MassHealth: The Eligibility Process

130 CMR: DIVISION OF MEDICAL ASSISTANCE

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130 CMR 502.000: HEALTH CARE REFORM: MASSHEALTH: THE ELIGIBILITY PROCESS

TABLE OF CONTENTS

Section

502.001: Application for Benefits 502.002: Reactivating the Application 502.003: Verification of Eligibility Factors 502.004: Matching Information 502.005: Time Standards for an Eligibility Determination 502.006: Coverage Dates 502.007: Continuing Eligibility 502.008: Notice 502.009: Voluntary Withdrawal 502.010: Issuance of a MassHealth Card 502.011: Severability

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502.001: Application for Benefits

(A) Filing an Application. To apply for MassHealth, a person or their authorized representative must file an application online atwww.mahix.org, complete a paper application, complete a telephone application, or apply in person at a MassHealth Enrollment Center (MEC). (1) Date of Application. (a) The date of application for an online, telephone, or in-person application is the date the application is submitted to the MassHealth agency. (b) The date of application for a paper application that is either mailed or faxed is the date the application is received by the MassHealth agency. (2) Online or Telephone Application Requirements. (a) People, or their authorized representative, if applicable, completing an application for MassHealth online at www.mahix.org or by telephone must be identity proofed pursuant to .001(A)(3). Eligibility based on an online or telephone application cannot be determined until the identity is proven or a paper application is submitted. (b) If an applicant submits a paper application or applies in person at a MEC, identity proofing is not required. (3) Identity Proofing Process. A person or their authorized representative, if applicable, completing an online or telephone application will be asked a series of questions to prove their identity. (a) If the individual is successfully identity proofed, the application may be submitted and an eligibility determination will be performed. (b) If the individual is not successfully identity proofed, the individual will be asked to provide one or two forms of acceptable documentation proving their identity. (c) When identity proof is received, an individual can submit an application and the eligibility process begins. The MassHealth agency will determine 1. the coverage type providing the most comprehensive medical benefits for which the applicant is eligible and the application is considered submitted on the date of successful identity proofing; and 2. the need to request any corroborative information necessary to determine eligibility, as provided in .001(B) through (D). (d) If identity proof is not received, the MassHealth agency is unable to determine eligibility for medical benefits. (e) To prove their identity, a person can submit the acceptable proofs of identity as described in 130 CMR 504.005(A)(1): Acceptable Proof of U.S. Citizenship and Identity or .005(A)(3): Acceptable Proof of Identity. (4) Paper Applications or In-person Applications at the MEC Containing Missing or Inconsistent Information. (a) If a paper application is received at a MEC or a MassHealth outreach site and the applicant did not answer all the required questions or if the application is unsigned, the MassHealth agency is unable to determine the applicant’s eligibility for MassHealth. (b) The MassHealth agency requests responses to all the unanswered questions necessary

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to determine eligibility. The MassHealth agency must receive such information within 15 days of the date of the request for the information. (c) If responses to all unanswered questions necessary to determine eligibility are received within 15 days of the date of the request referenced in 130 CMR 502.001(A)(4)(b), the eligibility process begins. The MassHealth agency will determine 1. the coverage type providing the most comprehensive medical benefits for which the applicant is eligible, and the application is considered submitted on the date the initial incomplete application was received by the MassHealth agency; or 2. the need to request any corroborative information during the provisional eligibility period necessary to determine eligibility, as provided in .001(B) through (D). (d) If responses to all unanswered questions necessary for determining eligibility are not received within the 15-day period referenced in .001(A)(4)(b), the MassHealth agency notifies the applicant that it is unable to determine eligibility for medical benefits. The date that the incomplete application was received will not be used in any subsequent eligibility determinations. If the required response is received after the 15-day period, the eligibility process begins and the application is considered submitted on the date the response is received. Although, if the required response is submitted more than one year after the initial incomplete application, a new application must be completed. (e) Inconsistent answers are treated as unanswered.

