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See our MassHealth - Long-Term Care page, for those Over 65 and people of any age who live in, or will be entering, a Nursing Facility.

Follow link for details on:

ASSETS Rules (Includes: rules about retaining the home, spending and transferring assets, and community spouse protections.)
INCOME Rules (MAGI does not apply to those applying for Long-Term Care.)
GUARDIANSHIP FEES – approved amounts to be paid from member’s assets
NURSING HOME RESIDENTS- Protection From Unfair Nursing Home Discharge and
LONG-TERM CARE INSURANCE asset protections, bed-holds

Also see: Senior Guide to Health Care Coverage- A guide for Seniors and people of any age needing long-term care services (Spanish version)

MassHealth Member Eligibility Regulations - 130 CMR 515.000 through 522.000 (referred to as Volume II) cover those over 65 and long-term care cases.

Application
Applications and accompanying forms for all populations may be obtained in one of the following ways:

• Contact MGH Patient Financial Services at (617) 726-2191 (recommended for MGH patients).
• Call the MassHealth Enrollment Center at 1-866-665-9993 (for English and other languages) or TTY: 1-888-665-9997 for deaf and hard of hearing.
• Online at MaHealthConnector.org

See forms and information from the MassHealth website

(People who are blind no longer apply through the Massachusetts Commission for the Blind per regulation changes outlined in MassHealth Eligibility Letter 189, October 15, 2009, effective retroactively to 12/1/08.)

NOTE: Applicants with Disabilities- MassHealth staff should make every reasonable effort to assist members and potential members with disabilities who need accommodations with MassHealth eligibility or services. For assistance beyond what is immediately available to MEC staff, EOHHS has designated a person – the MassHealth Disability Accommodation Ombudsman "My Ombudsman"- to assist. (More information: Overview; note- program is now availableto all MassHealth members, not just those in managed care organizations.)

Required Documentation

To apply for MassHealth, you need the following documentation:

• Birth dates for all family members
Citizenship* or Immigration status (copy of green card or other official immigration papers)
Social Security number (NOTE: This is not needed for MassHealth Limited. See section on Immigration status for more information)
Verification of disability determination, if applicable
• Copies of recent wage stubs for you and your family members
• Bank statement**
• Information about other income you are receiving (TAFDC, SSI, Child Support, Pensions, Social Security)
• Applicants with self-employment or rental income need to provide tax returns or business records in order to show allowable deductions from income.
• Applicants with health insurance or other coverage need to submit a copy of the insurance card.
• If you are applying based on having HIV/AIDS, you will need to submit proof of your HIV status.

  If you do not have some of these documents, you may be able to use sworn statements from someone who knows you. You should submit all documentation within 60 days.

Hospital-Determined Presumptive Eligibility

NOTE: hospital participation requires contracting with MassHealth. MGH does not currently have such a contract. MassHealth now allows qualified hospitals to make "presumptive eligibility" determinations for their patients. Presumptive eligibility will be determined based on attested information. The MassHealth agency will use estimated gross household income rather than MassHealth MAGI to assess whether the financial requirements described below have been met.

Qualified hospitals may determine presumptive eligibility for the following.

1. Children and Young Adults (19 & 20) up to 150 percent FPL;
2. Pregnant women up to 200 percent FPL;
3. Parents and caretaker relatives and other adults up to 133 percent FPL;
4. Individuals who need treatment for breast or cervical cancer up to 250 percent FPL;
5. Individuals who are HIV positive up to 200 percent FPL; and
6. Former foster care adolescents with no income limit (up to age 26).

The state will provide pregnant women who are determined presumptively eligible with full MassHealth Standard benefits (Eligibility, once established, continues for the duration of the pregnancy. Eligibility for postpartum care continues for 60 days following the termination of the pregnancy plus an additional period extending to the end of the month in which the 60-day period ends.).

