130 CMR, § 505.005

Current through Register 1536, December 6, 2024

Section 505.005 - MassHealth Family Assistance

(A)Overview. 130 CMR 505.005 contains the categorical requirements and financial standards for MassHealth Family Assistance.

(1) Children who are citizens, as defined in 130 CMR 504.002: U.S. Citizens, lawfully present immigrants, as defined in 130 CMR 504.003(A): Lawfully Present Immigrants, or nonqualified PRUCOLs, as defined in 130 CMR 504.003(C): Nonqualified Persons Residing under Color of Law (Nonqualified PRUCOLs), whose modified adjusted gross income of the MassHealth MAGI household is greater than 150 and less than or equal to 300% of the federal poverty level (FPL) are eligible for MassHealth Family Assistance.

(2) Children and young adults who are nonqualified PRUCOLs, as defined in 130 CMR 504.003(C): Nonqualified Persons Residing under Color of Law (Nonqualified PRUCOLs), whose modified adjusted gross income of the MassHealth MAGI household is at or below 150% of the FPL are eligible for MassHealth Family Assistance. Children under age one who are nonqualified PRUCOLs, as defined in 130 CMR 504.003(C), whose modified adjusted gross income of the MassHealth MAGI household is at or below 200% of the FPL are eligible for MassHealth Family Assistance. Young adults who are nonqualified PRUCOLs, as defined in 130 CMR 504.003(C), whose modified adjusted gross income of the MassHealth MAGI household is greater than 150 and less than or equal to 300% of the FPL, are eligible for MassHealth Family Assistance.

(3) Adults who are nonqualified PRUCOLs, as defined in 130 CMR 504.003(C): Nonqualified Persons Residing under Color of Law (Nonqualified PRUCOLs), whose modified adjusted gross income of the MassHealth MAGI household is at or below 300% of the FPL are eligible for MassHealth Family Assistance.

(4) HIV-positive individuals who are citizens as defined in 130 CMR 504.002: U.S.Citizens and qualified noncitizens as defined in 130 CMR 504.003(A)(1): Qualified Noncitizens, whose modified adjusted gross income of the MassHealth MAGI household is greater than 133 and less than or equal to 200% of the FPL are eligible for MassHealth Family Assistance.

(5) Disabled adults who are qualified noncitizens barred, as defined in 130 CMR 504.003(A)(2): Qualified Noncitizens Barred, nonqualified individuals lawfully present, as defined in 130 CMR 504.003(A)(3): Nonqualified Individuals Lawfully Present, or nonqualified PRUCOLs, as defined in 130 CMR 504.003(C): Nonqualified Persons Residing under Color of Law (Nonqualified PRUCOLs), whose modified adjusted gross income of the MassHealth Disabled Adult household is at or below 100% of the FPL are eligible for MassHealth Family Assistance.

(6) Certain Emergency Aid to the Elderly, Disabled and Children (EAEDC) recipients are eligible for MassHealth Family Assistance.

(7) Persons eligible for MassHealth Family Assistance must obtain and maintain all available health insurance as described in 130 CMR 503.007: Potential Sources of Health Care.

(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. Children younger than 19 years old are eligible for MassHealth Family Assistance coverage described in 130 CMR 505.005(B) if they meet the following criteria.

(1)Eligibility Requirements. A child is eligible if

(a) the child is younger than 19 years old;

(b) the child's modified adjusted gross income of the MassHealth MAGI household is greater than 150 and less than or equal to 300% of the federal poverty level (FPL);

(c) the child is ineligible for MassHealth Standard or CommonHealth;

(d) the child is a citizen as defined in 130 CMR 504.002: U.S. Citizens or a lawfully present immigrant as defined in 130 CMR 504.003(A), or a nonqualified PRUCOL, as defined in 130 CMR 504.003(C): Nonqualified Persons Residing under Color of Law (Nonqualified PRUCOLs);

(e) the child complies with 130 CMR 505.005(B)(2) and meets one of the following criteria:

1. the child is uninsured; or

2. the child has health insurance that meets the criteria at 130 CMR 506.012: Premium Assistance Payments.

(2)Access to Employer-sponsored Insurance and Premium Assistance Investigations for Individuals Who Are Eligible for MassHealth Family Assistance. MassHealth may perform an investigation to determine if individuals potentially eligible for MassHealth Family Assistance

(a) have health insurance that MassHealth can help pay for; or

(b) have access to employer-sponsored insurance in which MassHealth wants the individual to enroll and for which MassHealth will help pay.

