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130 CMR: DIVISION OF MEDICAL ASSISTANCE

Trans. by E.L. 260 Rev. 07/17/2026

130 CMR 508.000: MASSHEALTH: MANAGED CARE REQUIREMENTS

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508.002: MassHealth Members Excluded from Participation in Managed Care

(A) MassHealth Managed Care Provider. The following MassHealth members are excluded from participation with a MassHealth managed care provider. (1) a member who has Medicare; (2) a member who has access to other health insurance that meets the basic-benefit level as defined in 130 CMR 501.001: Definition of Terms; (3) a member who is 65 years of age or older; (4) a member who is not eligible for benefits under Title XIX or XXI of the Social Security Act; (5) a member who is only eligible for benefits under Title XIX or XXI of the Social Security Act through Title XXI during the period from conception to the end of pregnancy; (6) a member in a nursing facility, chronic disease or rehabilitation hospital, intermediate care facility for individuals with intellectual disabilities (ICF/ID), or a state psychiatric hospital for other than a short-term rehabilitative stay; (7) a member who is eligible for emergency Medicaid benefits pursuant to Section 1903(v) of the Social Security Act; (8) a member who is eligible for Children’s Medical Security Plan (CMSP); (9) a member who is eligible through the Emergency Aid to the Elderly, Disabled and Children (EAEDC) Program; (10) a member who is receiving hospice care through MassHealth on a fee-for-service basis, or who is terminally ill as documented by a medical prognosis of a life expectancy of six months or less; and (11) a member who has presumptive eligibility.

(B) SCO Plan. The following MassHealth members, 65 years of age and older, who are enrolled in Medicare Parts A and B and are eligible for Medicare Part D are excluded from participating in a SCO Plan. (1) a member who has access to other health insurance, with the exception of Medicare, that meets the basic-benefit level as defined in 130 CMR 501.001: Basic-benefit Level (BBL); (2) a member who does not live in the designated service area of a SCO Plan; (3) a member in an ICF/ID; (4) a member who is not eligible for MassHealth Standard; (5) a member who has presumptive eligibility; (6) a member who is enrolled in a home- and community-based services waiver, except the Home- and Community-Based Services Waiver–Frail Elder as described at 130 CMR 519.007(B): Home- and Community-Based Services Waiver–Frail Elder; (7) a member who is eligible through the Emergency Aid to the Elderly, Disabled and Children (EAEDC) Program; (8) a member who is a refugee described at 130 CMR 522.002: Refugee Resettlement Program; (9) a member who is not eligible for benefits under Title XIX or XXI of the Social Security Act; (10) a member who is only eligible for benefits under Title XIX or XXI of the Social Security Act through Title XXI during the period from conception to the end of pregnancy;