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130 CMR: DIVISION OF MEDICAL ASSISTANCE

Trans. by E.L. 251 Rev. 02/13/2026

130 CMR 501.000: HEALTH CARE REFORM: MASSHEALTH: GENERAL POLICIES

individual to reduce the costs of a health benefit plan premium to the individual.

Primary Care ACO. A type of ACO with which the MassHealth agency contracts under its ACO program.

Primary Care Clinician (PCC) Plan. A managed care option administered by the MassHealth agency through which enrolled members receive primary care and other medical services. See 130 CMR 450.118: Primary Care Clinician (PCC) Plan.

Protected Noncitizens. See 130 CMR 504.003(B): Protected Noncitizens.

Provisional Eligibility. Approval for MassHealth benefits when an applicant's certain self- attested circumstances show eligibility for MassHealth benefits but further verification is required for continued eligibility. (See 130 CMR 502.003: Verification of Eligibility Factors.)

Qualified Health Plan (QHP). A health plan licensed under M.G.L. c. 175, 176A, 176B, or 176G that has received the Commonwealth Health Insurance Connector’s Seal of Approval as meeting the criteria under 45 CFR §155.1000 and is offered through the Health Connector in accordance with the provisions of 45 CFR §155.1010.

Qualified Noncitizens. See 130 CMR 504.003(A)(1): Qualified Noncitizens.

Qualified Noncitizens Barred. See 130 CMR 504.003(A)(2): Qualified Noncitizens Barred.

Quality Control. A system of continuing review to measure the accuracy of eligibility decisions.

Redetermination. A review of a member's circumstances to establish whether they remain eligible for benefits.

Senior Care Organization (SCO). An organization that participates in MassHealth under a contract with the MassHealth agency and the Centers for Medicare & Medicaid Services to provide a comprehensive network of medical, health care, and social service providers that integrates all components of care, either directly or through subcontracts. SCOs are responsible for providing enrollees with the full continuum of Medicare- and MassHealth-covered services.

Sibling. Natural (full or half-blood), adoptive, or stepbrother or stepsister.

Spouse. A person married to the applicant or member according to the laws of the Commonwealth of Massachusetts.

Substantial Gainful Activity. Generally, employment that provides a set amount of gross earnings as determined by the SSA under Title XVI of the Social Security Act.