130 CMR: DIVISION OF MEDICAL ASSISTANCE Trans. by E.L. 201 Rev. 07/01/10 MASSHEALTH FINANCIAL REQUIREMENTS Chapter Page 506 506.000 TABLE OF CONTENTS Section 506.001: Introduction 506.002: Financial Responsibility 506.003: Countable Income 506.004: Noncountable Income 506.005: Verification of Income 506.006: Transfer of Income 506.007: Calculation of Financial Eligibility 506.008: Cost-of-Living Adjustment (COLA) Protections 506.009: The One-Time Deductible 506.010: Verification of Medical and Remedial-Care Expenses 506.011: MassHealth Standard, CommonHealth, Family Assistance, and the Children’s Medical Security Plan (CMSP) Premiums 506.012: Family Assistance Premium Assistance Payments 506.013: Copayments Required by MassHealth 506.014: Copayment and Cost Sharing Requirement Exclusions 506.015: Services Subject to Copayments 506.016: Members Unable to Pay Copayment 506.017: Calendar-Year Maximum 130 CMR: DIVISION OF MEDICAL ASSISTANCE Trans. by E.L. 180 Rev. 08/01/08 MASSHEALTH FINANCIAL REQUIREMENTS Chapter 506 Page 506.001 506.001: Introduction (A) 130 CMR 506.000 describes the rules governing financial eligibility for MassHealth. These rules are based on the size of the family group and countable income. (B) The formula for income standards used in the determination of financial eligibility, the deductible income standards, the premiums for Family Assistance, CommonHealth, and the Children’s Medical Security Plan (CMSP), and the Family Assistance premium assistance payment formulas are also contained in 130 CMR 506.000. (C) Financial eligibility for MassHealth Senior Buy-In and Buy-In is determined in accordance with 130 CMR 519.010, 519.011, and 520.000. 506.002: Financial Responsibility In determining eligibility for MassHealth, the gross income of all family group members is counted and compared to an income standard based on the family group size. Caretaker relatives and parents of children under age 19 who are pregnant or who are parents may choose whether or not to be part of the child’s family group. Family groups are comprised of families, couples, or individuals, as defined in 130 CMR 501.001. 506.003: Countable Income Eligibility is based on the family group's gross countable earned and unearned income as defined in 130 CMR 506.003, except as described in 130 CMR 506.003(C) below. (A) Gross Earned Income. (1) Gross earned income is the total amount of compensation received for work or services performed without regard to any deductions. (2) Gross earned income for the self-employed is the total amount of business income listed or allowable on a U.S. Tax Return. (3) Seasonal income is income derived from an income source that is associated with a particular time of the year. Annual gross income is divided by 12 to obtain a monthly gross income with the following exception: if the applicant or member has a disabling illness or accident during or after the seasonal employment period that prevents the person's continued or future employment, only current income will be considered in the eligibility determination. (B) Gross Unearned Income. (1) Gross unearned income is the total amount of income that does not directly result from the individual's own labor before any income deductions are made. (2) Unearned income includes, but is not limited to, social security benefits, railroad retirement benefits, pensions, annuities, federal veterans' benefits, and interest and dividend income. (C) Rental Income. Rental income is the total amount of gross income less any deductions listed or allowable on an applicant’s or member’s U.S. Tax Return. 130 CMR: DIVISION OF MEDICAL ASSISTANCE Trans. by E.L. 162 Rev. 06/01/07 MASSHEALTH FINANCIAL REQUIREMENTS Chapter 506 Page 506.004 506.004: Noncountable Income The following types of income are noncountable in the determination of eligibility: (A) income received by a TAFDC, EAEDC, or SSI recipient; (B) sheltered workshop earnings; (C) the portion of federal veterans' benefits identified as aid and attendance benefits, unreimbursed medical expenses, housebound benefits, enhanced benefits, or veterans’ benefits that are based on need and are provided by municipalities to resident veterans; (D) income-in-kind; (E) roomer and boarder income derived from persons residing in the applicant's or member's principal place of residence; (F) any other income that is excluded by federal laws other than the Social Security Act; and (G) income received by independent foster care adolescents described at 130 CMR 505.002(K). 506.005: Verification of Income (A) Verification of gross monthly earned income is mandatory and shall include, but not be limited to, the following: (1) two recent paystubs; (2) a signed statement from the employer; or (3) the most recent U.S. Tax Return. (B) Verification of gross monthly unearned income is mandatory and shall include, but not be limited to, the following: (1) a copy of a recent check or paystub showing gross income from the source; (2) a statement from the income source, where matching is not available; or (3) the most recent U.S. Tax Return. (C) Verification of gross monthly income may also include any other reliable evidence of the applicant's or member's earned or unearned income. 