Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid 600 Washington Street Boston, MA 02111 www.mass.gov/masshealth MassHealth Eligibility Letter 190 October 15, 2009 TO: MassHealth Staff FROM: Terence G. Dougherty, Interim Medicaid Director RE: Revisions to the Regulations about Premium Assistance The regulations about premium assistance are being revised to clarify when premium assistance payments begin. Payments begin in the month of the MassHealth eligibility determination for premium assistance or the month in which the insurance deduction begins, whichever is later. These regulations are effective November 1, 2009. MANUAL UPKEEP Insert Remove Trans. By 505.005 (4 of 12) 505.005 (4 of 12) E.L. 168 505.005 (6 of 12) 505.005 (6 of 12) E.L. 148 505.005 (7 of 12) 505.005 (7 of 12) E.L. 150 130 CMR: DIVISION OF MEDICAL ASSISTANCE Trans. by E.L. 190 Rev. 11/01/09 MASSHEALTH COVERAGE TYPES Chapter 505 Page 505.005 (4 of 12) (d) If the MassHealth agency determines the child has access to insurance as described at 130 CMR 505.005(B)(1)(a)(i), the applicant is notified in writing of the child’s eligibility for premium assistance and the need to enroll in such insurance. The child continues to be eligible for medical benefits for up to 60 days from the date of this notice to allow time for enrollment in the health- insurance plan. Once enrolled in the health-insurance plan, the child becomes eligible for premium assistance payments as described in 130 CMR 505.005(B)(4). (e) The medical benefits described in 130 CMR 505.005(B)(3)(d) end when the child is covered under the health-insurance plan. Coverage also ends if the family group member fails to enroll the child in the health-insurance plan, or fails to submit proof of such enrollment within 60 days of being notified of this requirement. (f) If the MassHealth agency determines the available insurance does not meet the requirements of 130 CMR 505.005(B)(1)(a) or, if the MassHealth agency is unable to complete its evaluation of the health insurance within 60 days of the MassHealth agency’s receipt of a complete MBR, the applicant is notified in writing of the child’s eligibility for the purchase of medical benefits under MassHealth Family Assistance, as described in 130 CMR 505.005(E). (4) Premium Assistance Payment. (a) The MassHealth agency makes monthly payments on behalf of a child toward the cost of the employer-sponsored health insurance premium if: (i) the child meets the requirements of 130 CMR 505.005(B)(1); (ii) the policyholder is a member of the child’s family group; and (iii) the policyholder is responsible for payment of more than the estimated member share described in 130 CMR 506.012(D)(1)(a). (b) The amount of the premium assistance payment is established in accordance with the MassHealth premium assistance payment formula described in 130 CMR 506.012(D). (c) Premium assistance payments are made in accordance with 130 CMR 506.012(A)(2) and (3). (5) Eligibility Date. Premium assistance payments begin in the month of the MassHealth eligibility determination for Family Assistance Premium Assistance, or in the month the health-insurance deduction begins, whichever is later. Each monthly payment is for coverage in the following month. (6) Copays, Coinsurance, and Deductibles. The MassHealth agency pays copays, coinsurance, and deductibles for children eligible for premium assistance provided: (a) the MassHealth agency has made a determination that the member was uninsured at the time of the eligibility determination, had access to employer- sponsored health insurance, and the MassHealth agency required the member’s enrollment in the health insurance plan; and 130 CMR: DIVISION OF MEDICAL ASSISTANCE Trans. by E.L. 190 Rev. 11/01/09 MASSHEALTH COVERAGE TYPES Chapter 505 Page 505.005 (6 of 12) (2) Premium Assistance Payment. (a) The MassHealth agency makes monthly payments toward the cost of the employer-sponsored health insurance if the adult: (i) meets the requirements of 130 CMR 505.005(C)(1); (ii) is responsible for payment of more than the estimated member share described in 130 CMR 506.012(E)(2); and (iii) continues to be employed by a qualified employer. (b) An adult whose spouse and/or children receive MassHealth benefits must enroll in a couple or family health insurance policy, if offered, if the employer contributes at least 50 percent of the premium cost for that coverage. (c) The amount of the premium assistance payment is established in accordance with the MassHealth premium assistance payment formula described in 130 CMR 506.012(E). (d) Premium assistance payments are made in accordance with 130 CMR 506.012(A)(3). (3) Eligibility Date. Premium assistance payments begin in the month of the MassHealth eligibility determination for Family Assistance, or in the month the health-insurance deduction begins, whichever is later. Each monthly payment is for coverage in the following month. (D) Premium Assistance for Persons Who Are HIV Positive. (1) Eligibility Requirements. (a) Premium assistance under MassHealth Family Assistance is available for persons who are HIV positive if they: (i) are under the age of 65; (ii) have family group gross income that is less than or equal to 200 percent of the federal poverty level; (iii) are ineligible for MassHealth Standard or MassHealth CommonHealth; and (iv) either have or choose to purchase available health insurance that the MassHealth agency has determined to be cost effective, in accordance with 130 CMR 505.005(D)(2). (b) The MassHealth agency establishes eligibility under the provisions of 130 CMR 505.005(D) for persons who are HIV positive and who also meet the requirements of 130 CMR 505.005(B) or (C). 130 CMR: DIVISION OF MEDICAL ASSISTANCE Trans. by E.L. 190 Rev. 11/01/09 MASSHEALTH COVERAGE TYPES Chapter 505 Page 505.005 (7 of 12) (2) Cost Effectiveness Determination. The MassHealth agency determines the cost effectiveness of the available insurance plan to establish the appropriate premium assistance payment amount, and notifies the applicant or member of its decision. (3) Premium Assistance Payment. Except as provided in 130 CMR 501.003(E)(2)(a), the MassHealth agency makes monthly premium payments on behalf of members. Health insurance premium payments are made directly to the insurance carrier, the employer, or to the most appropriate party, as determined by the MassHealth agency. If a direct payment is made to a family group member, proof of health-insurance payments may be required from the parent or member. (4) Premium Assistance Payment Amount. The MassHealth agency provides premium assistance in accordance with 130 CMR 506.012(F). (5) Eligibility Date. (a) Premium assistance payments begin in the month of the MassHealth agency’s eligibility determination for Premium Assistance or the month in which the insurance deduction begins, whichever is later. Each monthly payment is for coverage in the following month. (b) Persons eligible under the provisions of 130 CMR 505.005(D) are also eligible for services provided under the purchase of medical benefits as described in 130 CMR 450.105(H)(3) to the extent these services are not covered by the individual’s employer-sponsored health insurance. The medical coverage date for these services is established in accordance with 130 CMR 505.005(F)(3). (6) Premium Assistance for Persons Who Have Not Yet Verified HIV-Positive Status. The MassHealth agency also provides premium assistance, in accordance with 130 CMR 505.005(D), to persons meeting the requirements of 130 CMR 505.005(G)(1)(a) who would otherwise be eligible for premium assistance under 130 CMR 505.005(C). (E) The Purchase of Medical Benefits for Children. (1) Eligibility Requirements. Children under the age of 19 are eligible for the purchase of medical benefits under MassHealth Family Assistance if they meet all of the following requirements: (a) the child’s family group gross income is above 150 percent but does not exceed 300 percent of the federal-poverty level for citizens and qualified aliens; (b) the child’s family group gross income does not exceed 200 percent of the federal-poverty level for aliens with special status;