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MassHealth and private health insurance also known as Third Party Liability (TPL)

Help for MassHealth members to understand how to use their MassHealth and private health insurance also known as Third Party Liability (TPL).

MassHealth members can have both MassHealth and private health insurance at the same time. Private health insurance could be from employment, a family member or a parent with or without custody.

If you have private insurance, the private health insurance is considered a liable third party or “TPL”. This means the private health insurance is billed as the primary insurer and MassHealth is the secondary coverage

Private health insurance may also be known as “commercial health insurance”, “employer-sponsored insurance (ESI),” or “other insurance”.

Table of Contents

Overview

MassHealth members can have both MassHealth and private health insurance at the same time. If you have both types of insurance, the private health insurance is considered a liable third party or “TPL”. This means the private health insurance is billed as the primary insurer and MassHealth is the secondary coverage.  Private health insurance could be from your job, a family member, or a parent with or without custody. In some instances, MassHealth may require you to enroll into health insurance offered through work.

If you are a MassHealth member and you have private health insurance

  • You will not lose your MassHealth as long as you are still eligible for MassHealth;
  • Your private insurance will be the primary insurer and pay first for your health care;
  • MassHealth will pay for MassHealth-covered services if your private health insurance doesn’t, including out-of-pocket costs like copays or deductibles;
  • You will never have to pay more than you did when you or your dependents were on MassHealth only;
  • If you were receiving your MassHealth through a MassHealth managed care organization (MCO) plan (e.g. BMC Health Net or Tufts Health Together), an accountable care organization (ACO) plan (e.g. Fallon 365 or Partners HealthCare Choice), or through the Primary Care Clinician (PCC) Plan you will be disenrolled from the MassHealth MCO, ACO, or PCC Plan once you become enrolled in your private health insurance. An MCO, ACO, PCC Plan disenrollment notice will be mailed to your address that MassHealth has on record when this happens. You will still have MassHealth benefits, however how you receive them will change.

If you are a MassHealth member and may have access to private health insurance

You may be required to:

  • Supply information about the private insurance plan to see if it would be cost effective for MassHealth to require you to enroll;
  • Enroll in insurance through your job if MassHealth determines it is cost-effective. MassHealth will reimburse you for any costs in addition to those you had with MassHealth only;
  • Maintain any private health insurance that is available to you at no cost (including Medicare); and
  • Unless you are pregnant or under age 21, you could lose your MassHealth benefits if you do not enroll in private health insurance when you are required to do so by MassHealth.

Frequently Asked Questions (FAQs)

For more information, please see the below FAQs about when you have private health insurance and MassHealth.

If you have additional questions? Send us an email to MassHealthTPL@accenture.com

Additional Resources

Third Party Liability (TPL) indicator form

This form is for you or your providers to use to tell MassHealth about other health insurance or if your insurance has changed or ended.

Additional Resources

Sample letters mailed to members

ACO/MCO disenrollment – sample letter

This letter is to tell you that you are still eligible for MassHealth but your MassHealth accountable care organization (ACO), managed care organization (MCO) plan, or PCC Plan has ended.  This is because you have private health insurance coverage. You will still have MassHealth benefits, however your private health insurance will be primary insurer.

Third Party Liability (TPL) add letter – over age 18 and under age 18 sample letters

This letter is to tell you that you or your dependents are covered by another health insurance policy, in addition to MassHealth. If the health insurance information is incorrect or has ended, please call the Third-Party Liability Unit at (888)-628-7526.

Additional Resources

Contact the Third-Party Liability (TPL) unit

Contact us to report insurance updates, new coverage, make corrections or report terminations.

Monday and Tuesday from 8:00 am to 7:00 pm

Wednesday, Thursday, and Friday from 8:00 am to 5:00 pm

By phone: 888 628-7526 (TTY: 617 886-8102)

By fax: 1-617-357-7604

Have questions? Send us an email to MassHealthTPL@accenture.com 

Need to mail us documents? Send them to:

Third-Party Liability (TPL) Unit
PO Box 9212
Somerville, MA 02150

Reimbursement for mail order pharmacy expenses

MassHealth may reimburse members for out-of-pocket mail order pharmacy expenses for MassHealth covered services. This reimbursement may be available when a MassHealth member is required by their health insurer to fill a mail order prescription(s) and has to pay an expense (including co-insurance, copays, and deductibles) up front in compliance with their insurance policy.

To request reimbursement for out-of-pocket mail order pharmacy expenses, please complete the Pharmacy Mail Order Expense Reimbursement Form. Instructions explaining the documentation that you’ll need, and how to submit your request, are included on the form.

Additional Resources

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