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). (2) The premium formulas for MassHealth CommonHealth members whose eligibility is described in 130 CMR 505.004(B): Disabled Working Adults through (G): Disabled Children Younger than 18 Years Old are published annually as described in 506.011(A). (a) The premium formula for children with MassHealth MAGI household income between 150 and 300% of the FPL is published annually as described in 506.011(A). (b) The full premium formula for young adults with household income above 150% of the FPL, adults with household income above 150% of the FPL, and children with household income above 300% of the FPL is published annually as described in 506.011(A). The full premium is charged to members who have no health insurance and to members for whom the MassHealth agency is paying a portion of their health insurance premium. (c) The supplemental premium formula for young adults, adults, and children with household income above 300% of the FPL is published annually as described in 506.011(A). A lower supplemental premium is charged to members who have health insurance to which the MassHealth agency does not contribute. Members receiving a premium assistance payment from the MassHealth agency are not eligible for the supplemental premium rate. (d) CommonHealth members who are eligible to receive a premium assistance payment, as described in 130 CMR 506.012, that is less than the full CommonHealth premium receive their premium assistance payment as an offset to the CommonHealth premium assistance bill and are responsible for the difference. (3) The premium formula for MassHealth Family Assistance children whose eligibility is 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 and (E): Eligibility Requirement 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 506.011(A). (4) The premium formulas for MassHealth Family Assistance HIV-positive adults whose eligibility is described at 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 are published annually as described in 506.011(A). (a) The full premium formula for MassHealth Family Assistance HIV-positive adults between 150% and 200% of the FPL is charged to members who have no other health insurance and to members for whom the MassHealth agency is paying a portion of their health insurance premium. The full premium formula is published annually as described in 506.011(A). (b) The supplemental premium formula for MassHealth Family Assistance HIV-positive adults is charged to members who have other health insurance to which the MassHealth agency does not contribute. A lower supplemental premium is charged to these members. Members receiving a premium assistance payment from the MassHealth agency are not eligible for the supplemental premium rate. The supplemental formula is published annually as described in 506.011(A). (5) The premium formula for MassHealth Family Assistance for nonqualified PRUCOL (NQP) adults, as described in 130 CMR 505.005(D): Eligibility Requirements for Adults and Young Adults Aged 19 and 20 Who Are Nonqualified PRUCOLs with Modified Adjusted Gross Income of the MassHealth MAGI Household at or below 300% of the Federal Poverty Level is based on MassHealth MAGI household income and MassHealth MAGI household size as it relates to the FPL income guidelines and PBFG rules, as described at 130 CMR 506.011(B). The premium formula is published annually as described in 506.011(A). (6) The premium formula for Children’s Medical Security Plan (CMSP) members, as described in 130 CMR 522.004: Children’s Medical Security Plan (CMSP) is published annually as described in 506.011(A). (C) Premium Payment Billing. (1) With the exception of persons described in 130 CMR 505.004(C): Disabled Adults, MassHealth members who are assessed a premium are responsible for monthly premium payments beginning with the calendar month following the date of the MassHealth agency’s eligibility determination. (2) Persons described in 130 CMR 505.004(C): Disabled Adults who are assessed a premium, are responsible for monthly premium payments beginning with the calendar month following the date the deductible period ends, or the calendar month following the month in which the member has verified that the deductible has been met, whichever is later. (3) Members who are assessed a revised premium as the result of a reported change, or any adjustment in the premium schedule, are responsible for the new premium payment beginning (a) with the calendar month following the reported change if the premium is increased; or (b) with the calendar month of the reported change if the premium is decreased or no longer assessed. (4) Members who have been assessed premiums but who are subsequently determined eligible for MassHealth benefits that do not require a premium will not be charged a premium for the calendar month in which the coverage type changes or thereafter. (5) If the member contacts the MassHealth agency by telephone, in writing, or online and requests a voluntary withdrawal within 60 calendar days from the date of the eligibility notice and premium notification, MassHealth premiums are waived. (D) Delinquent Premium Payments. (1) Termination for Delinquent Premium Payments. If the MassHealth agency has billed a member for a premium payment, and the member does not pay the entire amount billed within 60 days of the date on the bill, the member’s eligibility for benefits is terminated. The member will be sent a notice of termination before the date of termination. The member’s eligibility will not be terminated if, before the date of termination, the member (a) pays all delinquent amounts that have been billed; (b) establishes a payment plan and agrees to pay the current premium being assessed and the payment-plan-arrangement amount; (c) is eligible for a nonpremium coverage type; (d) is eligible for a MassHealth coverage type that requires a premium payment and the delinquent