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 150 August 15, 2006 TO: MassHealth Staff FROM: Beth Waldman, Medicaid Director RE: Corrections to Regulations about the Expansion of MassHealth Family Assistance This letter transmits corrections to MassHealth regulations about the expansion of MassHealth Family Assistance. These regulations were originally filed as an emergency, effective July 1, 2006. These final changes are being made after public notice. At 130 CMR 505.005(B)(1)(a)(iii) and 505.005(E)(1)(b), the phrase “is above 150 percent but” has been deleted. At 130 CMR 505.005(B)(1)(a)(v) and 505.005(E)(1)(e), the manual citation has been changed to “130 CMR 505.005(H).” These regulations are effective July 2, 2006. MANUAL UPKEEP Insert Remove Trans. By 505.005 (2 of 12) 505.005 (2 of 12) E.L. 148 505.005 (7 of 12) 505.005 (7 of 12) E.L. 148 505.005 (8 of 12) 505.005 (8 of 12) E.L. 148 130 CMR: DIVISION OF MEDICAL ASSISTANCE Trans. by E.L. 150 Rev. 07/02/06 MASSHEALTH COVERAGE TYPES Chapter 505 Page 505.005 (2 of 12) (b) The health insurance must meet the criteria of 130 CMR 505.005(B)(1)(a)(i), 505.005(C)(1)(e), or 505.005(D)(2). (c) Persons eligible for premium assistance payments, in accordance with 130 CMR 505.005(B) and (C), are eligible for payment of part of the policyholder’s employer-sponsored health insurance premium in accordance with the MassHealth premium assistance payment formula described in 130 CMR 506.012(D) and (E). (3) (a) The purchase of medical benefits under MassHealth Family Assistance is available to: (i) children under the age of 19 who are uninsured at the time of the MassHealth agency’s eligibility determination and do not have access to employer-sponsored health insurance; and (ii) persons under the age of 65 who are HIV positive and who have no health insurance, or do not have health insurance that the MassHealth agency has determined to be cost effective. (b) Persons eligible for the purchase of medical benefits are eligible for services as described in 130 CMR 450.105(H)(3). (B) Premium Assistance for Children. (1) Eligibility Requirements. (a) Premium assistance under MassHealth Family Assistance is available to children under age 19 who meet all the following conditions: (i) the child has or has access to employer-sponsored health insurance where the employer contributes at least 50 percent of the premium cost, and the insurance meets the basic-benefit level, as defined at 130 CMR 501.001; (ii) 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; (iii) the child’s family group gross income does not exceed 200 percent of the federal-poverty level for aliens with special status; (iv) the child is ineligible for MassHealth Standard and MassHealth CommonHealth; and (v) for children whose family group income is above 200 percent but does not exceed 300 percent of the federal-poverty level, the child does not have employer-sponsored health insurance and has not had employer-sponsored health insurance during the six months before application, as provided in 130 CMR 505.005(H). 130 CMR: DIVISION OF MEDICAL ASSISTANCE Trans. by E.L. 150 Rev. 07/02/06 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 through its Health Insurance Premium Program (HIPP). 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 or the month in which the insurance deductions begin, whichever is later. These payments are for the following month’s coverage. (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; 130 CMR: DIVISION OF MEDICAL ASSISTANCE Trans. by E.L. 150 Rev. 07/02/06 MASSHEALTH COVERAGE TYPES Chapter 505 Page 505.005 (8 of 12) (c) the child is ineligible for MassHealth Standard or MassHealth CommonHealth; (d) the child is uninsured and does not have access to employer-sponsored health insurance; and (e) for children between 200 and 300 percent of the federal-poverty level, the child has not had employer-sponsored health insurance during the six months before application, as provided in 130 CMR 505.005(H). (2) Presumptive Eligibility Requirements. The MassHealth agency may determine uninsured children presumptively eligible for medical benefits under MassHealth Family Assistance in accordance with the requirements of 130 CMR 502.003 if: (a) the self-declared gross income of the family group is above 150 percent but does not exceed 300 percent of the federal-poverty level for citizens and qualified aliens; or (b) the self-declared gross income of the family group is above 150 percent but does not exceed 200 percent of the federal-poverty level for aliens with special status. (3) Premium. Families of children who meet the requirements of 130 CMR 505.005(E)(1) and (2) are assessed a monthly premium in accordance with 130 CMR 506.011(J). Children who are eligible for a limited period of time, as described at 130 CMR 505.005(B)(3), and children who meet the requirements at 130 CMR 501.006 are also assessed a monthly premium in accordance with 130 CMR 506.011(J). (4) Medical Coverage Date. (a) The medical coverage date for the purchase of medical benefits under MassHealth Family Assistance begins on the 10th day before the date a Medical Benefit Request is received at any MassHealth Enrollment Center or received by a MassHealth outreach worker at a designated outreach site if all required verifications have been received within 60 days of the date of the Request for Information. (b) If required verifications listed on the Request for Information are received after the 60-day period referenced in 130 CMR 505.005(E)(4)(a), the begin date of medical coverage is 10 days before the date on which the verifications were received if these verifications are received within one year of receipt of the Medical Benefit Request. (c) The begin and end dates for medical coverage under presumptive eligibility are described in 130 CMR 502.003.