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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

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 falls into Other Group Insurance Plans. 1. The total monthly cost of the health insurance premium = S. 2. The monthly contribution amount for an employer that a person covered by this plan is eligible for = T. 3. The MassHealth required member contribution toward the monthly health insurance premium = U. 4. Calculating the estimated premium assistance payment amount:

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

Other Group Insurance Plans cost-effective amount: W is compared to the cost of covering only those MassHealth eligible individuals = Z.

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

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

(F) MassHealth Premium Assistance Payment Administration. (1) Premium Assistance Payments. (a) The MassHealth agency makes only one premium assistance payment per policy. (b) Premium assistance payments are made directly each month to the policyholder. (c) Proof of health insurance premium payments may be required. (d) Premium assistance payments begin in the month of the MassHealth Premium Assistance eligibility determination or in the month that health insurance deductions begin, whichever is later. (e) Each monthly premium assistance payment is for health insurance coverage in the following month. (f) The MassHealth agency reviews the cost effectiveness of the member’s health insurance at least once every 12 months. (2) Change in Premium Assistance Calculation. (a) The premium assistance amount is recalculated when the MassHealth agency is informed of changes in the federal poverty level, health insurance premium, employer contribution, and whenever an adjustment is made in the premium assistance payment formula. (b) Members whose premium assistance amount changes as the result of a reported change or any adjustment in the premium assistance payment formula receive the new premium assistance payment beginning with the calendar month following the reported change. (3) Termination of Premium Assistance Payments. (a) If a member’s health insurance terminates for any reason, the MassHealth premium assistance payments end. (b) If there is a change in the services covered under the policy that affects the BBL requirements, the premium assistance payments end. (c) Members who become eligible for a different coverage type in which they are not eligible to receive a premium assistance benefit receive their final premium assistance payment in the calendar month in which the coverage type changes. (d) If a member voluntarily withdraws their MassHealth application for benefits, the MassHealth premium assistance payments end.

(130 CMR 506.013 Reserved)