EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES
COMMONWEALTH OF MASSACHUSETTS
OFFICE OF MEDICAID
ONE ASHBURTON PLACE, BOSTON, MA 02108
MAURA T. HEALEY KATHLEEN E. WALSH
GOVERNOR SECRETARY
KIMBERLEY DRISCOLL MIKE LEVINE
LIEUTENANT GOVERNOR ASSISTANT SECRETARY
FOR MASSHEALTH
May 6, 2024
Chair Michael J. Rodrigues Chair Aaron Michlewitz
Senate Committee on Ways and Means House Committee on Ways and Means
State House, Room 212 State House, Room 243
Boston, MA 02133 Boston, MA 02133
Chair Cindy F. Friedman Chair John H. Lawn, Jr.
Senate Chair, Joint Committee on Health House Chair, Joint Committee on Health Care
Care Financing Financing
State House, Room 313 State House, Room 236
Boston, MA 02133 Boston, MA 02133
Dear Chairs Rodrigues, Michlewitz, Friedman, and Lawn,
Section 65 of M.G.L. Chapter 118E as established by Section 131 of Chapter 224 of the Acts of
2012 requires Executive Office of Health and Human Services (EOHHS) to provide an annual
report evaluating the processes used to determine eligibility for Health Safety Net reimbursable
health services.
Specifically, Section 65 calls for: an analysis of the effectiveness of these processes in enforcing
eligibility requirements for publicly-funded health programs and in enrolling uninsured residents
into programs of health insurance offered by public and private sources; an assessment of the
impact of these processes on the level of reimbursable health services by providers; and
recommendations for ongoing improvements that will enhance the performance of eligibility
determination systems and reduce hospital administrative costs. Please find attached a report
which provides the required evaluation and illustrates service utilization trends.
I hope you find this report useful and informative. If you have any questions, please feel free to
contact Sarah Nordberg at Sarah.Nordberg@mass.gov.
Sincerely,
Mike Levine
cc: Kathleen E. Walsh
Health Safety Net Eligibility Background
The Health Safety Net (HSN) was created by Chapter 58 of the Acts of 2006 as the successor to
the Uncompensated Care Pool (UCP) to reimburse Acute Care Hospitals and Community Health
Centers (CHCs) for health services provided to uninsured and underinsured Massachusetts
residents.
An overview of HSN eligibility is as follows:
• All HSN-eligible individuals must be uninsured or underinsured. Once determined
eligible, the costs incurred by individuals are reimbursed through Primary or Secondary
HSN, and individuals may be required to pay a deductible (HSN Partial).
• HSN Primary is for patients who have no other health coverage and HSN is their
primary payer for eligible medical services.
• HSN Secondary is for patients who have other health insurance coverage. The
HSN pays for HSN reimbursable health services that are not covered by the
patient’s primary insurance coverage.
• Massachusetts residents may be determined for different HSN eligibility based on their
income level.
• Uninsured and underinsured individuals with incomes up to 150% of the FPL may
be eligible for HSN Primary or HSN Secondary, without a deductible.
• Uninsured and underinsured individuals with incomes between 150% and 300%
of the FPL may be eligible for HSN Primary Partial or Secondary Partial, which
includes a deductible based on the patient’s income.
• The HSN provides temporary medical and dental reimbursement to individuals
determined eligible for ConnectorCare coverage, which includes the 10 days prior to a
patient’s application date and 90 days after the submission of their application. This
allows sufficient time to complete the ConnectorCare enrollment process.
• HSN Secondary is available to individuals who are eligible for ConnectorCare
after the above period of time. HSN provides reimbursement for allowable dental
services not covered by their health plan.
• The HSN may also reimburse providers for reimbursable health services provided to
members of other Qualified Health Plans (QHPs) offered by the Connector that are not
covered by their primary insurance, as long as the member is otherwise HSN eligible.
• For HSN eligible recipients enrolled in MassHealth Limited which provides emergency
services only, the HSN reimburses providers for allowable reimbursable health services
not covered by their MassHealth plan.
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 • The HSN reimburses providers for emergency or urgent care bad debt at HSN authorized
Acute Care Hospitals, Hospital Licensed Health Centers or Community Health Centers
(CHCs) in cases where a provider is unable to collect payment from an uninsured patient
after pursuing collection activity for a specified time period. Bad debt payments are only
made for individuals who were uninsured and had no HSN eligibility at the time the
services were provided.
• Some individuals may qualify for other types of HSN eligibility under certain special
circumstances. These patients make up a very small percentage of the HSN caseload.
