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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

133% of the FPL, the MassHealth MAGI household is eligible for a new extended eligibility period.

(M) Use of Potential Health Insurance Benefits. Applicants and members must use potential health insurance benefits in accordance with 130 CMR 503.007: Potential Sources of Health care, and must enroll in health insurance, including Medicare, if available at no greater cost to the applicant or member than they would pay without access to health insurance, or if purchased by MassHealth in accordance with 130 CMR 505.002(O) or 130 CMR 506.012: Premium Assistance Payments. Members must access other health insurance benefits and must show their private health insurance card and their MassHealth card to providers at the time services are provided.

(N) Access to Employer-sponsored Insurance and Premium Assistance Investigations for Individuals Who Are Eligible for MassHealth Standard. (1) The MassHealth agency may perform an investigation to determine if individuals receiving MassHealth Standard (a) have health insurance that MassHealth may help pay for; or (b) have access to employer-sponsored health insurance in which MassHealth wants the individual to enroll and for which MassHealth will help pay. (2) The individual receives MassHealth Standard while MassHealth investigates the insurance. (a) Investigations for Individuals Who Are Enrolled in Health Insurance. 1. If the MassHealth agency determines that the health insurance the individual is enrolled in meets the criteria at 130 CMR 506.012: Premium Assistance Payments, the individual is notified in writing that MassHealth will provide MassHealth Standard Premium Assistance Payments as described at 130 CMR 506.012: Premium Assistance Payments. 2. If the MassHealth agency determines that the health insurance the individual is enrolled in does not meet the criteria at 130 CMR 506.012: Premium Assistance Payments, the individual is eligible for MassHealth Standard Direct Coverage. 3. Individuals described at 130 CMR 505.002(F)(1)(d) will not undergo an investigation. (b) Investigations for Individuals Who Have Potential Access to Employer-sponsored Health Insurance. 1. If the MassHealth agency determines the individual has access to employer- sponsored health insurance and the employer is contributing at least 50% of the premium cost and the insurance meets all other criteria described at 130 CMR 506.012: Premium Assistance Payments, the individual is notified in writing that they must enroll in this employer-sponsored coverage. MassHealth allows the individual up to 60 days to enroll in this coverage. Once enrolled in this health insurance plan, MassHealth provides MassHealth Standard Premium Assistance Payments as described in 130 CMR 506.012: Premium Assistance Payments. Failure to enroll in the employer-sponsored health insurance plan at the request of the MassHealth agency will result in the loss or denial of eligibility for all individuals unless the