1.Investigations for Individuals Who Are Enrolled in Health Insurance.

a. If MassHealth determines that the health insurance the individual is enrolled in meets the criteria at 130 CMR 506.012: Premium Assistance Payments, the individual is notified in writing that MassHealth will provide MassHealth Family Assistance Premium Assistance Payments as described at 130 CMR 450.105(G)(1): Premium Assistance and 130 CMR 506.012: Premium Assistance Payments.

b. If MassHealth determines that the health insurance the individual is enrolled in does not meet the criteria at 130 CMR 506.012, the individual continues to be eligible for MassHealth Family Assistance.

2.Investigations for Individuals Who Have Potential Access to Employer-sponsored Health Insurance (ESI).

a. If MassHealth determines the individual has access to employer-sponsored health insurance, the employer is contributing at least 50% of the premium cost, and the insurance meets all other criteria described at 130 CMR 506.012: Premium Assistance Payments, the individual is notified in writing that they must enroll in this employer-sponsored coverage that meets the criteria described in 130 CMR 506.012. MassHealth allows the individual up to 60 days to enroll in this coverage. Once enrolled in this health insurance plan, MassHealth provides MassHealth Family Assistance Premium Assistance Payments as described in 130 CMR 450.105(G)(1): Premium Assistance and 130 CMR 506.012. Failure to enroll in the employer-sponsored health insurance plan at the request of MassHealth will result in the loss or denial of eligibility.

b. If MassHealth determines the individual does not have access to employer-sponsored health insurance, the individual continues to be eligible for MassHealth Family Assistance.

(C)Eligibility Requirements for Children and Young Adults Who Are Nonqualified PRUCOLs with Modified Adjusted Gross Income of the MassHealth MAGI Household at or below 150% of the Federal Poverty Level. Children and young adults who are nonqualified PRUCOLs, as defined in 130 CMR 504.003(C): Nonqualified Persons Residing under Color of Law (Nonqualified PRUCOLs), are eligible for MassHealth Family Assistance coverage described in 130 CMR 505.005(C) if they meet the following criteria.

(1)Eligibility Requirements. The individual is eligible if

(a) the individual is younger than 19 years old and the individual's modified adjusted gross income of the MassHealth MAGI household is at or below 300% of the federal poverty level (FPL);

(b) the individual is a young adult and individual's modified adjusted gross income of the MassHealth MAGI household is at or below 150% of the FPL;

(c) the individual is ineligible for MassHealth Standard or MassHealth CommonHealth;

(d) the individual is a nonqualified PRUCOL, as defined in 130 CMR 504.003(C): Nonqualified Persons Residing under Color of Law (Nonqualified PRUCOLs); and

(e) the individual complies with 130 CMR 505.005(C)(2).

(2)Investigations for Individuals Who Have Potential Access to Employer-sponsored Insurance. MassHealth may perform an investigation to determine if individuals potentially eligible for MassHealth Family Assistance

(a) have health insurance that MassHealth can help pay for; or

(b) have access to employer-sponsored insurance in which MassHealth wants the individual to enroll and for which MassHealth will help pay.

1.Investigations for Individuals Who Are Enrolled in Health Insurance.

b. If MassHealth determines that the health insurance the individual is enrolled in does not meet the criteria at 130 CMR 506.012: Premium Assistance Payments, the individual continues to be eligible for MassHealth Family Assistance.

2.Investigations for Individuals Who Have Potential Access to Employer-sponsored Health Insurance (ESI).

a. If MassHealth determines the individual has access to employer-sponsored health insurance, the employer is contributing at least 50% of the premium cost, and the insurance meets all other criteria described at 130 CMR 506.012: Premium Assistance Payments, the individual is notified in writing that they must enroll in this employer-sponsored coverage that meets the criteria described in 130 CMR 506.012. MassHealth allows the individual up to 60 days to enroll in this coverage. Once enrolled in this health insurance plan, MassHealth provides MassHealth Family Assistance Premium Assistance Payments as described in 130 CMR 450.105(G)(1): Premium Assistance and (2): Payment of Copayments, Coinsurance, and Deductibles for Certain Children Who Receive Premium Assistance and 130 CMR 506.012. Failure to enroll in the employer-sponsored health insurance plan at the request of MassHealth may result in the loss or denial of eligibility.

b. If MassHealth determines the individual does not have access to employer-sponsored health insurance, the individual continues to be eligible for MassHealth Family Assistance.