• Only one hospital determined presumptive eligibility period per member is permitted within a 12-month time frame, starting with the effective date of the initial presumptive eligibility period.  An individual who has received MassHealth benefits within the previous 12 months may not be determined presumptively eligible by a hospital.
• Benefits provided through the hospital presumptive eligibility process will begin on the date that the hospital determined presumptive eligibility and will continue until whichever of the following occurs first:
  
• the last day of the month following the month of the presumptive eligibility determination, or
• the date when an eligibility determination is made based upon the individual’s submission of a complete application.

Note:   MassHealth will not charge a premium during the hospital presumptive period.

(Regulations::http://www.lawlib.state.ma.us/source/mass/cmr/cmrtext/130CMR502.pdf. See 502.003 (H).)

 

Retroactive Bank Records

** Per law bill H.975 MassHealth applicants are exempt from payment of certain bank fees to reproduce up to five years of retroactive bank records needed for the MassHealth application. Applicants need a written request signed by a MassHealth employee or agent in order to waive the fee. Banking institutions that refuse to provide the statements without charge upon request in a timely manner will be subject to a $50 fine. 6/08

Eligibility Representative Designation Form (ERD)

Designates person to help with applying for or getting health benefits (MassHealth, Commonwealth Care, the Children’s Medical Security Plan, Healthy Start, and the Health Safety Net).

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Managed Care and MassHealth

Those Under 65

(See also: Dual Eligibles below)

Most people under age 65 (as of 7/10 including those on CommonHealth - see article) who are approved for MassHealth must choose a either a primary care clinician (PCC) plan, or a MassHealth Managed Care Organization or MCO. As of March 1, 2018, another option is an Accountable Care Organizaion or ACO. See below for more information. Each MassHealth managed care plan offers all of the benefits of MassHealth, plus some extra benefits. Those who enroll in an MCO will get an MCO health insurance ID card in addition to their MassHealth card.

See the MGH/MGPO Desk Guide for participating plans.

Accountable Care Organizations (ACOs)

ACOs are designed to emphasize care coordination and member-centric care, as well as align financial incentives. ACOs are provider-led organizations that coordinate care, have an enhanced role for primary care, and are accountable for the quality and total cost of care. For more information, see MassHealth ACO- Updates and Outreach- MGH Community News, June 2018.

MassHealth managed care eligible members are

• Younger than age 65, without any third-party insurance coverage (including Medicare)
• Living in the community (not living permanently in a nursing facility)
• Covered by MassHealth: Standard, CommonHealth, CarePlus, or Family Assistance

Learn more:

• Partners Update (PowerPoint) 9/18 - includes who's eligible, who may voluntarily enroll, "categories" vs. plans, exclusivity exceptions, contracts- specialty and hospital care, behavioral health, plan selection and fixed enrollment (lock-in) and requesting exceptions, and referral circles.
• Partners Medicaid ACO SharePoint site

Services:

• MassHealth Flexible Services Program - Includes Nutrition and Housing Assistance, expected to start in January 2020

As of March 1, 2018 only MassHealth members in the Partners Healthcare Choice ACO may receive primary care from Partners Primary Care Providers (PCPs).


Specialty care:
The MassHealth health plans that allow you to see Partners specialty providers are:

• Partners HealthCare Choice ACO
• Community Care Cooperative ACO
• MassHealth PCC Plan
• Merrimack Valley ACO with NHP (My Care Family)
• Steward Health Choice ACO

Where can members of the Partners HealthCare Choice ACO go for behavioral health services? 
Partners Choice ACO members will have access to the Massachusetts Behavioral Health Partnership (MBHP) provider network, which is one of the largest in Massachusetts with over 1,200 clinics. For more information, contact Massachusetts Behavioral Health Partnership 1-800-495-0086 or online at www.masspartnership.com.
See more on the ACO Lock-In below.