• The HSN Medical Hardship program reimburses allowable medical expenses
from HSN authorized providers for services provided to patients who have
medical bills that exceed a specified proportion of their income. This is a
retrospective eligibility type for services delivered up to 12 months prior to the
application date. Individuals are only eligible to submit an application for this
coverage two times within a 12-month period. A financial contribution from the
patient may be required based on the patient’s income level.
• HSN Confidential is a program that reimburses providers for services
confidentially provided to minors seeking treatment for sexually transmitted
diseases and/or family planning services, as well as services provided to survivors
of domestic violence who have a reasonable fear of domestic violence. Providers
may only submit claims for confidential services when no other source of funding
is available to pay for the services confidentially. This eligibility type must be
renewed annually with the assistance of a provider.
• Uninsured individuals who meet the eligibility criteria for HSN and are unable to
complete a full application for health coverage at the time they receive medical
treatment can have their provider submit an application for temporary HSN
coverage on their behalf through a presumptive determination process. The HSN
reimburses for eligible services until the end of the month after their
determination date or at the time a determination is made on a full application,
whichever comes earlier. Individuals can only apply for temporary HSN once
annually.
Enforcement of Eligibility Requirements
Eligibility Determinations
The HSN uses the same application and determination systems as MassHealth for all types of
coverage mentioned above, except emergency or urgent care bad debt and those coverages listed
under special circumstances. As with MassHealth, all applications submitted for the HSN have
income, residency, access to other health insurance, and identity verified at the time of
application. Those applicants whose information cannot be verified through state and federal
data sources at the time of application are asked to provide that information within 90 days.
Similar to MassHealth, the HSN re-determines eligibility on an annual basis.
Claims Processing
With the exception of bad debt claims, all HSN claims must be for services provided to patients
with HSN eligibility. The HSN’s claims adjudication system matches all non-emergency bad
debt HSN claims to an HSN-eligible patient prior to payment, leaving no paid claims unmatched.
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All claims are checked for HSN eligibility when they come in through either the Medicaid
Management Information System (MMIS), the Pharmacy Online Processing Center (POPs), or
the DentaQuest Dental Processing Center. This allows the claims adjudication system to
immediately deny claims that cannot be matched to an HSN-eligible patient. An ongoing
eligibility feed from MMIS is used to allow the HSN claims processing system to properly
adjudicate bad debt claims, as claims for insured or HSN-eligible patients do not qualify for bad
debt reimbursement.
Since July 15, 2012, all HSN medical claims have been received for processing through the
MMIS system. HSN claims pass through the full range of claims editing available in MMIS,
including edits to capture duplicate claims, medically unnecessary services, medically unlikely
services, and correct coding initiative edits incorporated. However, MMIS is currently unable to
run full HSN claim edits or price HSN claims. Therefore, certain eligibility and claims editing
continues to occur outside of MMIS. Pricing also continues to occur outside of MMIS due to
differences in HSN and MassHealth pricing methodologies.
HSN pharmacy claims are processed and priced using MassHealth’s Pharmacy Online
Processing System (POPS). POPS processes HSN pharmacy claims as the HSN pays for
prescription drugs using the same rates as MassHealth.
As of January 1, 2017, MassHealth’s dental vendor, DentaQuest, began processing and pricing
HSN dental claims. Prior to that date, HSN dental claims were being processed directly by the
HSN. DentaQuest adjudicates and prices dental claims for the HSN using MassHealth edits and
pricing logic that already existed in the system, reducing the need for manual processes and
increasing overall claims processing efficiency.
Identifying Other Available Insurers
The HSN serves as a payer of last resort for services provided at Acute Care Hospitals, Hospital
Licensed Health Centers, and Community Health Centers to low-income patients who are unable
to obtain comprehensive or affordable health insurance coverage through other sources. As such,
the HSN does not make payments to providers if another payment source is available. To ensure
compliance with these principles, the HSN has implemented the following program integrity
measures:
• The HSN uses a common application and eligibility system to ensure that eligibility
policies are applied consistently between the HSN, MassHealth, and the Connector.
• The eligibility systems HSN providers access communicates HSN eligibility and cost
sharing policies.
• The HSN contracts with a vendor that reviews HSN paid claims to determine whether
another payer was available on the date of service, and to recommend the recovery of
payment in cases where the provider did not appropriately bill the primary payer prior to
billing the HSN.
• The HSN continues to work with MassHealth on a standardized reporting practice for all
HSN Secondary claims in order to deny any claims where the primary payer’s
adjudication information is not reported accurately. This will further enhance the
specificity and accuracy of any payments to providers that submit claims to HSN as a
secondary payer.
