receive the ongoing services of a primary care team. If the primary care team determines that the complex care enrollee requires the ongoing services of a primary care team, the primary care team shall develop and monitor a plan of care for said enrollee, and arrange for and deliver all services called for in the plan of care. If an enrollee is deemed to have complex care needs, but the primary care team determines the complex care enrollee does not require the services of a primary care team, the enrollee shall receive the services of a primary care physician and may appeal to the SCO to receive primary care team services. The SCO shall conduct a standard review and make a decision following receipt of all required documentation and, if requested by the primary care physician, the SCO shall conduct an expedited review. The timeline for standard and expedited reviews shall meet the requirements established under 42 C.
F.
R. 422.
568 and 422.
572. The SCO shall develop criteria for the primary care team to employ when determining whether the complex care enrollee requires the ongoing services of a primary care team. The SCO shall submit the criteria to the division of medical assistance for its approval.
(f) The division shall develop and issue a document for consumers to be known as the “SCO report card” containing information and data providing a basis upon which SCOs may be evaluated and compared by consumers. The document shall be made available to residents of the commonwealth, upon request. In preparing that report card, the division shall, to the extent possible, use information already reported by the SCO. The division shall consult with the department of public health and the division of insurance in determining the content and format of the report card, and shall make the report card available on the internet web site established by the division. The division shall issue its proposed methodology for the preparation of the SCO report card. The division shall issue the initial report card 1 year from the announcement of the methodology and annually thereafter.
(g) The division shall measure a SCO’s performance using a variety of objective quality assurance measures, including, but not limited to, ongoing provider education, consumer satisfaction surveys, outcome measures and practice guidelines.
(h)(1) Each SCO shall be required to contract with 1 or more ASAPs in its geographic service area unless otherwise provided by this section. The division, in concurrence with the executive office of elder affairs, shall develop procedures and criteria for assessing the circumstances under which a SCO may choose not to contract with any specific ASAP operating in the SCO’s service area and shall make those procedures and criteria available to the SCOs and ASAPs. The procedures and criteria shall include a requirement that any SCO so choosing shall demonstrate its reasons to the division, including, but not limited to, specific contractual, performance, administrative or clinical deficiencies for each ASAP with which the SCO chooses not to contract. The division, in consultation with the executive office of elder affairs, shall determine whether the SCO requesting not to contract with a given ASAP has met the criteria for such a request. The division shall share with the executive office of elder affairs all documentation provided by the SCO regarding its reasons not to contract with an ASAP.
(2) ASAPs under contract with SCOs shall employ geriatric support service coordinators, who shall be members of the primary care team and shall be responsible for:(i) arranging, coordinating and authorizing the provision of community long-term care and social support services with the agreement of other primary care team members designated by the SCO;(ii) coordinating non-covered services and providing information regarding other elder services, including, but not limited to, housing, home-delivered meals and transportation services;(iii) monitoring the provision and outcomes of community long-term care and support services, according to the enrollee’s service plan, and making periodic adjustments to the enrollee’s service plan as deemed appropriate by the primary care team;(iv) tracking enrollee transfer from one setting to another; and(v) scheduling periodic reviews of enrollee care plans and assessment of progress in reaching the goals of an enrollee’s care plan.
(3) SCOs and ASAPs shall be responsible for developing processes for assessing all enrollees upon enrollment to determine the need for involvement of the ASAPs and to assure appropriate ongoing monitoring of the enrollee’s need for medically necessary services.
(4) SCOs shall grant geriatric support services coordinators authorizing responsibility over a range and amount of services for specific conditions or circumstances for which agreement of the primary care team would not be required. In cases where the primary care team members cannot reach agreement regarding an enrollee’s service plan or the authorization thereof, any team member may request that the SCO conduct a clinical review within 3 working days of receiving a request for that review. Clinical reviewers shall not be members of the primary care team presenting the case, and all decisions by the clinical review team shall be final. SCOs shall be required to report the results of all clinical reviews to the division and to the executive office of elder affairs. Such reports shall be a component of a SCO’s performance review by the division.
(i) The division shall develop a capitation system for payment for Medicaid services in which the SCOs shall be at full or partial financial risk for any services that they authorize and purchase on behalf on an enrollee. Capitation rates shall be adequate to ensure the provision of quality health and long-term care services to all enrollees regardless of physical or mental health conditions. The division shall ensure that Medicaid rates are no greater than what the division would pay for an actuarially equivalent unenrolled population. The division may permit a risk-sharing relationship between the SCO and the ASAP, in which the two entities share the financial risk of providing coordinated services to enrollees under a system of capitated or sub-capitated rate payments.
(j) The division shall ensure that enrollees have a choice of at least 2 senior care organizations within their geographic area, where available. The division also shall ensure that enrollees have a choice of at least 2 primary care physicians and nursing facilities within each SCO network. Furthermore, when there is more than 1 home health agency within a SCO’s network, enrollees shall have a choice of home health agencies among those within the SCO’s network.
(k) A SCO shall meet all privacy standards set by the regulations established by the federal Department of Health and Human Services under the Healthcare Insurance Portability and Accountability Act of 1996.
(l) Enrollees in any SCO shall have access to the appropriate ombudsperson within the executive office of elder affairs, and shall have access to the SCO ombudsperson or like person within the SCO. The contacts and method of contact shall be provided, at a minimum, to each SCO enrollee upon enrollment.
(m) The division shall promulgate regulations to enforce the provisions of this chapter, and shall establish a senior care options advisory committee to advise the division regarding the ongoing operations of MassHealth senior care options. The advisory committee shall advise the division with regard to the appropriate outreach, enrollment and disenrollment policies for eligible persons. The SCO advisory committee shall include the chairs of the SCO advisory councils and 51 per cent of the advisory committee shall be SCO enrollees or representatives from elderly consumer groups and aging services organizations chosen by the division and the executive office of elder affairs.
(n) The division shall enter into an interdepartmental service agreement with the executive office of elder affairs in a manner that ensures that any and all coordinated care services are provided pursuant to the requirements specified in this section.
(o) The commissioner, in consultation with the secretary of the executive office of elder affairs, shall semi-annually submit to the house and senate committees on ways and means a report detailing the name and number of entities participating as senior care option organizations and expenditure data, including, but not limited to, an analysis of the program’s aggregate budget neutrality. Furthermore, the division shall collect detailed information on the functioning of the SCO demonstration project, including: enrollment and disenrollment rates, including detailed reasons for enrolling and disenrolling; the number of SCO enrollees in nursing homes, community settings and other settings; and other information to assist the special commission in completing various studies.
(p) A SCO shall meet standards established by 42 U.
S.
C. section 1395w–22 (f) and (g) and 42 U.
S.
C. section 1396u–2(b).
measures; waiver of measures due to hardship Section 9E. The secretary of health and human services may apply for authority from the secretary of the United States Department of Health and Human Services, pursuant to section 1115 of the Social Security Act that authorizes the secretary to waive provisions of Title XIX of the Social Security Act, to implement measures that: (1) change to a later date the time currently provided by federal law for starting the penalty periods for persons who transfer assets for less than fair market value; (2) require excess assets to be spent on health care or other necessary living expenses; (3) to treat annuities similarly to trusts and require the commonwealth to be a beneficiary to the extent of MassHealth benefits provided; and (4) increase look-back periods, for real estate transfers and transfers into irrevocable trusts; provided that any changes implemented as a result of a waiver authorized by this section shall not apply to new applications submitted before the effective date of this section or the effective date of any waiver granted, whichever is later; and provided further, that transfers of assets up to $300,000 from a primary residence shall not be affected by such waiver. The division or the department of elder affairs, as appropriate, may by regulation implement one or more of such measures under the terms and conditions approved by the secretary, provided that the division or the department, as appropriate, shall waive such measures to address hardships as determined by the division or department.
Section 1. As used in this chapter, the following words shall, unless the context clearly requires otherwise, have the following meanings:—“Actual costs”, all direct and indirect costs incurred by a hospital or a community health center in providing medically necessary care and treatment to its patients, determined in accordance with generally accepted accounting principles.
“Acute hospital”, the teaching hospital of the University of Massachusetts Medical School and any hospital licensed under section fifty-one of chapter one hundred and eleven and which contains a majority of medical-surgical, pediatric, obstetric, and maternity beds, as defined by the department of public health.
[Definitions of “Ambulatory surgical center” and “Ambulatory surgical center services” effective as provided by 1997, 47, Sec. 36 as amended by 2003, 9, Sec. 37.
] “Ambulatory surgical center”, any distinct entity that operates exclusively for the purpose of providing surgical services to patients not requiring hospitalization and meets the requirements of the federal Health Care Financing Administration for participation in the Medicare program.
“Ambulatory surgical center services”, services described for purposes of the Medicare program pursuant to 42 USC § 1395k(a)(2)(F)(I). These services include facility services only and do not include surgical procedures.
“Bad debt”, an account receivable based on services furnished to any patient which (i) is regarded as uncollectable, following reasonable collection efforts consistent with regulations of the division, which regulations shall allow third party payers to negotiate with hospitals to collect the bad debt of its enrollees, (ii) is charged as a credit loss, (iii) is not the obligation of any governmental unit or of the federal government or any agency thereof, and (iv) is not free care.
“Case mix”, the description and categorization of a hospital’s patient population according to criteria approved by the division including, but not limited to, primary and secondary diagnoses, primary and secondary procedures, illness severity, patient age and source of payment.
“Charge”, the uniform price for specific services within a revenue center of a hospital.
“Child”, a person who is under eighteen years of age.
“Commissioner”, the commissioner of the division of health care finance and policy.
“Community health centers”, health centers operating in conformance with the requirements of Section 330 of United States Public Law 95–626 and shall include all community health centers which file cost reports as requested by the division.
“Comprehensive cancer center”, the hospital of any institution so designated by the national cancer institute under the authority of 42 USC sections 408(a) and 408(b) organized solely for the treatment of cancer, and offered exemption from the medicare diagnosis related group payment system under 42 C.
F.
R. 405.
475(f).
“Critical access services”, those medically necessary health care services which are generally provided only by acute hospitals, as further defined in regulations promulgated by the division.
“Dependent”, the spouse and children of any employee if such persons would qualify for dependent status under the Internal Revenue Code or for whom a support order could be granted under chapters two hundred and eight, two hundred and nine or two hundred and nine C.
“Disproportionate share hospital”, any acute hospital that exhibits a payer mix where a minimum of sixty-three per cent of the acute hospital’s gross patient service revenue is attributable to Title XVIII and Title XIX of the federal Social Security Act other government payors and free care.
“Division”, the division of health care finance and policy in the executive office of health and human services.
“DRG”, a patient classification scheme which provides a means of relating the type of patients a hospital treats, such as its case mix, to the cost incurred by the hospital.
“Eligible person”, a person who qualifies for financial assistance from a governmental unit in meeting all or part of the cost of general health supplies, care or rehabilitative services and accommodations.
“Emergency bad debt”, bad debt related to emergency services provided by an acute hospital to an uninsured individual.
“Emergency medical condition”, a medical condition, whether physical or mental, manifesting itself by symptoms of sufficient severity, including severe pain, that the absence of prompt medical attention could reasonably be expected by a prudent layperson who possesses an average knowledge of health and medicine, to result in placing the health of the person or another person in serious jeopardy, serious impairment to body function, or serious dysfunction of any body organ or part, or, with respect to a pregnant woman, as further defined in section 1867(e)(1)(B) of the Social Security Act, 42 U.
S.
C. section 1395dd(e)(1)(B).
“Emergency services”, medically necessary health care services provided to an individual with an emergency medical condition.
“Employee”, a person who performs services primarily in the commonwealth for remuneration for a commonwealth employer. A person who is self-employed shall not be deemed to be an employee.
“Employer”, an employer as defined in section one of chapter one hundred and fifty-one A.
“Enrollee”, a person who becomes a member of an insurance program of the division either individually or as a member of a family.
“Executive office”, executive office of health and human services.
“Financial requirements”, a hospital’s requirement for revenue which shall include, but not be limited to, reasonable operating, capital and working capital costs, the reasonable costs of depreciation of plant and equipment and the reasonable costs associated with changes in medical practice and technology.
“Fiscal year”, the twelve month period during which a hospital keeps its accounts and which ends in the calendar year by which it is identified.
“Free care”, the following medically necessary services provided to individuals determined to be financially unable to pay for their care, in whole or in part, pursuant to applicable regulations of the division: (1) emergency, urgent, and critical access services provided by acute hospitals; (2) services provided by community health centers; and (3) patients in situations of medical hardship in which major expenditures for health care have depleted or can reasonably be expected to deplete the financial resources of the individual to the extent that medical services cannot be paid, as determined by regulations of the division.
“General health supplies, care or rehabilitative services and accommodations”, all supplies, care and services of medical, optometric, dental, surgical, podiatric, psychiatric, therapeutic, diagnostic, rehabilitative, supportive or geriatric nature, including inpatient and outpatient hospital care and services, and accommodations in hospitals, sanatoria, infirmaries, convalescent and nursing homes, retirement homes, facilities established, licensed or approved pursuant to the provisions of chapter one hundred and eleven B and providing services of a medical or health-related nature, and similar institutions including those providing treatment, training, instruction and care of children and adults; provided, however, that rehabilitative service shall include only rehabilitative services of a medical or health-related nature which are eligible for reimbursement under the provisions of Title XIX of the Social Security Act.
“Governmental unit”, the commonwealth, any department, agency board or commission of the commonwealth, and any political subdivision of the commonwealth.
“Gross inpatient service revenue”, the total dollar amount of a hospital’s charges for inpatient services rendered in a fiscal year.
“Gross patient service revenue”, the total dollar amount of a hospital’s charges for services rendered in a fiscal year.
“Health care services”, supplies, care and services of medical, surgical, optometric, dental, podiatric, chiropractic, psychiatric, therapeutic, diagnostic, preventative, rehabilitative, supportive or geriatric nature including, but not limited to, inpatient and outpatient acute hospital care and services; services provided by a community health center or by a sanatorium, as included in the definition of “hospital” in Title XVIII of the federal Social Security Act, and treatment and care compatible with such services or by a health maintenance organization.
“Health insurance company”, a company as defined in section one of chapter one hundred and seventy-five which engages in the business of health insurance.
“Health insurance plan”, the medicare program or an individual or group contract or other plan providing coverage of health care services and which is issued by a health insurance company, a hospital service corporation, a medical service corporation or a health maintenance organization.
“Health maintenance organization”, a company which provides or arranges for the provision of health care services to enrolled members in exchange primarily for a prepaid per capita or aggregate fixed sum as further defined in section one of chapter one hundred and seventy-six G.
“Hospital”, any hospital licensed under section fifty-one of chapter one hundred and eleven, the teaching hospital of the University of Massachusetts Medical School and any psychiatric facility licensed under section nineteen of chapter nineteen.
“Hospital agreement”, an agreement between a nonprofit hospital service corporation and the hospital signatory thereto approved by the division under section five of chapter one hundred and seventy-six A.
“Hospital service corporation”, a corporation established for the purpose of operating a nonprofit hospital service plan as provided in chapter one hundred and seventy-six A.
“Managed health care plan”, a health insurance plan which provides or arranges for, supervises and coordinates health care services to enrolled participants, including plans administered by health maintenance organizations and preferred provider organizations.
“Medicaid program”, the medical assistance program administered by the division of medical assistance pursuant to chapter one hundred and eighteen E and in accordance with Title XIX of the Federal Social Security Act or any successor statute.