MCO Lock-In - MassHealth Managed Care - First Fixed Enrollment Period Begins Jan 1, 2017 - MGH Community News, December 2016

MassHealth has instituted a MCO lock-in that limits when members can change plans. The first Fixed Enrollment Period begins January 1, 2017 for people who were enrolled in mandatory managed care on October 1, 2016.  MCO members who want to change plans will have to call MassHealth and show one of 11 permissible reasons (below) to change plans during their Fixed Enrollment Periods. Denial of a request to change plans is appealable. New applicants will have 90 days from managed care enrollment to freely change plans before they are locked in for the year.

ACO Lock-In- MassHealth Managed Care Transitions-MGH Community News, June 2018

• Continuity of Care

The continuity of care period during which new plans were required to honor authorizations from the former plan and to pay for ongoing services from former providers no longer in the new plan’s network ended May 31, 2018. Some plans may have agreed to longer continuity of care for individual members or for certain services.

• Fixed Enrollment

As of July 1, 2018, MassHealth members who were enrolled in ACOs and MCOs on March 1 are in their Fixed Enrollment Period. This means that unless they qualify for an exception, they are locked into their existing plan until March 1, 2019 when the next Plan Selection period begins. Note: going forward, members may have individual lock-in periods.

• Community Partners

MassHealth has notified the ACOs/MCOs about 33,000 members with complex care needs to be assigned Community Partners (Long Term Services and Supports or LTSS providers) after July 1. During the start-up of this new resource MassHealth will largely be controlling CP assignments. Members will receive a letter identifying the Community Partner organization and it will reach out to the member who is free to participate or decline. Right now Community Partners are not available by referral. For more information, see Community Partners (CP) Program- MGH Community News, August 2018.

Managed Care Obudsman

For members with disabilities or other complex care needs enrolled in managed care plans including the MCOs, ACOs, SCOs, and One Care, the One Care Ombudsman program can assist- call 855-781-9898 or email info@myombudsman.org.

Under 65 Auto-Assignment

Due to state budget constraints, MassHealth has stopped auto-assignment of members to managed care plans (NHP, Network Health, Fallon, BMC Health Net, and Health New England). As of February 10, 2011, the state will auto-assign individuals who don't select a plan to the PCC Plan.

For more information call the HMOs customer service number, visiting their web site, or speaking to a MassHealth Benefits Advisor at 1-800-841-2900 (TTY: 1-800-497-4648).

Over 65

There are a couple of voluntary managed care programs for the Over 65 population.

• Program for All Inclusive Care for the Elderly/Elder Service Plans (PACE/ESP) plans (see related programs on our Elder page)
• Senior Care Options (SCOs) (do not also have to be eligible for Medicare)

 

Dual Eligibles

There are two main programs in Massachusetts that seek to coordinate benefits and services for those eligible for both Medicare and MassHealth (Dual Eligibles). The first group are the Senior Care Options (SCOs) programs for those over 65 (this class of programs was launched in 2004). A new demonstration program is now getting underway- Integrated Care Organizations (ICOs)- Now called OneCare for those under age 65.

Learn more on our Dual Eligibles page.

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MassHealth and Cash Assistance

People eligible for certain cash assistance programs are automatically eligible for MassHealth. If an agency approves eligibility for cash assistance, the individual will also be enrolled in MassHealth without the need for a separate application to the DTA. When cash assistance ends, MassHealth will not automatically end. The DMA must determine if the former cash recipient is still eligible for MassHealth.

Persons automatically eligible for MassHealth Standard include:

• disabled children and adults who receive Supplemental Security Income,
• families with children eligible for Transitional Assistance for Families with Dependent Children (TAFDC), or Emergency Aid to Elders, Disabled and Children (EAEDC), and
• children eligible for foster care payments or adoption assistance subsidies.

Childless adults eligible for EAEDC are eligible for MassHealth Basic.

Refugees eligible for refugee resettlement assistance are eligible for MassHealth Standard for eight months from the date of entry into the United States.

