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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

5 time or distance to such requested provider is equal to or less than the travel time to, as determined by the MassHealth agency, a comparable provider in the network of a MassHealth managed care provider in the member's service area, or 2. the medical benefit of receiving care from a MassHealth managed care provider in the member's service area is substantially outweighed, as determined by the MassHealth agency, by the medical benefit of receiving care from the out-of-area MassHealth managed care provider requested by the member.

(B) Member Assignment to a MassHealth Managed Care Provider. If a member does not choose a MassHealth managed care provider within the time specified by the MassHealth agency in a notice to the member or in other circumstances determined appropriate by the MassHealth agency and consistent with applicable laws, the MassHealth agency assigns the member to an available MassHealth managed care provider. (1) The MassHealth agency assigns a member to a MassHealth managed care provider only if the MassHealth managed care provider is: (a) available for the member's coverage type; (b) in the member's service area as described in 130 CMR 508.004(A)(1), 130 CMR 508.005(A)(1), 508.006(A)(1)(a), 508.006(B)(1)(a), as applicable; (c) physically accessible to the member, if the member is disabled; (d) suitable for the member's age and sex (for example, the member is the appropriate age for a pediatrician); and (e) located in an area to which the member has available and affordable transportation. (2) If the MassHealth agency determines that no MassHealth managed care provider meeting the criteria of 130 CMR 508.003(B)(1) is available in the member's service area: (a) The member may 1. choose not to enroll with a MassHealth managed care provider if such circumstances prevail; or 2. select an available MassHealth managed care provider outside of the member's service area. (b) Any MassHealth Standard or CommonHealth member younger than 21 years old who is not enrolled with a MassHealth managed care provider pursuant to 130 CMR 508.003(B)(2)(a)1. must obtain any behavioral health services through the MassHealth behavioral health contractor. All other services for which the member is eligible may be obtained through any qualified participating MassHealth provider. (c) If, after a determination by the MassHealth agency under 130 CMR 508.003(B)(2), the MassHealth agency determines that a MassHealth managed care provider meeting the criteria of 130 CMR 508.003(B)(1) has become available, the member must enroll with such a provider, unless the member is otherwise enrolled with a MassHealth managed care provider pursuant to 130 CMR 508.003(B)(2)(a)2. (3) Notification. The MassHealth agency will notify a member in writing of the name and applicable contact information of the member's MCO, Accountable Care Partnership Plan, Primary Care ACO, or PCC, and the effective date of the member's enrollment with the MassHealth managed care provider.

(C) Member Choice to Transfer or Disenroll from a MassHealth Managed Care Provider. Members enrolled with a MassHealth managed care provider may transfer to another available