(B) Corroborative Information. The MassHealth agency requests all corroborative information necessary to verify eligibility. The applicant must supply such information within 90 days of the receipt of the Request for Information Notice, as described at .003(C).

(C) Corroborative Information Received. If all necessary information is received within 90 days of the receipt of the Request for Information Notice, as described at .003(C), the MassHealth agency will determine the most comprehensive medical benefits for which the applicant is eligible.

(D) Corroborative Information Not Received. If the necessary information is not received within 90 days of the receipt of the Request for Information Notice, as described at 130 CMR 502.003(C), with the exception of the individuals described at .001(D)(1) through (4), the MassHealth agency will attempt to redetermine eligibility using electronic data sources, if available, but if such information is not available from these sources, the applicant’s MassHealth benefits will be denied or terminated, as described in .003(D)(2). The MassHealth agency will notify the applicant accordingly. (1) If the only necessary information not received within the provisional eligibility period referenced in .003(E) is verification of breast or cervical cancer, the individual will not be considered as an individual with breast or cervical cancer and will be determined for the most comprehensive coverage for which the individual qualifies without this factor.

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(2) If the only necessary information not received within the provisional eligibility period referenced in .003(E) is verification of HIV-positive status, the individual will not be considered as an individual with HIV-positive status and will be determined for the most comprehensive coverage for which the individual qualifies without this factor. (3) If the only necessary information not received within the provisional eligibility period referenced in .003(E) is verification of disability status, the individual will not be considered a disabled individual and will be determined for the most comprehensive coverage for which the individual qualifies without this factor. (4) If immigration status information is not received within the reasonable opportunity period referenced in .003(F) and the immigration status cannot be verified using electronic data sources, the individual’s eligibility will be determined as an “other noncitizen” as described in .003(D): Other Noncitizens.

502.002: Reactivating the Application

If all required information is received by the MassHealth agency after the period described in .001(D), or after a denial of eligibility, the MassHealth agency reactivates the application and considers it submitted as of the date the information is received, and the medical coverage date is established in accordance with .006. A new application must be completed if all required information is not received within one year of receipt of the previous application.

502.003: Verification of Eligibility Factors

The MassHealth agency requires verification of eligibility factors including income, residency, citizenship, immigration status, and identity as described in 130 CMR 503.000: Health Care Reform: MassHealth: Universal Eligibility Requirements, .000: Health Care Reform: MassHealth: Citizenship and Immigration, and 130 CMR 506.000: Health Care Reform: MassHealth: Financial Requirements.

(A) Information Matches. The MassHealth agency initiates information matches with other agencies and information sources as described at .004 in the following order, when an application is received in order to verify eligibility: (1) the Federal Data Services Hub, which matches with the Social Security Administration, the Department of Homeland Security, and the Internal Revenue Service; and (2) other federal and state agencies and other informational services.

(B) Electronic Data Sources. If electronic data sources are unable to verify or are not reasonably compatible with the attested information, additional documentation will be required from the individual.

(C) Request for Information Notice. If additional documentation is required, including

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corroborative information as described at .001(B), a Request for Information Notice will be sent to the applicant listing all requested verifications and the deadline for submission of the requested verifications.

(D) Time Standards. The following time standards apply to the verification of eligibility factors. (1) The applicant or member has 90 days from the receipt of the Request for Information Notice to provide all requested verifications. (2) If the applicant or member fails to provide verification of information within 90 days of receipt of the MassHealth agency's request, the MassHealth agency does one of the following. (a) If the required information is available from electronic data sources, the MassHealth agency uses that information to redetermine eligibility. (b) If the required information is not available from electronic data sources, MassHealth coverage is denied or terminated except for individuals described at 130 CMR 502.001(D)(1) through (4). (c) If the required verifications are received within one year from the date of the application or renewal form was received, coverage is reinstated to the first day of the month in which the verifications were received. (d) If the required verifications are not received within one year of receipt of the previous application or renewal form, a new application must be completed.