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Immigrants and MassHealth

Immigrant benefits eligibility is complex. This information is provided for your reference, but please contact the CRC, Patient Financial Services, or the Massachusetts Immigrant Refugee Advocacy (MIRA) Coalition (617-350-5480) to confirm before advising patients/families.

Never advise an undocumented immigrant or one unsure of their status to go to USCIS. They should instead speak with an immigration advocate.

Key Reference document:

Understanding the Affordable Care Act in Massachusetts: Eligibility of non-citizens for MassHealth & other subsidized health benefits - Massachusetts Law Reform Institute, February 2022

Also see: our MassHealth Immigrant Eligibility page.

Language Access

MassHealth provides free aids and services to people with disabilities to communicate effectively with us, such as:

• Qualified American Sign Language interpreters
• Written information in other formats (large print, braille, accessible electronic formats, and other formats)
• Free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
  • If you need these services, contact us at (800) 841-2900, (TTY: (800) 497-4648).

The MassHealth Customer Service Center (CSC) has bilingual staff available to handle calls from LEP individuals. For languages for which there is no on-site bilingual staff, Language Line Services can be used for three-party translations by telephone.

At all walk-in sites, the Agency has contracted with Certified Languages International Communications d/b/a Century Link QCC to provide scheduled and unscheduled interpretation services for non-English speaking individuals over the phone in 150 languages and various dialects. (During the COVID-19 public health emergency, in-person service is not available.)

Source and for more information: The MassHealth language access plan is posted here: https://www.masslegalservices.org/system/files/library/MassHealth%20LAP%202019-21.pdf

Complaint process - to file a complaint with the Language Access Coordinator, submit the written complaint to: Patricia Grant Chief Operating Officer, MassHealth Executive Office of Health and Human Services 100 Hancock Street 6th floor Quincy, MA 02171 Patricia.Grant@mass.gov

 

For more information see our MassHealth Immigrant Eligibility page.

 

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Benefits - Detail
• How long does it take to receive MassHealth Benefits?

  MassHealth must make eligibility decisions within 45 days of receipt of application if the application is complete, and within 90 days if eligibility requires a determination of disability. When benefits begin depends on the coverage type.

  Benefits begin 10 days prior to the date of the application under MassHealth Standard, CommonHealth, CarePlus and Family Assistance if all required verifications have been received within 90 days of the date the Request for Information is received.

  For those age 65 and over in traditional Medicaid, retroactive eligibility is available for up to three months prior to the month of application, for any or all of the three prior months in which eligibility criteria have been met, which is important if someone has incurred medical bills before he or she applied.

• Covered Services
• Autism Services Coverage
• Behavioral Health- Effective January 1, 2019, the Massachusetts Behavioral Health Partnership (MBHP) now covers Repetitive Transcranial Magnetic Stimulation (rTMS) for MassHealth members who receive their behavioral health benefits through MBHP. This applies to all members enrolled in MBHP, including those also enrolled with Community Care Cooperative (C3), Partners Healthcare Choice, Steward Health Choice plans, and the Primary Care Clinician (PCC) Plan- MGH Community News, February 2019
• CARES for Kids program - new as of summer 2023. MassHealth's Coordinating Aligned, Relationship-centered, Enhanced Support (CARES) for Kids is a targeted case management (TCM) service that provides care coordination across the health, educational, state agency, and social service systems, for children and youth (under 21) with complex medical and social needs.
  • Eligibility
  • FAQs
  • Find a Provider - members need to designate an eligible provider to be responsible for theri care coordination under CARES
  • More information (MGH Community News, July 2023)
• Complex Care Assistant program - new as of fall 2023. MassHealth is launching a new service type for complex care members who are authorized to receive Continuous Skilled Nursing services. Continuous Skilled Nursing (CSN) services is defined as requiring in-home nursing services for more than two continuous hours a day. The new service is called Complex Care Assistant services and it will be provided through MassHealth enrolled CSN agencies. MassHealth created this new service type to provide an additional avenue of support for CCM members and as a pathway to pay family caregivers for specialized care to medically complex MassHealth members. This new service does not replace continuous skilled nursing (CSN) services; it is meant to complement CSN services and provide an additional care option. Complex care assistants can perform more skilled tasks than a home health aide, and they will work through a CSN agency. More information: Newsletter article (7/23) and at Mass.gov.