balance is from a CMSP benefit; or (e) requests a waiver of past-due premiums as described in 130 CMR 506.011(G). (2) Default on a Payment Plan. (a) If the member does not make payments in accordance with the payment plan within 30 days of the date on the bill, the member’s payment plan is terminated and the past due balance is due in full. (b) If the member is in a premium-paying coverage type and does not pay the past due amount within 60 days of the date on the bill, the member’s eligibility is terminated. (c) If a member has defaulted on a payment plan twice within a 24-month period, the member must pay in full any past due balances before they can be determined eligible for a coverage type that requires a premium payment. (d) A member may be granted additional payment plans if the member has been approved for a hardship waiver as described at 130 CMR 506.011(F). (E) Reactivating Coverage Following Termination When a Member Has a Past Due Balance. After a member has been terminated for delinquent premium payments as provided in 130 CMR 506.011(D)(1), the member may file a new application. (F) Waiver of Outstanding Premium Payments. Outstanding premium balances that are older than 24 months are waived. (G) Waiver or Reduction of Premiums for Undue Financial Hardship. (1) Undue financial hardship means that the member has shown to the satisfaction of the MassHealth agency that at the time the premium was or will be charged, or when the individual is seeking to reactivate benefits, the member (a) is homeless, or is more than 30 days in arrears in rent or mortgage payments, or has received a current eviction or foreclosure notice; (b) has a current shut-off notice, or has been shut off, or has a current refusal to deliver essential utilities (gas, electric, oil, water, or telephone); (c) has medical and/or dental expenses, totaling more than 7.5% of the family group’s gross annual income, that are not subject to payment by the Health Safety Net, and have not been paid by a third-party insurance, including MassHealth (in this case “medical and dental expenses” means any outstanding medical or dental services debt that is currently owed by the family group or any medical or dental expenses paid by the family group within the 12 months prior to the date of application for a waiver, regardless of the date of service); (d) has experienced a significant, unavoidable increase in essential expenses within the last six months; or (e) has suffered within the six months prior to the date of application for a waiver, or is likely to suffer in the six months following such date, economic hardship because of a state or federally declared disaster or public health emergency. (2) If the MassHealth agency determines that the requirement to pay a premium results in undue financial hardship for a member, the MassHealth agency may, in its sole discretion (a) waive payment of the premium or reduce the amount of the premiums assessed to a particular family; or (b) grant a full or partial waiver of a past due balance. Past due balances include all or a portion of a premium accrued before the first day of the month of hardship; or (c) both 130 CMR 506.011(G)(2)(a) and (b). (3) Hardship waivers may be authorized for 12 months. At the end of the 12-month period, the member may submit another hardship application. (a) The 12-month time period begins on the first day of the month in which the hardship application and supporting documentation is received by the MassHealth agency. (b) The 12-month time period may be retroactive to the first day of the third calendar month before the month of hardship application. (4) If a hardship waiver is granted and past due balances are not waived, the MassHealth agency will automatically establish a payment plan for the member for any past due balances. (a) The duration of the payment plan will be determined by the MassHealth agency. The minimum monthly payment on the payment plan will be $5. (b) The member must make full monthly payments on the payment plan for the hardship waiver to stay in effect. Failure to comply with the established payment plan will terminate the hardship waiver. (H) Voluntary Withdrawal. If a member wishes to voluntarily withdraw from receiving MassHealth coverage, it is the member’s responsibility to notify the MassHealth agency of their intention by telephone, in writing, or online. Coverage may continue through the end of the calendar month of withdrawal. The member is responsible for the payment of all premiums up to and including the calendar month of withdrawal, unless the request for voluntary withdrawal is made in accordance with 130 CMR 506.011(C)(5). (I) Change in Premium Calculation. The premium amount is recalculated when the MassHealth agency is informed of changes in the household’s MAGI household composition, health insurance status, or whenever an adjustment is made to any of the MassHealth premium formula tables described in 130 CMR 506.011(B). (J) Members Exempted from Premium Payment. The following members are exempt from premium payments: (1) 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; (2) MassHealth members with MassHealth MAGI household income or MassHealth Disabled Adult household income at or below 150% of the federal poverty level; (3) pregnant individuals and children younger than one year old; (4) children when a parent or guardian in the PBFG is eligible for a Qualified Health Plan (QHP) with Premium Tax Credits (PTC) who has enrolled in and has begun paying for a QHP; (5) children for whom child welfare services are made available under Part B of Title IV of the Social Security Act on the basis of being a child in foster care and individuals receiving benefits under Part E of that title, without regard to age; (6) individuals receiving hospice care; (7) independent former foster care children younger than 26 years old; and (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.