(E) Provisional Eligibility. The MassHealth agency will provide benefits while the applicant provides the MassHealth agency outstanding corroborative information in accordance with 130 CMR 502.003(D)(1), except for individuals described in .003(E)(2). Except as further set forth below, the MassHealth agency will accept self-attestation for all eligibility factors other than citizenship and immigration status, and make a provisional eligibility determination as if the applicant had supplied the information. MassHealth applicants can receive only one provisional eligibility approval during a 12-month period, unless the individual is pregnant. MassHealth members are required to enroll in managed care during the provisional eligibility period, if enrollment is otherwise required as described in 130 CMR 508.004: Managed Care Organizations (MCOs). MassHealth members who have been assessed a premium are subject to payment of premiums during the provisional eligibility period. Premium assistance is not awarded during the provisional eligibility period. It is only provided when all corroborative information has been received and the health insurance investigation is complete, as described in 130 CMR 505.000: Health Care Reform: MassHealth: Coverage Types. Provisional eligibility is subject to the following limitations. (1) Coverage Date. (a) Coverage for individuals who have been determined provisionally eligible begins on the first day of the month in which the application was received. (b) If all required verifications are received before the end of the provisional eligibility period, retroactive coverage is provided under .006(A)(2). (2) Limitations. Provisional eligibility is subject to the following limitations.

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(a) Provisional eligibility is not available for adults 21 years of age or older who have not verified all income in their MAGI household, as described at .000: Health Care Reform: MassHealth: Financial Requirements, unless the individual is 1. pregnant and has attested MAGI income at or below 200% of the federal poverty level (FPL); 2. 21 through 64 years old and HIV-positive with attested MAGI income at or below 200% of the FPL; or 3. in active treatment for breast or cervical cancer and is younger than 65 years old with attested MAGI income at or below 250% of the FPL. (b) The MassHealth agency will not accept self-attestation of disability. Disability must be verified as described in .002(E)(1): Disabled Adults. Eligibility for applicants who apply for benefits based on disability will be determined as if they were not disabled until disability is verified as described in .002(E)(1): Disabled Adults. (c) A member’s coverage type will not be redetermined during the provisional eligibility period, except that members granted provisional eligibility who attest to pregnancy will be enrolled in MassHealth Standard.

(F) Reasonable Opportunity to Verify Citizenship and Identity or Immigration Status. The MassHealth agency provides applicants and members a reasonable opportunity period to provide satisfactory documentary evidence of citizenship and identity or immigration status if MassHealth’s electronic data matches are unable to verify the applicant’s citizenship or immigration status. (1) Time Standards. The reasonable period begins on, and extends 90 days from, the date on which an applicant or member receives a reasonable opportunity notice. (2) Coverage Start Date. (a) Coverage for individuals who are pregnant and children younger than 19 years old who receive a reasonable-opportunity period will begin as follows. 1. If covered medical services were received during such period, and the individual would have been eligible at the time services were provided, the start date of coverage is determined upon receipt of the application and may be retroactive to the first day of the third calendar month before the month of application except as specified in .006(C). 2. If covered medical services were not received during such period, or the individual would not have been eligible at the time services were provided, the start date of coverage is determined upon receipt of the application and coverage begins on the first day of the month in which the application was received , except as specified in .006(C). (b) Coverage for all other individuals who receive a reasonable-opportunity period begins on the first day of the month in which the application was received.

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(c) If satisfactory documentary evidence of citizenship and identity or immigration status is received before the end of the reasonable-opportunity period, retroactive coverage is provided in accordance with .006(A)(2).

(G) Reasonable Opportunity Extension. Applicants or members who have made a good faith effort to resolve inconsistencies or obtain verification of immigration status may receive a 90-day extension. Requests for a reasonable opportunity extension must be made before the expiration of the verification time period.