“Medical assistance program”, the medicaid program, the Veterans Administration health and hospital programs and any other medical assistance program operated by a governmental unit for persons categorically eligible for such program.
“Medically necessary services”, medically necessary inpatient and outpatient services as mandated under Title XIX of the Federal Social Security Act. Medically necessary services shall not include: (1) non-medical services, such as social, educational and vocational services; (2) cosmetic surgery; (3) canceled or missed appointments; (4) telephone conversations and consultations; (5) court testimony; (6) research or the provision of experimental or unproven procedures including, but not limited to, treatment related to sex-reassignment surgery, and pre-surgery hormone therapy; and (7) the provision of whole blood; and provided, however, that administrative and processing costs associated with the provision of blood and its derivatives shall be payable.
“Medical service corporation”, a corporation established for the purpose of operating a nonprofit medical service plan as provided in chapter one hundred and seventy-six B.
“Medicare program”, the medical insurance program established by Title XVIII of the Social Security Act.
“Non-acute hospital”, any hospital which is not an acute hospital.
“Patient”, any natural person receiving health care services from a hospital.
[Definitions of “Pool” and “Payments subject to surcharge” effective as provided by 1997, 47, Sec. 36 as amended by 2003, 9, Sec. 37.
] “Pool”, the uncompensated care pool established pursuant to section 18.
“Payments subject to surcharge”, all amounts paid, directly or indirectly, by surcharge payors to acute hospitals for health services and ambulatory surgical centers for ambulatory surgical center services on or after the effective date of this section; provided, however, that “payments subject to surcharge” shall not include (i) payments, settlements, and judgments arising out of third party liability claims for bodily injury which are paid under the terms of property or casualty insurance policies, (ii) payments made on behalf of Medicaid recipients, Medicare beneficiaries, or persons enrolled in policies issued pursuant to chapter 176K or similar policies issued on a group basis; and provided further, that “payments subject to surcharge” may exclude amounts established in regulations promulgated by the division for which the costs and efficiency of billing a surcharge payor or enforcing collection of the surcharge from a surcharge payor would not be cost effective.
“Pediatric hospital”, an acute care hospital which limits services primarily to children and which qualifies as exempt from the Medicare Prospective Payment system regulations.
“Pediatric specialty unit”, a pediatric unit of an acute care hospital in which the ratio of licensed pediatric beds to total licensed hospital beds as of July 1, 1994, exceeded 0.
20. In calculating that ratio, licensed pediatric beds shall include the total of all pediatric service beds, and the total of all licensed hospital beds shall include the total of all licensed acute care hospital beds, consistent with Medicare’s acute care hospital reimbursement methodology as put forth in the Provider Reimbursement Manual Part 1, Section 2405.
3G.
“Private sector charges”, gross patient service revenue attributable to all patients less gross patient service revenue attributable to Titles XVIII and XIX, other publicly aided patients, free care and bad debt.
“Provider”, any person, corporation partnership, governmental unit, state institution or any other entity qualified under the laws of the commonwealth to perform or provide health care services.
“Publicly aided patient”, a person who receives hospital care and services for which a governmental unit is liable, in whole or in part, under a statutory program of public assistance.
“Public payer-dependent non-acute hospital”, any non-acute hospital that (1) was certified by the Secretary of the United States Department of Health and Human Services as participating in the federal medicare program pursuant to clause (iv) of 42 USC section 1395ww (d)(1)(B) on January first, nineteen hundred and ninety-six; (2) is not owned by the commonwealth; and (3) exhibits a payor mix in which a minimum of fifteen per cent of such hospital’s gross patient service revenue, as reported on the RSC–403 for hospital fiscal year nineteen hundred and ninety-four, was attributable to Title XIX of the federal Social Security Act. Such term does not include a hospital that was reimbursed for services provided to individuals entitled to medical assistance under chapter one hundred and eighteen E for fiscal year nineteen hundred and ninety-six pursuant to a contract between the hospital and the division of medical assistance.
“Purchaser”, a natural person responsible for payment for health care services rendered by a hospital.
“Revenue center”, a functioning unit of a hospital which provides distinctive services to a patient for a charge.
“Resident”, a person living in the commonwealth, as defined by the division by regulation; provided, however, that such regulation shall not define a resident as a person who moved into the commonwealth for the sole purpose of securing health insurance under this chapter. Confinement of a person in a nursing home, hospital or other medical institution shall not in and of itself, suffice to qualify such person as a resident.
“Secretary”, the secretary of health and human services.
“Self-employed”, a person who, at common law, is not considered to be an employee and whose primary source of income is derived from the pursuit of a bona fide business.
“Self-insurance health plan”, a plan which provides health benefits to the employees of a business, which is not a health insurance plan, and in which the business is liable for the actual costs of the health care services provided by the plan and administrative costs.
“Small business”, a business in which the total number of full-time employees, when averaged on an annual basis, does not exceed fifty, including only of the self-employed.
“Sole community provider”, any acute hospital which qualifies as a sole community provider under medicare regulations or under regulations promulgated by the division, which regulations shall consider factors including, but not limited to, such as isolated location, weather conditions, travel conditions, percentage of Medicare, Medicaid and free care provided and the absence of other reasonably accessible hospitals in the area. Such hospitals shall include those which are located more than twenty-five miles from other such hospitals in the commonwealth and which provide services for at least sixty percent of their primary service area.
“Specialty hospital”, an acute hospital which qualifies for an exemption from the medicare prospective payment system regulations or any acute hospital which limits its admissions to patients under active diagnosis and treatment of eyes, ears, nose and throat or to children or patients under obstetrical care.
“State institution”, any hospital, sanatorium, infirmary, clinic and other such facility owned, operated or administered by the commonwealth, which furnishes general health supplies, care or rehabilitative services and accommodations.
[Definition of “Surcharge payor” effective as provided by 1997, 47, Sec. 36 as amended by 2003, 9, Sec. 37.
] “Surcharge payor,” an individual or entity that pays for or arranges for the purchase of health care services provided by acute hospitals and ambulatory surgical center services provided by ambulatory surgical centers; provided, however, that the terms “surcharge payor” shall not include Title XVIII and Title XIX programs and their beneficiaries or recipients, other governmental programs of public assistance and their beneficiaries or recipients, and the workers compensation program established pursuant to chapter 152.
“Third party payer”, an entity including, but not limited to, Title XVIII and Title XIX programs, other governmental payers, insurance companies, health maintenance organizations and nonprofit hospital service corporations. Third party payer shall not include a purchaser responsible for payment for health care services rendered by a hospital, either to the purchaser or to the hospital.
“Title XIX,” Title XIX of the Social Security Act, 42 USC 1396 et seq.
, or any successor statute enacted into federal law for the same purposes as Title XIX.
“Uninsured patient”, a patient who is not covered by a health insurance plan, a self-insurance health plan, or a medical assistance program.
hospitals; uniform charges; penalties for excess charges Section 10. All purchasers and third party payers, excluding purchasers and payers under the workers’ compensation act, except as provided in chapter one hundred fifty-two, may enter into contractual arrangements with acute and non-acute hospitals for services. No such arrangement, including but not limited to prices or charges which may be charged for non-contracted services or which may be negotiated in individual contracts between such purchasers or third party payers and such acute or non-acute hospitals, shall be subject to prior approval by any public agency; provided, however, that nothing in this section or chapter shall limit the authority of the executive office to establish rates of payment for all health care services adjudged compensable under chapter one hundred fifty-two, and provided, further, that charges established by an acute or non-acute hospital for health care services rendered shall be uniform for all patients receiving comparable services.
Any acute or non-acute hospital that makes a charge or accepts payment based upon a charge in excess of that filed required or approved by the executive office or that fails to file any data, statistics or schedules or other information required under this chapter or by any regulation promulgated by the division or executive office or which falsifies the same, shall be subject to a civil penalty of not more than one thousand dollars for each day on which such violation occurs or continues, which penalty may be assessed in an action brought on behalf of the commonwealth in any court of competent jurisdiction. The attorney general shall bring any appropriate action, including injunctive relief, as may be necessary for the enforcement of the provisions of this chapter.
Section 11. All rates of payment to acute hospitals and non-acute hospitals under Title XIX shall be established by contract between the provider of such hospital services and the division of medical assistance, except as provided in subsections (a) and (b), or otherwise permitted by law. All rates shall be subject to all applicable Title XIX statutory and regulatory requirements and shall include reimbursement for the reasonable cost of providing competent interpreter services pursuant to section 25J of chapter 111 or section 23A of chapter 123.
All such rates for non-acute hospitals shall be effective as of the date specified in section thirteen A of chapter one hundred and eighteen E of the General Laws, unless otherwise specified by law.
(a) For disproportionate share hospitals, the executive office shall establish rates that equal the financial requirements of providing care to recipients of medical assistance.
(b) The executive office shall establish rates of payment which shall apply to emergency services and continuing emergency care provided in acute hospitals to medical assistance program recipients, including examination or treatment for an emergency medical condition or active labor in women or any other care rendered to the extent required by 42 USC 1395(dd), unless such services are provided pursuant to an agreement between the division of medical assistance and the acute hospital. Such rates of payment shall reflect the reasonable costs of providing such care, including the costs of providing competent interpreter services pursuant to section 25J of chapter 111 or section 23A of chapter 123 and shall take into account the characteristics of the hospital in which such care is provided, including, but not limited to, its status as a teaching hospital, specialty hospital, disproportionate share hospital, pediatric hospital, pediatric specialty unit or sole community provider. An acute hospital shall, when a medical assistance program recipient requires post emergency room care and, after screening and stabilizing the patient’s condition, notify the division of medical assistance or its designated representative and assist said division, to the extent possible, in transferring the recipient to an appropriate medical setting in accordance with said division’s direction. Nothing herein shall be construed to require the hospital to breach its obligation under said 42 USC 1395(dd) or require the recipient to forego any right to refuse transfer pursuant to said 42 USC 1395(dd). If an acute hospital is unable or prohibited by law or regulation from transferring the patient in accordance with said division’s direction, said executive office shall pay for any and all care associated with such patient’s treatment including, but not limited to, care or services provided in the emergency room or in an inpatient or outpatient setting. Whenever said division is required to pay for such care rendered in a non-emergency room setting, said division shall pay all reasonable costs for such services in such hospital, as determined by the division of health care finance and policy pursuant to this chapter and consistent with the provisions of Title XIX laws.
No acute hospital may charge to a governmental unit for services provided to publicly aided patients at a rate higher than the rate payable by the division of medical assistance under Title XIX for the same service, unless such service is provided by said division pursuant to a unique arrangement such as a selective contract or a managed care contract.
Nothing in this chapter shall be construed to conflict with the provisions of a waiver of otherwise applicable federal requirements which the division of medical assistance may obtain from the secretary of health and human services for the purpose of implementing a primary care case management system for delivering services, or for the purpose of implementing any other type of managed care service delivery system in which the eligible recipient is directed to obtain services exclusively from one provider or one group of providers.
If the division of medical assistance contracts with any third party payer for the provision of medical benefits for medical assistance recipients under Title XIX, said division shall assure that on a quarterly basis such contracted third party payers notify each acute hospital of the number of inpatient days of service provided by the hospital to such recipients covered by such contracts.
(c) The executive office shall establish rates of payment which shall apply to community hospitals located in rural and isolated areas where access to other such providers is not reasonably available. Such hospitals, specially designated by the commonwealth as sole community providers, shall receive payment rates calculated to reflect the rural characteristics of such community hospital and the essential nature of the services they provide, which rates shall not be less than ninety-seven per cent of such hospitals’ reasonable financial requirements.
Section 12. The executive office shall not consider the following as resources of such hospitals in the establishment, review or approval of acute and non-acute hospital rates and charges: restricted and unrestricted grants; gifts; contributions; bequests; fund principle; term endowments and endowment balances; restricted gifts; unrestricted gifts and all income from any of the foregoing, including unrestricted income from endowment funds and income and gains from investment of unrestricted funds. The following words shall have the following meanings as used in this paragraph:“Income and gains from investment of unrestricted funds”, interest, dividends, rents or other income on investments, including net gains or losses resulting from investment transactions.
“Term endowment”, funds available upon termination of restrictions.
“Unrestricted gifts”, gifts, grants, contributions and bequests, upon which there are no restrictions imposed by the donor.
“Unrestricted income from endowment funds”, income earned on investment of endowment funds which have no restrictions on income.
An acute or non-acute care hospital aggrieved by any action or failure to act by the executive office under this chapter may file an appeal pursuant to the provision of section nine.
Section 13. No acute hospital shall deny access to care and services which the hospital would provide under chapter one hundred and eighteen E to recipients of benefits under chapter one hundred and seventeen A.
Section 14. Notwithstanding any provisions of this chapter to the contrary, all costs and charges for patients who are residents of other countries shall, as provided herein, be exempted from the limitations imposed by this chapter. Any hospital shall be allowed to impose a surcharge on the normal charges that would otherwise be allowed for such residents of other countries. Such surcharges shall not be included in the calculation of gross patient service revenues. The normal charge and the patient discharge statistics shall otherwise be included under the provisions of this chapter.
organizations Section 15. A health maintenance organization organized under chapter one hundred and seventy-six G may (i) negotiate directly with any hospital with respect to such health maintenance organization’s rate of payment for hospital services and (ii) enter into an agreement with such hospital reflecting such rate of payment without the approval of the executive office established under chapter one hundred eighteen G. The specification in this section of contracting rights of health maintenance organizations shall not be construed as affirming or denying such rights with respect to any other third party payer.
requiring determination of need; recommendations Section 16. The division shall review and comment upon all capital expenditure projects requiring a determination of need pursuant to the provisions of section twenty-five of chapter one hundred and eleven of the General Laws, including, but not limited to, less costly or more effective alternative financing methods for such projects; the immediate and long-term financial feasibility of such projects; the probable impact of the project on costs of and charges for services; and the availability of funds for capital and operating needs. The division shall transmit to the department of public health its written recommendations on each project which shall become part of the written record compiled by said department during its review of such project. The division shall appear and comment on any application for a determination of need where a public hearing is required pursuant to the provisions of said section twenty-five C of said chapter. To carry out the purposes of this paragraph, the division shall appoint a senior professional employee to act as a liaison with said department.
Section 17. Upon petition of a receiver appointed under section seventy-two N of chapter one hundred and eleven, the executive office shall, in accordance with regulations to be promulgated hereunder, adjust the facility’s rate, if necessary, to insure compensation of the receiver and payment for a bond. Such adjustment shall not be in effect if the licensee is under the jurisdiction of the United States Bankruptcy Court.
[Text of section effective as provided by 1997, 47, Sec. 36 as amended by 2003, 9, Sec. 37.
] Section 18. (a) There is hereby established an Uncompensated Care Trust Fund, which shall be administered by the division. Expenditures from said Trust Fund shall not be subject to appropriation unless otherwise required by law. The purpose of said fund is to reimburse hospitals and community health centers for care provided to low-income, uninsured and underinsured residents of the commonwealth. The division shall administer said fund using such methods, policies, procedures, standards and criteria that it deems necessary for the proper and efficient operation of said fund and the programs funded thereby in a manner consistent with simplicity of administration, the provisions of this chapter and the best interests of low income uninsured and underinsured persons.