130 CMR: DIVISION OF MEDICAL ASSISTANCE Trans. by E.L. 186 Rev. 01/01/08 MASSHEALTH FINANCIAL REQUIREMENTS Chapter 506 Page 506.006 506.006: Transfer of Income All family group members are required to avail themselves of all potential income. (A) If the MassHealth agency determines that income has been transferred for the primary purpose of establishing eligibility for MassHealth, the income is counted as if it were received. (B) If the MassHealth agency is unable to determine the amount of available income, the family group remains ineligible until such information is made available. 506.007: Calculation of Financial Eligibility (A) The financial eligibility for various MassHealth coverage types is determined by comparing the family group's gross monthly income with the applicable income standard for the specific coverage. In determining gross monthly income, the MassHealth agency multiplies average weekly income by 4.333. (B) Generally, eligibility is based on 100 percent of the federal-poverty level for long-term unemployed adults; 133 percent of the federal-poverty level for parents and disabled nonworking adults; 200 percent of the federal-poverty level for pregnant women, persons who are HIV positive, and children who are special status aliens; and 300 percent of the federal-poverty level for children who are citizens, nationals, or qualified aliens, as well as for adults working for qualified employers. Disabled persons with income in excess of these applicable standards may be eligible for MassHealth CommonHealth. There are no income caps for premium-based CommonHealth and the Children’s Medical Security Plan (CMSP). (C) The monthly federal-poverty-level income standards are determined according to annual standards published in the Federal Register using the following formula. The MassHealth agency adjusts these standards annually. (1) Divide the annual federal-poverty-level income standard as it appears in the Federal Register by 12. (2) Multiply the unrounded monthly income standard by the applicable federal- poverty-level standard. (3) Round up to the next whole dollar to arrive at the monthly income standards. 506.008: Cost-of-Living Adjustment (COLA) Protections Applicants and members whose income increases each January as the result of a cost-of-living adjustment (COLA) will have their eligibility determined using their social security income just before the COLA, if such income can be verified, until the subsequent federal-poverty-level adjustment. 130 CMR: DIVISION OF MEDICAL ASSISTANCE Trans. by E.L. 112 Rev. 11/01/03 MASSHEALTH FINANCIAL REQUIREMENTS Chapter 506 Page 506.009 (1 of 2) 506.009: The One-Time Deductible (A) Eligibility Requirements. Disabled adults described in 130 CMR 505.004(C) may establish eligibility for MassHealth CommonHealth by meeting a one-time-only deductible. Once a deductible has been met, the person may be assessed a premium in accordance with the premium schedule in 130 CMR 506.011(I). Once the deductible has been met, the person is not required to meet another deductible if there is a lapse in CommonHealth coverage. (B) Definition of the Deductible. The deductible is the total dollar amount of incurred medical expenses that an applicant, whose family group gross income exceeds 133 percent of the federal- poverty level, must be responsible for before MassHealth eligibility is established. (C) The Deductible Period. The deductible period is a six-month period beginning on the date established in accordance with 130 CMR 505.004(I). (D) Calculating the Deductible. The amount of the deductible is determined by comparing the gross monthly income of the family group to the MassHealth CommonHealth Monthly Deductible Income Standards provided in the chart below and multiplying the difference by six. THE MASSHEALTH COMMONHEALTH MONTHLY DEDUCTIBLE INCOME STANDARDS Family Group Size Income Standards 1 542 2 670 3 795 4 911 5 1036 6 1161 7 1286 8 1403 9 1528 10 1653 + 133 for each additional person 130 CMR: DIVISION OF MEDICAL ASSISTANCE Trans. by E.L. 176 Rev. 10/01/07 MASSHEALTH FINANCIAL REQUIREMENTS Chapter 506 Page 506.009 (2 of 2) (E) Notification of the Deductible. (1) Except as provided in 130 CMR 501.003(C), the applicant who has excess monthly income will be informed that he or she is currently ineligible for MassHealth, but may establish eligibility by meeting the deductible. The applicant will be informed in writing of the following: (a) the deductible amount; and (b) the start and end dates of the deductible period. (2) A person who meets a deductible will be eligible for MassHealth CommonHealth effective with the begin date of the deductible period. (F) Persons Deemed to Have Met a Deductible. The following disabled adults will be considered to have met a deductible: (1) those who were receiving MassHealth on July 1, 1997 as the result of meeting a deductible; and (2) those who were denied eligibility with a deductible before July 1, 1997, but who submit medical bills on or after July 1, 1997 to meet the deductible. (G) Submission of