Commonwealth of Massachusetts
Executive Office of Health and Human Services
Office of Medicaid
600 Washington Street
Boston, MA  02111
www.mass.gov/masshealth

		MassHealth
		Eligibility Letter 177
		April 15, 2008

TO:	MassHealth Staff

FROM:	Tom Dehner, Medicaid Director

RE:	MassHealth Enrollment of Members in Employer-Sponsored Health Insurance

This letter transmits revisions to the regulation allowing MassHealth to enroll 
a member in employer-sponsored health insurance provided that the insurance plan 
meets the criteria for MassHealth payment of premium assistance.

These emergency regulations are effective July 1, 2007.

	MANUAL UPKEEP

Insert	Remove	Trans. By

503.006	503.006	E.L. 120
503.007	---		---

	130 CMR:  DIVISION OF MEDICAL ASSISTANCE

Trans. by E.L. 177

Rev. 07/01/07 

	MASSHEALTH
	UNIVERSAL ELIGIBILITY REQUIREMENTS

Chapter 503
Page 503.006

503.006:  Assignment for Third-Party Recoveries

As a condition of eligibility, an applicant or member must inform any MassHealth 
Enrollment Center when a family group member is involved in an accident, or 
suffers from an illness or injury, or other loss that has resulted or may result 
in a lawsuit or insurance claim. The applicant or member must

(A)  file an insurance claim for compensation, if available; and

(B)  agree to comply with all requirements of M.G.L. c. 118E, s. 22 including, 
but not limited to

(1)  assigning to the MassHealth agency or its agent the right to recover an 
amount equal to the MassHealth benefits provided from the proceeds of any claim 
or other proceeding against a third party;

(2)  providing information about the claim or any other proceeding and 
cooperating fully with the MassHealth agency or its agent, unless the MassHealth 
agency determines that cooperation would not be in the best interests of, or 
would result in serious harm or emotional impairment to, the applicant or 
member;

(3)  notifying a MassHealth Enrollment Center in writing within 10 days of 
filing any claim, civil action, or other proceeding; and

(4)  repaying the MassHealth agency from the money received from a third party 
for all MassHealth benefits provided on or after the date of the accident or 
other incident. If the member is involved in an accident or other incident after 
becoming MassHealth eligible, repayment will be limited to MassHealth benefits 
provided as a result of the accident or incident.

503.007:	Potential Sources of Health Care

The MassHealth agency is the payor of last resort and pays for health care and 
related services only when no other source of payment is available, except as 
otherwise required by federal law.

(A)	Health Insurance.  Every applicant and member must obtain and maintain 
available group health insurance in accordance with 130 CMR 505.000 et seq. and 
507.003. Failure to do so may result in loss or denial of eligibility for all 
individuals within the family group unless the applicant or member is

(1)  receiving MassHealth Standard or MassHealth CommonHealth; and 

(2)  under age 19 or pregnant.

130 CMR:  DIVISION OF MEDICAL ASSISTANCE 

Trans. by E.L. 177

Rev. 07/01/07

	MASSHEALTH
	UNIVERSAL ELIGIBILITY REQUIREMENTS

Chapter 503
Page 503.007

(B)  Use of Benefits.  The MassHealth agency does not pay for any health care 
and related services that are available

(1)  through the member’s health insurance, if any; or 

(2)  at no cost to the member including, but not limited to, any such services 
that are available through any agency of the local, state, or federal 
government, or any entity legally obligated to provide those services.

(C)  Employer-Sponsored Health Insurance.  The MassHealth agency may enroll 
MassHealth members in available employer-sponsored health insurance if that 
insurance meets the criteria for payment of premium assistance under 130 CMR 
506.012(A)(1) or 507.003.