Coverage Dates

(A) Start Date of Coverage for Applicants. For individuals applying for coverage, the date of coverage for MassHealth is determined by130 CME 502.006(A)(2), except as specified in 130 CMR 502.003(E)(1), (F)(2), and (H)(2). (1) The start date of coverage for individuals approved for benefits under provisional eligibility is described at 130 CMR 502.003(E)(1). (2) The start date of coverage for individuals who have been determined eligible for a MassHealth benefit is described at 130 CMR 502.006(A)(2)(a) through (d), except individuals described at 130 CMR 502.006(C). (a) If covered medical services were received during the period for which coverage is requested, and the individual would have been eligible at the time services were provided, the start date of coverage is determined upon receipt of the application or upon receipt of any requested verifications and may be retroactive to the first day of the third calendar month before the month of application, pursuant to 42 CFR 435.915 and except as specified in 130 CMR 502.006(C). (b) If covered medical services were not received during such period, or the individual would not have been eligible at the time services were provided, the start date of coverage is determined upon receipt of the application or upon receipt of any requested verifications and coverage begins on the first day of the month in which the application was received, except as specified in 130 CMR 502.006(C). (c) For individuals who fail to provide verifications of information within 90 days of the receipt of the MassHealth agency’s request and the MassHealth agency used information received from electronic data sources to determine eligibility, the start date of coverage is determined upon the agency’s eligibility determination and coverage begins as described in 130 CMR 502.006(A)(c)1. and 2. 1. If covered medical services were received during such period, and the individual would have been eligible at the time services were provided, the start date of coverage is determined upon receipt of information received from electronic data sources and may be retroactive to the first day of the third calendar month before the month of application except as specified in 130 CMR 502.006(C). 2. If covered medical services were not received during such period, or the individual would not have been eligible at the time services were provided, the start date of coverage is determined upon receipt of the information received from electronic data sources and coverage begins on the first day of the month in which the application was received, except as specified in 130 CMR 502.006(C). (d) For individuals denied for failure to provide verification of requested information who then provide requested verifications or report changes after the denial, the start date of coverage is described in 130 CMR 502.006(A)(2)(d)1. and 2. 1. If covered medical services were received during such period, and the individual would have been eligible at the time services were provided, the start date of coverage is determined upon receipt of the verifications and may be retroactive to the first day of the third calendar month before the received date of the verifications, except as specified in 130 CMR 502.003(D)(2)(d) and 130 CMR 502.006(C). 2. If covered medical services were not received during such period, or the individual would not have been eligible at the time services were provided, the start date of coverage is determined upon receipt of the verifications and coverage begins on the first day of the month that the verifications were received, except as specified in 130 CMR 502.003(D)(2)(d) and 130 CMR 502.006. (B) Coverage Dates for Existing Members Who Have a Change in Benefits. The date of coverage for existing members whose MassHealth coverage type changes due to a change in circumstances are described in 130 CMR 502.006(B)(1) through (4). (1) If covered medical services were received during such period, and the individual would have been eligible at the time services were provided, the start date of the new coverage may be retroactive to the first day of the third calendar month prior to (a). the receipt of the requested verifications; (b). the receipt date of the annual renewal; (c). the date of the eligibility determination for reported changes that do not result in request for verification; or (d). the date of the MassHealth agency’s eligibility determination due to information in the member’s case file. (2) If covered medical services were not received during such period, or the individual would not have been eligible at the time services were provided, the start date of the new coverage is the first day of the month of (a) the receipt of the requested verifications; (b) the receipt date of the annual renewal; (c) the date of the eligibility determination for reported changes that do not result in request for verification; or (d) the date of the MassHealth agency’s eligibility determination due to information in the member’s case file. (3) For existing members whose eligibility determination results in a less comprehensive benefit, the end date of the existing coverage is no sooner than 14 days from the date of the notice unless the MassHealth member files an appeal in a timely manner and requests continued MassHealth benefits pending such an appeal or reinstatement of benefits as described at 130 CMR 610.036: Continuation of Benefits Pending Appeal and the start date of the new coverage is ten days prior to (a) the receipt of the requested verifications; (b) the receipt date of the annual renewal; (c) the date of the eligibility determination for reported changes; or (d) the date of the MassHealth agency’s eligibility determination due to information in the member’s case file. (4) For existing members, effective dates for changes in premium payments are described at 130 CMR 506.011(C). (C) Limitations. MassHealth coverage start dates are subject to the following limitations. (1) The start date for Medicare premium payments for individuals determined eligible for MassHealth Standard, MassHealth CommonHealth, and MassHealth Medicare Savings Programs is described at 130 CMR 505.002(O), 505.004(L), and 505.007. (2) The start date for Premium Assistance Payments for individuals eligible for MassHealth Standard, MassHealth CommonHealth, MassHealth Family Assistance, and MassHealth CarePlus is described at 130 CMR 506.012(F)(1)(d). (D) End Date of Coverage. Except as specified in 130 CMR 502.003(H)(2), MassHealth benefits terminate or downgrade no sooner than 14 days from the date of termination or downgrade notice unless the MassHealth member timely files an appeal and requests continued MassHealth benefits pending such appeal or reinstatement of benefits as described at 130 CMR 610.036: Continuation of Benefits Pending Appeal. MassHealth will extend coverage to the end of the month only for individuals whose MassHealth eligibility is terminated and who become eligible for the Premium Tax Credit (PTC). If the effective date of the termination is on or before the 15th of the month, MassHealth coverage will end on the last day of that month. If the effective date of the termination is after the 15th of the month, MassHealth coverage will end on the last day of the following month.