(b) The Uncompensated Care Trust Fund shall consist of all amounts paid by acute hospitals and surcharge payors for the purposes of the uncompensated care pool pursuant to this section and section 18A; all appropriations for the purpose of uncompensated acute hospital care or uncompensated community health center care; any sums paid by acute hospitals pursuant to section 56 of chapter 495 of the acts of 1991; all property and securities acquired by and through the use of monies belonging to said fund and all interest thereon; less payments therefrom for the purposes of the uncompensated care pool and amounts transferred to the separate MassHealth account established by subsection (c). All interest earned on the amounts in said fund shall be deposited or retained in said fund. The commissioner shall from time to time requisition from said fund such amounts as the commissioner deems necessary to meet the current obligations of the division for the purposes of said fund and estimated obligations for a reasonable future period.
(c) Within said fund, the division shall establish a separate account for the insurance reimbursement program component of the MassHealth demonstration program established by section 9C of chapter 118E. This separate account shall consist of amounts transferred from the Uncompensated Care Trust Fund, any federal funds transferred from the Children’s and Seniors’ Health Care Assistance Fund established by section 2FF of chapter 29, and any funds as may be appropriated for deposit into this account. The division shall administer this account and disburse funds from this account for the purposes of said insurance reimbursement program component of said MassHealth program. Funds deposited in this account shall be kept separate and shall not be commingled with funds of the uncompensated care pool. The comptroller is hereby authorized and directed to effect the transfers authorized by this subsection pursuant to a spending plan filed by the division of medical assistance with the secretary of administration and finance and the house and senate committees on ways and means.
(d) Within said fund, the division shall administer an uncompensated care pool consisting of revenues produced by acute hospital assessments and the surcharge percentage calculated by the division pursuant to this section and section 18A and all appropriations for the purpose of uncompensated care provided by acute hospitals, or community health centers, including, but not limited to, federal funds made available for uncompensated care payments to certain acute hospitals as may be appropriated from the General Fund or any other fund. For purposes of this subsection, the words “revenues produced by acute hospital assessments” shall equal the value of and have the same meaning as the words “acute hospitals’ liability to the pool” established pursuant to subsection (e) and the words “revenues produced by the surcharge percentage” shall equal the value of and have the same meaning as the words “surcharge payors’ liability to the pool” as established pursuant to section 18A. Amounts placed in the Uncompensated Care Trust Fund, except for amounts transferred into the separate MassHealth account established in subsection (c), shall be expended by the division for the purposes of the uncompensated care pool; provided, however, that the division may expend up to $5,000,000 annually for demonstration projects where the division finds that such projects reduce the liability of said pool to acute hospitals and community health centers by at least the amount expended by said pool on such projects. The division shall administer the uncompensated care pool and require payments to the pool and disburse funds from the pool consistent with the surcharge payors’ and acute hospitals’ liability to the pool and the pool’s liability to an acute hospital or a community health center. The division shall specify by regulation appropriate mechanisms that provide for interim determination and payment of a surcharge payor’s liability to the pool and an acute hospital’s liability to and from the pool during each fiscal year and for final settlement of the pool for each fiscal year. The division may promulgate regulations which authorize the assessment of interest on any unpaid liability at a rate not to exceed an annual percentage rate of 18 per cent and late fees at a rate not to exceed 5 per cent per month. The division may calculate final settlements when it determines that data for a fiscal year are substantially complete and that further refinements would not materially affect the calculation. The division may incorporate final settlement amounts by prospective adjustment of acute hospitals’ and surcharge payors’ liability rather than by retrospective payments or assessments.
(e) An acute hospital’s liability to said pool shall equal the product of (1) the ratio of its private sector charges to all acute hospitals’ private sector charges; and (2) the private sector liability to the uncompensated care pool as determined by law less the surcharge payors’ liability established pursuant to section 18A. Before October 1 of each year, the division shall establish each acute hospital’s liability to the pool using the best data available, as determined by the division. The division shall update each acute hospital’s liability to the pool as updated information becomes available. For any fiscal year, an acute hospital’s final liability to said pool shall be calculated in accordance with subsection (d). The division shall specify by regulation an appropriate mechanism for interim determination and payment of an acute hospital’s liability to and from said pool.
(f) An acute hospital’s liability to said pool shall in the case of a transfer of ownership be assumed by the successor in interest to the acute hospital.
(g) The division shall establish by regulation an appropriate mechanism for enforcing an acute hospital’s liability to the pool in the event that an acute hospital does not make a scheduled payment to said pool. Such enforcement mechanism may include notification to the division of medical assistance requiring an offset of payments on the Title XIX claims of any such acute hospital, any health care provider under common ownership with the acute hospital or any successor in interest to the acute hospital, from the division of medical assistance in the amount of payment owed to said pool including any interest and late fees, and to transfer the withheld funds into said pool. If the division of medical assistance offsets claims payments as ordered by the division, it shall be deemed not to be in breach of contract or any other obligation for payment of noncontracted services, and providers to which payment is offset under order of the division shall serve all Title XIX recipients in accordance with the contract then in effect with the division of medical assistance, or, in the case of a noncontracting or disproportionate share hospital, in accordance with its obligation for providing services to Title XIX recipients pursuant to this chapter. In no event shall the division direct the division of medical assistance to offset claims unless an acute hospital has maintained an outstanding obligation to the uncompensated care pool for a period longer than 45 days and has received proper notice that said division intends to initiate enforcement actions in accordance with the regulations of said division.
(h) Said pool’s liability to an acute hospital shall be calculated periodically by the division based on the best data available. Such data shall include, but not be limited to, allowable free care charges as determined by the division and the cost-to-charge ratio, which shall be calculated by the division for each acute hospital. The final settlement of the pool’s liability to a hospital shall equal the product of allowable actual free care charges, adjusted for any audit findings, multiplied by its final cost-to-charge ratio. In the case of non-disproportionate share hospitals, such calculation shall represent the ratio of the reasonable actual costs of patient care services, as determined by the division, to gross patient service revenue for the most recent year for which audited financial statements for the hospital are available. In the case of disproportionate share hospitals, such calculation shall represent the ratio of the hospital’s reasonable financial requirements, as determined by the division, to gross patient service revenue for the most recent year for which audited financial statements for such hospital are available. The division shall, throughout the year, update each acute hospital’s ratio in the event more current audited financial statement information becomes available. Said division shall further establish, for each non-disproportionate share acute hospital for any given fiscal year, a final ratio using the reasonable costs for patient care services and gross patient service revenues as appearing in the audited financial statements for the fiscal year. For disproportionate share hospitals, said division shall establish a final ratio based upon its reasonable financial requirements, as defined by the division, and actual gross patient service revenues as appearing in the audited financial statements for the fiscal year. The final settlement of the pool’s liability to an acute hospital shall be calculated in accordance with subsection (d).
The pool’s liability to a community health center shall be calculated periodically by the division based on the best data available as determined by the division. Such data shall include, but not be limited to, allowable free care charges as determined by the division and the rates established by the division to be paid for free care services. Such rates shall represent the community health center’s reasonable financial requirements, as determined by the division.
(i) The division shall manage said pool in order to encourage maximum efficiency and appropriateness in the utilization of services. The division shall promulgate regulations detailing the definition of free care, including, but not limited to, defining the qualifications of eligible persons and the scope of eligible services, setting standards for reasonable efforts to notify uninsured or underinsured persons of the various insurance options as well as the availability of free care, and setting standards for reasonable efforts to collect costs of emergency care and setting standards to determine medical hardship. Said regulations shall include provision for the review of determinations of eligibility for free care and the establishment of penalties for acute hospitals or community health centers which upon audit show an excessive rate of incorrect eligibility determinations. The division shall adopt regulations prohibiting payments from said pool for non-urgent and non-emergency health care services provided to residents of other states and foreign countries. The division shall implement a utilization review program designed to monitor the appropriateness of services paid for by said pool and to promote the delivery of care in the most appropriate setting; provided, further, that the division may deny payment from the pool for services which it determines are not medically necessary. After consultation with consumer representatives and representatives of acute hospitals and community health centers, the division shall develop programs and guidelines to encourage maximum enrollment of pool beneficiaries into health care plans and programs of health insurance offered by public and private sources, and to promote the delivery of care in the most appropriate setting, through coordination of care and referral of primary care cases to community health centers. Such programs and guidelines shall not deny payments on the ground that services should have been provided in a more appropriate setting if the hospital was required to provide such services pursuant to 42 USC 1395(dd). The division may adopt regulations requiring disproportionate share hospitals to use a portion of payments received from said pool to reimburse physicians for the costs of free care which such physicians provide in such hospitals. In adopting regulations under this subsection, the division shall consult and work cooperatively with representatives of low income uninsured and underinsured persons, health care providers who provide health care to such persons, and organizations representing said persons and providers.
(j) The division shall adopt any other regulations necessary to manage said pool including, but not limited to, regulations: requiring data submissions, setting pool audit standards, establishing enforcement mechanisms consistent with this section, and establishing reasonable controls on utilization. The division shall require acute hospitals and community health centers to submit data that the division determines necessary to efficiently and effectively administer the uncompensated care pool. Said data may include, but shall not be limited to, charge and cost data, patient diagnoses and types of uncompensated service provided, patient demographics, write-off amounts, unique patient identifiers and other such data that would enable the division to conduct analyses, verify eligibility and calculate settlements on a case-by-case basis. The division shall consider all available options for collecting said data, including claims and electronic data submission, and shall implement the most efficient and effective method after consultation with interested parties. If the division finds that hospitals are not complying with the data submission requirements or if the data submitted are not sufficient to enable the division to verify eligibility and calculate settlements on a case-by-case basis, the division may adopt regulations providing for a claims adjudication process for payments from the uncompensated care pool. Such claims adjudication process shall maximize administrative simplicity to the extent practicable and shall not significantly delay cash flow from said pool. The division shall consult with interested parties, including the Massachusetts hospital association, in developing the methodology for such claims adjudication process and shall submit the methodology to the joint committee on health care 90 days in advance of adopting such regulations. The division shall analyze the data collected under this section in conjunction with any other pertinent data to determine the demographic characteristics and the clinical and social needs of uncompensated care recipients. If said analysis indicates that one or more managed care or case management programs would better meet the needs of low income individuals, the division shall consult with representatives of the uninsured and underinsured and the providers who serve them and other interested parties regarding the potential for managed care or case management approaches to improve care provided under said pool. If the division determines that such approaches would improve care, the division may contract with health care delivery or management organizations or to enter interagency service agreements with the division of medical assistance or the department of public health for the purpose of contracts with health care or managed care providers to deliver services to individuals eligible for free care or; provided, however, that no such contract shall be entered into until the division finds that the cost of such contract does not exceed the amounts that would otherwise have been expended on free care for these individuals; and, provided further, that the expenditures for such contracts shall not exceed $5,000,000 in any hospital fiscal year.
(k) The division, in conjunction with the division of medical assistance, shall promulgate regulations to develop and implement procedures to verify the eligibility of individuals for free care and to ensure that other coverage options are utilized fully before free care is granted. Said regulations shall require that the division of medical assistance review all applications for free care to determine whether the applicant is eligible for medical assistance pursuant to chapter 118E and whether any third party is financially responsible for the costs of care provided to the applicant. These systems may include but are not limited to investigation and recovery of third party liabilities, and penalties for noncompliance. The division shall compile and maintain a catalog of program information for all programs of health care coverage for low income persons including those sponsored by public and private organizations. The catalog shall include, at a minimum, eligibility criteria, benefits and services offered, enrollment procedures and information necessary for contact and follow-up. The division shall ensure that if free care is granted for the copayment and deductible of an eligible person with other coverage, no payments shall be made from the uncompensated care pool which would cause the total payment to the provider to exceed the applicable rates for free care services. The division shall refuse to allow payments or shall disallow payments to acute hospitals and community health centers for free care provided to individuals if reimbursement is available from other public or private sources including, but not limited to, the Medicaid or Medicare program, or if the individual is not eligible for free care. The division shall require acute hospitals and community health centers to screen each free care applicant for other sources of coverage and for potential eligibility for government programs, and to document the results of such screening. If an acute hospital or community health center determines that an applicant is potentially eligible for Medicaid or another government program, said acute hospital or community health center shall assist the applicant in applying for benefits under such program. The division shall audit free care accounts of acute hospitals and community health centers to determine compliance with this section and shall deny pool payment for any audited account for any acute hospital or community health center that fails to document compliance with this section.
(l) The division shall enter into interagency agreements with the department of revenue to verify income data for recipients of free care and to recover payments made by the pool on behalf of individuals who are ineligible for free care or on whose behalf the pool has paid for emergency bad debt. Such written agreements shall include provisions permitting the division to provide a list of persons receiving or applying for free care, including any applicable members of the households of such recipients or applicants which would be counted in determining eligibility, and to furnish relevant information including, but not limited to, name, social security number, if available, and other data required to assure positive identification. Such written agreements shall include provisions permitting the department of revenue to examine the data available under the wage reporting system established under section 3 of chapter 62E and make positive identification of cases in which recipients or applicants for free care, individually or as part of a household unit, are receiving wages in excess of any threshold eligibility requirements established by the division. The department of revenue is hereby authorized to furnish the division with information on the cases of persons so identified, including, but not limited to, name, social security number and other data to ensure positive identification, name and identification number of employer, and amount of wages received. The division may inform acute hospitals and community health centers only of an individuals eligibility or noneligibility for free care based on information obtained from the department of revenue, but may not release any specific information concerning the individual.
The division shall promulgate regulations requiring acute hospitals to submit data that will enable the department of revenue to pursue recoveries from individuals who are ineligible for free care payments and on whose behalf the pool has made payments to acute hospitals for emergency bad debt.
(m) The division shall deposit any amounts received pursuant to chapter 62D in the Uncompensated Care Trust Fund to reimburse the uncompensated care pool for expenditures made for persons who received free care through said pool or on whose behalf the pool paid emergency bad debt and who, upon review, were determined to be ineligible for free care based upon applicable income standards.
(n) The division shall not at any time make payments from said pool for any period in excess of amounts that have been paid into or are available in said pool for such period; provided, however, that the division may temporarily prorate payments from said pool for cash flow purposes. In the event that after making allowable free care payments to community health centers, there exists a shortfall of pool revenue, excluding any revenue in the separate MassHealth insurance reimbursement program account, in any fiscal year to cover allowable free care payments to acute hospitals, the division shall allocate such payments so that those acute hospitals with the greatest proportional requirement for pool income shall receive a greater proportional payment from said pool. In the event that there exists a surplus of pool revenue in any fiscal year over that necessary to cover allowable free care payments, the division shall apply such surplus to allowable free care payments for any succeeding fiscal year in which there is a shortfall of pool revenue.
The division shall establish fines or penalties not to exceed $10,000 per diversion for any hospital which diverts a free care patient from care at the hospital without the consent of the hospital to which the patient is being diverted. Any amount collected shall be deposited into the Uncompensated Care Trust Fund.
