130 CMR 505.00 — MassHealth: Coverage Types

130 CMR: DIVISION OF MEDICAL ASSISTANCE

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130 CMR 505.000: HEALTH CARE REFORM: MASSHEALTH: COVERAGE TYPES

TABLE OF CONTENTS

Section

130 CMR 505.00 MassHealth: Coverage Types

505.001 Introduction

505.001: Introduction

505.002 MassHealth Standard

505.002: MassHealth Standard (130 CMR 505.003 Reserved)

505.004 MassHealth CommonHealth

505.004: MassHealth CommonHealth

505.005 MassHealth Family Assistance

505.005: MassHealth Family Assistance

505.006 MassHealth Limited

505.006: MassHealth Limited

505.007 Medicare Savings Program (MSP, also called Buy-in)

505.007: Medicare Savings Program (MSP, also called Buy-in)

505.008 MassHealth CarePlus

505.008: MassHealth CarePlus

505.009 Severability

505.009: Severability

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505.001 Introduction

505.001: Introduction

130 CMR 505.000 explains the categorical requirements and financial standards that must be met to qualify for a MassHealth coverage type. The rules of financial responsibility and calculation of financial eligibility are detailed in 130 CMR 506.000: MassHealth: Financial Requirements.

(A) The MassHealth coverage types are the following: (1) MassHealth Standard − for people who are pregnant, children, parents and caretaker relatives, young adults, disabled individuals, certain persons who are HIV positive, individuals with breast or cervical cancer, independent foster care adolescents, Department of Mental Health (DMH) members, and medically frail as such term is defined in 130 CMR 505.008(F); (2) MassHealth CommonHealth − for disabled adults, disabled young adults, and disabled children who are not eligible for MassHealth Standard; (3) MassHealth CarePlus − for adults 21 through 64 years old who are not eligible for MassHealth Standard; (4) MassHealth Family Assistance − for children, young adults, certain noncitizens, and persons who are HIV positive who are not eligible for MassHealth Standard, MassHealth CommonHealth, or MassHealth CarePlus; (5) MassHealth Limited − for certain lawfully present immigrants as described in 130 CMR 504.003(A): Lawfully Present Immigrants, nonqualified PRUCOLs, and other noncitizens as described in 130 CMR 504.003: Immigrants; and (6) MassHealth Medicare Savings Programs (MSP, also called Senior Buy-in and Buy-in) − for certain Medicare beneficiaries.

(B) The financial standards referred to in 130 CMR 505.000 use MassHealth modified adjusted gross income (MAGI) household or MassHealth Disabled Adult household, as defined in 130 CMR 506.002: Household Composition.

505.002 MassHealth Standard

505.002: MassHealth Standard

(A) Overview. (1) 130 CMR 505.002 contains the categorical requirements and financial standards for MassHealth Standard serving children, young adults, parents, caretaker relatives, people who are pregnant, disabled individuals, certain individuals with breast or cervical cancer, certain individuals who are HIV positive, independent foster-care adolescents, Department of Mental Health members, and medically frail as such term is defined in 130 CMR 505.008(F). (2) Persons who receive Supplemental Security Income (SSI) benefits from the Social Security Administration (SSA) are eligible for MassHealth Standard. (3) Persons who receive Transitional Aid to Families with Dependent Children (TAFDC) cash assistance from the Department of Transitional Assistance (DTA) are eligible for

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MassHealth Standard. (4) Children, adults, and parents and caretaker relatives who receive Emergency Aid to the Elderly, Disabled and Children (EAEDC) cash assistance are eligible for MassHealth Standard if they meet the citizenship and immigration requirements described at 130 CMR 504.002: U.S. Citizens and 130 CMR 504.003(A)(1): Qualified Noncitizens, (2): Qualified Noncitizens Barred, and (3): Nonqualified Individuals Lawfully Present. (5) Persons who do not otherwise meet the requirements of 130 CMR 505.002, but who meet the AFDC rules that were in effect on July 16, 1996, are eligible for MassHealth Standard. (6) Persons eligible for MassHealth Standard coverage are eligible for medical benefits as described at 130 CMR 450.105(A): MassHealth Standard and 130 CMR 508.000: MassHealth: Managed Care Requirements.

(B) Eligibility Requirements for Children and Young Adults. Children and young adults may establish eligibility for MassHealth Standard coverage subject to the requirements described in 130 CMR 505.002(B). (1) Children Younger than One Year Old. (a) A child younger than one year old born to an individual who was not receiving MassHealth Standard on the date of the child's birth is eligible if

the modified adjusted gross income of the MassHealth MAGI household is less than or equal to 200% of the federal poverty level (FPL); and
the child is a citizen as described in 130 CMR 504.002: U.S. Citizens or a lawfully present immigrant as described in 130 CMR 504.003(A): Lawfully Present Immigrants. (b) A child born to an individual who was receiving MassHealth on the date of the child's birth is automatically eligible for one year and is exempt from the requirement to provide verification of citizenship and identity. (c) A child receiving MassHealth Standard who receives inpatient services on the date of their first birthday remains eligible until the end of the stay for which the inpatient services are furnished. (2) Children One through 18 Years Old. (a) A child one through 18 years old is eligible if
the modified adjusted gross income of the MassHealth MAGI household is less than or equal to 150% of the FPL; and
the child is a citizen as described in 130 CMR 504.002: U.S. Citizens or a lawfully present immigrant as described in 130 CMR 504.003(A): Lawfully Present Immigrants. (b) Eligibility for a child who is pregnant is determined under 130 CMR 505.002(D). (3) Young Adults 19 through 20 Years Old. (a) A young adult is eligible if
the modified adjusted gross income of the MassHealth MAGI household is less than or equal to 150% of the FPL; and
the young adult is a citizen as described in 130 CMR 504.002: U.S. Citizens or a lawfully present immigrant as described in 130 CMR 504.003(A): Lawfully Present

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Immigrants. (b) A young adult receiving MassHealth Standard who receives inpatient services on the date of their 21 st birthday remains eligible until the end of the stay for which the inpatient services are furnished. (c) Eligibility for a young adult who is pregnant is determined under 130 CMR 505.002(D).

