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5 130 CMR: DIVISION OF MEDICAL ASSISTANCE

Trans. by E.L. 256 Rev. 02/13/26

130 CMR 516.000: MASSHEALTH: THE ELIGIBILITY PROCESS

(G) Verification Exceptions for Special Circumstances. Except with respect to the verifications of citizenships and immigration status, the MassHealth agency will permit, on a case-by-case basis, self-attestation of individuals for all eligibility criteria when documentation does not exist at the time of application or renewal, or is not reasonably available, such as in the case of individuals who are homeless or have experienced domestic violence or a natural disaster.

516.004: Matching Information

The MassHealth agency initiates information matches with other agencies and information sources when an application is received in order to update or verify eligibility. These agencies and information sources may include, but are not limited to, the following agencies: Federal Data Services Hub, the Department of Unemployment Assistance, the Department of Public Health's Bureau of Vital Statistics, the Department of Industrial Accidents, the Department of Veterans Services, the Department of Revenue, the Bureau of Special Investigations, the Social Security Administration, Systematic Alien Verification for Entitlements, the Department of Transitional Assistance, health insurance carriers, and banks and other financial institutions.

516.005: Time Standards for Eligibility Determination

(A) For applicants who do not apply on the basis of a disability, a determination of eligibility must be made within 45 days from the date of receipt of the completed application. All requested information must be received within 30 days of the date of request.

(B) For applicants who apply for MassHealth on the basis of a disability, a determination of eligibility must be made within 90 days from the date of receipt of the completed application, including a disability supplement, if required.

(C) If the MassHealth agency determines that unusual circumstances exist, the timeframes for determining eligibility are extended. Unusual circumstances include delay caused by the applicant, by an examining physician, or by other events beyond the control of the MassHealth agency.

516.006: Coverage Dates

(A) Start Date of Coverage. For individuals applying for coverage, the date of coverage for MassHealth is determined by the coverage type for which the applicant may be eligible. 130 CMR 519.000: MassHealth: Coverage Types describes the rules for establishing this date.

(B) End Date of Coverage. MassHealth benefits terminate or downgrade no sooner than 14 days from the date of the termination or downgrade notice unless the MassHealth member timely files an appeal and requests continued MassHealth benefits pending such appeal.