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 • The HSN works with MassHealth and the Connector to deny medical claims for patients
that are enrolled in medical plans through The Health Connector. This ensures that HSN
is only paying on claims that are truly HSN’s responsibility.
Verification of Income and Eligibility
Income is verified by MassHealth during the eligibility determination process. Income
verification may be in the form of a match to federal and state data hubs. If an applicant reports
income that does not reasonably match those sources, verification of income is requested within
90 days. Individuals that submit their verification of income within this period receive their HSN
eligibility begin date 10 days prior to their application date. MassHealth also performs regular
data matches for HSN individuals with the Department of Revenue and other data sources on all
eligible individuals with a Social Security Number in order to verify wage information.
As explained above, eligibility is also verified for each HSN claim before it is paid. HSN
Primary and Secondary claims are run through eligibility logic during the adjudication process to
ensure that the HSN eligible individual is known to the MMIS system and has HSN eligibility on
the date of service. For bad debt claims, the system ensures that no eligibility is present on the
date of service before allowing the claim to pass.
The HSN also has a grievance process in place for patients who believe they received an
inaccurate eligibility determination or would like to dispute an action taken by the HSN or a
provider. HSN staff promptly responds to patients with most grievances resolved promptly. For
more complicated cases, collaboration with other state offices and agencies may be required, but
patients receive regular updates until a resolution is reached.
Encouraging Enrollment in Other Available Insurance Programs
Section 65 of MGL Chapter 118E requires the HSN to “develop programs and guidelines to
encourage maximum enrollment of uninsured individuals who receive health services reimbursed
by the fund into health care plans and programs of health insurance offered by public and private
sources.” Since the implementation of this requirement in 2006, the HSN has undertaken various
initiatives to encourage patients to enroll in available, affordable insurance plans. For instance,
in March 2020, the HSN awarded grant funds to six Awardees to enhance the ability of low-
income individuals to complete and maintain enrollment in comprehensive health coverage,
particularly through the range of options provided by MassHealth and the Health Connector.
Additionally, the HSN awards grant funding to the Massachusetts Fishing Partnership who
employs Massachusetts Health Connector Navigators who are certified application counselor’s,
performs substance abuse disorder initiatives, and safety programs with the overall goal of
assisting and maintaining health insurance enrollment among the fishing community while also
reducing the HSN’s liability with its SUD and safety programs.
As a result of the Affordable Care Act (ACA), many patients who previously were eligible only
for the HSN have become eligible for other programs. Under the ACA, a new coverage type
called MassHealth CarePlus was created to cover certain patients with incomes up to 133% of
the FPL who were not previously eligible for Medicaid. MassHealth Standard also became
available to certain HSN patients between 19 and 20 years of age in this income range. On
January 1, 2014, approximately 30,000 HSN patients were transitioned into MassHealth
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 Standard and CarePlus coverage. The ACA also expanded subsidies to individuals that fall
within 300-400% of the FPL through advanced premium tax credits (APTCs). APTCs can be
applied to the cost of Qualified Health Plans offered by the Connector to reduce the premium
amounts paid by members who may have only been eligible for HSN in the past.
The HSN continues to actively work with MassHealth, the Health Connector, and other
community stakeholders on efforts to encourage the uptake in comprehensive coverage for those
who qualify.
Impact of HSN Eligibility Policies on the Level of Total HSN Demand from Providers
The effects of HSN eligibility requirements and other changes related to health care reform are
reflected in HSN payment and demand statistics. Demand from hospitals and Community Health
Centers (CHCs) reflects the impact of policies on overall utilization of HSN reimbursable
services.
As seen in Figure 1, UCP/HSN Spending has returned to pre-pandemic levels as utilization
shifted to pre-COVID-19 levels.
HSN Total Demand and Payments Per Million (Figure)
HSN DEMAND
600
500
78 87 65 112
40 61 68
400 111
62 67 67 23 14 20 91
68 72 80 69 78 86
300 82
200
342 347 336 322
298 298 305 291 305 298
263
100
0
HSN13 HSN14 HSN15 HSN16 HSN17 HSN18 HSN19 HSN20 HSN21 HSN22 HSN23
Hospital CHC Shortfall
Recommendations for Ongoing Improvement
The Health Safety Net works collaboratively with MassHealth, the Connector, and other state
agencies to streamline eligibility systems and determination processes and ensure program
integrity. The Health Safety Net will c