Bills to Meet the Deductible. (1) Criteria. To establish eligibility, the applicant must submit verification of medical or remedial bills whose total equals or exceeds the deductible and that meets the following criteria. (a) The bill must not be subject to further payment by health insurance or other liable third-party coverage, including the Health Safety Net. (b) The bill must be for an allowable medical or remedial expense as provided in 130 CMR 506.009(G)(2). A remedial expense is a nonmedical support service made necessary by the medical condition of any individual in the family group. (c) The bill must be unpaid and a current liability, or, if paid, was paid during the six-month deductible period. (d) The bill may not be for one of the following services: (i) cosmetic surgery; (ii) rest-home care; (iii) weight-training equipment; (iv) massage therapy; 130 CMR: DIVISION OF MEDICAL ASSISTANCE Trans. by E.L. 63 Rev. 10/01/99 MASSHEALTH FINANCIAL REQUIREMENTS Chapter 506 Page 506.010 (v) special diets; and (vi) room and board charges for individuals in residential programs. (2) Expenses Used to Meet the Deductible. (a) Bills to meet the deductible are applied in the following order: (i) Medicare and other health insurance premiums credited prospectively for the cost of six month's coverage; (ii) expenses incurred by any member of the family group for necessary medical and remedial-care services that are recognized under state law but are not covered by MassHealth, including guardianship fees and related expenses as defined at 130 CMR 515.001, and described in and allowed under 130 CMR 520.026(E)(3); and (iii) expenses incurred by any member of the family group for necessary medical and remedial-care services that are covered by MassHealth. (b) Any bills or portions of bills that are used to meet the deductible are not paid by MassHealth and remain the responsibility of the applicant. 506.010: Verification of Medical and Remedial-Care Expenses (A) Medical or remedial-care expenses must be verified by a bill or written statement from a health-care provider with the exception of expenses for nonprescription drugs, which must be verified by a receipt from the provider of the drug. (B) Verifications must include all of the following information: (1) the type of service provided; (2) the name of the person for whom the service was provided; (3) the amount charged for the service including the current balance; and (4) the date of service. 130 CMR: DIVISION OF MEDICAL ASSISTANCE Trans. by E.L. 192 Rev. 12/15/09 MASSHEALTH FINANCIAL REQUIREMENTS Chapter 506 Page 506.011 (1 of 7) 506.011: MassHealth Standard, CommonHealth, Family Assistance, and the Children’s Medical Security Plan (CMSP) Premiums (A) MassHealth Standard, CommonHealth, Family Assistance, and the Children’s Medical Security Plan (CMSP) Premiums. MassHealth may charge a premium to certain MassHealth CommonHealth and Family Assistance members, and to certain women with breast or cervical cancer who receive MassHealth Standard in accordance with 130 CMR 505.002(H) who have incomes above 150 percent of the federal-poverty level. MassHealth may charge a premium to members of the Children’s Medical Security Plan (CMSP) who have incomes at or above 200 percent of the federal-poverty level. Only one premium per family group will be assessed. Certain members are exempt from paying premiums, in accordance with 130 CMR 506.011(K). (1) MassHealth Standard premiums for women with breast and cervical cancer are based on family group gross countable income and family group size as it relates to the federal-poverty guidelines. (2) MassHealth CommonHealth premiums are based on family group gross countable income, family group size as it relates to the federal-poverty-level income guidelines, and whether or not the member has other health insurance. (3) MassHealth Family Assistance premiums for the purchase of medical benefits, as described in 130 CMR 505.005(E), are based on the number of eligible members in the family group. (4) CMSP premiums are based on family group countable income and family group size as it relates to the federal-poverty level income guidelines. (5) When the family group contains members in more than one coverage type or program, including CMSP, who are responsible for a premium or member share, the family group is responsible for only the higher premium amount or member share. (B) Premium Payments. MassHealth may charge monthly premiums to persons described in 130 CMR 501.006; 505.002(C)(2), (F)(2), and (H); 505.004(B) through (E); 505.005(B)(3), (E) through (G); and 522.004(C). (1) Persons described in 130 CMR 501.006, 505.002(C)(2), (F)(2), and (H), 505.004(B) through (E), 505.005(B)(3), (E) through (G), and 522.004(C) who are assessed a premium are responsible for monthly premium payments beginning with the calendar month following the date of MassHealth’s eligibility determination, unless the member contacts the MassHealth agency, by telephone or in writing, and requests a voluntary withdrawal within 60 calendar days from the date of the eligibility notice and premium notification. 