(H) Hospital-determined Presumptive Eligibility. (1) Presumptive Eligibility Determinations. A qualified hospital may make presumptive eligibility determinations for its patients in accordance with 130 CMR 450.110: Hospital- determined Presumptive Eligibility. Presumptive eligibility will be determined based on attested information. The MassHealth agency will use estimated gross household income rather than MassHealth MAGI to assess whether the financial requirements described below have been met. The qualified hospital may determine presumptive eligibility for the following: (a) MassHealth Standard if the individual appears to meet categorical and financial requirements in .002: MassHealth Standard and the individual is 1. a child younger than one year old; 2. a child one through 18 years old; 3. a young adult 19 through 20 years old; 4. pregnant; 5. a parent or caretaker relative; 6. an individual with breast or cervical cancer; 7. an individual who is HIV positive; or 8. an independent foster care adolescent up to 26 years old; (b) MassHealth CarePlus if the individual appears to meet categorical and financial requirements in .008: MassHealth CarePlus and the individual is an adult 21 through 64 years old; (c) MassHealth Family Assistance if the individual appears to meet categorical and financial requirements in .005(C): Eligibility Requirements for Children and Young Adults Who Are Nonqualified PRUCOLs with Modified Adjusted Gross Income of the MassHealth MAGI Household at or below 150% of the Federal Poverty Level or .005(E): Eligibility Requirement for HIV-Positive Individuals Who Are Citizens or Qualified Noncitizens with Modified Adjusted Gross Income of the MassHealth MAGI Household Greater than 133 and Less than or Equal to 200% of the Federal Poverty Level and is 1. a child or a young adult who is a nonqualified PRUCOL as described in 130 CMR 504.003(C): Nonqualified Persons Residing under Color of Law (Nonqualified PRUCOLs); or 2. an individual who is HIV positive; or

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(d) MassHealth CommonHealth if the individual appears to meet categorical and financial requirements in .004: MassHealth CommonHealth for disabled children younger than 20 years old. (2) Coverage Start Date. Benefits provided through the hospital presumptive eligibility process will begin on the date that the hospital determines presumptive eligibility and will continue until (a) the end of the month following the month in which the hospital determined presumptive eligibility, if the individual has not submitted a complete application as described in .001 by that date; or (b) an eligibility determination is made based upon the individual’s submission of a complete application as described in .001, if the complete application was submitted before the end of the month following the month of the hospital-presumptive eligibility determination. (3) Premium Assessment. Individuals who are determined eligible through hospital- determined presumptive eligibility will not be assessed a premium. Premium assistance is not awarded during the presumptive eligibility period. (4) Continued Eligibility. The individual must submit a complete application as described in .001 to determine continued eligibility for MassHealth.

(I) Verification Exceptions for Special Circumstances. Except with respect to the verification of citizenship and immigration status, the MassHealth agency will permit, on a case-by-case basis, self-attestation of individuals for all eligibility criteria when documentation does not exist at the time of application or renewal, or is not reasonably available, such as in the case of individuals who are homeless or have experienced domestic violence or a natural disaster.

502.004: Matching Information

The MassHealth agency may initiate information matches with other agencies and information sources when an application is received, at annual renewal, and periodically, to update or verify eligibility. These agencies and information sources may include, but are not limited to, the following: the Federal Data Services Hub, the Department of Unemployment Assistance, the Department of Public Health's Bureau of Vital Statistics, the Department of Industrial Accidents, the Department of Veterans' Services, the Department of Revenue, the Bureau of Special Investigations, the Social Security Administration, the Systematic Alien Verification for Entitlements, the Department of Transitional Assistance, and health insurance carriers.

502.005: Time Standards for an Eligibility Determination

(A) For applicants who do not apply based on a disability, the MassHealth agency makes an eligibility determination (1) within 60 days from the date of receipt of the complete application if the applicant is

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potentially eligible for MassHealth Family Assistance; or (2) within 45 days from the date of receipt of the complete application for all other nondisabled applicants.

(B) For applicants who apply based on a disability, the MassHealth agency makes an eligibility determination within 90 days from the date of receipt of the complete application.

(C) Households with one or more applicants 65 years of age or older who are not eligible for benefits under 130 CMR 501.000: Health Care Reform: MassHealth: General Policies through 130 CMR 508.000: MassHealth: Managed Care Requirements will be determined by the time standards described at 130 CMR 516.005: Time Standards for Eligibility Determination for the entire household.