• Costs: Premiums & Co-Pays

MassHealth permanently eliminated copayments effective 4/1/24.

This policy includes members in MassHealth Fee-For-Service (FFS), Primary Care Accountable Care Organizations, Accountable Care Partnership Plans (ACPPs), Managed Care Organizations (MCOs), One Care Plans, Senior Care Options (SCO) Plans, and Program of Allinclusive Care for the Elderly (PACE) Organizations. This does NOT apply to Children’s Medical Security Plan (CMSP) members – CMSP members must still pay copays.

- See the full Eligibility Letter (mass.gov) and Pharmacy Facts

 

Previous Copay Policy (7/1/21 - spring 2024)

MassHealth’s copay policy changed on July 1, 2021. The revised cost sharing policies limits members’ copay and premium obligations to 5% of the member’s household income. These changes are not expected to increase members’ copay and premium obligations and was implemented in two phases: the first phase became effective on July 1, 2020, and the second phase became effective on July 1, 2021.

Overview of the Phase 1 Changes

On July 1, 2020, MassHealth excluded the following list of services and populations from copays (see list below). Please note that copays for acute inpatient hospital stays were also eliminated on March 18th, 2020.

Services

The following services were newly excluded from copays as of July 1, 2020:

• FDA-approved medications for detoxification and maintenance treatment of substance use disorders (SUD);
• preventive services rated Grade A and B by the US Preventive Services Task Force (USPSTF) or broader exclusions specified by MassHealth (e.g., low-dose aspirin; colonoscopy preparation); and 
• vaccines and their administration recommended by the Advisory Committee on Immunization Practices (ACIP).

Populations

The following populations were newly excluded from copays as of July 1, 2020:

• members with incomes at or under 50% federal poverty level (FPL); and
• members automatically eligible for MassHealth because they are receiving other public assistance such as Supplemental Security Income (SSI), Transitional Aid to Families with Dependent Children (TAFDC), or services through the Emergency Aid to the Elderly, Disabled and Children (EAEDC) Program.

For the complete list of copay exclusions, go to https://www.mass.gov/service-details/masshealth-copayments-frequently-asked-questions or refer to 130 CMR 506.015 and 130 CMR 520.037.

Overview of the Phase 2 Changes

Starting July 1, 2021

• a member’s cost sharing obligation for copays and premiums COMBINED  will not exceed 5% of the member’s monthly household income. 
• MassHealth will replace the current $250 annual pharmacy copay cap with a member-specific monthly PHARMACY COPAY CAP not to exceed 2% of the member’s monthly household income. Please note however, for the duration of the COVID-19 federal Public Health Emergency, MassHealth will also ensure that members will not be charged more than $250 in total copays annually.
• A copay cap is the highest dollar amount that a member can be charged in copays in a month.
• MassHealth will calculate a monthly copay cap for each member based on the lowest income in their household and their household size, as applicable. MassHealth will round the member’s monthly copay cap down to the nearest ten dollar increment up to $60 and determine their final monthly copay cap as shown in the table below.

  If a member's copay cap is calculated to be:	Their final monthly copay cap will be:
  $0 - $9.99	No Copays
  $10 - $19.99	$10
  $20 - $29.99	$20
  $30 - $39.99	$30
  $40 - $49.99	$40
  $50 - $59.99	$50
  $60 or over	$60

• For example, if a member’s monthly copay cap is $12.50 in July, a member will not be charged more than $10 of copays in July. If a member’s household income or family size changes in August, their monthly copay cap may change for August.
• MassHealth PREMIUMS will not exceed 3% of the member’s monthly household income, as applicable. This limit does not apply to CommonHealth members.