(C) Eligibility Requirements for Parents and Caretaker Relatives. (1) A parent or caretaker relative of a child younger than 19 years old is eligible for MassHealth Standard coverage if (a) the modified adjusted gross income of the MassHealth MAGI household is less than or equal to 133% of the FPL; (b) the individual is a citizen as described at 130 CMR 504.002: U.S. Citizens or a qualified noncitizen as described in 130 CMR 504.003(A)(1): Qualified Noncitizens; and (c) 1. the parent lives with their children, and assumes primary responsibility for the child’s care, in the case of a parent who is separated or divorced, has custody of their children, or has children who are absent from home to attend school; or 2. the caretaker relative lives with children to whom they are related by blood, adoption, or marriage (including stepsiblings), or is a spouse or former spouse of one of those relatives, and assumes primary responsibility for the child’s care if neither parent lives in the home. (2) The parent or caretaker relative complies with 130 CMR 505.002(M).

(D) Eligibility Requirements for People who are Pregnant. (1) A person who is pregnant is eligible if (a) the modified adjusted gross income of the MassHealth MAGI household is less than or equal to 200% of the FPL; and (b) the individual is a citizen as described in 130 CMR 504.002: U.S. Citizens, lawfully present immigrant, nonqualified PRUCOL, or other noncitizen as described in 130 CMR 504.003: Immigrants. (2) In determining the MassHealth MAGI household size, the unborn child or children are counted as if born and living with the person. (3) Eligibility, once established, continues for the duration of the pregnancy. (4) Eligibility for postpartum care for pregnant individuals who meet the requirements of 130 CMR 505.002(B)(2) and (3), (C) through (H), and (L) continues for 12 months following the termination of the pregnancy plus an additional period extending to the end of the month in which the 12-month period ends.

(E) Disabled Individuals. (1) Disabled Adults. A disabled adult 21 through 64 years old or a disabled young adult 19 through 20 years old who does not meet the requirements described at 130 CMR 505.002(B)(3)(a)1. is eligible for MassHealth Standard coverage if they meet the following requirements:

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(a) the individual is permanently and totally disabled as defined in 130 CMR 501.001: Definition of Terms; (b) the modified adjusted gross income of the MassHealth Disabled Adult household as described in 130 CMR 506.002(C): MassHealth Disabled Adult Household is less than or equal to 133% of the FPL, or the individual is eligible under § 1634 of the Social Security Act (42 U.S.C. § 1383c) as a disabled adult child or as a disabled widow or widower, or is eligible under the provisions of the Pickle Amendment as described at 130 CMR 519.003: Pickle Amendment Cases; (c) the individual is a citizen as described in 130 CMR 504.002: U.S. Citizens or a qualified noncitizen as described in 130 CMR 504.003(A)(1): Qualified Noncitizens; and (d) the individual complies with 130 CMR 505.002(M). (2) Determination of Disability. Disability is established by (a) certification of legal blindness by the Massachusetts Commission for the Blind (MCB); (b) a determination of disability by the SSA; or (c) a determination of disability by the Disability Evaluation Services (DES). (3) Extended MassHealth Eligibility. Disabled persons whose SSI disability assistance has been terminated and who are determined to be potentially eligible for MassHealth continue to receive MassHealth Standard until the MassHealth agency makes a determination of ineligibility.

(F) Individuals with Breast or Cervical Cancer. (1) Eligibility Requirements. An individual with breast or cervical cancer is eligible for MassHealth Standard coverage if they meet all the following requirements: (a) the individual is younger than 65 years old; (b) the individual has been certified by a physician to need treatment for breast or cervical cancer, including precancerous conditions; (c) the modified adjusted gross income of the MassHealth MAGI household is less than or equal to 250% of the federal poverty level (FPL); (d) for individuals with breast or cervical cancer whose MassHealth MAGI household modified adjusted gross income is greater than 133% of the FPL, but does not exceed 250% of the FPL, the individual must

be uninsured; or
have insurance that does not provide creditable coverage. An individual is not considered to have creditable coverage when the individual is in a period of exclusion for treatment of breast or cervical cancer, has exhausted the lifetime limit on all benefits under the plan, including treatment of breast or cervical cancer, or has limited scope coverage or coverage only for specified illness; or
be an American Indian or Alaska Native who is provided care through a medical care program of the Indian Health Service or of a tribal organization; (e) the individual is a citizen as described in 130 CMR 504.002: U.S. Citizens or a qualified noncitizen as described in 130 CMR 504.003(A)(1): Qualified Noncitizens; and

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(f) the individual does not otherwise meet the requirements for MassHealth Standard described at 130 CMR 505.002(B) through (E). (2) Premiums. Individuals who meet the requirements of 130 CMR 505.002(F) are assessed a monthly premium in accordance with 130 CMR 506.011: MassHealth and the Children’s Medical Security Plan (CMSP) Premiums. (3) Duration of Eligibility. Individuals meeting the requirements of 130 CMR 505.002(F) are eligible for MassHealth Standard for the duration of their cancer treatment.

