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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

8 (2) The MassHealth agency may disenroll a member from a PCC's panel or a Primary Care ACO’s Participating PCP’s panel, at the PCC's or PCP’s request, if the PCC or PCP demonstrates to the MassHealth agency's satisfaction that (a) there is a pattern of noncompliant or disruptive behavior by the member that is not the result of the member's special needs; (b) the continued enrollment of the member with the provider seriously impairs the provider's ability to furnish services to either this particular member or other members; or (c) the PCC or PCP is unable to meet the medical needs of the member. (3) If the MassHealth agency approves a request for disenrollment under this 130 CMR 508.003(D)(1), (2)(a), or (2)(b), it will state the good cause basis for disenrollment in a notice to the member in accordance with 130 CMR 610.032(A)(10).

(E) Reenrollment. Any member enrolled with a MassHealth managed care provider who loses and then regains managed care eligibility may be automatically reenrolled with the MassHealth managed care provider with which the member was most recently enrolled, if such MassHealth managed care provider is available for the member's coverage type and service area. (1) A member enrolled with an MCO, Accountable Care Partnership Plan, or Primary Care ACO who loses managed care eligibility during a plan selection period will receive a new plan selection period upon regaining eligibility. (2) A member enrolled with an MCO, Accountable Care Partnership Plan, or Primary Care ACO who loses managed care eligibility during the fixed enrollment period will not receive a new plan selection period upon regaining managed care eligibility; provided, however, that if a member's loss of managed care eligibility causes the member to miss part or all of the member's annual plan selection period, the member will receive a new plan selection period upon regaining managed care eligibility.

508.004: Managed Care Organizations (MCOs)

(A) Enrollment in an MCO. (1) Selection Procedure. When a member becomes eligible for managed care, the MassHealth agency notifies the member of the member’s obligation to select a MassHealth managed care provider within the time period specified by the MassHealth agency. The MassHealth agency makes available to the member a list of the MCOs in the member’s service area. The list of MCOs that the MassHealth agency will make available to members will include those MCOs that contract with the MassHealth agency to serve the coverage type for which the member is eligible and provide services within the member’s service area. The member’s service area is determined by the MassHealth agency based on zip codes or geographic area. Service area listings may be obtained from the MassHealth agency. (2) MassHealth members are assigned to MCOs, may transfer from MCOs, may be disenrolled from MCOs, and may be re-enrolled in MCOs as described in 130 CMR 508.003(B) through 130 CMR 508.003(E).

(B) Obtaining Services when Enrolled in an MCO. (1) Primary Care Services. When the member selects or is assigned to an MCO, that MCO will deliver the member’s primary care, determine if the member needs medical or other