(o) Within the Uncompensated Care Trust Fund, there shall be established a medical assistance intergovernmental transfer account, administered by the commissioner of the division of medical assistance, consisting of any transfers to the commonwealth from publicly-operated entities providing Title XIX or Title XXI reimbursable services, and federal reimbursements related to medical assistance payments, so called, to publicly-operated entities. All amounts credited to this account shall be held in trust and shall be available for expenditure by the commissioner of the division of medical assistance to be used for medical assistance payments to entities designated and authorized by the general court, or which have contractually agreed to make intergovernmental transfers to said account; provided, however, that any amount in excess of such medical assistance payments may be credited to the General Fund; provided, further, that the amount of all such expenditures shall be subject to annual approval by the general court. The maximum payments and transfers from said account shall not exceed those permissible for federal reimbursement under Title XIX or Title XXI of the Social Security Act or any successor federal statute. The comptroller may make payments, including payments during the accounts payable period, in anticipation of revenues, including receivables due and collectibles during the months of July and August, and shall establish procedures for reconciling overpayments or underpayments from said account to publicly-operated entities; provided, that said procedures shall include, but not be limited to, appropriate mechanisms for refunding intergovernmental transfers and federal reimbursements upon recoupment of any such overpayments. The division of medical assistance shall notify the division of health care finance and policy regarding revenue and expenditure activity within said account and submit to the secretary of administration and finance and the house and senate committees on ways and means a schedule of said payments ten days prior to any expenditures, and no funds shall be expended without an enforceable agreement with or legal obligation imposed upon the recipient public entity to make an intergovernmental transfer in an appropriate amount to said account.
(p) Within the Uncompensated Care Trust Fund, there shall be established a department of mental retardation transfer account, administered by the secretary of health and human services, consisting of any receipts from the assessment collected pursuant to section 27, including transfers by the department of mental retardation of amounts sufficient to pay the assessment for public facilities, any federal financial participation received by the commonwealth as a result of expenditures funded by such assessments, and any interest thereon. The secretary may authorize expenditures of amounts from such account without further appropriation. The comptroller shall transfer no later than the first business day of each quarter, the amounts indicated by the department of mental retardation to provide the appropriate payment adjustments for operating the intermediate care facilities for the mentally retarded and the community residences serving individuals with mental retardation. The comptroller shall establish such procedures as may be necessary to accomplish the purpose of this section, including procedures for the proper transfer, accounting and expenditures of funds under this section. The comptroller may make payments in anticipation of receipts and shall establish procedures for reconciling overpayments and underpayments from said account. The secretary shall account for revenue and expenditure activity within said account.
centers; surcharges; calculation of percentage; billing method; enforcement; civil penalties [Text of section effective as provided by 1997, 47, Sec. 36 as amended by 2003, 9, Sec. 37.
] Section 18A. (a) Acute hospitals and ambulatory surgical centers shall assess a surcharge on all payments subject to surcharge as defined in section 1. The surcharge shall be distinct from any other amount paid by a surcharge payor for the services of an acute hospital or ambulatory surgical center. The surcharge amount shall equal the product of (i) the surcharge percentage and (ii) amounts paid for said services by a surcharge payor. The division shall calculate the surcharge percentage by dividing $100,000,000 by the projected annual aggregate payments subject to surcharge. The division shall determine the surcharge percentage before the effective date of this section and may redetermine the surcharge percentage before the following April 1 if the division projects that the initial surcharge established the previous October will produce less than $90,000,000 or more than $110,000,000. Before each succeeding October 1, the division shall redetermine the surcharge percentage incorporating any adjustments from prior years. In each determination or redetermination of the surcharge percentage, the division shall use the best data available as determined by the division and may consider the effect on projected surcharge payments of any modified or waived enforcement under subsection (e). The division shall incorporate all adjustments, including, but not limited to, updates or corrections or final settlement amounts by prospective adjustment rather than by retrospective payments or assessments.
(b) Each acute hospital and ambulatory surgical center shall bill a surcharge payor an amount equal to the surcharge described in subsection (a) as a separate and identifiable amount distinct from any amount paid by a surcharge payor for acute hospital or ambulatory surgical center services. Each surcharge payor shall pay such surcharge amount to the division for deposit in the uncompensated care pool on behalf of said acute hospital or ambulatory surgical center. Upon the written request of a surcharge payor, the division may implement another billing or collection method for such surcharge payor; provided, however, that the division has received all information that it requests which is necessary to implement such billing or collection method; and provided further, that the division shall specify by regulation the criteria for reviewing and approving such requests and the elements of such alternative method or methods.
(c) The division shall specify by regulation appropriate mechanisms that provide for determination and payment of a surcharge payor’s liability, including requirements for data to be submitted by surcharge payors, acute hospitals and ambulatory surgical centers.
(d) A surcharge payor’s liability to said pool shall in the case of a transfer of ownership be assumed by the successor in interest to the surcharge payor.
(e) The division shall establish by regulation an appropriate mechanism for enforcing a surcharge payor’s liability to said pool in the event that a surcharge payor does not make a scheduled payment to said pool; provided, however, that the division may, for the purpose of administrative simplicity, establish threshold liability amounts below which enforcement may be modified or waived. Such enforcement mechanism may include assessment of interest on the unpaid liability at a rate not to exceed an annual percentage rate of 18 per cent and late fees or penalties at a rate not to exceed 5 per cent per month. Such enforcement mechanism may also include notification to the division of medical assistance requiring an offset of payments on the claims of the surcharge payor, any entity under common ownership or any successor in interest to the surcharge payor, from the division of medical assistance in the amount of payment owed to said pool including any interest and penalties, and to transfer the withheld funds into said pool. If the division of medical assistance offsets claims payments as ordered by the division, said division of medical assistance shall be deemed not to be in breach of contract or any other obligation for payment of noncontracted services, and a surcharge payor to which payment is offset under order of the division shall serve all Title XIX recipients in accordance with the contract then in effect with the division of medical assistance. In no event shall the division direct the division of medical assistance to offset claims unless the surcharge payor has maintained an outstanding liability to the uncompensated care pool for a period longer than 45 days and has received proper notice that said division intends to initiate enforcement actions in accordance with the regulations of the division.
(f) Any surcharge payor that fails to file any data, statistics or schedules or other information required under this chapter or by any regulation promulgated by the division or which falsifies the same, shall be subject to a civil penalty of not more than $5,000 for each day on which such violation occurs or continues, which penalty may be assessed in an action brought on behalf of the commonwealth in any court of competent jurisdiction. The attorney general shall bring any appropriate action, including injunctive relief, as may be necessary for the enforcement of the provisions of this chapter.
officers; establishment of subdivisions; duties; rules and regulations Section 2. There is hereby established a division of health care finance and policy under the supervision and control of the commissioner. The secretary of health and human services shall appoint the commissioner, with the approval of the governor, who shall serve at the pleasure of the secretary and may be removed by the secretary at any time, subject to the approval of the governor. The commissioner shall have such educational qualifications and administrative and other experience as the secretary of health and human services determines to be necessary for the performance of the duties of commissioner. The position of commissioner shall be classified in accordance with section forty-five of chapter thirty and the salary shall be determined in accordance with section forty-six C of said chapter thirty.
The commissioner shall appoint and may remove such agents and subordinate officers as the commissioner may deem necessary and may establish such subdivisions within the division as the commissioner deems appropriate from time to time to fulfill the following duties:(a) to collect, analyze and disseminate health care data to assist in the formulation of health care policy and in the provision and purchase of health care services;[There is no clause (b).
] (c) to administer the uncompensated care pool established by section eighteen; and(d) to provide, on a basis calculated to reduce or contain the costs of the program, a program of insurance coverage for health care services for persons in the commonwealth who are not otherwise eligible for or covered by a health insurance plan, a self-insurance health plan, a medical assistance program or any other plan or program which provides for payment by a third-party payer for health care services;The division shall adopt and amend rules and regulations, in accordance with chapter thirty A, for the administration of its duties and powers and to effectuate the provisions and purposes of this chapter. Such regulations shall be adopted, after notice and hearing, only upon consultation with representatives of nonprofit hospital service corporations established under chapter one hundred and seventy-six A, elected representatives of health systems agencies designated pursuant to Title XV of the federal public health service act, representatives of companies authorized to sell accident and health insurance under chapter one hundred and seventy-five and the Massachusetts Hospital Association.
Section 21. The division may establish programs to enable small businesses to purchase health insurance for their employees at rates which are as equivalent as possible to the rates at which large employers can purchase health insurance. Such programs shall include, but not be limited to, the following:(1) the study of the insurance market and the practices of insurance companies, hospital service corporations, medical service corporations and health maintenance organizations, to determine the causes of the relative unavailability of health insurance plans for small businesses and of disproportionate health insurance premium costs for small businesses and to recommend and develop initiatives and strategies to improve the availability and reduce the relative cost of health insurance for small businesses;[There is no subsection (2).
] (3) the awarding of technical assistance grants to private organizations to assist them to act as brokers on behalf of small businesses seeking to procure health insurance plans;(4) the establishment of a small business health insurance pool for businesses consisting of six or fewer full-time employees, for the purpose of purchasing health insurance plans for employees and their dependents of businesses in the pool, and the study of the expansion of such pool to cover small businesses of up to ten full-time employees; provided, however, that not more than thirty per cent in the aggregate of the employees may be enrolled in a health insurance plan of a single health insurance company, hospital service corporation, or health maintenance organization;(5) the evaluation of the effectiveness of the initiatives of the division and tax incentives in reducing the cost of health insurance to small businesses and the impact of such voluntary incentives on the number of small businesses offering health insurance to their employees.
Any small business health insurance pool program established by the division may, subject to appropriation or the availability of unappropriated funds, establish by negotiation with private third-party payors, and purchase on such terms as it deems to be in the best interest of the commonwealth and enrollees in said program, from one or more insurance companies, hospital service corporations, medical service corporations, or health maintenance organizations, a policy of group general or blanket insurance providing hospital, surgical, medical, and other health insurance benefits covering persons who are the employees and their dependents of small businesses in which the number of full-time employees does not exceed six. The division shall execute all agreements or contracts pertaining to said policies or any amendments thereto for and on behalf of and in the name of the division. Said division may negotiate a contract for such term not to exceed three years as it may, in its discretion, deem to be the most advantageous to the division and the eligible small business employees. The division shall endeavor to purchase health insurance plans in an economical manner and shall enroll individuals in managed health care plans whenever practicable; and provided, further, that the division shall ensure that every enrollee shall have a choice of at least two policies providing health care insurance benefits. The division shall promulgate regulations regarding eligibility criteria, enrollment, and termination policies. The division shall allow, on an annual basis, an opportunity for enrollees to transfer their enrollments among participating health insurance plans. The division shall establish a schedule of premium contributions, co-payments, deductibles, or co-insurance amounts to be paid by eligible small businesses and individual enrollees; provided, however that such schedule shall provide for enrollees to pay one hundred per cent of such premium contributions if their income substantially exceeds the non-farm poverty guidelines of the United States Office of Management and Budget.
Section 22. There is hereby established an advisory council to the division to advise on the overall operation and policy of the division. The council shall consider any item recommended by the commissioner, the chairman of the council, a majority of the council members or by a subcommittee of the council and shall have the right to at least sixty days prior review and comment on any proposed rule or regulation of the division, with the exception of regulations promulgated on an emergency basis. The council shall consist of the commissioner, the commissioners of the departments of medical assistance, transitional assistance, social services, public health and education and the secretaries of the executive offices of health and human services, elder affairs, and administration and finance or their respective designees and sixteen members to be appointed by the commissioner for terms of three years. The commissioner shall fill any vacancy of members so appointed which may occur in the council for the remainder of the unexpired term. Of the appointed members, eight shall be providers of, or representatives of provider organizations, whose rates of reimbursement are determined by the commissioner and eight shall be non-providers with demonstrated experience in the field of consumer advocacy and with no financial interest in any provider of services whose rates of reimbursement are determined by the division. The provider appointees shall reflect the interests and concerns of all providers rendering services for which rates of reimbursement are established by the division. No single provider group, organization of providers, or class of provider shall have more than one representative on said council unless each provider group or class of provider is represented on the council. Two of the non-provider members shall be selected from recommendations by state-wide organizations representing the interests of the elderly and two non-provider members shall be selected from recommendations made by state-wide labor organizations; provided however, that one of the two non-provider members so selected from recommendations made by state-wide labor organizations shall be selected from recommendations made by the Massachusetts State Labor Council, AFL-CIO. All appointed members shall be reimbursed for their necessary travel expenses incurred in the performance of their duties.
The council shall meet at least three times annually and upon the call of the chairman or upon written application to the chairman by any eight members. The council shall annually elect a chairman from among its non-provider members. The council may appoint subcommittees; provided, however, that at all times there are at least four council members on each subcommittee, two of whom are providers and two of whom are non-providers; and provided, further, that at all times the total subcommittee membership consists of equal numbers of providers and non-providers. The subcommittees shall from time to time make recommendations to the division on matters of policy and operation of the division. The council shall be notified at least ten days in advance of any public meeting or hearing scheduled by the division.
There shall be an advisory board to advise the division relative to small business access to affordable health care. Such board shall consist of nine members appointed by the commissioner, five of whom shall represent small businesses, one of whom shall be an agent or broker of health insurance, one of whom shall represent a hospital service corporation, one of whom shall represent a health insurance company, and one of whom shall represent a health maintenance organization. Said board shall meet from time to time and shall advise the commissioner on all matters concerning small businesses for which the division is authorized to establish programs, and shall review menu or cafeteria plans, so-called, for the purpose of recommending whether such plans ought to be included as an allowable deduction under subsection (c) of section fourteen G of chapter one hundred and fifty-one A. Said board shall further advise the division on all matters relating to small business health insurance reform in relation to chapter one hundred and seventy-six J.
There shall be an advisory board to advise the division on matters relative to the uninsured. Such board shall consist of nine members appointed by the commissioner, three of whom shall be consumer representatives, one of whom shall be an organized labor representative, one of whom shall be a hospital representative, one of whom shall be a community health center representative, one of whom shall be a physician representative, one of whom shall be a health insurance representative, and one of whom shall be a business representative. Such board shall advise the division on all matters relative to the programs of the division to provide health insurance to the uninsured.
The commissioner may establish such other advisory boards as he deems necessary to advise it in matters relating to the functions, duties and powers set forth in this chapter.
underinsured Section 23. The division shall establish a continuing program of investigation and study of the uninsured and underinsured in the commonwealth, including the health insurance needs of the residents of the geographically isolated or rural areas of the commonwealth. Said continuing investigation and study shall examine the overall impact of programs developed by the division and the division of medical assistance on the uninsured, the underinsured, and the role of employers in assisting their employees in affording health insurance.
Section 24. The division shall develop and issue a document for consumers to be known as the health plan report card, containing information and data providing a basis by which health insurance plans may be evaluated and compared by consumers. The division may contract for the design and production of said report. The report shall be made available to residents of the commonwealth, upon request, by the office of patient protection in the department of public health, and shall be updated and issued annually by said office in consultation with the division. In preparing such report card, the division shall, to the extent possible, use information already reported by health insurance plans, including, but not limited to, the health plan employer data and information set established by the National Committee on Quality Assurance. The division shall consult with the department of public health and the division of insurance in determining the content and format of such report card, and shall make such report card available on the internet site established by the office of patient protection in the department of public health.
and community based residences; form for calculation; division’s authority to audit; appeals; enforcement Section 27. (a) For the purposes of this section, the following words shall have the following meanings:“Assessment,” the user fee imposed pursuant to this section.
“Intermediate care facility for the mentally retarded or ICF/MR,” a privately or publicly operated intermediate care facility for the mentally retarded.
“Community based residence,” a privately or publicly operated community based residence serving individuals with mental retardation licensed or certified in accordance with section 15 of chapter 19B.
“Bed day,” a day of services provided to an individual living in an intermediate care facility for the mentally retarded or a community based residence serving individuals with mental retardation.