(G) Eligibility Requirements for Individuals Who Are HIV Positive. An individual who is HIV positive is eligible for MassHealth Standard coverage if (1) the individual is younger than 65 years old; (2) the individual has verified their HIV positive status by providing a letter from doctor, qualifying health clinic, laboratory, or AIDS service provider or organization. The letter must indicate the individual’s name and their HIV-positive status; (3) the modified adjusted gross income of the MassHealth MAGI household is less than or equal to 133% of the FPL; (4) the individual is a citizen as described in 130 CMR 504.002: U.S. Citizens or a qualified noncitizen as described in 130 CMR 504.003(A)(1): Qualified Noncitizens; and (5) the individual does not meet the requirements for MassHealth Standard described at 130 CMR 505.002(B) through (E).

(H) Eligibility Requirements for Former Foster-care Individuals. (1) An individual who was in foster care under the responsibility of a state or tribe and enrolled in Medicaid coverage on their 18th birthday, or later date of aging out, receives MassHealth Standard coverage until (a) their 26th birthday if the individual is a citizen, as described at 130 CMR 504.002: U.S. Citizens, or qualified noncitizen, as described at 130 CMR 504.003(A)(1): Qualified Noncitizens; or (b) their 21st birthday if the individual is a qualified noncitizen barred, as described at 130 CMR 504.003(A)(2): Qualified Noncitizens Barred, or a nonqualified individual lawfully present, as described at 130 CMR 504.003(A)(3): Nonqualified Individuals Lawfully Present. (2) An individual who was in foster care under the responsibility of a state or tribe on their 18th birthday and not enrolled in Medicaid coverage receives MassHealth Standard coverage until their 21st birthday if the individual is a citizen, as described at 130 CMR 504.002: U.S.US Citizens, a qualified noncitizen as described at 130 CMR 504.003(A)(1): Qualified Noncitizens, a qualified noncitizen barred, as described at 130 CMR 504.003(A)(2): Qualified Noncitizens Barred, or a nonqualified individual lawfully present, as described at 130 CMR 504.003(A)(3): Nonqualified Individuals Lawfully Present.

130 CMR: DIVISION OF MEDICAL ASSISTANCE

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130 CMR 505.000: HEALTH CARE REFORM: MASSHEALTH: COVERAGE TYPES

(I) Eligibility Requirements for Department of Mental Health (DMH) Members. An individual who receives services from the DMH, or has been determined eligible for such services and is on a waiting list, is eligible for MassHealth Standard if the individual (1) is younger than 65 years old; (2) has modified adjusted gross income of the MassHealth MAGI household of less than or equal to 133% of the FPL; (3) is a citizen as described at CMR 504.002: U.S. Citizens or qualified noncitizen as described at 130 CMR 504.003(A)(1): Qualified Noncitizens; and (4) is not otherwise eligible for MassHealth Standard.

(J) Eligibility Requirements for Individuals Who Are Medically Frail. An individual who is medically frail is eligible for MassHealth Standard if the individual (1) is younger than 65 years old; (2) is medically frail as defined at 130 CMR 505.008(F); (3) has modified adjusted gross income of the MassHealth MAGI household of less than or equal to 133% of the FPL; (4) is a citizen as described at 130 CMR 504.002: U.S. Citizens or qualified noncitizen as described at 130 CMR 504.003(A)(1): Qualified Noncitizens; and (5) has been determined to meet the eligibility criteria for MassHealth CarePlus and has elected to receive MassHealth Standard benefits.

(K) Eligibility Requirements for Certain Emergency Aid to the Elderly, Disabled and Children (EAEDC) Recipients. (1) Eligibility Requirements. Certain EAEDC recipients are eligible for MassHealth Standard. if (a) the individual is

a child and 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): Lawfully Present Immigrants;
the individual is a young adult and 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): Lawfully Present Immigrants;
the individual is a parent or caretaker relative and is a citizen as defined in 130 CMR 504.002: U.S. Citizens or a qualified noncitizen as defined in 130 CMR 504.003(A)(1): Qualified Noncitizens;
the individual is an adult 21 to 64 and is a citizen as defined in 130 CMR 504.002: U.S. Citizens or a qualified noncitizen as defined in 130 CMR 504.003(A)(1): Qualified Noncitizens; and (b) the individual receives EAEDC cash assistance. (2) Eligibility End Date. Individuals whose EAEDC cash assistance terminates and who are determined to be potentially eligible for MassHealth continue to receive medical benefits under MassHealth Standard until a determination of ineligibility is made by MassHealth.

