Commercial Insurance
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. MassHealth considers other insurances to be the primary insurance. This is sometimes referred to as commercial insurance or employer-sponsored insurance.
Medicare as Primary Insurance
Some MassHealth members have MassHealth and Medicare at the same time. MassHealth considers Medicare to be the primary insurance. This means Medicare is billed as the primary insurer and MassHealth is the secondary coverage. Note: This does not apply to members who have Medicare/MassHealth and participate in managed care plans such as SCO, PACE, or One Care.
Members Who Have More Than One Insurance in Addition to MassHealth
There are some members who could have more than one insurance in addition to MassHealth (including Medicare). MassHealth considers any additional insurance to be the primary to MassHealth. This means these insurances must be billed as the primary and secondary insurers prior to MassHealth. Adjudication details from all payers must be submitted to MassHealth as reported on the other payer’s Explanation of Benefits (EOB).
Provider Requirements to Verify Eligibility and Obtain Payment
MassHealth regulations at 130 CMR 450.316 require providers to make diligent efforts to identify and obtain payment first from other resources, including casualty payer payments, to ensure that MassHealth is always the payer of last resort. Diligent efforts include, but are not limited to the following:
- determining the existence of health insurance by asking the member if they have other insurance and by using insurance databases available to the provider.
- verifying the member’s other health insurance coverage, currently known to the MassHealth agency through the eligibility verification system (EVS) on each date of service and at the time of billing.
Updating a Member’s Third-Party Insurance Information
When a provider has evidence that a MassHealth member’s third party (TPL) health insurance information differs from what appears in the Eligibility Verification System (EVS) record, the provider should inform the Third-Party Liability Unit of the changes. To ensure the member’s file is updated to reflect current information, providers should submit the Third-Party Liability Indicator (TPLI) form with acceptable documentation to the Third Party Liability Unit.
| Date published: | July 29, 2022 |
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