Member Notifications of These Changes

• Beginning in late May 2021, MassHealth will send members an initial notice explaining these changes and notifying them of their initial monthly copay cap.
• Starting July 1, 2021, MassHealth will send a notice to members whenever their monthly copay cap changes or whenever they meet their current monthly copay cap. 


Previous Policy (Prior to July 1, 2021)

Patient costs depend on the program in which one is enrolled. Some people do not pay anything for MassHealth. Some people pay a monthly premium. See Coverage Types. MassHealth can grant a temporary premium waiver for those facing severe financial hardship - Application for Waiver or Reduction of MassHealth Premium.

The PHARMACY copayments - see the Pharmacy Copayment flyer

• $1 for generic and over-the-counter drugs treating diabetes, hypertension and high cholesterol and
• $3.65 for each prescription and refill for all other generic, brand-name, and over-the-counter drugs covered by MassHealth (increased from $3 on 10/1/11).
• As of 10/1/11, there are no MassHealth pharmacy co-pays for family-planning services and supplies, such as oral contraceptives, diaphragms and condoms, and contraceptive jellies, creams, foams, and suppositories.
• There is an annual maximum of $250 on pharmacy co-payments for people on MassHealth (this amount increased on 1/1/12 from the previous $200).
• Can't afford the pharmacy co-pay? If you are unable to pay a copayment at the time of service, the pharmacy must still fill your prescription. However, the copayment is still your responsibility, and the pharmacy can bill you for the copayment. You should not go without necessary medications because you cannot afford the copayment now. -Excerpted from Pharmacy Copayment flyer
• NOTE: Dual-eligibles receiving Medicaid Home and Community Based Waivers should have no co-pay for Part D drugs. Justice in Aging created an FAQ, Low-Income Subsidy (“Extra Help”) for Dual Eligibles Receiving Home and Community-Based Services, to give advocates working with dual eligibles the tools they need to prevent these co-pays. (Also see MGH Community News, September 2019)

Most MassHealth members have this additional co-payment: $3 for an acute inpatient hospital stay.  Calendar year maximums for these co-payments are $36 for non-pharmacy services.

Exemptions and Alternative co-pays:

• There is no longer a co-payment for non-emergency services provided in a hospital emergency room.
• Children under 19, pregnant and postpartum women, MassHealth Limited and Senior Buy-In members, people who are institutionalized, and certain other MassHealth members do not have these co-payments.
• MassHealth members who are enrolled in an HMO pay the co-payments charged by the HMO.
• Dental Services

Effective January 1, 2021, full MassHealth dental coverage has been restored for adults, including coverage for root canal services, crowns and additional periodontal services. (See the full HCFAMA post and the  full MassHealth Transmittal letter DEN-109, January 2021)

Previous restorations:

• MassHealth denture and related coverage (full and partial dentures, including repairs) for adults was restored as of May 15, 2015.
• Adult Periodontal coverage resumed as of April 22, 2019. For more information, see MassHealth Adult Dental to Cover Additional Periodontal Services- MGH Community News, March 2019.

  Background - MassHealth Dental Cuts: As of July 1, 2010, MassHealth cut dental services for most adult patients. Advocates worked hard to restore coverage which was restored incrementally. As of 3/1/14, MassHealth resumed coverage of diagnostic and preventive services (such as checkups, cleanings, and x-rays), extractions, emergency treatment, and all dental fillings for adults (a prior partial restoration only included fillings for front teeth). Funding for denture and related coverage was included in the state FY15 budget.

  Populations who retain full coverage: Children, Adults with intellectual disabilities who are served by the Dept of Developmental Services, Seniors who are on Senior Care Options plans (SCO's) and dual eligibles enrolled in OneCare are covered for all appropriate dental services.