(D) The time standards described in .005(A) through (C) may be extended by the amount of time used by the applicant to respond to requests for additional information needed to make the disability determination.

502.006: Coverage Dates

(A) Start Date of Coverage for Applicants. For individuals applying for coverage, the date of coverage for MassHealth is determined by130 CME 502.006(A)(2), except as specified in 130 CMR 502.003(E)(1), (F)(2), and (H)(2). (1) The start date of coverage for individuals approved for benefits under provisional eligibility is described at .003(E)(1). (2) The start date of coverage for individuals who have been determined eligible for a MassHealth benefit is described at .006(A)(2)(a) through (d), except individuals described at .006(C). (a) If covered medical services were received during the period for which coverage is requested, and the individual would have been eligible at the time services were provided, the start date of coverage is determined upon receipt of the application or upon receipt of any requested verifications and may be retroactive to the first day of the third calendar month before the month of application, pursuant to 42 CFR 435.915 and except as specified in .006(C). (b) If covered medical services were not received during such period, or the individual would not have been eligible at the time services were provided, the start date of coverage is determined upon receipt of the application or upon receipt of any requested verifications and coverage begins on the first day of the month in which the application was received, except as specified in .006(C). (c) For individuals who fail to provide verifications of information within 90 days of the receipt of the MassHealth agency’s request and the MassHealth agency used information received from electronic data sources to determine eligibility, the start date of coverage is

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determined upon the agency’s eligibility determination and coverage begins as described in .006(A)(c)1. and 2. 1. If covered medical services were received during such period, and the individual would have been eligible at the time services were provided, the start date of coverage is determined upon receipt of information received from electronic data sources and may be retroactive to the first day of the third calendar month before the month of application except as specified in .006(C). 2. If covered medical services were not received during such period, or the individual would not have been eligible at the time services were provided, the start date of coverage is determined upon receipt of the information received from electronic data sources and coverage begins on the first day of the month in which the application was received, except as specified in .006(C). (d) For individuals denied for failure to provide verification of requested information who then provide requested verifications or report changes after the denial, the start date of coverage is described in .006(A)(2)(d)1. and 2. 1. If covered medical services were received during such period, and the individual would have been eligible at the time services were provided, the start date of coverage is determined upon receipt of the verifications and may be retroactive to the first day of the third calendar month before the received date of the verifications, except as specified in .003(D)(2)(d) and .006(C). 2. If covered medical services were not received during such period, or the individual would not have been eligible at the time services were provided, the start date of coverage is determined upon receipt of the verifications and coverage begins on the first day of the month that the verifications were received, except as specified in 130 CMR 502.003(D)(2)(d) and .006.

(B) Coverage Dates for Existing Members Who Have a Change in Benefits. The date of coverage for existing members whose MassHealth coverage type changes due to a change in circumstances are described in .006(B)(1) through (4). (1) If covered medical services were received during such period, and the individual would have been eligible at the time services were provided, the start date of the new coverage may be retroactive to the first day of the third calendar month prior to (a). the receipt of the requested verifications; (b). the receipt date of the annual renewal; (c). the date of the eligibility determination for reported changes that do not result in request for verification; or (d). the date of the MassHealth agency’s eligibility determination due to information in the member’s case file. (2) If covered medical services were not received during such period, or the individual would not have been eligible at the time services were provided, the start date of the new coverage is the first day of the month of (a) the receipt of the requested verifications;

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(b) the receipt date of the annual renewal; (c) the date of the eligibility determination for reported changes that do not result in request for verification; or (d) the date of the MassHealth agency’s eligibility determination due to information in the member’s case file. (3) For existing members whose eligibility determination results in a less comprehensive benefit, the end date of the existing coverage is no sooner than 14 days from the date of the notice unless the MassHealth member files an appeal in a timely manner and requests continued MassHealth benefits pending such an appeal or reinstatement of benefits as described at 130 CMR 610.036: Continuation of Benefits Pending Appeal and the start date of the new coverage is ten days prior to (a) the receipt of the requested verifications; (b) the receipt date of the annual renewal; (c) the date of the eligibility determination for reported changes; or (d) the date of the MassHealth agency’s eligibility determination due to information in the member’s case file. (4) For existing members, effective dates for changes in premium payments are described at .011(C).