(D)Eligibility Requirement for Adults and Young Adults Who Are Nonqualified PRUCOLs with Modified Adjusted Gross Income of the MassHealth MAGI Household at or below 300% of the Federal Poverty Level. Individuals who are nonqualified PRUCOLs, as defined in 130 CMR 504.003(C): Nonqualified Persons Residing under Color of Law (Nonqualified PRUCOLs), are eligible for MassHealth Family Assistance coverage described in 130 CMR 505.005(D) if they meet the following criteria.

(1) The individual is eligible if

(a) the individual is a nonqualified PRUCOL, as defined in 130 CMR 504.003(C): Nonqualified Persons Residing under Color of Law (Nonqualified PRUCOLs);

(b) the individual is ineligible for MassHealth Standard or MassHealth CommonHealth;

(c) the individual is uninsured;

(d) the individual does not have access to affordable Minimum Essential Coverage as defined in § 1401 of the Patient Protection and Affordable Care Act; and

(e) the individual is either

1. a young adult 19 through 20 years old 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 (FPL); or

2. 21 through 64 years old with modified adjusted gross income of the MassHealth MAGI household at or below 300% of the FPL.

(2) Members eligible for benefits described in 130 CMR 505.005(D) receive MassHealth Family Assistance benefits described in 130 CMR 450.105(G)(4): Managed Care Participation and 130 CMR 508.000: MassHealth: Managed Care Requirements.

(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. Individuals who are HIV positive are eligible for MassHealth Family Assistance coverage described in 130 CMR 505.005(E) if they meet the following criteria.

(1) The individual is eligible if

(a) the individual is younger than 65 years old;

(b) the individual is ineligible for MassHealth Standard or MassHealth CommonHealth;

(c) the individual's modified adjusted gross income of the MassHealth MAGI household is greater than 133 and less than or equal to 200% of the FPL;

(d) the individual is a citizen as defined in 130 CMR 504.002: U.S. Citizens or qualified noncitizen, as defined in 130 CMR 504.003(A)(1): Qualified Noncitizens; and

(e) the individual has verified their HIV-positive status by providing a letter from a doctor, qualifying health clinic, laboratory, or AIDS service provider or organization. The letter must indicate the individual's name and their HIV-positive status.

(2)Health Insurance Investigation. MassHealth may perform an investigation to determine if individuals receiving MassHealth Family Assistance have health insurance that MassHealth may help pay for, as described at 130 CMR 506.012: Premium Assistance Payments.

(a) If MassHealth determines that the health insurance the individual is enrolled in meets the criteria at 130 CMR 506.012: Premium Assistance Payments, the individual is notified in writing that MassHealth will provide MassHealth Family Assistance Premium Assistance Payments as described at 130 CMR 450.105(G)(1): Premium Assistance and (2): Payment of Copayments, Coinsurance, and Deductibles for Certain Children Who Receive Premium Assistance and 130 CMR 506.012.

(b) If MassHealth determines that the health insurance the individual is enrolled in does not meet the criteria at 130 CMR 506.012: Premium Assistance Payments, the individual is eligible for MassHealth Family Assistance Direct Coverage.

(3) Unless otherwise indicated in 130 CMR 505.005(E)(2), individuals determined eligible for MassHealth Family Assistance as described in 130 CMR 505.005(E) will receive benefits as described in 130 CMR 450.105(G)(4): Managed Care Participation.

(F)Eligibility Requirement for Disabled Adults Who Are Qualified Noncitizens Barred, Nonqualified Individuals Lawfully Present, and Nonqualified PRUCOLs with Modified Adjusted Gross Income of the MassHealth Disabled Adult Household at or below 100% of the Federal Poverty Level. Individuals who are disabled adults are eligible for MassHealth Family Assistance coverage described in 130 CMR 505.005(F) if they meet the following criteria.

(1)Eligibility Requirements. The individual is eligible if

(a) the individual is totally and permanently disabled as defined in 130 CMR 501.001: Definition of Terms;

(b) the individual is younger than 65 years old;

(c) the individual is ineligible for MassHealth Standard or MassHealth CommonHealth;

(d) the individual's modified adjusted gross income of the MassHealth Disabled Adult household is at or below 100% of the FPL; and

(e) the individual is a qualified noncitizen barred as described in 130 CMR 504.003(A)(2): Qualified Noncitizens Barred, nonqualified individual lawfully present, as defined in 130 CMR 504.003(A)(3): Nonqualified Individuals Lawfully Present, or a nonqualified PRUCOL, as defined in 130 CMR 504.003(C): Nonqualified Persons Residing under Color of Law (Nonqualified PRUCOLs).

