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)
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
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† 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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