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130 CMR 505.000: HEALTH CARE REFORM: MASSHEALTH: COVERAGE TYPES

(L) Extended Eligibility. (1) Members of an EAEDC or Transitional Aid to Families with Dependent Children (TAFDC) household whose cash assistance terminates continue to receive four months of MassHealth Standard, or Family Assistance (if enrolled in Family Assistance), coverage beginning in the month the household became ineligible if they are (a) terminated from EAEDC or TAFDC and are determined to be potentially eligible for MassHealth; or (b) terminated from TAFDC because of receipt of or an increase in spousal or child support payments. (2) Members of a TAFDC household who become ineligible for TAFDC for employment- related reasons continue to receive MassHealth Standard for a full 12-calendar-month period beginning with the month after MassHealth determined that they became ineligible for TAFDC if (a) the household continues to include a child; (b) a parent or caretaker relative continues to be employed; and (c) the parent or caretaker relative complies with 130 CMR 505.002(M). (3) Members of a MassHealth MAGI household who receive MassHealth Standard (whether or not they receive TAFDC) and have earnings that raise the MassHealth MAGI household’s modified adjusted gross income above 133% of the FPL continue to receive MassHealth Standard for a full 12-calendar-month period that begins with the month after MassHealth determined that the members’ MAGI exceeds 133% of the FPL if (a) the MassHealth household continues to include a child younger than 19 years old living with the parent or caretaker; (b) a parent or caretaker relative continues to be employed; (c) the parent or caretaker relative complies with 130 CMR 505.002(M); and (d) the member is a citizen or a qualified noncitizen. (4) MassHealth independently reviews the continued eligibility of the TAFDC, EAEDC, and MassHealth MAGI households at the end of the extended period described in 130 CMR 505.002(L)(1) through (3). (5) If an individual in a MassHealth MAGI household who receives MassHealth under 130 CMR 505.002(L)(1) or (2) had income at or below 133% of the FPL during their extended period, and now has income including earnings that raise the MassHealth MAGI modified adjusted gross income above that limit, the MassHealth MAGI household is eligible for another full 12-calendar-month period that begins with the date on which the member’s MAGI exceeds 133% of the FPL if (a) the MassHealth household continues to include a child younger than 19 years old living with the parent or caretaker; (b) a parent or caretaker relative continues to be employed; and (c) the parent or caretaker relative complies with 130 CMR 505.002(M). (6) If a MassHealth MAGI household’s modified adjusted gross income decreases to 133% of the FPL or below during its extended eligibility period, and the decrease is timely reported to MassHealth, the MassHealth MAGI household’s eligibility for MassHealth Standard may be redetermined. If the MassHealth MAGI household’s gross income later increases above

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133% of the FPL, the MassHealth MAGI household is eligible for a new extended eligibility period.

(M) Use of Potential Health Insurance Benefits. Applicants and members must use potential health insurance benefits in accordance with 130 CMR 503.007: Potential Sources of Health care, and must enroll in health insurance, including Medicare, if available at no greater cost to the applicant or member than they would pay without access to health insurance, or if purchased by MassHealth in accordance with 130 CMR 505.002(O) or 130 CMR 506.012: Premium Assistance Payments. Members must access other health insurance benefits and must show their private health insurance card and their MassHealth card to providers at the time services are provided.

(N) Access to Employer-sponsored Insurance and Premium Assistance Investigations for Individuals Who Are Eligible for MassHealth Standard. (1) The MassHealth agency may perform an investigation to determine if individuals receiving MassHealth Standard (a) have health insurance that MassHealth may help pay for; or (b) have access to employer-sponsored health insurance in which MassHealth wants the individual to enroll and for which MassHealth will help pay. (2) The individual receives MassHealth Standard while MassHealth investigates the insurance. (a) Investigations for Individuals Who Are Enrolled in Health Insurance.

If the MassHealth agency 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 Standard Premium Assistance Payments as described at 130 CMR 506.012: Premium Assistance Payments.
If the MassHealth agency 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 Standard Direct Coverage.
Individuals described at 130 CMR 505.002(F)(1)(d) will not undergo an investigation. (b) Investigations for Individuals Who Have Potential Access to Employer-sponsored Health Insurance.
If the MassHealth agency 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 at 130 CMR 506.012: Premium Assistance Payments, the individual is notified in writing that they must enroll in this employer-sponsored coverage. MassHealth allows the individual up to 60 days to enroll in this coverage. Once enrolled in this health insurance plan, MassHealth provides MassHealth Standard Premium Assistance Payments as described in 130 CMR 506.012: Premium Assistance Payments. Failure to enroll in the employer-sponsored health insurance plan at the request of the MassHealth agency will result in the loss or denial of eligibility for all individuals unless the

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individual is younger than 21 years old or is pregnant. 2. If the MassHealth agency determines the individual does not have access to employer-sponsored health insurance, the individual is eligible for MassHealth Standard Direct Coverage. 3. Individuals described at 130 CMR 505.002(F) and (G) will not undergo an investigation.

(O) Medicare Premium Payment. (1) The MassHealth agency, in accordance with the Medicare Savings Program as described at 130 CMR 519.010: Medicare Savings Program (MSP) – Qualified Medicare Beneficiaries (QMBs) and 519.011: Medicare Savings Program (MSP)– Specified Low Income Medicare Beneficiaries (SLMBs) and Qualifying Individuals (QIs), or in accordance with 130 CMR 519.002(E), pays the following for members who meet the requirements of 130 CMR 505.002(C) and (E): (a) the cost of the monthly Medicare Part B premiums; (b) where applicable, the cost of the hospital insurance under Medicare Part A for members who are entitled to Medicare Part A; and (c) where applicable, for the deductibles and coinsurance under Medicare Parts A and B. (2) The coverage begins in accordance with 130 CMR 519.010: Medicare Savings Program (MSP) – Qualified Medicare Beneficiaries (QMBs) and 519.011: Medicare Savings Program (MSP)– Specified Low Income Medicare Beneficiaries (SLMBs) and Qualifying Individuals (QIs).