130 CMR: DIVISION OF MEDICAL ASSISTANCE Trans. by E.L. 192 Rev. 12/15/09 MASSHEALTH FINANCIAL REQUIREMENTS Chapter 506 Page 506.011 (2 of 7) (2) Persons described in 130 CMR 505.004(C) 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 with the calendar month following the reported change. (4) Members who have been assessed premiums but who are subsequently determined eligible for a coverage type other than Standard, CommonHealth, Family Assistance, or CMSP are not charged a premium for the calendar month in which the coverage type changes or thereafter. (C) Delinquent Premium Payments. (1) Termination for Delinquent Premium Payments. If MassHealth 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, then 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; or (d) is eligible for a MassHealth coverage type that requires a premium payment and the delinquent balance is from a CMSP benefit. (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). 130 CMR: DIVISION OF MEDICAL ASSISTANCE Trans. by E.L. 192 Rev. 12/15/09 MASSHEALTH FINANCIAL REQUIREMENTS Chapter 506 Page 506.011 (3 of 7) (3) Referral to State Intercept Program for Collection of Delinquent Payment. The MassHealth agency may refer a member who is 150 days or more in arrears to the State Intercept Program (SIP) in compliance with 815 CMR 9.00: Collection of Debts. Members will not be referred to SIP for collection of a past due balance if they have and are currently paying on the payment-plan arrangement that was approved by the MassHealth agency. (D) Reactivating Coverage Following Termination When a Member Has a Past-Due Balance. (1) If no waiting list has been established pursuant to 130 CMR 501.003(C) and (D) or 522.004(H), after the member has paid in full all payments due, or has established a payment plan with MassHealth, MassHealth will reactivate coverage. (2) If a waiting list has been established, children (through age 18) eligible for CMSP or adults (aged 19 or older) whose eligibility has been terminated will be placed on the waiting list upon payment of all payments due. They will not be allowed to reenroll until MassHealth is able to reopen enrollment for those placed on the waiting list. When MassHealth is able to open enrollment for those on the waiting list, their eligibility will be processed in the order they were placed on the waiting list. (E) Waiver of Outstanding Premium Payments. Outstanding premium balances that are older than 24 months are waived. (F) Waiver or Reduction of Premiums for Extreme Financial Hardship. (1) Extreme financial hardship means that the member has shown to the satisfaction of the MassHealth agency that 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, regardless of the date of service); or (d) has experienced a significant, unexpected increase in essential expenses within the last six months. 130 CMR: DIVISION OF MEDICAL ASSISTANCE Trans. by E.L. 192 Rev. 12/15/09 MASSHEALTH FINANCIAL REQUIREMENTS Chapter 506 Page 506.011 (4 of 7) (2) If the MassHealth agency determines that the requirement to pay a premium results in extreme 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 six months. At the end of the six- month period, the member may submit another hardship application. (a) The six-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 six-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. (G) 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 his or her intention by phone or, preferably, in writing. 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(B)(1). 130 CMR: DIVISION OF MEDICAL ASSISTANCE Trans. by E.L. 192 Rev. 12/15/09 MASSHEALTH FINANCIAL REQUIREMENTS Chapter 506 Page 506.011 (5 of 7) (H) Change in Premium Calculation. The premium amount is recalculated when the MassHealth agency is informed of changes in income, family group size, or health-insurance status, and whenever an adjustment is made in the CommonHealth premium schedule, the Standard premium schedule for women with breast or cervical cancer, the Family Assistance premium amount for the purchase of medical benefits schedule, or the CMSP premium schedule. (I) The Monthly MassHealth Standard, CommonHealth, and Certain Family Assistance Members Premium Schedules. 130 CMR 506.011(I) provides the formulas that the MassHealth agency uses to determine the monthly premiums for people who are receiving MassHealth Standard or CommonHealth, and for certain MassHealth Family Assistance members who are HIV positive. (1) Monthly Full Premium Formula for CommonHealth and Certain Family Assistance Members Receiving Benefits under 130 CMR 505.005(F) and (G). Full payment is required of members who have no health insurance and of members for whom the MassHealth agency is paying a portion of their health-insurance premium. The full premium formula is provided below. FULL PREMIUM FORMULA Base Premium Above 150% FPL—start at $15 Additional Premium Cost Add $5 for each additional 10% FPL until 200% FPL Range of Premium Cost $15 - $35 Base Premium Above 200% FPL—start at $40 Additional Premium Cost Add $8 for each additional 10% FPL until 400% FPL Range of Premium Cost $40 - $192 Base Premium Above 