(b) Each intermediate care facility for the mentally retarded and each community-based residence serving individuals with mental retardation shall pay an assessment per bed day. The assessment shall be implemented as a broad-based health care related fee as defined in 42 U.
S.
C. Sec. 1396b(w)(3)(B). The assessment shall be imposed at a uniform rate and shall be sufficient in the aggregate to generate an amount equal to six per cent of the total gross revenues generated by all such facilities in each fiscal year. The assessment shall be paid to the division at least quarterly. The division may promulgate regulations that authorize the assessment of interest on any unpaid liability at a rate not to exceed an annual rate of 18 per cent and late fees at a rate not to exceed 5 per cent per month. The receipts from the assessment, any federal financial participation received by the commonwealth as a result of expenditures funded by these assessments and interest thereon shall be credited to an account established within the Uncompensated Care Trust Fund.
(c) The commissioner shall prepare a form on which each ICF/MR and each community based residence shall report its total bed days and shall calculate the assessment due. The commissioner shall distribute the forms to each intermediate care facility for the mentally retarded and each community based residence for individuals with mental retardation at least annually. The failure to distribute the form or the failure to receive a copy of the form shall not stay the obligation to pay the assessment by the date specified in this section. The division may require additional reports, including but not limited to monthly census data, as it deems necessary to monitor collections and compliance.
(d) The division shall have the authority to inspect and copy the records of an ICF/MR or community residence for the purposes of auditing its calculation of the assessment. In the event that the division determines that an ICF/MR or a community-based residence has either overpaid or underpaid the assessment, the division shall notify the ICF/MR or the community based residence of the amount due or refund the overpayment. The division may impose per diem penalties if an ICF/MR or a community-based residence fails to produce documentation as requested by the division.
(e) In the event that an ICF/MR or a community based residence is aggrieved by a decision of the division as to the amount due, the ICF/MR or the community based residence may file an appeal to the division of administrative law appeals within 60 days of the notice of underpayment or the date the notice was received, whichever is later. The division of administrative law appeals shall conduct each appeal as an adjudicatory proceeding pursuant to chapter 30A, and an ICF/MR or a community based residence aggrieved by a decision of the division of administrative law appeals shall be entitled to judicial review pursuant to section 14 of said chapter 30A.
(f) The division shall establish by regulation appropriate mechanisms for enforcing the provisions of this section. Such enforcement may include notification to the department of mental retardation to take appropriate actions, including the revocation of licensure or certification for failure to remit delinquent fees.
(g) The division, in consultation with the department of mental retardation and the division of medical assistance, shall promulgate regulations necessary to implement this section.
units; rates for supplies, care and rehabilitative services and accommodations; rates for educational assessments Section 2A. The secretary shall establish rates of payment for health care services. The secretary shall have the sole responsibility for establishing rates to be paid to providers for health care services by governmental units, including the division of industrial accidents. The rates shall be adequate to meet the costs incurred by efficiently and economically operated facilities providing care and services in conformity with applicable state and federal laws and regulations and quality and safety standards and which are within the financial capacity of the commonwealth. The secretary shall have the sole responsibility for establishing fair and adequate charges to be used by state institutions for general health supplies, care and rehabilitative services and accommodations, which charges shall be based on the actual costs of the state institution reasonably related, in the circumstances of each institution, to the efficient production of the services in the institution and shall also have sole responsibility for determining rates paid for educational assessments conducted or performed by psychologists and trained, certified educational personnel pursuant to the tenth paragraph of section 3 of chapter 71B, notwithstanding any general or special law or rule or regulation to the contrary.
Section 3. In addition to the powers conferred on state agencies, the division shall have the following powers:—(a) to make, amend and repeal rules and regulations for the management of its affairs;(b) to make contracts and execute all instruments necessary or convenient for the carrying on of its business;(c) to acquire, own, hold, dispose of, and encumber personal property and to lease real property in the exercise of its powers and the performance of its duties;(d) to enter into agreements or transactions with any federal, state or municipal agency or other public institution or with any private individual, partnership, firm, corporation, association or other entity;(e) to design and to revise, consistent with this chapter, a basic schedule of health care services that enrollees in any health insurance program implemented by the division shall be eligible to receive. Such covered services shall include those which typically are included in employer-sponsored health benefit plans in the commonwealth. The division may promulgate schedules of covered health care services which differ from the basic schedule and which apply to specific classes of enrollees. The division may promulgate a schedule of premium contributions, co-payments, co-insurance, and deductibles for said programs, including reduced premiums based on a sliding fee, and other fees and revise them from time to time, subject to the approval of the division of insurance; and provided, however, that such schedule shall provide for such enrollees to pay one hundred per cent of such premium contributions if their income substantially exceeds the non-farm poverty guidelines of the United States office of management and budget;(f) to maintain a prudent level of reserve funds to protect the solvency of any trust funds under the operation and control of the division.
(g) without imposing undue hardship upon any individual, to secure payment for unpaid bills owed to acute hospitals by persons ineligible for free care which have been accounted for as bad debt by the hospital and which are voluntarily referred by a hospital to the department for collection; provided, however, that such unpaid charges shall be considered debts owed to the commonwealth and that all payments received shall be credited to the Uncompensated Care Trust Fund; and provided, further, that all actions to secure such payments shall be conducted in compliance with a protocol previously submitted by the division to the committee on health care and the house and senate committees on ways and means.
Section 4. The commissioner shall make an annual report to the secretary of the executive office of health and human services and to the general court the first Wednesday in November specifying the management of its affairs, an analysis of reimbursement policy for each class of providers of services and for state institutions, a projection of the percentage change and fiscal impact of any changes in rates or regulations for every provider and program under its jurisdiction for the fiscal year beginning July first in the year following such November first, a detailed analysis of the factors influencing each increase and an explanation for any rate increase in excess of the consumer price index. Said report shall further detail efforts of the division to coordinate its rate making function with rule making functions of other state agencies regulating said providers and institutions, and its recommendations for legislation, if any.
Section 5. Each acute hospital shall pay to the commonwealth an amount for the estimated expenses of the division. Such amount shall be equal to the amount appropriated by the general court for the expenses of the division of health care finance and policy minus amounts collected from (1) filing fees, (2) fees and charges generated by the division’s publication or dissemination of reports and information, and (3) federal matching revenues received for such expenses or received retroactively for expenses of predecessor agencies. Each acute hospital shall pay such net amount multiplied by the ratio of the hospital’s gross patient service revenues to the total of all such hospital’s gross patient services revenues. Each acute hospital shall make a preliminary payment to the division on October first of each year in an amount equal to one-half of the previous year’s total assessment. Thereafter, each hospital shall pay, within thirty days notice from the division, the balance of the total assessment for the current year based upon its most current projected gross patient service revenue. The division shall subsequently adjust the assessment for any variation in actual and estimated expenses of the division of health care finance and policy and for changes in hospital gross patient service revenue. Such estimated and actual expenses shall include an amount equal to the cost of fringe benefits, as established by the division of administration pursuant to section six B of chapter twenty-nine. In the event of late payment by any such hospital, the treasurer shall advance the amount of due and unpaid funds to the division prior to the receipt of such monies in anticipation of such revenues up to the amount authorized in the then current budget attributable to such assessments, and the division shall reimburse the treasurer for such advances upon receipt of such revenues. The provisions of this paragraph shall not apply to any state institution or to any acute hospital which is operated by a city or town.
and utilization of health care services; methodologies Section 6. The division shall promulgate such regulations as may be necessary to ensure the uniform reporting of revenues, charges, costs and utilization of health care services delivered by institutional and non-institutional providers. Such uniform reporting shall enable the division to identify, on a patient-centered and provider-specific basis, statewide and regional trends in the cost, availability and utilization of medical, surgical, diagnostic and ancillary services provided by acute hospitals, nursing homes, chronic care and rehabilitation hospitals, other specialty hospitals, clinics, including mental health clinics, and such ambulatory care providers as the division may specify.
The division shall, before adopting such regulations, consult with other agencies of the commonwealth, and the federal government, affected providers, as applicable, to ensure that the reporting requirements imposed from time to time under such regulations are not duplicative, excessive or costly. To the extent that any requirements imposed by the division result in additional costs to the reporting providers, such additional costs shall be included in any rates promulgated by the division for such providers. The division may specify, by regulation, categories of information which may be furnished under an assurance of confidentiality to the provider. Such assurance may only be extended by the division if the data furnished is not to be used for setting rates. The division shall work with other state agencies including, but not limited to, without limitation, the departments of public health and mental health and the divisions of medical assistance and insurance to collect and disseminate data concerning the cost of health insurance in the commonwealth, the health status of individuals and to publish such data and make it available to the public.
With respect to any acute or non-acute hospital, the division shall, by regulation, designate information necessary to effect the purposes of this chapter including, but not be limited to, the filing of a charge book, the filing of cost data and audited financial statements and the submission of merged billing and discharge data. The division shall, by regulation, designate standard systems for determining, reporting and auditing volume, case-mix, proportion of low income patients and any other information necessary to effectuate the purposes of this chapter and to prepare reports comparing acute and non-acute care hospitals by cost, utilization and outcome. Such regulations may require such hospitals to file required information and data by electronic means; provided, however, that the division shall allow reasonable waivers from such requirement. The division shall, at least annually, publish a report analyzing such comparative information for the purpose of assisting third-party payers and other purchasers of health services in making informed decisions. Such report shall include comparative price and service information relative to outpatient mental health services.
When collecting information or compiling reports intended to compare individual health care providers, the commission shall require that:(a) provider organizations which are representative of the target group for profiling shall be meaningfully involved in the development of all aspects of the profile methodology, including collection methods, formatting and methods and means for release and dissemination;(b) the entire methodology for collecting and analyzing the data shall be disclosed to all relevant provider organizations and to all providers under review;(c) data collection and analytical methodologies shall be used that meet accepted standards of validity and reliability;(d) the limitations of the data sources and analytic methodologies used to develop provider profiles shall be clearly identified and acknowledged, including, but not limited to, the appropriate and inappropriate uses of the data;(e) to the greatest extent possible, provider profiling initiatives shall use standard-based norms derived from widely accepted, provider-developed practice guidelines;(f) provider profiles and other information that have been compiled regarding provider performance shall be shared with providers under review prior to dissemination; provided, however, that opportunity for corrections and additions of helpful explanatory comments shall be provided prior to publication; and, provided, further, that such profiles shall only include data which reflect care under the control of the provider for whom such profile is prepared;(g) comparisons among provider profiles shall adjust for patient case-mix and other relevant risk factors and control for provider peer groups, when appropriate;(h) effective safeguards to protect against the unauthorized use or disclosure of provider profiles shall be developed and implemented;(i) effective safeguards to protect against the dissemination of inconsistent, incomplete, invalid, inaccurate or subjective profile data shall be developed and implemented;(j) the quality and accuracy of provider profiles, data sources and methodologies shall be evaluated regularly;(k) providers shall be reimbursed for the reasonable costs that are required for assembling, formatting and transmitting data and information to organizations that develop or disseminate provider profiles; and(l) the benefits of provider profiling shall outweigh the costs of developing and disseminating the profiles.
hospitals; annual reports Section 6A. (a) In fulfillment of its duties pursuant to clause (a) of the second paragraph of section 2, the division shall collect and analyze such data as it deems necessary in order to better protect the public’s interest in monitoring the financial conditions of acute hospitals. Such information shall be analyzed on an industry-wide and hospital–specific basis and shall include, but not be limited to: (1) gross and net patient service revenues; (2) sources of hospital revenue, including revenue excluded from consideration in the establishment of hospital rates and charges pursuant to section 12; (3) private sector charges; (4) trends in inpatient and outpatient case mix, payor mix, hospital volume and length of stay; and (5) other relevant measures of financial health or distress.
(b) The division shall publish annual reports and establish a continuing program of investigation and study of financial trends in the acute hospital industry, including an analysis of systemic instabilities or inefficiencies that contribute to financial distress in the acute hospital industry. Such reports shall include an identification and examination of hospitals that the division considers to be in financial distress, including any hospitals at risk of closing or discontinuing essential health services, as defined by the department of public health pursuant to section 51G of chapter 111, as a result of financial distress.
(c) The division may modify uniform reporting requirements established pursuant to section 6 and may require hospitals to report required information quarterly to effectuate the purposes of this section.
Section 7. The executive office (1) shall determine, after public hearing, at least annually for institutional providers, and at least biennially for non-institutional providers, the rates to be paid by each governmental unit to providers of health care services; (2) shall determine, after public hearing, at least annually, the rates to be charged by each state institution for general health supplies, care or rehabilitative services and accommodations; (3) shall certify to each affected governmental unit the rates so determined; (4) shall determine, after public hearing, at least annually, and certify to the division of industrial accidents of the department of labor and industries, rates of payment for general health supplies, care or rehabilitative services and accommodations, which rates shall be paid for services under chapter 152; (5) shall, upon request of the division of insurance, assist the division of insurance in the performance of its duties as set forth in section four of chapter one hundred and seventy-six B; (6) may establish fair and reasonable classifications upon which any rates may be based for rest homes, nursing homes and convalescent homes; provided, however, that the executive office shall not cause a decrease in a rate or add a penalty to a rate because such home has an equity position which is less than zero.
Such rates for nursing homes and rest homes, as defined under section seventy-one of chapter one hundred and eleven, shall be established as of October first of each year for facilities whose rate is set on a retrospective basis and as of July first of each year for facilities whose rate is set on a prospective basis. In setting such prospective or retrospective rates of reimbursement, the executive office shall use as base year costs for rate determination purposes the reported costs of the calendar year not more than four years prior to the current rate year, adjusted for reasonableness and to incorporate any audit findings applicable to said base year costs; provided, however, that no base year cost shall be incorporated unless a comprehensive desk audit has been completed for the costs incurred in that base year. In any appeal of any matter arising out of the setting of such prospective rates of reimbursement, the aggrieved party shall not be permitted to introduce into the record of such an appeal evidence of costs for any year other than the base year used to establish the rate. Notwithstanding any other general or special law or regulation to the contrary, except as provided in chapter one hundred and eighteen E, each governmental unit shall pay to a provider of services and each state institution shall charge as a provider of health care services, as the case may be, the rates for general health supplies, care and rehabilitative services and accommodations determined and certified by the executive office.
In establishing rates of payment to providers of services, the executive office shall control rate increases and shall impose such methods and standards as are necessary to ensure reimbursement for those costs which must be incurred by efficiently and economically operated facilities and providers. Such methods and standards may include, but are not limited to the following: peer group cost analyses; ceilings on capital and operating costs; productivity standards; caps or other limitations on the utilization of temporary nursing or other personnel services; use of national or regional indices to measure increases or decreases in reasonable costs; limits on administrative costs associated with the use of management companies; the availability of discounts for large volume purchasers; the revision of existing historical cost bases, where applicable, to reflect norms or models of efficient service delivery; and other means to encourage the cost-efficient delivery of services. Rates produced using these methods and standards shall be in conformance with Title XIX, including the upper limit on provider payments.
In determining rates to be paid by governmental units to providers of services, the executive office shall include as an operating expense of a provider of services any contribution made in lieu of taxes by such provider of services to a city or town and shall establish by regulation those expenses treated as business deductions under the Internal Revenue Code, which shall be included as allowable operating expenses in determining rates of reimbursement. Except for ceilings or maximum rates of reimbursement, which are determined in accordance with rate determination methods imposed on nursing homes, any ceiling or maximum imposed by the division upon the rate of reimbursement to be paid to rest homes shall reflect the actual costs of rest home providers and shall not prevent any such rest home provider from receiving full payment for costs necessarily incurred in the provision of services in compliance with federal or state regulations and requirements.
