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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

(e) the individual is a qualified noncitizen barred as described in 130 CMR 504.003(A)(2): Qualified Noncitizens Barred, nonqualified individual lawfully present, as defined in 130 CMR 504.003(A)(3): Nonqualified Individuals Lawfully Present, or a nonqualified PRUCOL, as defined in 130 CMR 504.003(C): Nonqualified Persons Residing under Color of Law (Nonqualified PRUCOLs). (2) Determination of Disability. Disability is established by (a) certification of legal blindness by the Massachusetts Commission of the Blind (MCB); (b) a determination of disability by the SSA; or (c) a determination of disability by the Disability Evaluation Services (DES). (3) Access to Employer-sponsored Insurance and Premium Assistance Investigations for Individuals Who Are Eligible for MassHealth Family Assistance. The MassHealth agency may perform an investigation to determine if individuals potentially eligible for MassHealth Family Assistance (a) are enrolled in 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 Payments, the individual continues to be eligible for MassHealth Family Assistance Direct Coverage. 2. Investigations for Individuals Who Have Potential Access to Employer-sponsored Health Insurance (ESI). a. If the MassHealth agency determines the individual has access to employer- sponsored health insurance and the employer is contributing at least 50% of the 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: Premium Assistance Payments. 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 (2): Payment of Copayments, Coinsurance, and Deductibles for Certain Children Who Receive Premium Assistance and 130 CMR 506.012. Failure to enroll in the employer- sponsored health insurance plan at the request of MassHealth may result in the loss or denial of eligibility.