(P) Medical Coverage Date. (1) The medical coverage date for MassHealth Standard is described at 130 CMR 502.006: Coverage Dates, except as described at 130 CMR 505.002(P)(2). (2) Provisional eligibility is described in 130 CMR 502.003(E): Provisional Eligibility.

(Q) Continuous Eligibility. (1) Continuous Eligibility, as defined in 501.001: Continuous Eligibility (CE), will be granted to children under age 19. Children in a CE period will receive 12 months of continuous coverage upon completion of initial application or annual renewal period. (2) Coverage will continue without downgrading or ending except for reasons found at 130 CMR 501.001: Definition of Terms.

(130 CMR 505.003 Reserved)

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505.004 MassHealth CommonHealth

505.004: MassHealth CommonHealth

(A) Overview. (1) 130 CMR 505.004 contains the categorical requirements and financial standards for MassHealth CommonHealth coverage available to disabled children and disabled adults. (2) Persons eligible for MassHealth CommonHealth coverage are eligible for medical benefits as described in 130 CMR 450.105(E): MassHealth CommonHealth.

(B) Disabled Adults. Disabled adults must meet the following requirements: (1) be 21 through 64 years old; (2) (a) be permanently and totally disabled, as defined in 130 CMR 501.001: Definition of Terms; or (b) be HIV positive and have a modified adjusted gross income of the MassHealth Disabled Adult household that is less than or equal to 200% of the federal poverty level (FPL); (3) be ineligible for MassHealth Standard; (4) be a citizen as described in 130 CMR 504.002: U.S. Citizens or a qualified noncitizen as described in 130 CMR 504.003(A)(1): Qualified Noncitizens; and (5) comply with 130 CMR 505.004(J).

(C) Disabled Young Adults. Disabled young adults are eligible for MassHealth CommonHealth if they meet the following requirements: (1) (a) be permanently and totally disabled, as defined in 130 CMR 501.001: Definition of Terms (b) be HIV positive and have a modified adjusted gross income of the MassHealth Disabled Adult household that is less than or equal to 200% of the FPL; (2) be ineligible for MassHealth Standard; (3) (a) be a citizen as described at 130 CMR 504.002: U.S. Citizens or qualified noncitizen as described in 130 CMR 504.003(A)(1): Qualified Noncitizens; or (b) be a nonqualified PRUCOL as described in 130 CMR 504.003(C): Nonqualified Persons Residing under Color of Law (Nonqualified PRUCOLs) with a modified adjusted gross income of the MassHealth Disabled Adult household income that is less than or equal to 150% of the FPL; and (4) comply with 130 CMR 505.004(J).

(D) Disabled 18-year-olds. Disabled 18-year-olds must meet the following requirements: (1) be ineligible for MassHealth Standard; (2) be a citizen as described at 130 CMR 504.002: U.S. Citizens or lawfully present immigrant or a nonqualified PRUCOL, as described in 130 CMR 504.003: Immigrants, and either (a) if not working, be permanently and totally disabled, as defined in 130 CMR 501.001: Definition of Terms; or (b) if working, be permanently and totally disabled (except for engagement in substantial gainful activity), as defined in 130 CMR 501.001: Definition of Terms.

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(E) Disabled Children Younger than 18 Years Old. Disabled children younger than 18 years old must meet the following requirements: (1) be permanently and totally disabled, as defined in 130 CMR 501.001: Definition of Terms; (2) be ineligible for MassHealth Standard; and (3) be a citizen as described at 130 CMR 504.002: U.S. Citizens, lawfully present immigrant, or a nonqualified PRUCOL, as described in 130 CMR 504.003: Immigrants.

(F) Determination of Disability. Disability is established by (1) certification of legal blindness by the Massachusetts Commission for the Blind (MCB); (2) a determination of disability by the SSA; or (3) a determination of disability by the Disability Evaluation Services (DES).

(G) MassHealth CommonHealth Premium. Disabled adults, disabled young adults, and disabled children who meet the requirements of 130 CMR 505.004 may be assessed a premium in accordance with the premium schedule provided in 130 CMR 506.011(B)(2).

(H) Use of Potential Health Insurance Benefits. Applicants and members must use potential health insurance benefits, in accordance with 130 CMR 503.007: Potential Sources of Health care, and must enroll in health insurance, including Medicare, if available at no greater cost to the applicant or member than they would pay without access to health insurance, or if purchased by the MassHealth agency in accordance with 130 CMR 505.002(O) and 130 CMR 506.012: Premium Assistance Payments. Members must access those other health insurance benefits and must show their private health insurance card and their MassHealth card to providers at the time services are provided.

(I) Access to Employer-sponsored Health Insurance and Premium-assistance Investigations for Individuals Who Are Eligible for MassHealth CommonHealth. (1) The MassHealth agency may perform an investigation to determine if individuals receiving MassHealth CommonHealth (a) have health insurance that MassHealth may help pay for; or (b) have access to employer-sponsored health insurance in which MassHealth wants the individual to enroll and for which MassHealth will help pay. (2) The individual receives MassHealth CommonHealth while the MassHealth agency investigates the insurance. (a) Investigations for Individuals Who Are Enrolled in Health Insurance.

