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130 CMR: DIVISION OF MEDICAL ASSISTANCE

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

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

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 130 CMR 502.006, 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 130 CMR 506.012(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