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6 130 CMR: DIVISION OF MEDICAL ASSISTANCE

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

130 CMR 516.000: MASSHEALTH: THE ELIGIBILITY PROCESS

516.007: Continuing Eligibility

(A) Annual Renewals. The MassHealth agency reviews eligibility once every 12 months. Eligibility may also be reviewed as a result of a member’s changes in circumstances or a change in MassHealth eligibility rules, or as a result of a member’s failure to provide verification within requested timeframes. The MassHealth agency updates eligibility based on information received as the result of such review. The MassHealth agency reviews eligibility (1) by information matching with other agencies, health insurance carriers, and information sources; (2) through a written update of the member's circumstances on a prescribed form; (3) through an update of the member’s circumstances, in person; or (4) based on information in the member’s case file.

(B) Eligibility Determinations. The MassHealth agency determines, as a result of this review, if (1) the member continues to be eligible for the current coverage type; (2) the member’s current circumstances require a change in coverage type; or (3) the member is no longer eligible for MassHealth.

(C) Eligibility Reviews. MassHealth reviews eligibility in the following ways. (1) Automatic Renewal. Members whose continued eligibility can be determined based on electronic data matches with federal and state agencies will have their eligibility automatically renewed. (a) The MassHealth agency will notify the member if eligibility has been reviewed using the automatic renewal process. (b) If the member's coverage type changes to a more comprehensive benefit, the start date for the new coverage is determined as described at 130 CMR 519.000: MassHealth Coverage Types. (2) MassHealth Eligibility Renewal Application. If the individual is residing in the community and their continued eligibility cannot be determined based on reliable information in their account or electronic data match with federal and state agencies, a MassHealth eligibility review form must be completed. (a) The MassHealth agency will notify the member of the need to complete the MassHealth eligibility review form. (b) The member will be given 45 days from the date of the request to return the MassHealth eligibility review form. 1. If the review is completed within 45 days, eligibility will be determined using the information provided by the individual with verification confirmed through electronic data matches if available. 2. If the review is not completed within 45 days, eligibility will be terminated within 14 days from the date of the termination notice. 3. If the requested review form is submitted within 30 days from the date of the termination, a second eligibility determination is made within 15 days. Eligibility may be established retroactive to the date of termination, if otherwise eligible.