If the MassHealth agency determines that the health insurance that 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 CommonHealth Premium Assistance as described at 130 CMR 506.012: Premium Assistance Payments.
If the MassHealth agency determines that the health insurance that the individual is enrolled in does not meet the criteria at 130 CMR 506.012: Premium Assistance

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Payments, the individual continues to be eligible for MassHealth CommonHealth. (b) Investigations for Individuals Who Have Potential Access to Employer-sponsored Health Insurance.

If the MassHealth agency determines that 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 in 130 CMR 506.012: Premium Assistance Payments, the individual is notified in writing that they must enroll in this employer-sponsored coverage. MassHealth allows the individual up to 60 days to enroll in this coverage. Once enrolled in this health insurance plan, MassHealth provides premium assistance payments as described in 130 CMR 506.012: Premium Assistance Payments. Failure to enroll in the employer-sponsored health insurance plan at the request of MassHealth will result in the loss or denial of eligibility for all individuals unless the individual is younger than 19 years old, the individual is 19 through 20 years old, and has household income less than or equal to 150% of the FPL, or is pregnant.
If the MassHealth agency determines the individual does not have access to employer-sponsored health insurance, the individual continues to be eligible for MassHealth CommonHealth.

(J) Medicare Premium Payment. (1) Members who meet the requirements of 130 CMR 505.004 may, subject to federal authority and meeting any other eligibility requirements of the respective MSP, also enroll in the Medicare Savings Program as described in 130 CMR 519.010: Medicare Savings Program (MSP) – Qualified Medicare Beneficiaries (QMBs) and 519.011: Medicare Saving Program (MSP) – Specified Low Income Medicare Beneficiaries (SLMBs) and Qualifying Individuals (QIs). (2) The coverage begins in accordance with 130 CMR 519.010: Medicare Savings Program (MSP) – Qualified Medicare Beneficiaries (QMBs) and 519.011: Medicare Savings Program (MSP)– Specified Low Income Medicare Beneficiaries (SLMBs) and Qualifying Individuals (QIs).

(K) Medical Coverage Date. (1) The medical coverage date for MassHealth CommonHealth is described at 130 CMR 502.006: Coverage Dates, except as described at 130 CMR 505.004(M)(2) and (3). (2) Persons described in 130 CMR 505.004(C) who have been notified by the MassHealth agency that they must meet a one-time deductible have their medical coverage date established in accordance with 130 CMR 506.009(E): Notification of the Deductible. (3) Provisional eligibility is described in 130 CMR 502.003(E): Provisional Eligibility.

(L) 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.

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(M) Continuous Eligibility. (1) Continuous Eligibility, as defined in 501.001: Continuous Eligibility (CE), will be granted to children under age 19. Childre in a CE period will receive 12 months of continuous coverage upon completion of initial application or annual renewal period. (2) Coverage will continue without downgrading or ending except for reasons found at 130 CMR 501.001.

505.005 MassHealth Family Assistance

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), 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): Nonqualified Persons Residing under Color of Law (Nonqualified PRUCOLs), 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

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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 (FPL). 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 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:

the child is uninsured; or
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. The MassHealth agency 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.
Investigations for Individuals Who Are Enrolled in Health Insurance. a. If the MassHealth agency 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 the MassHealth agency 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.
Investigations for Individuals Who Have Potential Access to Employer-sponsored Health Insurance (ESI). a. If the MassHealth agency determines the individual has access to employer- sponsored health insurance, the employer is contributing at least 50% of the

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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 the MassHealth agency 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 (FPL). Children and young adults who are nonqualified PRUCOLs, as defined in 130 CMR 504.003(C): Nonqualified Persons Residing under Color of Law (Non- qualified 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 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. The MassHealth agency 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.

Investigations for Individuals Who Are Enrolled in Health Insurance. a. If the MassHealth agency 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 the MassHealth agency determines that the health insurance the individual is enrolled in does not meet the criteria at 130 CMR 506.012: Premium Assistance

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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 the MassHealth agency 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: Premium Assistance Payments. 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 the MassHealth agency 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 (FPL). 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 section 1401 of the Patient Protection and Affordable Care Act; and (e) the individual is either

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 FPL; or
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.

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(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 (FPL). 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

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(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 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. The MassHealth agency 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.

Investigations for Individuals Who Are Enrolled in Health Insurance. a. If the MassHealth agency 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 the MassHealth agency 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 Direct Coverage.
Investigations for Individuals Who Have Potential Access to Employer-sponsored Health Insurance (ESI). a. If the MassHealth agency 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 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: 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.

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b. If the MassHealth agency 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

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
a parent, caretaker relative, or adult 21 through 64 years old 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.

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

(H) MassHealth Family Assistance Coverage Start 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(H)(2). (2) Provisional eligibility is described in 130 CMR 502.003(E): Provisional Eligibility.

(I) 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.

(J) Continuous Eligibility. (1) Continuous Eligibility, as defined in 501.001: Continuous Eligibility (CE), will be granted to children under age 19. Children in a CE period will receive 12 months of continuous coverage upon completion of initial application or annual renewal period. (2) Coverage will continue without downgrading or ending except for reasons found at 130 CMR 501.001.

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505.006 MassHealth Limited

505.006: MassHealth Limited

(A) Overview. 130 CMR 505.006 contains the categorical requirements and financial standards for MassHealth Limited coverage for children, young adults, and adults 21 through 64 years old who are parents, caretakers, adults, and disabled adults.

