Code of Massachusetts Regulations
130 CMR - DIVISION OF MEDICAL ASSISTANCE
Title 130 CMR 516.000 - MassHealth: The Eligibility Process
Section 516.007 - Continuing Eligibility

Universal Citation: 130 MA Code of Regs 130.516

Current through Register 1531, September 27, 2024

(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 time frames. 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. Households, 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 516.006.

(2) MassHealth Eligibility Renewal Application. If the individual is residing in the community and his or her continued eligibility cannot be determined based on reliable information contained in his or her 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 paper 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.

(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 his or her continued eligibility cannot be determined based on reliable information contained in his or her 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 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.

(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.

(b) If the electronic data match indicates a change in circumstances that would result in an increase or no change in benefits, the MassHealth agency will automatically update the case using the information received from the electronic data match and redetermine eligibility. If the member's coverage type changes to a more comprehensive benefit, the member will be sent a notice informing him or her of the start date for the new benefit. The effective date of the change is the date of the redetermination of eligibility.

Disclaimer: These regulations may not be the most recent version. Massachusetts may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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