  Note: As MassHealth members who are enrolled in a Senior Care Option (SCO) program or the OneCare program (for dual eligibles) may receive full dental coverage through these programs, those eligible may want to consider if one of these programs is right for them

• More Background Information: filling restoration and denture restoration.
  • (Previous partial restoration that took effect January 1, 2013 covered composite [white] fillings for 6 front teeth [top and bottom]). Fillings for back teeth [premolars and molars] were not covered for this group; exceptions below. More information.)
  • Services covered (for adults)- exams & x-rays, cleaning, extractions and emergency services and fillings for all teeth and as of 5/15/15 - denture coverage and certain prosthodontic services (full and partial dentures, including repairs).
    

Find a MassHealth Dentist (Note: Search for a dentist who accepts MassHealth here, but benefits info. on this site is out of date as of 7/9/10, see above instead.)

Also:

• Family Assistance covers dental for kids- MGH Community News, October 2009
• Discounts: Amazon Prime Discount for Those with Medicaid or EBT Cards- MGH Community News, March 2018
• Durable Medical Equipment
• Home Care- Special Programs - see Elder Service Plans/Programs of All-Inclusive Care of the Elderly (ESP/PACE) and Senior Care Options (SCOs) and Money Follows the Person
  • UMass Commonwealth Medicine- Community Case Management- MGH Community News, November 2018
  • For patients with MassHealth Standard or CommonHealth who require continuous skilled nursing for more than 2 hours a day

• Home care- Prior Authorization-As of March 1, 2016, MassHealth requires prior authorization of continuing home care services after a certain number of visits that varies by service type. A physician unaffiliated with the home care agency must attest to medical necessity and document a face-to-face encounter. More information: New MassHealth Prior Authorization Policy for Home Health Services and VNA Referral to ASAPs, MGH Community News, March 2016
• Home Health Aide Services- As of July 1, 2019, MassHealth members may receive medically necessary home health aide services for hands-on assistance with activities of daily living (ADL) without the need for a concurrent home health skilled nursing or therapy service. For more information, see MassHealth to Cover Home Health Aid Without Requiring Concurrent Nursing or Skilled Service- MGH Community News, June 2019.
• Homelessness - people experiencing homelessness
  • Continuous Coverage Pilot
    • Effective December 1, 2023 and through December 31, 2027,  people who have been confirmed as homeless for 6+ months will have 24 months of continuous eligibility.
    • Eligible Population: MassHealth eligible individuals under age 65 with a confirmed status of homelessness for at least 6 months. Confirmed status of homelessness” is verified through Statewide Homeless Management Information System and/or from the Department of Housing and Community Development, Emergency Assistance shelter system for families.
    • Duration of Continuous Eligibility: 24 months- The 24-month continuous eligibility period for individuals experiencing homelessness will begin no later than the third month before the month of application or on the effective date of the most recent renewal of eligibility.
    • 12 Month Verification: 12 months into the 24-month continuous eligibility period, MassHealth will make a reasonable effort to confirm that the individual still meets the continuous eligibility criteria before resuming the remainder of the 24-month eligibility period. MassHealth will utilize available data sources and standard member outreach procedures in an attempt to verify information. The termination of continuous eligibility would only result in the event of a response affirming out of state residency, death or voluntary withdrawal. Mail being returned or undelivered will not result in a termination of benefits or an interruption in the continuous eligibility period unless there is sufficient evidence indicating reason for termination.
    • Learn more: MGH Community News, June 2023