(B) Eligibility Requirements. (1) MassHealth Limited is available to the following: (a) other noncitizens as described in 130 CMR 504.003(D): Other Noncitizens who are

children younger than one year old with modified adjusted gross income of the MassHealth MAGI household that is less than or equal to 200% of the federal poverty level (FPL);
children one through 18 years old with modified adjusted gross income of the MassHealth MAGI household that is less than or equal to 150% of the FPL;
young adults 19 through 20 years old with modified adjusted gross income of the MassHealth MAGI household that is less than or equal to 150% of the FPL;
adults 21 through 64 years old who are parents, caretakers, or adults with modified adjusted gross income of the MassHealth MAGI household that is less than or equal to 133% of the FPL; and
disabled adults 21 through 64 years old with modified adjusted gross income of the MassHealth Disabled Adult household that is less than or equal to 133% of the FPL; (b) nonqualified PRUCOLs as described in 130 CMR 504.003(C): Nonqualified Persons Residing under Color of Law (Nonqualified PRUCOLs) who are
children younger than one year old with modified adjusted gross income of the MassHealth MAGI household that is less than or equal to 200% of the FPL;
children one through 18 years old with modified adjusted gross income of the MassHealth MAGI household that is less than or equal to 150% of the FPL;
young adults 19 through 20 years old with modified adjusted gross income of the MassHealth MAGI household that is less than or equal to 150% of the FPL;
adults 21 through 64 years old who are parents, caretakers, or adults with modified adjusted gross income of the MassHealth MAGI household that is less than or equal to 133% of the FPL; and
disabled adults 21 through 64 years old with modified adjusted gross income of the MassHealth Disabled Adult household that is less than or equal to 133% of the FPL; (c) qualified noncitizens barred, as described in 130 CMR 504.003(A)(2): Qualified Noncitizens Barred, and nonqualified individuals lawfully present, as described in 130 CMR 504.003(A)(3): Nonqualified Individuals Lawfully Present who are
adults, including parents and caretaker relatives, 21 through 64 years old with modified adjusted gross income of the MassHealth MAGI household that is less than or equal to 133% of the FPL;
disabled adults 21 through 64 years old with modified adjusted gross income of

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the MassHealth Disabled Adult household that is less than or equal to 133% of the FPL. 3. parents and caretakers who are 21 through 64 years old who are receiving EAEDC; and 4. adults 21 through 64 years old who are receiving EAEDC. (2) Nonqualified PRUCOLs eligible for MassHealth Limited in 130 CMR 505.006(B)(1)(b) and qualified noncitizens barred and nonqualified individuals lawfully present eligible for MassHealth Limited in 130 CMR 505.006(B)(1)(c) may also be eligible for MassHealth CommonHealth if they meet the categorical and financial requirements in 130 CMR 505.004 or MassHealth Family Assistance if they meet the categorical and financial requirements in 130 CMR 505.005. (3) Persons eligible for MassHealth Limited coverage are eligible for medical benefits as described in 130 CMR 450.105(F): MassHealth Limited. These individuals are eligible for medical benefits under MassHealth Limited only to the extent that such benefits are not covered by their health insurance.

(C) Use of Potential Health Insurance Benefits. All individuals who meet the requirements of 130 CMR 505.006 must use potential health insurance benefits in accordance with 130 CMR 503.007: Potential Sources of Health care, and must enroll in health insurance, including Medicare, if available at no greater cost to the applicant or member than they would pay without access to health insurance. Members must access those other health insurance benefits and must show both their private health insurance card and their MassHealth card to providers at the time services are provided.

(D) Medical Coverage Date. (1) The medical coverage date for MassHealth Limited is described at 130 CMR 502.006: Coverage Dates, except as described at 130 CMR 505.006(D)(2). (2) Provisional eligibility is described in 130 CMR 502.003(E): Provisional Eligibility.

(E) Referral to Children’s Medical Security Plan. The MassHealth agency submits the names of children who are eligible for MassHealth Limited coverage to the Children’s Medical Security Plan.

505.007 Medicare Savings Program (MSP, also called Buy-in)

505.007: Medicare Savings Program (MSP, also called Buy-in)

Medicare Savings Program coverage is available to Medicare beneficiaries in accordance with 130 CMR 519.010: Medicare Savings Program (MSP) – for Qualified Medicare Beneficiaries (QMBs) and 130 CMR 519.011: Medicare Savings Program (MSP) – Specified Low Income Medicare Beneficiaries (SLMBs) and Qualifying Individuals (QIs). MassHealth Standard members receive this benefit under 130 CMR 505.002(O). MassHealth CommonHealth members receive this benefit in accordance with 130 CMR 505.004(J).

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505.008 MassHealth CarePlus

505.008: MassHealth CarePlus

(A) Overview. (1) 130 CMR 505.008 contains the categorical requirements and financial standards for MassHealth CarePlus. This coverage type provides coverage to adults 21 through 64 years old. (2) Persons eligible for MassHealth CarePlus Direct Coverage are eligible for medical benefits, as described in 130 CMR 450.105(B): MassHealth CarePlus and 130 CMR 508.000: MassHealth: Managed Care Requirements and must meet the following conditions. (a) The individual is an adult 21 through 64 years old. (b) The individual is a citizen, as described in 130 CMR 504.002: US Citizens, or a qualified noncitizen, as described in 130 CMR 504.003(A)(1): Qualified Noncitizens. (c) The individual’s modified adjusted gross income of the MassHealth MAGI household is less than or equal to 133% of the federal poverty level (FPL). (d) The individual is ineligible for MassHealth Standard. (e) The adult complies with 130 CMR 505.008(C). (f) The individual is not enrolled in or eligible for Medicare Parts A or B.

