Page 24

24

130 CMR: DIVISION OF MEDICAL ASSISTANCE

Trans. by E.L. 254 Rev. February 13, 2026

130 CMR 505.000: HEALTH CARE REFORM: MASSHEALTH: COVERAGE TYPES

2. Investigations for Individuals Who Have Potential Access to Employer-sponsored Health Insurance. If the MassHealth agency determines the individual has access to employer-sponsored insurance and the employer is contributing at least 50% of the premium cost and the insurance meets all other criteria described in 130 CMR 506.012: Premium Assistance Payments, the individual is notified in writing that they must enroll in this employer-sponsored coverage. MassHealth will allow the individual up to 60 days to enroll in this coverage. Once enrolled in the health insurance plan, MassHealth will provide MassHealth CarePlus Premium Assistance Payments as described at 130 CMR 506.012: Premium Assistance Payments. Failure to enroll in the employer-sponsored health insurance plan at the request of MassHealth will result in loss or denial of eligibility for all individuals. (2) If the MassHealth agency determines the individual does not have access to employer- sponsored insurance, the individual continues to be eligible for MassHealth CarePlus.

(D) MassHealth CarePlus Coverage Begin Date. (1) The MassHealth CarePlus coverage start date is described at 130 CMR 502.006: Coverage Dates, except as described at 130 CMR 505.008(D)(2). (2) Provisional eligibility is described in 130 CMR 502.003(E): Provisional Eligibility.

(E) Medically Frail. If an individual is determined medically frail or is an individual with special medical needs and has been determined to meet the eligibility criteria for MassHealth CarePlus as described in 130 CMR 505.008, the individual may elect at any time to receive MassHealth Standard benefits, as described in 130 CMR 505.002(J). If at any time after enrolling in MassHealth CarePlus an individual becomes medically frail or is determined to be medically frail, the individual may elect to receive MassHealth Standard benefits. The effective date of MassHealth Standard is the date of the reported change. To be considered medically frail or a person with special medical needs, an individual must be (1) an individual with a disabling mental disorder (including children with serious emotional disturbances and adults with serious mental illness); (2) an individual with a chronic substance use disorder; (3) an individual with a serious and complex medical condition; (4) an individual with a physical, intellectual, or developmental disability that significantly impairs their ability to perform one or more activities of daily living; or (5) an individual with a disability determination based on Social Security criteria.

(F) Continuous Eligibility. (1) Continuous Eligibility, as defined in 501.001: Continuous Eligibility (CE), will be granted to children under age 19. Children in a CE period will receive 12 months of continuous coverage upon completion of initial application or annual renewal period. (2) Coverage will continue without downgrading or ending except for reasons found at 130 CMR 501.001.