(C) Limitations. MassHealth coverage start dates are subject to the following limitations. (1) The start date for Medicare premium payments for individuals determined eligible for MassHealth Standard, MassHealth CommonHealth, and MassHealth Medicare Savings Programs is described at .002(O), 505.004(L), and 505.007. (2) The start date for Premium Assistance Payments for individuals eligible for MassHealth Standard, MassHealth CommonHealth, MassHealth Family Assistance, and MassHealth CarePlus is described at .012(F)(1)(d).

(D) End Date of Coverage. Except as specified in .003(H)(2), MassHealth benefits terminate or downgrade no sooner than 14 days from the date of termination or downgrade notice unless the MassHealth member timely files an appeal and requests continued MassHealth benefits pending such appeal or reinstatement of benefits as described at 130 CMR 610.036: Continuation of Benefits Pending Appeal. MassHealth will extend coverage to the end of the month only for individuals whose MassHealth eligibility is terminated and who become eligible for the Premium Tax Credit (PTC). If the effective date of the termination is on or before the 15th of the month, MassHealth coverage will end on the last day of that month. If the effective date of the termination is after the 15th of the month, MassHealth coverage will end on the last day of the following month.

502.007: Continuing Eligibility

(A) Annual Renewals. The MassHealth agency reviews eligibility once every 12 months. Eligibility may also be reviewed because of a member's change in circumstances, or a change in

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MassHealth eligibility rules, or because of a member’s failure to provide verification within requested time frames. The MassHealth agency updates eligibility based on information received because of such review. The MassHealth agency reviews eligibility (1) by information matching with other agencies, health insurance carriers, and information sources; (2) through a written update of the member's circumstances on a prescribed form; (3) through an update of the member’s circumstances in person, by telephone, or on the MAHIX.org account; or (4) based on information in the member’s case file.

(B) Eligibility Determinations. The MassHealth agency determines, because of this review, if (1) the member continues to be eligible for the current coverage type; (2) the member’s current circumstances require a change in coverage type, premium payment, or premium assistance payment; or (3) the member is no longer eligible for MassHealth.

(C) Eligibility Reviews. MassHealth reviews eligibility in the following ways. (1) Automatic Renewal. Members whose continued eligibility can be determined based on electronic data matches with federal and state agencies will have their eligibility automatically renewed. (a) If the data match results in no change in benefits or in a more comprehensive benefit, the MassHealth agency will notify the member that eligibility has been reviewed using the automatic renewal process. (b) In addition, if the member's coverage type changes to a more comprehensive benefit, the member will be sent a notice informing them of the start date for the new coverage. The start date of the new coverage is described at .006, except that premium assistance payments begin in the month of the MassHealth agency's eligibility determination or in the month that the insurance deduction begins, whichever is later in accordance with .012(F)(1)(d). (2) Prepopulated Renewal Application. Members whose continued eligibility cannot be determined based on electronic data matches with federal and state agencies and members whose eligibility would change to a less comprehensive benefit as a result of the data matches will be required to complete a prepopulated renewal application. (a) The MassHealth agency will notify the member of the need to complete the renewal application. (b) The member will be given 45 days from the date of the request to return the paper prepopulated renewal application, log onto their MAHIX.org account to complete the renewal application online, or call the MassHealth agency to complete the renewal application telephonically. 1. If the renewal application is completed within 45 days, eligibility will be determined using the information provided by the individual with verification