In determining rates to be paid by governmental units to acute-care hospitals, as defined in section 25B of chapter 111, and any hospital or separate unit of a hospital that provides acute psychiatric services, as defined in said section 25B, the executive office shall include as an operating expense the reasonable cost of providing competent interpreter services as required by section 25J of said chapter 111 or section 23A of chapter 123.
No hospital shall receive reimbursement or payment from any governmental unit for amounts paid to employees, as salary, or to consultant or other firms, as fees, where the primary responsibility of the employees or consultants is, either directly or indirectly, to persuade or seek to persuade the employees of the hospital to support or oppose unionization. Attorney’s fees for services rendered in dealing directly with a union, in advising hospital management of its responsibilities under the National Labor Relations Act, or for services at an administrative agency or court or for services by an attorney in preparation for the agency or in court proceeding shall not be deemed to be support or opposition to unionization.
The executive office shall establish rates on a prospective basis, subject to rules and regulations promulgated by the executive office whenever possible; provided, however, that whenever the executive office by regulation provides that a final rate for a reporting period shall be computed on the actual cost of a provider of services, or a state institution, for such period, it shall establish an interim rate for said provider or institution within twenty-one days of the beginning of said interim rate period, from which interim rate said provider may appeal as provided under section thirty-six.
The executive office shall also adopt regulations to enable each provider or institution to secure adjustment in said interim rate from time to time to meet current reasonable costs. Said provider or institution shall have the right at any time to petition the division for an increase in said interim rate. A petition for an adjustment in an interim rate shall include a certified statement that such a petition is not interposed for delay, a detailed explanation, under oath, of the basis upon which said increase is sought, together with a sworn statement of an independent licensed accountant or independent certified public accountant that he has examined the pertinent data relative to the accounts forming the basis of the petition and that in his opinion, said accounts are as represented by the petitioner. The petitioner shall provide such other information as the executive office shall require. The executive office, subject to such rules and regulations as it may establish, may waive the required independent audit for non-institutional providers whenever the executive office determines that such audit would create a financial hardship. The commissioner shall report in writing his recommendations to the petitioner, giving his reasons therefore in detail, and the petitioner shall have ten days to file objections, arguments and comments to the executive office. The executive office shall thereupon make a rate determination which shall become effective when filed with the state secretary. No appeal under section nine of this chapter shall be allowed from an interim rate determined under the provisions of this paragraph.
Whenever a final rate for a filing period is to be determined after the end of such period, the executive office shall calculate a preliminary final rate within 60 days after receipt of a satisfactory financial and operating cost report from a provider of services or state institution for such filing period. If such reports provide all the information required by the executive office and are attested to by an independent licensed accountant or an independent certified public accountant in such a manner and form as the executive office may require, the executive office may, prior to a field audit, establish such preliminary final rate on the basis of such information submitted. No appeal may be taken from such preliminary final rate. Ninety per cent of the difference between the interim rate and said preliminary final rate shall become payable by or to governmental units when certified to the state secretary. Said preliminary final rate may be promulgated as the final rate of a provider of services or state institution if the division is satisfied with a provider’s report. In the event that a final rate is determined without a field audit, the executive office shall institute such procedures, including random field audits, as are required to assure accurate reporting by providers of health care services and state institutions. If the executive office is not satisfied with the provider’s report, the executive office shall within six months and after a field audit promulgate a different rate of payment.
In establishing rates for nursing pools pursuant to section 72Y of chapter 111, the executive office shall establish annually the limit for the rate for service provided by nursing pools to licensed facilities. The executive office shall establish industry-wide class rates for such services and shall establish separate class rates for services provided to nursing facilities and hospitals. The executive office shall establish separate rates for registered nurses, licensed practical nurses and certified nursing assistants. The executive office may establish rates by geographic region. The rates shall include an allowance for wages, payroll taxes and fringe benefits, which shall be based upon, and shall not exceed, median wages, payroll taxes and fringe benefits paid to permanent medical personnel of the same type at health care facilities in the same geographic region. The rates shall also include an allowance for reasonable administrative expenses and a reasonable profit factor, as determined by the executive office. The executive office may exempt from the rates certain categories, as defined by the executive office, of fixed-term employees that work exclusively at a particular health care facility for a period of at least 90 days and for whose services there is a contract between a facility and a nursing pool registered with the department of public health. The executive office shall establish procedures by which nursing pools shall submit cost reports, which may be subject to audit, to the executive office for the purpose of establishing rates. The executive office shall determine the nursing pool rate contained in this paragraph by considering wage and benefit data collected from cost reports received from nursing pools and from health care facilities, and other relevant information gathered through other collection tools or reasonable methodologies.
The executive office shall set rates for rest homes, nursing homes and convalescent homes, beginning with interim rates for the rate year beginning October first, nineteen hundred and eighty-nine, by recalculating the base year whenever estimated costs for payments to nursing pools are no longer reflective of or are higher than actual costs to such facilities for such payments.
Notwithstanding the provisions of any general or special law or any rule or regulation to the contrary, the division, in determining the rate of payment for prescribed drugs dispensed to publicly-aided or industrial accident patients by pharmacy providers, shall not apply or use, either directly or indirectly, a discount from the primary standard used by the division in establishing such rate.
Except as otherwise provided in this section any person aggrieved by any rate determination made under this section shall have a right of appeal as provided under section nine.
The executive office may enter into such contracts or agreements with the federal government, a political subdivision of the commonwealth, or any public or private corporation or organization, as it deems necessary; provided, however, that the executive office shall not enter into any contract or agreement with a private corporation or organization to furnish information and statistical data to be used by said executive office as its sole basis for setting rates, if such private corporation or organization is to make or receive payments based upon the rates so set.
Each governmental unit shall cooperate with the executive office at all times in the furtherance of the executive office’s purposes. Each state institution shall permit the division or any designated representatives thereof, to examine its books and accounts and shall file with the executive office from time to time or upon request such data, statistics, schedules or other information as the executive office may reasonably require.
Each rate established by the executive office shall be deemed a regulation and shall be subject to review as hereinafter provided. The executive office shall promulgate rules and regulations for the administration of its duties and the determination of rates as are herein required subject to the procedures prescribed by chapter thirty A. Every rate, classification and other regulation established by the division shall be consistent where applicable with the principles of reimbursement for provider costs in effect from time to time under Titles XVIII and XIX of the Social Security Act governing reimbursements or grants available to the commonwealth, its departments, agencies, boards, divisions or political subdivisions for general health supplies, care, and rehabilitative services and accommodations.
In the event that any aggregate rates certified by the executive office exceed the upper limit of payment in effect for any period under Titles XVIII or Title XIX of the Social Security Act or any other requirement of said Titles, where applicable, the executive office shall redetermine and recertify any such aggregate rates in order to bring them into compliance with such federal requirement for the entire period during which such upper limit is effective.
The provisions of this section shall not apply to acute or non-acute hospitals; provided, however, that the provisions of this section shall apply to acute and non-acute hospitals for services under the workers’ compensation act.
governmental units to certain health care service providers; penalties for non-compliance Section 8. Any provider of health care services that receives reimbursement or payment for treatment of injured workers under chapter one hundred fifty-two and any provider of health care services other than an acute or non-acute hospital that receives reimbursement or payment from any governmental unit for general health supplies, care and rehabilitative services and accommodations, shall, as a condition of such reimbursement or payment: (1) permit the secretary, or any designated representative thereof, the attorney general or his designee, to examine such books and accounts as may reasonably be required for it to perform its duties; (2) file with the secretary from time to time or on request, such data, statistics, schedules, or other information as it may reasonably require, including outcome data and such information regarding the costs, if any, of such provider for research in the basic biomedical or health delivery areas or for the training of health care personnel which are included in its charges to the public for health care services, supplies and accommodations; and (3) accept reimbursement or payment at the rates established by the secretary, subject to a right of appeal under section nine, as discharging in full any and all obligations of an eligible person and the governmental unit to pay, reimburse or compensate the provider of health care services in any way for general health supplies, care, and rehabilitative services or accommodations provided.
Any provider of health care services that knowingly fails to file with the division data, statistics, schedules or other information required pursuant to this section or by any regulation promulgated by the division or knowingly falsifies the same shall be punished by a fine of not less than one hundred nor more than five hundred dollars.
If, upon application by the division or its designated representative, the superior court upon summary hearing determines that a provider of health care services has, without justifiable cause, refused to permit any examination or to furnish information, as required in this section, it shall issue an order directing all governmental units to withhold payment for general health supplies, care and rehabilitative services and accommodations to such provider of services until further order of the court.
In addition, the appropriate licensing authority may suspend or revoke, after an adjudicatory proceeding in accordance with chapter thirty A, the license of any provider of services that knowingly fails to file with the division data, statistics, schedules or other information required by this section or by any regulation of the division or that knowingly falsifies the same.
Section 9. Except for rates established pursuant to section eleven, any person, corporation or other party aggrieved by an interim rate or a final rate established by the division, or by failure of the executive office to set a rate or to take other action required by law and desiring a review thereof shall, within thirty days after said rate is filed with the state secretary or may, at any time, if there is a failure to determine a rate or take any action required by law, file an appeal with the division of hearings officers established by section four H of chapter seven. Any appeal filed under this section shall be accompanied by a certified statement that said appeal is not interposed for delay. On appeal, the rate determined for any provider of services shall be adequate, fair and reasonable for such provider, based upon, the costs of such provider, but not limited thereto.
On an appeal from an interim rate or a final rate the division of hearings officers shall conduct an adjudicatory proceeding in accordance with chapter thirty A, and said division shall file its decision with the commissioner and the state secretary within thirty days after the conclusion of the hearing.
Said decision shall contain a statement of the reasons therefore, including a determination of each issue of fact or law upon which such decision was based. If such decision results in a recommendation for a rate different from that certified, the executive office shall establish a new rate based upon such statement of reasons. If the commissioner determines that the statement of reasons is inadequate to determine a fair, reasonable and adequate rate, it may remand the appeal to the hearing officer for further investigation. Any party aggrieved by a decision of the division may, within thirty days of the receipt of such decision, file a petition for review in superior court for the county of Suffolk, which shall have exclusive jurisdiction thereof.
A provider may appeal as an aggrieved party in accordance with the provisions of the preceding sentence, in the event that a remand by the executive office to a hearing officer does not result in a final decision by the executive office within twenty-one days of the date of remand.
The petition shall set forth the grounds upon which the decision of the division should be set aside. The aggrieved party shall, within seven days after the petition for review is filed, notify the executive office and all the parties to the appeal before said division that a petition for review has been filed by sending each a copy thereof. Within forty days after the petition for review is filed, or within such further time as the court may allow, the division of hearings officers shall file in court the original or a certified copy of the record under review. The court may affirm, modify or set aside the decision of the executive office in whole or in part, remand the decision to the executive office for further proceedings, or enter such other order as justice may require. Nothing herein shall be construed to prevent the division from granting temporary relief if, in its discretion, such relief is justified nor, from informally adjusting or settling controversies with the consent of all parties.
Judicial review shall be governed by section fourteen of chapter thirty A to the extent not inconsistent with the provisions of this section.
Chapter 119: Section 1. Declaration of policy; purpose Section 1. It is hereby declared to be the policy of this commonwealth to direct its efforts, first, to the strengthening and encouragement of family life for the protection and care of children; to assist and encourage the use by any family of all available resources to this end; and to provide substitute care of children only when the family itself or the resources available to the family are unable to provide the necessary care and protection to insure the rights of any child to sound health and normal physical, mental, spiritual and moral development.
The purpose of this chapter is to insure that the children of the commonwealth are protected against the harmful effects resulting from the absence, inability, inadequacy or destructive behavior of parents or parent substitutes, and to assure good substitute parental care in the event of the absence, temporary or permanent inability or unfitness of parents to provide care and protection for their children.
The health and safety of the child shall be of paramount concern and shall include the long-term well-being of the child.
In all matters and decisions by the department, the policy of the department, as applied to children in its care and protection or children who receive its services, shall be to define best interests of the child as that which shall include, but not be limited to, considerations of precipitating factors and previous conditions leading to any decisions made in proceedings related to the past, current and future status of the child, the current state of the factors and conditions together with an assessment of the likelihood of their amelioration or elimination; the child’s fitness, readiness, abilities and developmental levels; the particulars of the service plan designed to meet the needs of the child within his current placement whether with the child’s family or in a substitute care placement and whether such service plan is used by the department or presented to the courts with written documentation; and the effectiveness, suitability and adequacy of the services provided and of placement decisions, including the progress of the child or children therein. The department’s considerations of appropriate services and placement decisions shall be made in a timely manner in order to facilitate permanency planning for the child.
In all department proceedings that affect the child’s past, current and future placements and status, when determining the best interests of the child, there shall be a presumption of competency that a child who has attained the age of 12 is able to offer statements on his own behalf and shall be provided with timely opportunities and access to offer such statements, which shall be considered by the department if the child is capable and willing. In all matters relative to the care and protection of a child, the ability, fitness and capacity of the child shall be considered in all department proceedings.
For purposes of this section, the words “all department proceedings” shall include departmental hearings and proceedings but shall not include a court proceeding even when the department is a party.
Chapter 119: Section 2 to 20. Repealed, 1972, 785, Sec. 6 Chapter 119: Section 21. Definitions applicable to Secs. 22 to 51F Section 21. The following words and phrases when used in sections twenty-two to fifty-one F, inclusive, shall, unless the context otherwise requires, be construed as follows:—“Department”, the department of social services.
“Parent”, means mother or father, unless specified parent as defined under section one of chapter one hundred eighteen.
“Child in need of services”, a child below the age of seventeen who persistently runs away from the home of his parents or legal guardian, or persistently refuses to obey the lawful and reasonable commands of his parents or legal guardian, thereby resulting in said parent’s or guardian’s inability to adequately care for and protect said child, or a child between the ages of six and sixteen who persistently and wilfully fails to attend school or persistently violates the lawful and reasonable regulations of his school.
“Custody”, shall include the following powers: — (1) to determine the child’s place of abode, medical care and education; (2) to control visits to the child; (3) to consent to enlistments, marriages and other contracts otherwise requiring parental consent. In the event that the parent or guardian shall object to the carrying out of any power conferred by this paragraph, said parent or guardian may take application to the committing court and said court shall review and make an order on the matter.
“Evidence”, shall be admissible according to the rules of the common law and the General Laws and may include reports to the court by any person who has made an investigation of the facts relating to the welfare of the child and is qualified as an expert according to the rules of the common law or by statute or is an agent of the department or of an approved charitable corporation or agency substantially engaged in the foster care or protection of children. Such person may file with the court in a proceeding under said sections a report in full of all the facts obtained as a result of such investigation. The person reporting may be called as a witness by any party for examination as to the statements made in the report. Such examination shall be conducted as though it were on cross-examination. Evidence may include testimony of foster parents or pre-adoptive parents concerning the welfare of a child if such child has been in the care of the foster or pre-adoptive parents for six months or more, and may include the testimony of the child if the court determines that the child is competent and willing, after consultation with counsel, if any, to testify.