400% FPL—start at $202 Additional Premium Cost Add $10 for each additional 10% FPL until 600% FPL Range of Premium Cost $202 - $392 Base Premium Above 600% FPL—start at $404 Additional Premium Cost Add $12 for each additional 10% FPL until 800% FPL Range of Premium Cost $404 - $632 Base Premium Above 800% FPL—start at $646 Additional Premium Cost Add $14 for each additional 10% FPL until 1000% Range of Premium Cost $646 - $912 Base Premium Above 1000% FPL—start at $928 Additional Premium Cost Add $16 for each additional 10% FPL Range of Premium Cost $928 - greater (2) Monthly Full Premium Formula for CommonHealth Children with Income Above 150 Percent to 300 Percent of the Federal-Poverty Level. The premium formula is provided below. If income is above 300% of the federal-poverty level, refer to the “Full Premium Formula” chart in 130 CMR 506.011(I)(1). FULL PREMIUM FORMULA % of Federal-Poverty Level (FPL) Premium Cost Above 150% to 200% $12 per child ($36 per family group maximum) Above 200% to 250% $20 per child ($60 per family group maximum) Above 250% to 300% $28 per child ($84 per family group maximum) 130 CMR: DIVISION OF MEDICAL ASSISTANCE Trans. by E.L. 192 Rev. 12/15/09 MASSHEALTH FINANCIAL REQUIREMENTS Chapter 506 Page 506.011 (6 of 7) (3) Monthly Supplemental Premium Formula. A lower supplemental payment is required of members who have health insurance to which the MassHealth agency does not contribute. The supplemental premium formula is provided below. SUPPLEMENTAL PREMIUM FORMULA % of Federal-Poverty Level (FPL) Premium Cost Above 150% to 200% 60% of full premium Above 200% to 400% 65% of full premium Above 400% to 600% 70% of full premium Above 600% to 800% 75% of full premium Above 800% to 1000% 80% of full premium Above 1000% 85% of full premium (4) Monthly Premium Schedule for Standard for Women with Breast or Cervical Cancer (BCC). Women with breast or cervical cancer who are described at 130 CMR 505.002(H) and have income above 150 percent of the federal-poverty level in accordance with DPH requirements as certified by DPH to the MassHealth agency are assessed a monthly premium in accordance with the following premium schedule. BCC PREMIUM SCHEDULE % of Federal-Poverty Level (FPL) Premium Cost Above 150% to 160% $15 Above 160% to 170% $20 Above 170% to 180% $25 Above 180% to 190% $30 Above 190% to 200% $35 Above 200% to 210% $40 Above 210% to 220% $48 Above 220% to 230% $56 Above 230% to 240% $64 Above 240% to 250% $72 130 CMR: DIVISION OF MEDICAL ASSISTANCE Trans. by E.L. 205 Rev. 10/01/11 MASSHEALTH FINANCIAL REQUIREMENTS (7 of 7) Chapter Page 506 506.011 (J) Monthly Family Assistance Premiums for the Purchase of Medical Benefits for Children. MassHealth Family Assistance members for whom the MassHealth agency purchases medical benefits under 130 CMR 505.005(B)(3) and (E) are assessed a monthly premium in accordance with the following premium schedule. FAMILY ASSISTANCE PREMIUM SCHEDULE % of Federal-Poverty Level (FPL) Premium Cost Above 150% to 200% $12 per child ($36 family group maximum) Above 200% to 250% $20 per child ($60 family group maximum) Above 250% to 300% $28 per child ($84 family group maximum) (K) Children’s Medical Security Plan (CMSP) Premiums. CMSP PREMIUM SCHEDULE % of Federal-Poverty Level (FPL) Premium Cost Greater than or equal to 200%, but less than or equal to 300.9% $7.80 per child per month; family group maximum $23.40 per month Greater than or equal to 301.0%, but less than or equal to 400.0% $33.14 per family group per month Greater than or equal to 400.1% $64.00 per child per month (L) Members Exempted from Premium Payment. The following members are exempt from premium payments: (1) MassHealth members who 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 health-care provider through referral, in accordance with federal law; (2) MassHealth members with family group income at or below 150 percent of the federal- poverty level; (3) pregnant women and children under age one receiving MassHealth Standard; and (4) children when a parent or guardian in the family group is paying a premium for and is receiving Commonwealth Care. The premiums for children will be waived after the parent or guardian has enrolled in a Commonwealth Care health plan and is paying a Commonwealth Care health-plan premium, but the premiums for children will not be waived before the parent or guardian has enrolled in a Commonwealth Care health plan. 130 CMR: DIVISION OF MEDICAL ASSISTANCE Trans. by E.L. 148 Rev. 07/01/06 MASSHEALTH FINANCIAL REQUIREMENTS Chapter 506 Page 506.012 (1 of 5) 506.012: Family Assistance Premium Assistance Payments (A) Requirements. (1) The MassHealth agency makes monthly payments toward the cost of employer- sponsored health insurance for members who meet the requirements of 130 CMR 505.005(B), (C), and (D). The MassHealth agency makes only one premium assistance payment per policy. The amount of the MassHealth agency’s payment is based on the following information: (a) the total cost of the member’s health insurance premium; (b) the employer share of the member’s health insurance premium; and (c) the MassHealth estimated