Page 16

16

130 CMR: DIVISION OF MEDICAL ASSISTANCE

Trans. by E.L. 254 Rev. February 13, 2026

130 CMR 505.000: HEALTH CARE REFORM: MASSHEALTH: COVERAGE TYPES

premium cost, and the insurance meets all other criteria described at 130 CMR 506.012: Premium Assistance Payments, the individual is notified in writing that they must enroll in this employer-sponsored coverage that meets the criteria described in 130 CMR 506.012. MassHealth allows the individual up to 60 days to enroll in this coverage. Once enrolled in this health insurance plan, MassHealth provides MassHealth Family Assistance Premium Assistance Payments as described in 130 CMR 450.105(G)(1): Premium Assistance and 130 CMR 506.012. Failure to enroll in the employer-sponsored health insurance plan at the request of MassHealth will result in the loss or denial of eligibility. b. If the MassHealth agency determines the individual does not have access to employer-sponsored health insurance, the individual continues to be eligible for MassHealth Family Assistance.

(C) Eligibility Requirements for Children and Young Adults Who Are Nonqualified PRUCOLs with Modified Adjusted Gross Income of the MassHealth MAGI Household at or below 150% of the Federal Poverty Level (FPL). Children and young adults who are nonqualified PRUCOLs, as defined in 130 CMR 504.003(C): Nonqualified Persons Residing under Color of Law (Non- qualified PRUCOLs), are eligible for MassHealth Family Assistance coverage described in 130 CMR 505.005(C) if they meet the following criteria. (1) Eligibility Requirements. The individual is eligible if (a) the individual is younger than 19 years old and the individual’s modified adjusted gross income of the MassHealth MAGI household is at or below 300% of the FPL; (b) the individual is a young adult and individual’s modified adjusted gross income of the MassHealth MAGI household is at or below 150% of the FPL; (c) the individual is ineligible for MassHealth Standard or MassHealth CommonHealth; (d) the individual is a nonqualified PRUCOL, as defined in 130 CMR 504.003(C): Nonqualified Persons Residing under Color of Law (Nonqualified PRUCOLs); and (e) the individual complies with 130 CMR 505.005(C)(2). (2) Investigations for Individuals Who Have Potential Access to Employer-sponsored Insurance. The MassHealth agency may perform an investigation to determine if individuals potentially eligible for MassHealth Family Assistance (a) have health insurance that MassHealth can help pay for; or (b) have access to employer-sponsored insurance in which MassHealth wants the individual to enroll and for which MassHealth will help pay. 1. Investigations for Individuals Who Are Enrolled in Health Insurance. a. If the MassHealth agency determines that the health insurance the individual is enrolled in meets the criteria at 130 CMR 506.012: Premium Assistance Payments, the individual is notified in writing that MassHealth will provide MassHealth Family Assistance Premium Assistance Payments as described at 130 CMR 450.105(G)(1): Premium Assistance and (2): Payment of Copayments, Coinsurance, and Deductibles for Certain Children Who Receive Premium Assistance and 130 CMR 506.012. b. If the MassHealth agency determines that the health insurance the individual is enrolled in does not meet the criteria at 130 CMR 506.012: Premium Assistance