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confirmed through electronic data matches if available. If verification through electronic data match is unsuccessful, the MassHealth agency will request required verifications as described in .003 and the individual continues to receive benefits pending verification. 2. If the renewal application is not completed within 45 days, the MassHealth agency will a. use information received from electronic sources, if available, and redetermine eligibility; or b. if information is not available from electronic sources, terminate MassHealth coverage as described at .006(B). 3. If the individual submits the prepopulated renewal application within 90 days of the termination date, as described in .007(C)(2)(b)2., and is determined eligible for a MassHealth benefit, the date of coverage for MassHealth is determined in accordance with .006(A). The begin date of MassHealth coverage may be retroactive to the date of the termination if the individual requests retroactive coverage and has incurred covered medical services since the date of the termination. 4. If the prepopulated renewal application is returned, but the required verifications are not submitted with the form, a second 90-day period starts on the date that the prepopulated form is returned. 5. If the prepopulated renewal application is not submitted within 90 days of the previous termination date, a new application is required. (c) If the member's coverage type changes, the start date for the new coverage type is determined as follows. 1. If the member's coverage type changes, the start date for the new coverage type is effective as described in .006(A). 2. Premium assistance payments begin in the month of the MassHealth agency's eligibility determination or in the month the insurance begins, whichever is later in accordance with 130 CMR 506.012(F)(1)(d). (3) Periodic Data Matches. The MassHealth agency matches files of MassHealth members with other agencies and information sources as described in .004 to update or verify eligibility. (a) If the electronic data match indicates a change in circumstances that would result in potential reduction or termination of benefits, the MassHealth agency will notify the member of the information that was received through the data match and require the member to respond within 30 days of the date of the notice. 1. If the member responds within 30 days and confirms the data is correct, eligibility will be determined using the confirmed data from the electronic data match. 2. If the member responds within 30 days and provides new information, eligibility will be determined using the information provided by the member. Additional verification from the member will be required. 3. If the member does not respond within 30 days, eligibility will be determined

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using available information received from the electronic data sources. If information necessary for eligibility determination is not available from electronic data sources, MassHealth coverage will be terminated. (b) If the electronic data match indicates a change in circumstances that would result in an increase or no change in benefits, the MassHealth agency will automatically update the case using the information received from the electronic data match and redetermine eligibility. If the member’s coverage type changes to a more comprehensive benefit, the member will be sent a notice informing them of the start date for the new benefit. The effective date of the more comprehensive benefit is determined in accordance with 130 CMR 502.006(A).

502.008: Notice

(A) The MassHealth agency provides all applicants and members a written notice of the eligibility determination for MassHealth. The notice contains an eligibility decision for each member who has requested MassHealth, and either provides information so the applicant or

member can determine the reason for any adverse decision or directs the applicant or member to such information.

(B) The MassHealth agency also provides members a notice, in accordance with 130 CMR 610.015: Time Limits, of any loss of coverage, or any changes in coverage type, premium, or premium assistance payments.

(C) The notices described in .008(A) and (B) provide information about the applicant's and member's right to a fair hearing, except for notices about hospital-determined presumptive eligibility, as described in .003(H), and notices about federal or state law requiring an automatic change adversely affecting some or all members, as described in 42 CFR 431.220(b). Information about the appeal process is found at 130 CMR 610.000: MassHealth: Fair Hearing Rules.

502.009: Voluntary Withdrawal

The applicant or authorized representative may voluntarily withdraw their application for MassHealth.

502.010: Issuance of a MassHealth Card

(A) The MassHealth agency issues a MassHealth card to new members.

(B) A temporary card may be issued to a member if there is an immediate need.

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.000: HEALTH CARE REFORM: MASSHEALTH: THE ELIGIBILITY PROCESS

502.011: Severability

The provisions of .000 are severable. If any provision of .000 or application of any provision to an applicable individual, entity, or circumstance is held invalid or unconstitutional, that holding will not be construed to affect the validity or constitutionality of any remaining provisions of .000 or application of those provisions to applicable individuals, entities, or circumstances.

REGULATORY AUTHORITY

.000: M.G.L. c. 118E.

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130 CMR: DIVISION OF MEDICAL ASSISTANCE

Trans. by E.L. 252 Rev. 02/13/2026

.000: HEALTH CARE REFORM: MASSHEALTH: THE ELIGIBILITY PROCESS

This page is reserved.

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