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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

506.011: MassHealth Premiums and the Children’s Medical Security Plan (CMSP) Premiums

(A) Introduction. The MassHealth agency may charge a monthly premium to MassHealth Standard, CommonHealth, or Family Assistance members who have income above 150% of the federal poverty level (FPL), as provided in 130 CMR 506.011. The MassHealth agency does not charge a monthly premium to members of the CMSP whose family income is at or below 300% of the FPL. The MassHealth agency may provide an option for children whose family income is above 300% of the FPL to buy into CMSP coverage under this section through a sliding scale premium based on that income. MassHealth and CMSP premiums amounts are calculated based on a member’s household modified adjusted gross income (MAGI) and their household size as described in 130 CMR 506.002 and 130 CMR 506.003 and the premium billing family group (PBFG) rules as described in 130 CMR 506.011(A). Certain members are exempt from paying premiums, in accordance with 130 CMR 506.011(J). The MassHealth agency will annually adjust and publish the monthly premium amount for each coverage type to account for the last calendar year's increase in federal poverty level (FPL) income standards, starting in calendar year 2026. (1) Premium Billing Family Groups. Premium formula calculations for MassHealth and CMSP premiums are based on premium billing family groups (PBFGs). A PBFG is comprised of (a) an individual; (b) a couple who are two persons married to each other according to the rules of the Commonwealth of Massachusetts and are living together; or (c) a family who live together and consist of 1. a child or children younger than 19 years old, any of their children, and their parents; 2. siblings younger than 19 years old and any of their children who live together, even if no adult parent or caretaker is living in the home; or 3. a child or children younger than 19 years old, any of their children, and their caretaker relative when no parent is living in the home. (2) A child who is absent from the home to attend school is considered as living in the home. (3) A parent may be natural, adoptive, or a stepparent. Two parents are members of the same PBFG as long as they are mutually responsible for one or more children who live with them. (4) In a family with more than one child, any child with a MAGI household income that does not exceed 300% FPL will have its premium liability determined based on the MAGI household income of the child in the family PBFG with the lowest percentage of the FPL. If a child in the PBFG has an income percentage of the FPL at or below 150% of the FPL, premiums for all children in the PBFG are waived. (5) MassHealth and CMSP premiums for children with a MassHealth MAGI household income greater than 300% of the FPL and all premiums for young adults and adults are calculated using the individual’s FPL and the corresponding premium amount as described in 130 CMR 506.011. (6) For individuals within a PBFG that is approved for more than one premium billing coverage type, except where application of 130 CMR 506.011(A)(4) will result in a lower premium for children in the PBFG, the following apply. (a) When the PBFG contains members in more than one coverage type or program, including CMSP, and who are responsible for a premium or required member contribution, the PBFG is responsible for only the higher premium or required member contribution. (b) When the PBFG includes a parent or caretaker relative who is paying a premium for and is receiving Qualified Health Plan (QHP) with Premium Tax Credits, the premiums for children in the PBFG are waived once the parent or caretaker relative enrolls in and pays for a QHP. (c) The maximum premium for a PBFG may not exceed the sum of the monthly premium cost for three children.

(B) MassHealth and Children’s Medical Security Plan (CMSP) Premium Formulas. (1) The premium formula for MassHealth Standard members with breast or cervical cancer (BCC) whose eligibility is described in 130 CMR 505.002(F): Individuals with Breast or Cervical Cancer published annually as described in 506.011(A).