member share of the health insurance premium. (2) Premium assistance payments are made directly each month to the policyholder for members meeting the requirements of 130 CMR 505.005(B) and (D), except as provided in 130 CMR 506.012(A)(3). Proof of health insurance premium payments may be required. (3) Members meeting the requirements of 130 CMR 505.005(C), as well as members meeting the requirements of 130 CMR 505.005(B) and (D) whose employer-sponsored health insurance is from a qualified employer, have premium assistance payments made monthly on their behalf to either their employer or their health insurance carrier. The qualified employer must reduce the member’s payroll deduction by the amount of the premium assistance payment. (4) 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. (5) Members who become eligible for a different coverage type receive their final premium assistance payment in the calendar month in which the coverage type changes. The MassHealth agency may continue to pay the health insurance premiums of certain members in accordance with 130 CMR 507.003 if it determines it is cost effective to do so. (6) Members who are American Indians or Alaska Natives, as defined in 130 CMR 501.001, 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 the purchase of medical benefits under MassHealth Family Assistance. (B) Voluntary Withdrawal. If a member voluntarily withdraws, the MassHealth premium assistance payments end. (C) Change in Premium Assistance Calculation. The premium assistance amount is recalculated when the MassHealth agency is informed of changes in family group size, health insurance premium, employer contribution, and whenever an adjustment is made in the premium assistance payment formula. 130 CMR: DIVISION OF MEDICAL ASSISTANCE Trans. by E.L. 148 Rev. 07/01/06 MASSHEALTH FINANCIAL REQUIREMENTS Chapter 506 Page 506.012 (2 of 5) (D) The Monthly Premium Assistance Payment Formula for Children. The premium assistance payment calculation in 130 CMR 506.012(D) provides a formula for determining the MassHealth premium assistance payment amount for children, and the monthly amount members are required to pay towards their health insurance premiums. (1) Actual Premium Assistance Payment Amount. The actual premium assistance payment amount is calculated by using the following formula. (a) The estimated premium assistance payment amount is first determined by subtracting the employer share of the policyholder’s health insurance premium and the MassHealth estimated member share of the health insurance premium from the total cost of the health insurance premium. The estimated member share is described below. % of Federal Poverty Level (FPL) Estimated Member Share Above 150% to 200% $12 per child ($36 per family group maximum) Above 200% to 250% $20 per child ($60 per family group maximum) Above 250% to 300% $28 per child ($84 per family group maximum) (b) The resulting estimated premium assistance payment amount is then compared to the cost-effective amount, as described below: (i) if the family member is employed by a small employer as described at 130 CMR 501.001, the estimated premium assistance payment amount is compared to the cost-effective amount, which is the MassHealth agency’s cost of covering the family group members who are beneficiaries of the insurance; or (ii) if the family member is employed by a large employer as described at 130 CMR 501.001, the estimated premium assistance payment amount is compared to the cost-effective amount, which is the MassHealth agency’s cost of covering MassHealth-eligible children who would be covered by the insurance. (c) If the estimated premium assistance payment amount is less than the cost- effective amount, then the MassHealth agency sets the actual premium assistance payment amount at the estimated premium assistance payment amount. (d) If the estimated premium assistance payment amount is equal to or greater than the cost-effective amount, then the MassHealth agency sets the actual premium assistance payment amount at the cost- effective amount. (2) Member Assignment. If the MassHealth agency determines that a policyholder’s share of the health insurance premium including any remaining premium, as described in 130 CMR 506.012 (D)(3)(b), would exceed five percent of the family group’s gross income, the member must enroll in the purchase of medical benefits under MassHealth Family Assistance. This assignment is limited to those uninsured members who have access to health insurance. 