Page 6

6

130 CMR: DIVISION OF MEDICAL ASSISTANCE

Trans. by E.L. 253 Rev. 02/13/2026

130 CMR 503.000: HEALTH CARE REFORM: MASSHEALTH: UNIVERSAL ELIGIBILITY REQUIREMENTS

503.006: Assignment for Third-party Recoveries

As a condition of eligibility, an applicant or member must inform the MassHealth agency when any such individual is involved in an accident, or suffers from an illness or injury, or other loss that has resulted or may result in a lawsuit or insurance claim. The applicant or member must

(A) file an insurance claim for compensation, if available; and

(B) agree to comply with all requirements of M.G.L. c. 118E, § 22, including, but not limited to (1) assigning to the MassHealth agency or its agent the right to recover an amount equal to the MassHealth benefits provided from the proceeds of any claim or other proceeding against a third party; (2) providing information about the claim or any other proceeding and cooperating fully with the MassHealth agency or its agent, unless the MassHealth agency determines that cooperation would not be in the best interests of, or would result in serious physical or emotional harm to, the applicant or member, in accordance with 130 CMR 503.005; (3) notifying the MassHealth agency in writing within ten days of filing any claim, civil action, or other proceeding; and (4) repaying and cooperating fully with the MassHealth agency or its agent to ensure the member’s legal representative repays the MassHealth agency from the money received from a third party for all MassHealth benefits provided on or after the date of the accident or other incident, provided that if the member is involved in an accident or other incident after becoming MassHealth eligible, repayment will be limited to MassHealth benefits provided as a result of the accident or incident.

503.007: Potential Sources of Health Care

The MassHealth agency is the payer of last resort and pays for health care and related services only when no other source of payment is available, except as otherwise required by federal law.

(A) Health Insurance. Every applicant and member must obtain and maintain available health insurance in accordance with 130 CMR 505.000: Health Care Reform: MassHealth: Coverage Types. Failure to do so may result in loss or denial of eligibility unless the applicant or member is (1) receiving MassHealth Standard or MassHealth CommonHealth; and (2) younger than 21 years old or pregnant.

(B) Use of Benefits. The MassHealth agency does not pay for any health care and related services that are available (1) through the member’s health insurance, if any; or (2) at no cost to the member including, but not limited to, any such services that are available through any agency of the local, state, or federal government, or any entity legally obligated