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130 CMR: DIVISION OF MEDICAL ASSISTANCE

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

130 CMR 506.000: MASSHEALTH: FINANCIAL REQUIREMENTS

required member contribution receive their premium assistance payment as an offset to the CommonHealth monthly premium bill and are responsible for the difference. (b) The required member contribution formula for MassHealth Family Assistance premium assistance eligible children, as described in 130 CMR 505.005 (B): Eligibility Requirements for Children with Modified Adjusted Gross Income of the MassHealth MAGI Household Greater than 150% and Less than or Equal to 300% of the Federal Poverty Level, whose household MAGI is between 150% and 300% of the FPL is published annually as described in 506.012(D)(1). (c) The required member contribution formula for MassHealth Family Assistance premium assistance for HIV-positive 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 is published annually as described in 506.012(D)(1). (3) The following members do not have a required member contribution: (a) MassHealth Standard premium assistance eligible members described at 130 CMR 505.002: MassHealth Standard; (b) MassHealth CommonHealth premium assistance eligible members, as described in 130 CMR 505.004: MassHealth CommonHealth, who have household MAGI at or below 150% of the FPL; (c) MassHealth CarePlus premium assistance eligible members, as described in 130 CMR 505.008: MassHealth CarePlus; (d) MassHealth Family Assistance premium assistance eligible members, 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, whose household MAGI is at or below 150% of the FPL; and (e) MassHealth members who have verified that they are American Indians or Alaska Natives who have received or are eligible to receive an item or service furnished by the Indian Health Service, an Indian tribe, a tribal organization, or an urban Indian organization, or by a non-Indian healthcare provider through referral, in accordance with federal law. These members receive premium assistance payments totaling the full employee share, to the extent that it is cost effective for the MassHealth agency. If it is not cost effective for the MassHealth agency, these members may choose to accept a premium assistance amount that is lower than the full-employee share or they may choose to enroll in direct coverage under MassHealth Family Assistance.

(E) MassHealth Premium Assistance Payment Amount Calculation. (1) Formulas. The MassHealth agency uses two formulas to calculate the premium assistance payments. The formulas are based on the category of assistance a member is enrolled in. In the event an individual is covered by more than one private health insurance policy, MassHealth will include that individual in the calculation of one premium assistance policy. (a) The monthly premium assistance formula for ESI 50% Plans is described in 130 CMR 506.012(E)(2). (b) The monthly premium assistance formula for Other Group Insurance Plans is described in 130 CMR 506.012(E)(3). (2) MassHealth Premium Assistance Payment Amount Calculation — ESI 50% Plans. (a) Determination of Actual Premium Assistance Payment Amount. To determine the actual premium assistance payment amount, MassHealth must review and compare the estimated premium assistance payment amount and the cost-effective amount. The estimated premium assistance payment amount and cost-effective amount are compared to calculate the actual premium assistance payment amount. 1. Estimated Premium Assistance Premium Payment Amount. The estimated premium assistance payment amount is calculated by subtracting the employer share of the policyholder’s health insurance premium and the MassHealth required member contribution of the health insurance premium, as described in 130 CMR 506.012(D), from the total cost of the health insurance premium. 2. Cost-effective Amount. The ESI 50% Plans cost-effective amount is the MassHealth agency’s cost of providing direct MassHealth benefits to the premium