130 CMR: DIVISION OF MEDICAL ASSISTANCE Trans. by E.L. 148 Rev. 07/01/06 MASSHEALTH FINANCIAL REQUIREMENTS Chapter 506 Page 506.012 (3 of 5) (3) Estimated Member Share of Premium. (a) Families are responsible for paying toward the cost of covering their Family Assistance-eligible children under their employer-sponsored health insurance, as described in 130 CMR 506.012(D)(1)(a). (b) If the actual premium assistance payment amount is set at the cost- effective amount, the family is also responsible for payment of the remainder of the health insurance premium, which is the difference between the estimated premium assistance payment and the cost-effective amount. The additional premium payment responsibility reflects coverage of additional family members who are not eligible for Family Assistance. (4) Example. A parent and two children apply for MassHealth. Their family group gross monthly income exceeds 150 percent, but is no greater than 200 percent of the federal-poverty level based on a family of three. The parent works for a small employer. (a) The total monthly cost of the health insurance premium = S. (b) The employer’s monthly share of the health insurance premium = T. (c) The MassHealth estimated member share of the monthly health insurance premium = U. (See 130 CMR 506.012(D)(1)(a).) (d) Calculation (i) 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) (ii) Small employer cost-effective test: W is compared to the MassHealth cost of covering the three family group members as follows: X = the MassHealth monthly cost of covering members X x 3 members = Y (the MassHealth monthly cost-effective amount) If W is less than Y, the MassHealth agency sets the actual premium assistance payment amount at W. If W is equal to or greater than Y, the MassHealth agency sets the premium assistance payment amount at Y. 130 CMR: DIVISION OF MEDICAL ASSISTANCE Trans. by E.L. 164 Rev. 10/01/06 MASSHEALTH FINANCIAL REQUIREMENTS Chapter 506 Page 506.012 (4 of 5) (iii) Large employer cost-effective test: If the parent works for a large employer, then W is compared to the cost of covering only the children in the family group under MassHealth. X x 2 children = Z (the MassHealth monthly cost-effective amount) 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 premium assistance payment amount at Z. (E) The Monthly Premium Assistance Payment Formula for Adults. The premium assistance payment calculation in 130 CMR 506.012(E) provides a formula for determining the MassHealth premium assistance payment amount for adults who are employed by qualified employers, and the monthly amount members are required to pay toward their health insurance premiums. Adults whose children receive premium assistance in accordance with 130 CMR 505.005(B) or (D), or Health Insurance Premium Program (HIPP) payments in accordance with 130 CMR 507.003 have their premium assistance payments determined in accordance with 130 CMR 506.012(D). (1) Actual Premium Assistance Payment Amount. The actual premium assistance payment amount is calculated by using the following formula. (a) The estimated premium assistance payment amount is first determined by subtracting the employer share of the policyholder’s health insurance premium and the MassHealth estimated member share of the health insurance premium from the total cost of the health insurance premium. The estimated member share is then determined in accordance with 130 CMR 506.012(E)(2)(a)(i). (b) The resulting estimated premium assistance payment amount is then compared to the maximum contribution amount, which is the maximum amount the MassHealth agency pays per insured adult toward employer-sponsored health insurance. (c) If the estimated premium assistance payment amount is less than the maximum contribution amount, then the MassHealth agency sets the actual premium assistance payment amount at the estimated premium assistance payment amount. (d) If the estimated premium assistance payment amount is equal to or greater than the maximum contribution amount, then the MassHealth agency sets the actual premium assistance payment amount at the maximum contribution amount. 130 CMR: DIVISION OF MEDICAL ASSISTANCE Trans. by E.L. 171 Rev. 07/01/07 MASSHEALTH FINANCIAL REQUIREMENTS Chapter 506 Page 506.012 (5 of 5) (2) Estimated Member Share of Premium. (a) The monthly premium amount for which premium assistance adults are responsible is determined as follows. These premium amounts apply except when a covered adult is eligible for MassHealth Standard or CommonHealth. Covered adults eligible for MassHealth Standard or CommonHealth are assessed a member share according to 130 CMR 506.011(I). MEMBER SHARE OF PREMIUM % of Federal-Poverty Level (FPL) Premium Cost Above 150% to 200% $27 per covered adult in the family group Above 200% to 250% $53 per covered adult in the family group Above 250% to 300% $80 per covered adult in the family group (b) If the actual premium assistance payment amount is set at the maximum contribution amount, the member is responsible for payment of the remainder of the health insurance premium, which is the difference between the estimated premium assistance payment and the maximum contribution amount. (3) Maximum Contribution Amount. The maximum contribution amount is the maximum amount, as determined by the MassHealth agency, that the MassHealth agency contributes per insured adult toward the policyholder’s share of the health insurance premium when the health insurance plan is offered through a MassHealth-approved billing and enrollment intermediary, or the Insurance Partnership agent. (F) Calculation of Monthly Premium Amount for Adults Who Are HIV Positive. The formula for HIV-positive adults who are described in 130 CMR 505.005(D) is the same as the