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MassHealth Members and Benefits

This is part of the MassHealth Provider Handbook.

Table of Contents

What is a MassHealth member?

A MassHealth member is a person determined by MassHealth to be eligible for MassHealth.

What are the member coverage types?

A member is eligible for services and benefits according to the member’s coverage type. A coverage type is a scope of medical services, other benefits, or both that are available to members who meet specific eligibility criteria. The following MassHealth coverage types are offered to eligible individuals, families, and people with disabilities: Standard, CommonHealth, CarePlus, Family Assistance, and Limited.

What provider services are covered for each coverage type?

Each coverage type has a list of services that MassHealth members in that coverage type can receive. Payment for the covered services listed in 130 CMR 450.105 is subject to all conditions and restrictions of MassHealth, including all applicable prerequisites for payment. See individual program regulations for information on covered services and specific service limitations, including age restrictions applicable to certain services. Providers should refer to their program manual for a full list of services, restrictions, and conditions. View the online chart of MassHealth covered services.

How do I check a member’s eligibility?

Regulations require providers to check eligibility before providing services to the member. Providers can use Provider Online Service Center (POSC) portal to check the Eligibility Verification System (EVS) via DDE (single check) or batch (multiple member checks simultaneously). EVS messages let providers know the type of health plan, including ACOs, in which a member is enrolled and whom to contact with billing questions.

Eligibility Verification (EVS)

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The MassHealth Eligibility Verification System (EVS) is designed to display the status of a member’s health care coverage for the date(s) of service requested (please note EVS does not display eligibility for future dates). This includes the identification of the health plan and the type of plan that the member is enrolled, if applicable. For members who have health care coverage in addition to MassHealth, EVS will display information about existing third-party payers including but not limited to the following:

  • the third-party carrier name(s) and plan details
  • 7-digit MassHealth proprietary Carrier Code

For more information about checking member eligibility, please refer to the following web pages:

Learn more about EVS codes and messages. For information regarding Provider Online Service Center (POSC), please refer to the POSC section of this handbook.

Dental — Member Benefits

Dental care is one of many benefits available to children and adults who are eligible for MassHealth. In general, members are eligible for the dental benefit if they are enrolled in one of the following coverage types:

  • MassHealth Standard
  • MassHealth CommonHealth
  • MassHealth Family Assistance
  • CarePlus
  • MassHealth Limited (emergency services only)
  • Children’s Medical Security Plan

The MassHealth dental program regulations at 130 CMR 420.000 and 450.105 describe the dental benefit, service limitations, and member eligibility.

MassHealth Member Dental Customer Service (DentaQuest)

(800) 207-5019
TTY: (800) 466-7566
Hours: 8 a.m. to 6 p.m. (Monday through Friday)

Dental — Eligibility Verification

For dental, eligibility must be verified on the date of service prior to providing care and documentation (fax from IVR, screen shot or print out) should be kept on file.

Participating MassHealth dental providers may access member eligibility information 24 hours a day, 7 days a week through the MassHealth Dental Program’s Interactive Voice Response (IVR) system at (800) 207-5019 or through the provider web portal.

MassHealth Covered Services

Services Standard CommonHealth Buy-In** Family Assistance*** CarePlus
Abortion Yes Yes No Yes Yes
Acute inpatient hospital † Yes Yes No Yes Yes
Adult day health Yes Yes No No No
Adult foster care Yes Yes No No No
Ambulatory prenatal care Yes Yes No Yes Yes
Ambulatory surgery center services Yes Yes No No Yes
Audiologist/hearing services Yes Yes No Yes Yes
Behavioral health (mental health and substance use disorder) services Yes Yes No Yes Yes
Chiropractor † Yes Yes No Yes Yes
Chronic disease and rehabilitation inpatient hospital Yes Yes No Yes Yes
Community health center Yes Yes No Yes Yes
Continuous skilled nursing Yes Yes No No No
Day habilitation Yes Yes No No No
Dental services † Yes Yes No Yes Yes
Dialysis services Yes Yes No Yes Yes
Durable medical equipment (includes oxygen and respiratory therapy equipment) Yes Yes No Yes Yes
Early intervention Yes Yes No Yes No
Early and periodic screening, diagnosis and treatment (EPSDT) services Yes Yes No No No
Emergency Inpatient and Outpatient Hospital Services Yes Yes No Yes Yes
Family planning Yes Yes No Yes Yes
Group adult foster care services Yes Yes No Yes Yes
Hearing aid and dispensing services Yes Yes No Yes Yes
Home health Yes Yes No Yes Yes
Hospice Yes Yes No Yes Yes
Intensive Early Intervention Yes Yes No Yes No
Laboratory Yes Yes No Yes Yes
Medicare Part B premium No No Yes No No
Medical/surgical supplies Yes Yes No Yes Yes
Nursing facility services Yes Yes No No Yes
Nurse midwife Yes Yes No Yes Yes
Nurse practitioner Yes Yes No Yes Yes
Orthotic† Yes Yes No Yes Yes
Outpatient hospital Yes Yes No Yes Yes
Personal care Yes Yes No No No
Pharmacy Yes Yes No Yes Yes
Physician Yes Yes No Yes Yes
Podiatrist Yes Yes No Yes Yes
Preventive pediatric healthcare screening and diagnostic (PPHSD) services No No No Yes No
Prosthetic† Yes Yes No Yes Yes
Radiology and diagnostic services Yes Yes No Yes Yes
Therapy (physical, occupational, and speech/language) Yes Yes No Yes Yes
Transportation (emergency) Yes Yes No Yes Yes
Transportation (non-emergency) Yes Yes No No Yes
Vision care (exams/treatment)† Yes Yes No Yes Yes
Vision care (ophthalmic materials) Yes Yes No Yes Yes
 

† This symbol indicates increased service coverage for members 21 years of age and older. The increased coverage was the result of health-care reform legislation effective July 1, 2006.

** MassHealth Senior Buy-In also covers Medicare Part A Premium and Medicare Parts A and B coinsurance and deductibles, where applicable.

*** Persons in Family Assistance with HIV will receive coverage for all medically necessary services, including the expansion of chiropractor, dental, vision, orthotic, prosthetic, and tobacco-cessation services.

Date published: July 29, 2022

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