(B) Use of Potential Health Insurance Benefits. All applicants and members must use potential health insurance benefits in accordance with 130 CMR 503.007: Potential Sources of Health care and must enroll in health insurance, if available at no greater cost to the applicant or member than they would pay without access to health insurance, or if purchased by MassHealth in accordance with 130 CMR 505.008(C) or 506.012: Premium Assistance Payments. Members must access those other health insurance benefits and must show both their private health insurance card and their MassHealth card to providers at the time services are provided.

(C) Access to Employer-sponsored Insurance and Premium Assistance Investigations for Individuals Who Are Eligible for MassHealth CarePlus. (1) The MassHealth agency may perform an investigation to determine if individuals receiving MassHealth CarePlus have (a) health insurance that MassHealth can help pay for; or (b) access to employer-sponsored insurance that MassHealth wants the individual to enroll and for which MassHealth will help pay.

Investigations for Individuals Who Are Enrolled in Health Insurance. If the MassHealth agency 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 CarePlus Premium Assistance Payments as described at 130 CMR 506.012. If MassHealth determines that the health insurance the individual is enrolled in does not meet the criteria at 130 CMR 506.012, the individual is eligible for MassHealth CarePlus Direct Coverage.

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Investigations for Individuals Who Have Potential Access to Employer-sponsored Health Insurance. If the MassHealth agency determines the individual has access to employer-sponsored 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. MassHealth will allow the individual up to 60 days to enroll in this coverage. Once enrolled in the health insurance plan, MassHealth will provide MassHealth CarePlus Premium Assistance Payments as described at 130 CMR 506.012: Premium Assistance Payments. Failure to enroll in the employer-sponsored health insurance plan at the request of MassHealth will result in loss or denial of eligibility for all individuals. (2) If the MassHealth agency determines the individual does not have access to employer- sponsored insurance, the individual continues to be eligible for MassHealth CarePlus.

(D) MassHealth CarePlus Coverage Begin Date. (1) The MassHealth CarePlus coverage start date is described at 130 CMR 502.006: Coverage Dates, except as described at 130 CMR 505.008(D)(2). (2) Provisional eligibility is described in 130 CMR 502.003(E): Provisional Eligibility.

(E) Medically Frail. If an individual is determined medically frail or is an individual with special medical needs and has been determined to meet the eligibility criteria for MassHealth CarePlus as described in 130 CMR 505.008, the individual may elect at any time to receive MassHealth Standard benefits, as described in 130 CMR 505.002(J). If at any time after enrolling in MassHealth CarePlus an individual becomes medically frail or is determined to be medically frail, the individual may elect to receive MassHealth Standard benefits. The effective date of MassHealth Standard is the date of the reported change. To be considered medically frail or a person with special medical needs, an individual must be (1) an individual with a disabling mental disorder (including children with serious emotional disturbances and adults with serious mental illness); (2) an individual with a chronic substance use disorder; (3) an individual with a serious and complex medical condition; (4) an individual with a physical, intellectual, or developmental disability that significantly impairs their ability to perform one or more activities of daily living; or (5) an individual with a disability determination based on Social Security criteria.

(F) Continuous Eligibility. (1) Continuous Eligibility, as defined in 501.001: Continuous Eligibility (CE), will be granted to children under age 19. Children in a CE period will receive 12 months of continuous coverage upon completion of initial application or annual renewal period. (2) Coverage will continue without downgrading or ending except for reasons found at 130 CMR 501.001.

130 CMR: DIVISION OF MEDICAL ASSISTANCE

Trans. by E.L. 254 Rev. February 13, 2026

130 CMR 505.000: HEALTH CARE REFORM: MASSHEALTH: COVERAGE TYPES

505.009 Severability

505.009: Severability

The provisions of 130 CMR 505.000 are severable. If any provision of 130 CMR 505.000 or application of any provision to an applicable individual, entity, or circumstance is held invalid or unconstitutional, that holding will not be construed to affect the validity or constitutionality of any remaining provisions of 130 CMR 505.000 or application of those provisions to applicable individuals, entities, or circumstances.

REGULATORY AUTHORITY

130 CMR 505.000: M.G.L. c. 118E.

130 CMR: DIVISION OF MEDICAL ASSISTANCE

Trans. by E.L. 254 Rev. February 13, 2026

130 CMR 505.000: HEALTH CARE REFORM: MASSHEALTH: COVERAGE TYPES

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130 CMR 505.00 — MassHealth: Coverage Types

130 CMR 505.00 MassHealth: Coverage Types

505.001 Introduction

505.002 MassHealth Standard

505.004 MassHealth CommonHealth

505.005 MassHealth Family Assistance

505.006 MassHealth Limited

505.007 Medicare Savings Program (MSP, also called Buy-in)

505.008 MassHealth CarePlus

505.009 Severability

505.001 Introduction

505.002 MassHealth Standard

505.004 MassHealth CommonHealth

505.005 MassHealth Family Assistance

505.006 MassHealth Limited

505.007 Medicare Savings Program (MSP, also called Buy-in)

505.008 MassHealth CarePlus

505.009 Severability

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