(2)Determination of Disability. Disability is established by

(a) certification of legal blindness by the Massachusetts Commission of the Blind (MCB);

(b) a determination of disability by the Social Security Administration (SSA); or

(c) a determination of disability by the Disability Evaluation Services (DES).

(3)Access to Employer-sponsored Insurance and Premium Assistance Investigations for Individuals Who Are Eligible for MassHealth Family Assistance. MassHealth may perform an investigation to determine if individuals potentially eligible for MassHealth Family Assistance

(a) are enrolled in health insurance that MassHealth can help pay for; or

(b) have access to employer-sponsored insurance in which MassHealth wants the individual to enroll and for which MassHealth will help pay.

1.Investigations for Individuals Who Are Enrolled in Health Insurance.

2.Investigations for Individuals Who Have Potential Access to Employer-sponsored Health Insurance (ESI).

a. If MassHealth determines the individual has access to employer-sponsored health insurance and the employer is contributing at least 50% of the premium cost and the insurance meets all other criteria described in 130 CMR 506.012: Premium Assistance Payments, the individual is notified in writing that they must enroll in this employer-sponsored coverage that meets the criteria described in 130 CMR 506.012: Premium Assistance Payments. MassHealth allows the individual up to 60 days to enroll in this coverage. Once enrolled in this health insurance plan, MassHealth provides MassHealth Family Assistance Premium Assistance Payments as described in 130 CMR 450.105(G)(1): Premium Assistance and (2): Payment of Copayments, Coinsurance, and Deductibles for Certain Children Who Receive Premium Assistance and 130 CMR 506.012. Failure to enroll in the employer-sponsored health insurance plan at the request of MassHealth may result in the loss or denial of eligibility.

b. If MassHealth determines the individual does not have access to employer-sponsored health insurance, the individual continues to be eligible for MassHealth Family Assistance.

(G)Eligibility Requirements for Certain Emergency Aid for Elderly, Disabled and Children (EAEDC) Recipients.

(1)Eligibility Requirements. Certain EAEDC recipients are eligible for MassHealth Family Assistance if

(a) the individual is

1. a child or a young adult and is a nonqualified PRUCOL as described at 130 CMR 504.003(C): Nonqualified Persons Residing under Color of Law (Nonqualified PRUCOLs); or

2. a parent, caretaker relative or adult 21 through 64 years of age who is a qualified noncitizen barred, as described in 130 CMR 504.003(A)(2): Qualified Noncitizens Barred, nonqualified individual lawfully present, as defined in 130 CMR 504.003(A)(3): Nonqualified Individuals Lawfully Present, or a nonqualified PRUCOL, as defined in 130 CMR 504.003(C): Nonqualified Persons Residing under Color of Law (Nonqualified PRUCOLs); and

(b) the individual receives EAEDC cash assistance.

(2)Extended Eligibility. Individuals whose EAEDC cash assistance ends and who are determined to be potentially eligible for MassHealth continue to receive medical benefits under MassHealth Family Assistance until a determination of ineligibility is made by MassHealth.

(H)MassHealth Family Assistance Premiums. Individuals who meet the requirements of130 CMR 505.005 may be assessed a premium in accordance with the premium schedule provided in 130 CMR 506.011(B)(3) through (5).

(I)MassHealth Family Assistance Coverage Begin Date.

(1) The medical coverage date for MassHealth Family Assistance is described at 130 CMR 502.006: Coverage Dates, except as described at 130 CMR 505.005(B) and 130 CMR 505.005(I)(2) and (3).

(2) Provisional eligibility is described in 130 CMR 502.003(E): Provisional Eligibility.

(3) For those individuals eligible for MassHealth Family Assistance as described in130 CMR 505.005(B), the begin date of the Premium Assistance is in accordance with130 CMR 506.012(F)(1)(d).

(J)Postpartum Coverage. For people who are pregnant, MassHealth will provide postpartum care for 12 months following the termination of a pregnancy plus an additional period extending to the end of the month in which the 12-month period ends.