What Benefits Will I Get?
NOTE: Glossary words are highlighted. Click on any glossary word to see its definition.
What benefits will I get?
MassHealth benefits depend on the type of coverage you have. MassHealth Standard and CommonHealth offer the most benefits. MassHealth Limited only covers emergency health services. When you apply for MassHealth, you will be given the most complete coverage for which you qualify.
For specific benefits by coverage type, see Coverage Types.
You can also find benefit information in: MassHealth Member Booklet English; MassHealth Member Booklet Spanish
MassHealth benefits include some or all of the following:
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Inpatient care at hospitals or other medical facilities, including:
nursing services
rehabilitation services
long-term care
acute care (limited to 20 days for members age 21 or older)
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Outpatient care in doctor's offices, clinics, hospitals, etc., including:
office visits
preventive care
family planning
abortion services
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Tests, medical equipment, and medical services, including:
diagnostic tests
X-rays
radiology services
hearing tests
vision tests, eyeglasses, and visual aids
medical equipment and supplies
therapy services
orthotics and prosthetics
renal dialysis service
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Well-child services for children under 21, including:
checkups
vision and hearing screenings
early intervention
immunizations
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Mental health and substance abuse treatment (see Mental Health and Substance Abuse Services)
inpatient and outpatient
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Dental services, including: (see Dental Program)
cleanings and checkups
extractions
emergency treatment
fillings, root canals, dentures, and other approved procedures (only for members under 21 and DDS clients)
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Prescription drugs for non-Medicare recipients
- Tobacco cessation services, including: (see Smoking Cessation Services)
group or individual counseling
nicotine replacement medicine
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Other services, including:
home health care (see Home Health Services)
community-based long-term care (see Home and Community-based Waiver)
hospice services
transportation services (see MassHealth Transportation Services)
adult foster care (see Group Adult Foster Care)
adult family care (see Adult Family Care)
adult day care
chiropractic services
All MassHealth coverage types include emergency ambulance service. MassHealth Standard is the only coverage type that pays for long-term care in a medical facility such as a nursing home.
Note: Your coverage might include services not listed above. When you are enrolled in MassHealth, you will be given a list of all of the services offered by your particular coverage.
Is there any cost for MassHealth?
Your cost will depend on the program in which you are enrolled. Some people do not pay anything for MassHealth. Some people pay a monthly premium. Members with incomes at or below 150% of the Federal Povery Guidelines do not pay monthly premiums. See Coverage Types for more information.
You might also have a small copayment for drugs and certain services. Children under 19, pregnant and postpartum women, MassHealth Limited and Senior Buy-In members, people who are institutionalized, and certain other MassHealth members do not have these copayments.
MassHealth copayments are:
- $1 for certain generic and over-the-counter drugs covered by MassHealth that are mainly used to treat diabetes, hypertension, and high cholesterol
- $3 for other generic, brand-name, and over-the-counter drugs covered by MassHealth
- $3 for an acute inpatient hospital stay
- Calendar year maximums for these copayments are $200 for pharmacy services and $36 for nonpharmacy services.
Note: A pharmacy must fill your prescription even if you cannot pay the copayment. However, you still owe the copayment and the pharmacy can bill you for it. For more information, see Copayments on the MassHealth web site.
MassHealth members who are enrolled in a Managed Care Organization (MCO) pay the same copayments as other MassHealth members.
What should I do if I can't afford the monthly premium?
If you are supposed to pay a premium but you are facing an extreme financial hardship, MassHealth can grant a waiver or lower the monthly premiums until you are able to pay again. Examples of extreme financial hardships are:
- homelessness
- overdue rent, eviction, or foreclosure
- utility shut-offs
- high medical or dental bills not covered by insurance
- other large unexpected expenses
You can request a waiver form by calling MassHealth Customer Service at 1-800-841-2900 (TTY: 1-800-497-4648). MassHealth also has a copy of the waiver form online at Application for Waiver or Reduction of MassHealth Premium. You must call MassHealth Customer Service to get a log number and return date for the form before you send it in.
A waiver will not eliminate any past due premiums, but MassHealth will set up a payment plan to make it easier for you to pay your back debts.
Note: If your income has decreased, make sure you notify MassHealth Customer Service. If your income is no longer over the 150% FPG cutoff, you will not have to pay monthly premiums.
If I have an emergency out of state, will MassHealth cover my expenses?
If you have an emergency out of state, MassHealth may pay for emergency treatment. You need to show your MassHealth card to the health care facility where you are treated and notify your primary care doctor or health plan within 24 hours of the emergency (or as soon as possible).
If you have private insurance for which you are getting premium assistance, your private insurance may also pay for treatment of an out-of-state emergency. Check with your insurance company.
MassHealth does not cover non-emergency out-of-state care except in special cases where the nearest facility is across a state border. MassHealth does not cover any services provided out of the United States or its territories.
If I get TAFDC and my benefits stop, do I lose my MassHealth coverage?
If your TAFDC benefits stop, you do not lose your MassHealth coverage right away.
If your TAFDC benefits stop because your income increases, your MassHealth coverage will continue automatically for 12 months, even if your income is greater than the MassHealth income limits.
If your benefits stop for any other reason, you will receive MassHealth for at least 4 more months.
Before your coverage ends, MassHealth will send you an eligibility review form to fill out and send in. After reviewing the form, MassHealth will let you know if you are eligible for the same MassHealth benefits you had before, if you are eligible for a different type of coverage, or if you are no longer eligible for MassHealth.
You should send the eligibility review form to:
- MassHealth Enrollment Center
Central Processing Unit
P.O. Box 129124
Boston, MA 02112-9124
What are my rights and responsibilities?
When you are a MassHealth applicant or member, you have certain rights and responsibilities:
- The Division of Medical Assistance (DMA) has to keep the information you have provided to them confidential.
- DMA cannot discriminate against you because of race, color, sex, age, country of origin, religion, sexual orientation, handicap, or creed.
- You must report changes that could affect your MassHealth eligibility to the DMA within 10 days of the changes. Failure to do so can result in the loss of benefits.
- You or anyone who is applying for you must give correct information to the DMA. Failure to do so may result in fines or imprisonment.
- You have the right to ask for a hearing to appeal MassHealth decisions regarding your benefits, eligibility, and services.
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