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7 130 CMR: DIVISION OF MEDICAL ASSISTANCE

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

130 CMR 516.000: MASSHEALTH: THE ELIGIBILITY PROCESS

(c) If the member's coverage type changes, the start date for the new coverage type is effective as of the date of the written notice.

(3) Review Form for Individuals in Need of Long-term-care Services in a Nursing Facility. If the individual is in need of long-term-care services in a nursing facility and their continued eligibility cannot be determined based on reliable information in their account or electronic data match with federal and state agencies, a written update of the member’s circumstances on a prescribed form must be completed. (a) The MassHealth agency will notify the member of the need to complete the prescribed review form. (b) The member will be given 45 days to return the review form to the MassHealth agency. 1. If the review is completed within 45 days, eligibility will be determined using the information provided by the member, 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 90 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. (c) If the member's coverage type changes, the start date for the new coverage type is effective as of the date of the written notice. (4) Periodic Data Matches. The MassHealth agency matches files of MassHealth members with other agencies and information sources as described in 130 CMR 516.004 to update or verify eligibility. (a) If the electronic data match indicates a change in circumstances that would result in potential reduction or termination of benefits, the MassHealth agency will notify the member of the information that was received through the data match and require the member to respond within 30 days of the date of the notice. 1. If the member responds within 30 days and confirms the data is correct, eligibility will be determined using the confirmed data from the electronic data match. 2. If the member responds within 30 days and provides new information, eligibility will be determined using the information provided by the member. Additional verification will be required. 3. If the member does not respond within 30 days, eligibility will be determined using available information received from the electronic data sources. If information necessary for eligibility determination is not available from electronic data sources, MassHealth coverage will be terminated.