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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

billing family group (PBFG) who are beneficiaries of the ESI. (b) Comparison of Payment Amounts. The MassHealth agency compares the estimated premium assistance payment amount and cost-effective amount to determine the actual premium assistance payment amount. 1. If the estimated premium assistance payment amount is less than the cost-effective amount, the MassHealth agency sets the actual premium assistance payment amount at the estimated premium assistance payment amount. 2. If the estimated premium assistance payment amount is equal to or greater than the cost-effective amount, the MassHealth agency sets the actual premium assistance payment amount at the cost-effective amount. The policy holder is responsible for payment of the remainder of the health insurance premium, if any. (c) Example. A parent and two children apply for MassHealth. The two children are eligible for MassHealth, but the parent is not eligible. Their health insurance is an ESI 50% plan. 1. The total monthly cost of the health insurance premium = S. 2. The employer’s monthly share of the health insurance premium = T. 3. The MassHealth estimated member share of the monthly health insurance premium = U. 4. Calculating the estimated premium assistance payment amount:

S = (total cost of premium) - T = (employer’s share of the cost) V = (employee’s share of the cost) - U = (the MassHealth estimated member share of the cost) W = (estimated premium assistance payment amount)

ESI 50% Plans cost-effective amount: W is compared to the MassHealth cost of covering the three individuals (X).

If W is less than X, the MassHealth agency sets the actual premium assistance payment amount at W.

If W is equal to or greater than X, the MassHealth agency sets the actual premium assistance payment amount at X.

(3) MassHealth Premium Assistance Payment Amount Calculation — Other Group Insurance Plans. (a) Determination of Actual Premium Assistance Payment Amount. To determine the actual premium assistance payment amount, the MassHealth agency 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 Payment Amount. The estimated premium assistance payment amount is calculated by subtracting both the MassHealth required member contribution, as described in 130 CMR 506.012(D), and any contribution amount from an employer a person covered by this plan is eligible for from the total cost of the health insurance premium. 2. Cost-effective Amount. The Other Group Insurance Plans cost-effective amount is the MassHealth agency’s cost of covering MassHealth-eligible premium billing family group (PBFG) members who are beneficiaries of the Other Group Insurance Plan. (b) Comparison of Payment Amounts. The MassHealth agency compares the estimated premium assistance payment amount and cost-effective amount to determine the actual premium assistance payment amount. 1. If the estimated premium assistance payment amount is less than the cost-effective amount, the MassHealth agency sets the actual premium assistance payment amount at the estimated premium assistance payment amount. 2. If the estimated premium assistance payment amount is equal to or greater than the cost-effective amount, the MassHealth agency sets the actual premium assistance payment amount at the cost-effective amount. The policy holder is responsible for