formula described at 130 CMR 506.012(E) except that the estimated member share is the same as the premium described at 130 CMR 506.011(I)(1). The maximum contribution amount is the maximum amount that the MassHealth agency contributes per insured adult who is HIV positive. (G) Termination of Health Insurance. If a member’s health insurance terminates for any reason, the MassHealth premium assistance payments end. 130 CMR: DIVISION OF MEDICAL ASSISTANCE Trans. by E.L. 206 MASSHEALTH FINANCIAL REQUIREMENTS Chapter 506 Rev. 01/01/12 Page 506.013 506.013: Copayments Required by MassHealth The MassHealth agency requires its members to make the copayments described in 130 CMR 506.015, up to the calendar-year maximum described in 130 CMR 506.017, except as excluded in 130 CMR 506.014. If the usual-and-customary fee for the service or product is less than the copayment amount, the member must pay the amount of the service or product. 506.014: Copayment and Cost Sharing Requirement Exclusions (A) Excluded Individuals. (1) The following individuals do not have to pay the copayments described in 130 CMR 506.015: (a) members under 19 years of age; (b) members who are pregnant or in the postpartum period that extends through the last day of the second calendar month following the month in which their pregnancy ends (for example, if the woman gave birth May 15, she is exempt from the copayment requirement until August 1); (c) MassHealth Limited members; (d) MassHealth Senior Buy-In members or MassHealth Standard members for drugs covered under Medicare Parts A and B only, when provided by a Medicare-certified provider; (e) members who are inpatients in nursing facilities, chronic-disease or rehabilitation hospitals, or intermediate-care facilities for the mentally retarded or who are admitted to a hospital from such a facility or hospital; (f) members receiving hospice services; (g) persons receiving medical services through the Emergency Aid to the Elderly, Disabled and Children Program pursuant to 130 CMR 450.106, if they do not receive MassHealth Basic, MassHealth Standard, or MassHealth Essential; (h) members who are independent foster care adolescents who were in the care and custody of the Department of Children and Families on their 18th birthday and who are eligible for MassHealth Standard until they reach age 21; and (i) members who are American Indians or Alaska Natives who are currently receiving or have ever received an item or service furnished by the Indian Health Service, an Indian tribe, a tribal organization, or an urban Indian organization, or through referral, in accordance with federal law. (2) Members who have accumulated copayment charges totaling the calendar-year maximum of $250 on pharmacy services do not have to pay further MassHealth copayments on pharmacy services during the calendar year in which the member reached the MassHealth copayment maximum for pharmacy services. (3) Members who have accumulated copayment charges totaling the calendar-year maximum of $36 on nonpharmacy services do not have to pay further MassHealth copayments on nonpharmacy services during the calendar year in which the member reached the MassHealth copayment maximum for nonpharmacy services. (4) Members who have other comprehensive medical insurance, including Medicare, do not have to pay MassHealth copayments on nonpharmacy services. (5) Members who are inpatients in a hospital do not have to pay a separate copayment for pharmacy services provided as part of the hospital stay. 130 CMR: DIVISION OF MEDICAL ASSISTANCE Trans. by E.L. 206 MASSHEALTH FINANCIAL REQUIREMENTS Chapter 506 Rev. 01/01/12 Page 506.015 (B) Excluded Services. The following services are excluded from the copayment requirement described in 130 CMR 506.015: (1) family planning services and supplies such as oral contraceptives, contraceptive devices, such as diaphragms ands condoms, and contraceptive jellies, creams, foams, and suppositories; (2) nonpharmacy behavioral-health services; and (3) emergency services. 506.015: Services Subject to Copayments MassHealth members are responsible for making the following copayments unless excluded in 130 CMR 506.014. (A) Pharmacy Services. The copayment for pharmacy services is (1) $1 for each prescription and refill for each generic drug and over-the- counter drug covered by MassHealth in the following drug classes: antihyperglycemics, antihypertensives, and antihyperlipidemics; and (2) $3.65 for each prescription and refill for all other generic and over-the- counter drugs, and all brand-name drugs covered by MassHealth. (B) Nonpharmacy Services. The copayment for nonpharmacy services is $3 for an acute inpatient hospital stay. 506.016: Members Unable to Pay Copayment Providers may not refuse services to a member who is unable to pay at the time the service is provided. However, the member remains liable to the provider for the copayment amount. 506.017: Calendar-Year Maximum Members are responsible for the MassHealth copayments described in 130 CMR 506.015, up to the following calendar-year maximums: (A) $250 for pharmacy services; and (B) $36 for nonpharmacy services.