• Hospice - MassHealth Standard, CommonHealth and CarePlus coverage types cover hospice. The CarePlus program replaced MassHealth Essential and Basic and also serves those newly eligible for MassHealth under Medicaid expansion under the Affordable Care Act (i.e., those who would not qualify in past under categorical eligibility rules). Paving the way for this change, as of July 1, 2013 hospice was a covered benefit for MassHealth Essential and MassHealth Basic members. Reference: http://www.mass.gov/eohhs/docs/masshealth/bull-2013/hos-10.pdf.
• Housing - Mitigating the Costs of Housing (MATCH) program MATCH is close to exhausting funding - see below for more
  • MATCH is close to exhausting funding - last day to apply is May 12 2024 and applications must be completed by July 12, 2024.
  • Provides MassHealth members with up to $5,500 of housing supports.
  • Members are eligible if: (1) they're enrolled in managed care or the Frail Elder Waiver, (2) they're moving from a place where they do not need to pay for housing costs (such as nursing homes, emergency shelters, correctional facilities, etc.) into community-based housing where they do need to pay for housing costs.
  • The member must be referred to the program by their managed care plan (MCO) or, if enrolled in the Frail Elder Waiver (and not also a MCO), by their Aging Services Access Point agency (ASAP). 
  • More information: see the website and this newsletter article (12/22)

• Justice Involved Individuals - formerly incarcerated people
  • Continuous Eligibility Pilot
  • As of April 1, 2023 and until the end of the pilot (through December 31, 2027) people re-entering the community from incarceration will have 12 months of continuous eligibility.
  • Eligible Populations: MassHealth eligible individuals under age 65 released from a correctional institution. Including County Correctional Facilities (CCFs), State Department of Corrections (DOC) Facilities, and Department of Youth Services (DYS) juvenile justice facilities
  • Duration of Continuous Eligibility: 12 months following release date
    • Eligibility period begins at the date of release and will extend through the end of the 12th month following release.
    • If eligibility determination is made after release date (but within 12 months of release), the individual will be eligible for continuous eligibility through the end of the 12th month following release. This may result in continuous eligibility periods of less than 12 months for some individuals.
  • Existing procedures notify MassHealth when a member is in custody or is being released.
  • Learn more: MGH Community News, June 2023.

• Medications/Prescription Drugs- MassHealth covers prescription drugs, however coverage varies if one also has additional insurance or is enrolled in certain MassHealth or Medicare programs.
• Who pays?
  • For those eligible for both MassHealth and Medicare ("dual eligibles"), Medicare provides most of one's prescription drug coverage through a Medicare prescription drug plan (Medicare D plan).
  • Those enrolled in a Program of All-Inclusive Care for the Elderly plan also called an Elder Service Plan (ESP/PACE), Senior Care Options (SCO) plan, a OneCare Plan, a Medicare Advantage plan, a Medicare supplement (Medigap) plan, or have drug coverage through a current or former employer, should contact their plan to find out more information about whether or not to enroll in a Medicare prescription drug plan.
  • Dual eligibles not in the groups listed above must enroll in a Medicare prescription drug plan (or Medicare will assign one). More about Medicare D

• What drugs are covered and which need prior authorization (PA)? See the MassHealth Drug List and Prior Authorization Forms for Pharmacy Services.

  • Prior approval for high dose opioids and methadone (MGH Community News, March 2016)

• What are my co-pays and what happens if I can't afford the co-pay? Pharmacy Copayment flyer (Spanish)
  • Can't afford the co-pay? If you are unable to pay a copayment at the time of service, the pharmacy must still fill your prescription. However, the copayment is still your responsibility, and the pharmacy can bill you for the copayment. You should not go without necessary medications because you cannot afford the copayment now. -Excerpted from Pharmacy Copayment flyer (Spanish)
• Nutrition- Enteral Nutrition Products
  • GUIDELINES for Medical Necessity Determination for Enteral Nutrition Products
  • Prescription and Medical Necessity Review FORM for Enteral Nutrition Products

• Personal Emergency Response (PERS) - e.g., "Lifeline" devices
  • See PERS on our Elder services page

• Pregnant members and newborns - information for MassHealth Members who are pregnant is now available on the MassHealth website. This site (new in fall of 2023) includes the pregnancy checklist for MassHealth Members as well as covered services, coverage options for infants, behavioral health services, home visiting programs, social services and more.