Chapter 119: Section 22. Visitation of family foster homes; removal of child; discharge of child to parent or legal guardian Section 22. An agent of the department shall visit each family foster home, not supervised and approved by a licensed placement agency, at least once a year and may be authorized by the department to remove a child to its care if in its judgment the welfare of the child or its protection from neglect or abuse so require. An agent who is refused such entry, or who is hindered in the removal of such child, may make complaint, on oath, to a justice of the court having jurisdiction, who may thereupon issue a warrant authorizing him to obtain sufficient aid, and at any reasonable time enter the building designated, and any part thereof, to investigate the treatment and condition of a child found there and to remove such child as herein provided. The department shall take such child temporarily into its care and forthwith notify the child’s parent or legal guardian, and shall, upon request, discharge such child to its parent or legal guardian. If the parent or legal guardian is unable or refuses to make suitable provisions for the child, the department shall make lawful provisions for its care under section twenty-three or twenty-four.
Chapter 119: Section 23. Responsibility of department to provide foster care for children; grandparent visitation; child profile form; assignment of support rights Section 23. The department shall have the responsibility, including financial responsibility, for providing foster care for children through its own resources or by use of appropriate voluntary agencies according to the rules and regulations of the department in the following instances:A. Upon the application of a parent or guardian or any person acting in behalf of the child, or of the child himself, the department may accept for foster care any child under eighteen years who in its judgment is in need of foster care. Said judgment shall be exercised in accordance with guidelines and standards developed by said department and shall be reviewed by the executive office of human services. Such acceptance shall entail no abrogation of parental rights or responsibilities, but the department may accept from parents a temporary delegation of certain rights and responsibilities necessary to provide the foster care for a period of time under conditions agreed upon by both and terminable by either.
The department may file a petition for care and responsibility in the probate court on behalf of a child accepted into foster care if the department determines that continued placement beyond 6 months is required for reasons unrelated to parental unfitness and the parent consents to continued placement. At the initial hearing on the petition, the court shall determine whether continued placement with the department is in the child’s best interests and shall issue its determination, including the rationale therefor, in written form. The allowance of the petition shall not abrogate a parent’s right to make decisions on behalf of the child, but the department may accept from the parent a temporary delegation of certain rights and responsibilities necessary to continue to provide foster care for the child under conditions agreed upon by both and terminable by either.
Notwithstanding any general or special law to the contrary, a permanency hearing shall be held within 60 days of the transfer of responsibility by order of the probate court or within 12 months of initial placement into foster care with the department, whichever date is later. The hearing shall be conducted as provided in section 29B.
Whenever the child is placed in family foster care, the court shall ensure that grandparents, upon their request, have access to reasonable visitation rights with the child who is the subject of the petition and that the department establish a schedule for such visitation unless it is determined by the court or the department that such visitation is not in the child’s best interests. In determining the best interests of the child the court or the department shall consider the goal of the service plan and the relationship between the grandparents and the child’s parents or legal guardian. Grandparents who are denied the right to visit with said child may appeal a denial by the department through the department’s fair hearing process. The department may establish reasonable conditions governing grandparents visitation, including but not limited to requiring that the grandparents be restrained from revealing the whereabouts of the child’s placement.
The court shall, whenever reasonable and practical, and based upon a determination of the best interests of the child, ensure that children placed in foster care who are separated from siblings who are either in other foster or pre-adoptive homes, or in the homes of parents or extended family members, have access to, and visitation rights with, such siblings throughout the period of placement in the care and custody of the commonwealth, or subsequent to such placements if the children or their siblings are separated through adoption or long-term placements in foster care.
The courts shall determine, at the time of initial placements wherein children and their siblings are separated through placements in foster, pre-adoptive, or adoptive care, that such visitation rights be implemented through a schedule of visitations or supervised visitations to be arranged and monitored through the appropriate public or private agency, and with the participation of the foster, pre-adoptive or adoptive parents, or extended family members, and other parties who are relevant to the preservation of sibling relationships and visitation rights. Periodic reviews shall be conducted, so as to evaluate the effectiveness and appropriateness of the visitations between siblings placed in care.
B. The department may accept from parents voluntary surrender of custody of their children under eighteen years for purposes of giving consent for adoption under the same conditions as noted in paragraph A of this section.
C. The department may seek and shall accept on order of a probate court the responsibility for a child under 18 years of age who is without proper guardianship due to death, unavailability, incapacity or unfitness of the parent or guardian or on the consent of the parent or parents. Such responsibility shall include the right to: determine the child’s abode, medical care and education; control visits to the child; give consent to enlistments, marriages and other contracts requiring parental consent and to consent to adoption only when it is expressly included in the order of the court. In making an order, the probate court shall consider the provisions of section 29C and shall make the written certification and determinations required by said section 29C. If a child is in the care of the department of mental health or the department of mental retardation, the responsibility enumerated above and all rights therein contained shall continue in the department. The department shall continue to have responsibility for a mentally retarded person, notwithstanding the fact that such person has reached the age of 18, if the department has accepted responsibility for such person prior to his reaching the age of 18 and such person has been declared to be legally incompetent. Responsibility shall continue in the department until such person shall be declared to be no longer legally incompetent.
Whenever the child is placed in family foster care, the court shall ensure that grandparents, upon their request, have access to reasonable visitation rights with the child who is the subject of the petition and that the department establish a schedule for such visitation unless it is determined by the court or the department that such visitation is not in the child’s best interests. In determining the best interests of the child the court or the department shall consider the goal of the service plan and the relationship between the grandparents and the child’s parents or legal guardian. Grandparents who are denied the right to visit with said child may appeal a denial by the department through the department’s fair hearing process. The department may establish reasonable conditions governing grandparents visitation, including but not limited to requiring that the grandparents be restrained from revealing the whereabouts of the child’s placement.
D. The department shall accept on commitment from any division of the juvenile court department any child under eighteen years of age declared in need of foster care under section twenty-six or to be a child in need of services under section thirty-nine G.
E. Any child under eighteen years who is left in any place and who is seemingly without a parent or legal guardian available shall be immediately reported to the department, which shall proceed to arrange care for such child temporarily and shall forthwith cause search to be made for parent or guardian. If parent or guardian cannot be found or is unable or refuses to make suitable provisions for the child, the department shall make such lawful provision as seems for the best interest of such child within the provisions of this chapter.
F. If the department has in its care a child whose parent or parents have consented to his adoption and the department has been unable to place such child in an adoptive home within sixty days of the receipt of such consent, it shall so notify all children’s foster care agencies in the commonwealth licensed to place children for adoption. Said notice shall request that each such agency attempt to find an adoptive home for such child. If one of said agencies locates an adoptive home for such child the department shall cooperate with such agency in the placement of the child in such home and in the supervision of the placement during the one year waiting period. Any person in whose home such child has been placed by the division shall also be informed by the department if such child has become eligible for adoption, and such person may request consideration as a prospective adoptive parent.
G. A temporary shelter care facility program or a group care facility, licensed under the provisions of chapter twenty-eight A, may, for a seventy-two-hour period, provide temporary shelter to a child under eighteen without parental consent, provided that the child’s welfare would be endangered if such shelter were not immediately provided. At the expiration of such seventy-two-hour period, the licensee shall (1) secure the consent of parent or guardian to continued custody and care, (2) refer the child to the department for custody and care, or (3) refuse to provide continued care and custody to said child.
H. The department may pay a sum not exceeding eleven hundred dollars for the funeral and burial of a child in its care provided that the cost of funeral and burial does not exceed fifteen hundred dollars and there are insufficient resources to pay for the cost of such funeral and burial. Any resources of the child shall be deducted from the maximum cost of the funeral and burial allowable hereunder and the difference, subject to the limitation set forth in this paragraph, shall be paid by the department.
Whenever a child is placed in a foster home, or is transferred from one foster home to another, or from a state facility for the care of children to a foster home, a completed child profile form shall precede or accompany the child to the foster home.
In the case of an emergency placement, such child profile form shall be received by the foster parents from the department, the department of youth services, the department of mental health, other departments of the commonwealth responsible for the placement of foster children, or placement agency within ten days of the child’s placement in the foster home. At the time of an emergency placement, the department, the department of youth services, the department of mental health, other departments of the commonwealth responsible for the placement of foster children, or placement agency shall provide to the foster parents, in verbal or written form, a brief statement describing the child’s outstanding problem behaviors and mental and emotional problems.
The department shall develop a child profile form which shall be used by all other departments of the commonwealth or placement agencies and which shall contain the child profile and any other relevant information necessary to the care, well-being, protection, and parenting of the child by the foster parents. Said child profile shall contain, but not be limited to, a history of the child’s previous placements and reasons for placement changes; a history of the child’s problem behaviors and mental and emotional problems; educational status and school related problem behaviors, and any other psychological, educational, medical, and health information necessary.
The child profile form shall immediately be prepared by the department of the commonwealth which is granted care and custody of the child at the time such care and custody is granted.
The department may continue to have the responsibility for any person provided for in this section under twenty-one years for the purposes of specific educational or rehabilitative programs, under conditions agreed upon by both the department and such person and terminable by either.
The department shall obtain and provide to the IV–D agency, as set forth in chapter one hundred and nineteen A, an assignment of support rights on behalf of each child receiving foster care maintenance payments pursuant to Title IV, Part E, of the Social Security Act, including, but not limited to the following information: the child’s name, date of birth, place of birth, Social Security number, address and benefit level and, if known, each parent’s name, date of birth, place of birth, Social Security number, most recent address and most recent employer. The department shall notify said IV–D agency forthwith when a child for whom support is collected no longer receives foster care maintenance payments pursuant to Title IV, Part E, of the Social Security Act.
Chapter 119: Section 23A. Children born to inmates of correctional institutions or jails; care and custody Section 23A. Any child born to an inmate of the Massachusetts Correctional Institution, Framingham, or of the Industrial School for Girls at Lancaster, or of a jail or a house of correction, shall be accepted by the department, and any child whose mother is committed to the Massachusetts Correctional Institution, Framingham, to a jail or a house of correction, or to the custody of the youth service board, may be accepted by the department. Thereupon the department in consultation with the commissioner of correction or the chairman of the youth service board shall make such provision at said place of commitment or elsewhere for the care of said child as may seem to be for the best interests of said child.
Chapter 119: Section 23B. Services to unwed mothers Section 23B. The department may, through its own resources or the resources of other appropriate agencies, provide services to mothers bearing children out of wedlock.
Chapter 119: Section 24. Procedure to commit child to custody or other disposition; notice; report of conditions affecting the child; expedited hearings Section 24. The divisions of the juvenile court department, upon the petition under oath of a person alleging on behalf of a child under the age of 18 within the jurisdiction of the court that the child: (a) is without necessary and proper physical or educational care and discipline; (b) is growing up under conditions or circumstances damaging to the child’s sound character development; (c) lacks proper attention of the parent, guardian with care and custody or custodian; or (d) has a parent, guardian or custodian who is unwilling, incompetent or unavailable to provide any such care, discipline or attention, may issue a precept to bring the child before the court, shall issue a notice to the department and summonses to both parents of the child to show cause why the child should not be committed to the custody of the department or that any other appropriate order should not be made. The summonses shall include notice that the court may dispense with the right of the parents to notice of or consent to the adoption, custody or guardianship or any other disposition of the child named therein if it finds that the child is in need of care and protection and that the best interests of the child would be served by any such disposition. Notice shall be by personal service upon the parent. If the identity or whereabouts of a parent is unknown, the petitioner shall cause notice in a form prescribed by the court to be served upon such parent by publication once in each of three successive weeks in any newspaper as the court may order. If, after reasonable search, no parent can be found, a summons shall be issued to the child’s legal guardian, if any, known to reside within the commonwealth and, if none, to the person with whom such child last resided, if known. If, after a recitation under oath by the petitioner of the facts of the condition of the child who is the subject of the petition, the court is satisfied that there is reasonable cause to believe that the child is suffering from serious abuse or neglect or is in immediate danger of serious abuse or neglect and that immediate removal of the child is necessary to protect the child from serious abuse or neglect, the court may issue an emergency order transferring custody of the child to the department or to a licensed child care agency or individual described in clause (2) of the first paragraph of section 26. A transfer of custody shall be for a period not exceeding 72 hours except that upon the entry of the order, notice shall be given to either or both parents, guardian with care and custody or other custodian to appear before the court. The court shall, at that time, determine whether temporary custody shall continue until a hearing on the merits of the petition for care and protection is concluded before the court. The court shall also consider the provisions of section 29C and shall make the written certification and determinations required by said section 29C.
Upon the issuance of the precept and order of notice, the court shall appoint a person qualified under section 21 to make a report to the court under oath of an investigation into conditions affecting the child. The report shall then be attached to the petition and be a part of the record.
If a child who is the subject of a petition is alleged to be abandoned as defined in section 3 of chapter 210, hearings on the petition under section 26 shall be scheduled and heard on an expedited basis. Any child may be committed to the department under this section without a hearing or notice with the consent of the parents or guardian.
Chapter 119: Section 25. Hearing; custody of child Section 25. When such child is taken into custody upon said precept and brought before said court, the court may then hear said petition, or said petition may be continued to a time fixed for hearing, and the court may allow the child to be placed in the care of some suitable person or licensed agency providing foster care for children or the child may be committed to the custody of the department, pending a hearing on said petition.
If the court commits a child to the custody of the department, the court shall consider the provisions of section 29C and shall make the written certification and determinations required by said section 29C.
Chapter 119: Section 26. Procedure at hearing; order of commitment; visitation rights; reimbursement of commonwealth; petition for review Section 26. If the child is identified by the court and it appears that the precept and summonses have been duly and legally served, that said notice has been issued to the department and said report is received, the court may excuse the child from the hearing and shall proceed to hear the evidence.
If the court finds the allegations in the petition proved within the meaning of this chapter, it may adjudge that the child is in need of care and protection. In making such adjudication, the health and safety of the child shall be of paramount concern. If the child is adjudged to be in need of care and protection, the court may commit the child to the custody of the department until he becomes 18 years of age or until, in the opinion of the department, the object of his commitment has been accomplished, whichever occurs first, and the court shall consider the provisions of section 29C and shall make the written certification and determinations required by said section 29C and any other appropriate order with reference to the care and custody of the child as may be in his best interest including, but not limited to, any one or more of the following:—(1) It may permit the child to remain with his parents, guardian, or other custodian, subject to conditions and limitations which the court may prescribe including supervision as directed by the court for the care and protection of the child.
(2) It may, subject to such conditions and limitations as it may prescribe, transfer temporary legal custody to any of the following:—(i) any individual who, after study by a probation officer or other person or agency designated by the court, is found by the court to be qualified to give care to the child;(ii) any agency or other private organization licensed or otherwise authorized by law to receive and provide care for the child;(iii) the department of social services.
(3) It may order appropriate physical care including medical or dental care.
(4) It may enter an order to dispense with the need for consent of any person named in section 2 of chapter 210, to the adoption, custody, guardianship or other disposition of the child named therein, upon a finding that the child is in need of care and protection pursuant to this section and that the best interests of the child will be served by such an order. In determining whether such an order should be made, the standards set forth in section 3 of said chapter 210 concerning an order to dispense with the need for consent to adoption of a child shall be applied. If the child who is the subject of the petition is under the age of 12, and if the court adjudicates the child to be in need of care and protection in accordance with this section, the court shall enter an order dispensing with the need for consent to adoption upon finding that the best interests of the child, as defined in paragraph (c) of said section 3 of said chapter 210, will be served thereby. The entry of such an order shall have the effect of terminating the rights of a person named therein to receive notice of or to consent to any legal proceeding affecting the custody, guardianship, adoption or other disposition of the child named therein.
