Premium Schedule
Premium Billing Family Groups (PBFG)
Premium formula calculations for MassHealth and CMSP premiums are based on the Premium Billing Family Group (PBFG). A premium billing family group consists of
- an individual,
- a couple—two persons who are married to each other according to the laws of the Commonwealth of Massachusetts,
OR
- a family—a family is defined as persons who live together, and consists of:
- a child or children younger than 19 years of age, any of their children, and their parents,
- siblings younger than 19 years of age and any of their children who live together even if no adult parent or caretaker relative is living in the home, or
- a child or children younger than 19 years of age, any of their children, and their caretaker relative when no parent is living in the home.
- A child who is absent from the home to attend school is considered as living in the home.
- A parent may be a natural, step, or adoptive parent. Two parents are members of the same premium billing family group as long as they are both mutually responsible for one or more children who live with them.
Calculating Premiums
MassHealth and CMSP premiums for children younger than 19 years of age with household income at or below 300% of the FPL will have their premium amount determined using the lowest percentage of the FPL of all children in the PBFG. If any child in the PBFG has a percentage of the FPL at or below 150% of the FPL, premiums for all children younger than 19 years of age in the PBFG will be waived.
MassHealth and CMSP premiums for children younger than 19 years of age with household income greater than 300% of the FPL, and all premiums for young adults or adults are calculated using the individual’s FPL.
When the PBFG contains members in more than one coverage type or program, including CMSP, who are responsible for a premium, the PBFG is responsible for only the higher premium amount.
When the PBFG includes a parent or caretaker relative who is paying a premium for and is getting a ConnectorCare plan and Advance Premium Tax Credits, the premiums for children in the PBFG will be waived once the parent or caretaker relative has enrolled in and begun paying for a ConnectorCare plan.
Premium Formulas
MassHealth Standard and Premium Formula for Members with Breast or Cervical Cancer
The premium formula for MassHealth Standard members with breast or cervical cancer whose eligibility is described in 130 CMR 506.000 is as follows.
Standard Breast and Cervical Cancer Premium
|
% of Federal Poverty Level (FPL) |
Monthly Premium Cost |
|
Above 150% to 160% |
$15 |
|
Above 160% to 170% |
$20 |
|
Above 160% to 170% |
$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 |
MassHealth CommonHealth Premium Formulas
The premium formula uses age, income, and whether or not the member has other health insurance.
The premium formula for MassHealth CommonHealth members whose eligibility is described in 130 CMR 506.000 is as follows.
The full premium formula for children younger than 19 years of age with household income between 150% and 300% of the FPL is provided below.
CommonHealth Full Premium Formula
Children between 150% and 300%
|
% of Federal Poverty Level (FPL) |
Monthly Premium Cost |
|
Above 150% to 200% |
$12 per child (36 PBFG maximum) |
|
Above 200% to 250% |
$20 per child ($60 PBFG maximum) |
|
Above 250% to 300% |
$28 per child ($84 PBFG maximum) |
The full premium formula for young adults 19 or 20 years of age with household income above 150% of the FPL, adults 21 years of age and older with household income above 150% of the FPL, and children with household income above 300% of the FPL is provided below. The full premium is charged to members who have no health insurance and to members for whom the MassHealth agency is paying a portion of their health insurance premium.
|
CommonHealth Full Premium Formula Young Adults and Adults Above 150% of the FPL and Children above 300% of the FPL |
||
|
Base Premium |
Additional Premium Cost |
Range of Monthly Premium Cost |
|
Above 150$ FPL and Children above 300% FPL – start $15 |
Add $5 for each additional 10% FPL until 200% FPL |
$15 - $35 |
|
Above 200% FPL – start $40 |
Add $8 for each additional 10% FPL until 400% FPL |
$40 - $192 |
|
Above 400% FPL – start at $202 |
Add $10 for each additional 10% FPL until 600% |
$202 – $392 |
|
Above 600% FPL – start at $404 |
Add $12 for each additional 10% FPL until 800% FPL |
$404 - $632 |
|
Above 600% FPL – start at $646 |
Add $14 for each additional 10% FPL until 1,000% FPL |
$646 - $912 |
|
1,000% FPL – start at $928 |
Add $16 for each additional 10% FPL |
$928 + greater |
The supplemental premium formula for young adults, adults, and children is provided below. A lower supplemental premium is charged to members who have health insurance that the MassHealth agency does not contribute to. Members getting a premium assistance payment from MassHealth are not eligible for the supplemental premium rate.
CommonHealth Supplemental Premium Formula
|
% of Federal Poverty Level (FPL) |
Monthly 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 1,000% |
80% of full premium |
|
Above 1,000% |
85% of full premium |
CommonHealth members who are eligible to get a premium assistance payment, as described in 130 CMR 506.000, that is less than the full CommonHealth premium will get their premium assistance payment as an offset to the CommonHealth monthly premium bill, and will be responsible for the difference.
MassHealth Family Assistance Premium Formulas
The premium formula for MassHealth Family Assistance children whose eligibility is described in 130 CMR 506.000 is as follows.
Family Assistance for Children Premium Formula
|
% of Federal Poverty Level (FPL) |
Monthly Premium Cost |
|
Above 150% to 200% |
$12 per child ($36 PBFG maximum) |
|
Above 250% to 300% |
$20 per child ($60 PBFG maximum) |
|
Above 250% to 300% |
$28 per child ($84 PBFG maximum) |
The premium formulas for MassHealth Family Assistance HIV-positive adults whose eligibility is described in 130 CMR 506.000 are as follows. The premium formula uses income and whether or not the member has other health insurance.
The full premium formula for Family Assistance HIV-positive adults between 150% and 200% of the FPL 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. The full premium formula is provided below.
Family Assistance for HIV + Adults Premium Formula
|
% of Federal Poverty Level (FPL) |
Monthly 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 |
The supplemental premium formula for Family Assistance HIV-positive adults is charged to members who have health insurance that the MassHealth agency does not contribute to. The supplemental premium formula is provided below.
Family Assistance for HIV + Adults Premium Formula Supplemental Premium Formula
|
% of Federal Poverty Level (FPL) |
Monthly Premium Cost |
|---|---|
|
Above 150% to 200% |
60% of full premium |
Family Assistance for HIV+ Adults Supplemental Premium Formula
% of Federal Poverty Level (FPL) Above 150% to 200%
Monthly Premium Cost 60% of full premium
The premium formula for MassHealth Family Assistance Nonqualified PRUCOL adults as described in 130 CMR 506.000 is based on the MassHealth MAGI household income and the MassHealth MAGI household size as it relates to the FPL income guidelines and the Premium Billing Family Group (PBFG) rules, as described in 130 CMR 506.000. The premium formula is as follows.
Family Assistance for Nonqualified PRUCOL Adults Premium Formula
The premium formula can be found at 956 CMR 12.00.
Children’s Medical Security Plan (CMSP) Premium Formula
The premium formula for CMSP members whose eligibility is described in 130 CMR 506.000 is as follows.
|
CMSP Premium Schedule |
|
|
% of Federal Poverty Level (FPL) |
Monthly Premium Cost |
|
Greater than or equal to 200%, but less than or equal to 300.9% |
$7.80 per child per month; PBFG maximum $23.40 per month |
|
Greater than or equal to 300.1%, but less than or equal to 400.0% |
$33.14 per PBFG per month |
|
Greater than or equal to 400.1% |
$64.00 per child per month |