Page 12

12

130 CMR: DIVISION OF MEDICAL ASSISTANCE

Trans. by E.L. 250 Rev. 01/30/2026

130 CMR 506.000: MASSHEALTH: FINANCIAL REQUIREMENTS

(8) members who have accumulated premium and copayment charges totaling an amount equal to 5% of the member’s MAGI income of the MassHealth MAGI household or the MassHealth Disabled Adult household, as applicable, in a given calendar quarter do not have to pay further MassHealth premiums during the quarter in which the member reached the 5% cap.

506.012: Premium Assistance Payments

(A) Coverage Types. Premium assistance payments are available to MassHealth members who are eligible for the following coverage types: (1) MassHealth Standard, as described in 130 CMR 505.002: MassHealth Standard, with the exception of those individuals described in 130 CMR 505.002(F)(1)(d); (2) MassHealth Standard for Kaileigh Mulligan, as described in 130 CMR 519.007: Individuals Who Would Be Institutionalized; (3) MassHealth CommonHealth, as described in 130 CMR 505.004: MassHealth CommonHealth; (4) MassHealth CarePlus, as described in 130 CMR 505.008: MassHealth CarePlus; (5) MassHealth Family Assistance for HIV-positive adults and HIV-positive young adults, as described in 130 CMR 505.005(E): Eligibility Requirements for HIV-Positive Individuals Who Are Citizens or Qualified Noncitizens with Modified Adjusted Gross Income of the MassHealth MAGI Household Greater than 133 and Less than or Equal to 200% of the Federal Poverty Level; (6) MassHealth Family Assistance for disabled adults whose Disabled Adult MassHealth household income is at or below 100% of the FPL and who are qualified noncitizens barred, nonqualified individuals lawfully present, and nonqualified PRUCOLs, as described in 130 CMR 505.005(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; (7) MassHealth Family Assistance for children younger than 19 years old and young adults 19 through 20 years old whose household MAGI is at or below 150% of the FPL and who are nonqualified PRUCOLs, as described in 130 CMR 505.005(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; and (8) MassHealth Family Assistance for children younger than 19 years old whose household MAGI is between 150% and 300% of the FPL and who are citizens, protected noncitizens, qualified noncitizens barred, nonqualified individuals lawfully present, and nonqualified PRUCOLs, as described in 130 CMR 505.005(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.

(B) Criteria. MassHealth may provide a premium assistance payment to an eligible member when all of the following criteria are met. (1) The health insurance coverage meets the Basic Benefit Level (BBL) as defined in 130 CMR 501.001: Definition of Terms. Instruments including but not limited to Health Reimbursement Arrangements, Flexible Spending Arrangements, as described in IRS Pub. 969, or Health Savings Accounts, as described at IRC § 223(c)(2), cannot be used to reduce the health insurance deductible in order to meet the basic-benefit level requirement. (2) The health insurance policy holder is either (a) in the PBFG; or (b) resides with the individual who is eligible for the premium assistance benefit and is related to the individual by blood, adoption, or marriage. (3) At least one person covered by the health insurance policy is eligible for MassHealth benefits as described in 130 CMR 506.012(A) and the health insurance policy is a policy that meets the criteria of the MassHealth coverage type for premium assistance benefits as described in 130 CMR 506.012(C).

(C) Eligibility. Eligibility for MassHealth premium assistance is determined by the individual’s coverage type and the type of private health insurance the individual has or has access to. MassHealth has three categories of health insurance for which it may provide premium