The department of social services shall file a petition or, in the alternative, a motion to amend a petition pending pursuant to this section, to dispense with parental consent to adoption, custody, guardianship or other disposition of the child under the following circumstances: (i) the child has been abandoned; (ii) the parent has been convicted by a court of competent jurisdiction of the murder or voluntary manslaughter of another child of such parent, of aiding, abetting, attempting, conspiring or soliciting to commit such murder or voluntary manslaughter or of an assault constituting a felony which resulted in serious bodily injury to the child or to another child of such parent; or (iii) the child has been in foster care in the custody of the state for 15 of the immediately preceding 22 months. For the purposes of this paragraph, a child shall be considered to have entered foster care on the earlier of: (a) the date of the first judicial finding, pursuant to section 24 or this section, that the child has been subjected to abuse or neglect; or (b) the date that is 60 days after the date on which the child is removed from the home. For the purposes of this section, “serious bodily injury” shall mean bodily injury which involves a substantial risk of death, extreme physical pain, protracted and obvious disfigurement or protracted loss or impairment of the function of a bodily member, organ or mental faculty. The department shall concurrently identify, recruit, process, and approve a qualified family for adoption.
The department need not file such a motion or petition to dispense with parental consent to the adoption, custody, guardianship or other disposition of the child if the child is being cared for by a relative or the department has documented in the case plan a compelling reason for determining that such a petition would not be in the best interests of the child or that the family of the child has not been provided, consistent with the time period in the case plan, such services as the department deems necessary for the safe return of the child to the child’s home if reasonable efforts as set forth in section 29C are required to be made with respect to the child.
Notwithstanding the foregoing, the following circumstances shall constitute grounds for dispensing with the need for consent to adoption, custody, guardianship or other disposition of the child: (i) the child has been abandoned; (ii) the parent has been convicted by a court of competent jurisdiction of the murder or voluntary manslaughter of another child of such parent, of aiding, abetting, attempting, conspiring or soliciting to commit such murder or voluntary manslaughter or of an assault constituting a felony which resulted in serious bodily injury to the child or to another child of the parent.
(5) Whenever the child is placed in family foster care, the court shall ensure that grandparents, upon their request, have access to reasonable visitation rights with the child who is the subject of the petition and that the department establish a schedule for such visitation unless it is determined by the court or the department that such visitation is not in the child’s best interests. In determining the best interests of the child the court or the department shall consider the goal of the service plan and the relationship between the grandparents and the child’s parents or legal guardian. Upon recommendation by the department or on its own accord, the court may establish reasonable conditions governing grandparent visitations, including but not limited to requiring that the grandparents be restrained from revealing the whereabouts of the child’s placement.
The court shall, whenever reasonable and practical, and based upon a determination of the best interests of the child, ensure that children placed in foster care who are separated from siblings who are either in other foster or pre-adoptive homes or in the homes of parents or extended family members, have access to, and visitation rights with, such siblings throughout the period of placement in the care and custody of the commonwealth, or subsequent to such placements, if the children or their siblings are separated through adoption or long-term or short-term placements in foster care.
The courts shall determine, at the time of the initial placements wherein children and their siblings are separated through placements in foster, pre-adoptive, or adoptive care, that such visitation rights be implemented through a schedule of visitations or supervised visitations, to be arranged and monitored through the appropriate public or private agency, and with the participation of the foster, pre-adoptive or adoptive parents, or extended family members, and the child, if reasonable, and other parties who are relevant to the preservation of sibling relationships and visitation rights.
Periodic reviews shall be conducted, so as to evaluate the effectiveness and appropriateness of the visitations between siblings placed in care.
Any child who has attained the age of 12 years, may request visitation rights with siblings who have been separated and placed in care or have been adopted in a foster or adoptive home other than where the child resides.
In appropriate cases the court shall order the parents or parent of said child to reimburse the commonwealth or other agency for care.
On any petition filed in any court pursuant to this section, the department, parents, person having legal custody of, counsel for a child, the probation officer, guardian or guardian ad litem may petition the court not more than once every six months for a review and redetermination of the current needs of such child whose case has come before the court, except that any person against whom a decree to dispense with consent to adoption has been entered pursuant to clause (4) shall not have such right of petition for review and redetermination. Unless the court enters written findings setting forth specific extraordinary circumstances that require continued intervention by the court, the court shall enter a final order of adjudication and permanent disposition, no later than fifteen months after the date the case was first filed in court; provided, however, that the date by which a final order of adjudication and permanent disposition shall be entered may be extended once for a period not to exceed three months; and, provided, further, that said extension shall only be granted if the court makes written finding that the parent has made consistent and goal-oriented progress likely to lead to the child’s return to the parent’s care and custody. Findings in support of such final order of adjudication and permanent disposition shall be made in writing within a reasonable time of the court’s order. The court shall not lose jurisdiction over the petition by reason of its failure to enter a final order and the findings in support thereof within the time set forth in this paragraph.
Chapter 119: Section 26A. Registration of interest for foster care placement; criminal record review Section 26A. When deciding whether to approve or reject a registration of interest for foster care placement, the department shall conduct a review of any misdemeanor offense discovered through a criminal offender record information search conducted pursuant to section 172B of chapter 6 in order to assist the department in accurately evaluating whether the mere existence of the offense has a substantial effect on the applicant’s current or future ability to assume and carry out the responsibilities of a foster parent in such a manner that the rights of the child to sound health and normal physical, mental, spiritual and moral development are insured. The review shall include, but not be limited to, a review of the following: the time that has elapsed between the date of the offense and the filing of the registration of interest, the seriousness and specific circumstances of the offense, the number and nature of other offenses, the age of the offender at the time of the offense, the findings and recommendations of the family resource worker assigned by the department to discuss the facts surrounding the misdemeanor with the applicant, the recommendations given to the family resource worker by personal or employment references chosen by the applicant or received otherwise, the current and future needs of the child to be placed and the probable effect that the misdemeanor would have on the applicant’s ability to fulfill those needs, any reports or recommendations received by the department from the applicant’s parole or probation officer should one have been assigned, a copy of the police report pertaining to the offense in question if obtainable within a reasonable period of time or discussions with a police officer familiar with the facts surrounding the offense and, unless inappropriate, discussions with the child to be placed regarding his current and past relationship with the applicant. Nothing in this section shall be construed to affect the discretion of the department to approve or reject the registration of interest for foster care placement.
Chapter 119: Section 27. Appeals; procedure; notice of right of appeal; time limits Section 27. A child, parent, guardian or person appearing in behalf of such child, or the department, may appeal from the adjudication of the court and from any order of commitment made as a result of the adjudication under the provisions of section twenty-six to the appeals court. The trial justice entering the adjudication or order of commitment shall, prior to said adjudication, or within ten days thereafter, file detailed findings of fact and conclusions of law. Pending the appeal, the child may be committed to the custody of the department or placed in the care of some suitable person or licensed children’s foster care agency. The district court or juvenile court where the order of adjudication was entered shall retain jurisdiction to and may enter any order for the needs of the child. The court shall notify the child, parent, guardian or person appearing in behalf of such child of the right of appeal at the time of adjudication and also at the time of commitment.
The claim of appeal under this section shall be filed in the office of the clerk of the said division of the district court department or the division of the juvenile court department within 30 days of the entry of the adjudication or order of commitment by the court. The completion of said appeal shall be governed by the Massachusetts rules of appellate procedure.
Chapter 119: Section 28. Orders for payment of support; who may bring action; expiration of order or judgment Section 28. (a) During the pendency of an action brought pursuant to section twenty-four, temporary orders providing for the support of a child may be entered. The court may thereafter enter a judgment against the party chargeable with support. When the court makes an order of support on behalf of a party, and such party is not covered by a private group health insurance plan, the court shall determine whether the person chargeable with support has private health insurance or a group plan available to him through an employer or organization that may be extended to cover the party for whom support is ordered. When said court has determined that the person chargeable with support has such insurance, said court shall include in the order or judgment a provision relating to said insurance.
Any such order of support shall conform to and be enforced in accordance with the provisions of section twelve of chapter one hundred and nineteen A.
(b) Actions under this section to establish support of a child may be commenced by a parent, whether a minor or not; by the child; by the child’s guardian, next of kin or other person standing in a parental relationship to the child; by the authorized agent of the department of social services or any agency licensed under chapter 28A provided that the child is in their custody or is or was a recipient of any type of public assistance by the IV-D agency as set forth in chapter 119A on behalf of the department of transitional assistance, the department of social services, the division of medical assistance, or any other public assistance program of the commonwealth. In the event that someone other than the IV-D agency commences the action, if the parent or child is or was a recipient of any type of public assistance, the court shall notify said IV-D agency of the pendency of the action and said IV-D agency shall be permitted to intervene in the action.
(c) An order, or judgment of support pursuant to this section may be entered notwithstanding the default of the person chargeable with support or his failure to appear personally.
(d) In determining the amount of current support to be paid, the court shall apply the child support guidelines established by the chief administrative justice of the trial court, or, in the absence of such standards, shall consider the factors set forth in section thirty-two of chapter two hundred and nine.
(e) The person chargeable with support shall comply with said order, or judgment until the same is dismissed or expires. When an action brought under section twenty-four of this chapter is dismissed or a final order of commitment is entered, the order or judgment of support shall expire six months after the judgment of dismissal or final order of commitment. At the time of such dismissal or final order of commitment, the court shall notify the parties and the IV–D agency, as set forth in chapter one hundred and nineteen A, of the expiration date of the support order or judgment.
Chapter 119: Section 29. Counsel for child; appointment Section 29. Whenever a child is before any court under subsection C of section twenty-three or sections twenty-four to twenty-seven, inclusive, or section twenty-nine B, said child shall have and shall be informed of the right to counsel at all hearings, and if said child is not able to retain counsel, the court shall appoint counsel for said child. The parent, guardian or custodian of such child shall have and shall be informed of the right to counsel at all hearings under said sections and in any other proceeding regarding child custody where the department of social services or a licensed child placement agency is a party, including such proceedings under sections five and fourteen of chapter two hundred and one; and if said parent, guardian or custodian of such child is financially unable to retain counsel, the court shall appoint counsel for said parent, guardian or custodian. The probate and family court department of the trial court shall establish procedures for notifying said parent, guardian or custodian of such right, and for appointing counsel for an indigent parent, guardian or custodian within fourteen days of a licensed child placement agency filing or appearing as a party in any such action. In any such proceeding regarding child custody, where the department of social services or a licensed child placement agency is a party, the parent, guardian or custodian of such child shall have and shall be informed of the right to a service or case plan for the child and his family which complies with applicable state and federal laws and regulations regarding such plans. The department or agency shall provide a copy of such plan to the parent, guardian or custodian of the child and to the attorneys for all parties appearing in the proceeding within forty-five days of the department or agency filing an appearance in such proceeding. Thereafter, any party may have the original or changed plan introduced as evidence, and with the consent of all parties such plan shall be filed with the court. Notwithstanding the provisions of this section, the court may make such temporary orders as may be necessary to protect the child and society.
The department, upon its request, shall be represented by the district attorney for the district in which the case is being heard.
Chapter 119: Section 29A. Legal fees of minors in criminal proceedings; liability of parents Section 29A. The parents of an unemancipated minor shall be liable for such reasonable legal fees and expenses of an attorney representing the minor in criminal proceedings. Except where the parent is the alleged victim, the court shall determine whether the parent or guardian of an unemancipated minor is indigent. If the parent or guardian is not determined to be indigent, the court shall assess a $300 fee against the parent or guardian to pay for the cost of any attorney that is supplied by the committee for public counsel services or assigned to represent the minor by the court and paid out of public funds in the criminal proceedings. If the parent is determined to be indigent but is still able to contribute toward the payment of some of the costs, the court shall order the parent to pay a reasonable amount toward the cost of appointed counsel. This section shall not apply to a parent who, as a result of a decree of a court of competent jurisdiction, does not have custody of the minor.
Chapter 119: Section 29B. Determination of future status of committed children; orders; permanency hearings; appeals Section 29B. Except as provided herein, within 12 months of the original commitment, grant of custody or transfer of responsibility of a child to the department by a court of competent jurisdiction, and not less frequently than every 12 months thereafter while the child remains in the care of the department, the committing court shall conduct a permanency hearing, in accordance with rules established by the chief justice for administration and management, to determine and periodically review thereafter the permanency plan for the child. The plan shall address whether and, if applicable, when: (1) the child will be returned to the parent; (2) the child will be placed for adoption and the steps the department shall take to free the child for adoption; (3) the child will be referred for legal guardianship; or (4) the child will be placed in another planned permanent living arrangement. The department shall file a permanency plan prior to a permanency hearing which shall address the above placement alternatives.
In the case of a child placed in foster care outside the state in which the home of the parents of the child is located, the permanency plan shall also address whether the out-of-state placement continues to be appropriate and in the best interests of the child. In the case of a child who has attained age 16, the permanency plan shall also address the services needed to assist the child in making the transition from foster care to independent living.
Upon making its determination, the court may make any appropriate order as may be in the child’s best interests including, but not limited to, orders with respect to the child’s care or custody. At the same time, the court shall consider the provisions of section 29C, and shall make the written certification and determinations required by said section 29C. The health and safety of the child shall be of paramount, but not exclusive, concern.
The permanency hearing shall be held within 30 days of a hearing at which a court determines that reasonable efforts to preserve and reunify families are not required pursuant to section 29C. The court may, however, make such determination at the time of the permanency hearing.
If continuation of reasonable efforts to return the child safely to his parent or guardian are found to be inconsistent with the permanency plan for the child or if reasonable efforts are not required pursuant to the provisions set forth in section 29C, the department shall make reasonable efforts to place the child in a timely manner in accordance with the permanency plan. In subsequent permanency hearings held on behalf of the child, the court shall determine whether the department has made such efforts in accordance with section 29C.
A child, parent, guardian or the department may appeal to the appeals court from the determination or order of the trial court. The claim of appeal shall be filed in the office of the clerk or register of the trial court within 30 days following the court’s determination or order. Thereafter, the appeal shall be governed by the Massachusetts Rules of Appellate Procedure. The scope of appellate review shall be limited to abuse of judicial discretion.
Chapter 119: Section 29C. Judicial certification of need to remove child from home Section 29C. If a court of competent jurisdiction commits, grants custody or transfers responsibility for a child to the department or its agent, the court shall certify that the continuation of the child in his home is contrary to his best interests and shall determine whether the department or its agent, as appropriate, has made reasonable efforts prior to the placement of a child with the department to prevent or eliminate the need for removal from the home; but, if a child has been placed voluntarily with the department by the parent pursuant to paragraph A of section 23 and the parent consents to continued placement pursuant to a petition filed pursuant to said paragraph A or paragraph C of said section 23, the court shall determine at an initial hearing only whether continued placement is in the child’s best interests. Except as provided herein, if a court has previously committed, granted custody or transferred responsibility for a child to the department or its agent, the court shall determine not less than annually whether the department or its agent has made reasonable efforts to make it possible for the child to return safely to his parent or guardian. In making any determination, the health and safety of the child shall be of paramount concern.
Reasonable efforts by the department prior to removal of a child from the home or to return the child to a parent or guardian shall not be required if the court finds that: (1) the child has been abandoned as defined in section 3 of chapter 210; (2) the parent’s consent to adoption of a sibling of the child was dispensed with under section 26 or under said section 3 of said
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