130 CMR, § 506.013

Current through Register 1537, December 20, 2024

Section 506.013 - MassHealth Small Business Employee (SBE) Premium Assistance Program

(A)Introduction. 130 CMR 506.013 describes the rules and requirements for the Small Business Employee (SBE) Premium Assistance Program eligibility and the payment calculation for individuals who are eligible for this program, as described at 130 CMR 505.009: MassHealth Small Business Employee Premium Assistance.

(B)Premium Assistance Eligibility Criteria. MassHealth provides a premium assistance payment to eligible individuals as described at 130 CMR 505.009: MassHealth Small Business Employee Premium Assistance if such individuals have access to an employer-sponsored health insurance (ESI) that meets all of the following criteria.

(1) The ESI meets the Basic Benefit Level (BBL), as described at 130 CMR 501.001: Definition of Terms.

(2) The ESI policy holder is in the premium billing family group (PBFG).

(3) At least one person covered by the ESI policy is eligible for MassHealth SBE Premium Assistance benefits, as described in 130 CMR 505.009: MassHealth Small Business Employee Premium Assistance.

(4) The ESI is from an employer that offers an individual health-insurance plan to the employee for which the employee contribution costs more than the Health Connector affordability schedule as defined in 956 CMR 6.05: Determining Affordability but less than 9.5% of the MassHealth MAGI income.

(5) The ESI does not cover any individuals who are eligible for or receiving a MassHealth premium assistance payment as described in 130 CMR 506.012.

(6) Effective January 1, 2015, the ESI is a small-group health insurance plan purchased by the individual's employer through the Health Connector.

(C)Required Member Contribution. For individuals eligible for the MassHealth SBE Premium Assistance Program, as described in 130 CMR 505.009: MassHealth Small Business Employee Premium Assistance, whose household MassHealth MAGI income is between 133% and 300% of the federal poverty level (FPL) the required member contribution can be found at 956 CMR 12.00: Eligibility, Enrollment and Hearing Process for Connector Care.

(D)MassHealth SBE Premium Assistance Payment Amount Calculations.

(1)Calculation of Estimated Premium. MassHealth compares the estimated premium assistance payment amount and the maximum premium assistance amount to calculate the actual premium assistance amount.

(a) The estimated premium assistance payment amount is calculated by subtracting the employer share of the policyholder's health-insurance premium and the MassHealth required member contribution of the health-insurance premium, as described in 130 CMR 506.013(C), from the total cost of the health-insurance premium.

(b) The SBE maximum premium assistance amount is $150 per adult covered by the employer-sponsored plan in the PBFG and cannot exceed two adults.

(2)Comparison of Payment Amounts. MassHealth compares the estimated premium assistance payment amount and the SBE maximum premium assistance amount and uses the following formula to determine the actual premium assistance payment amount.

(a) If the estimated premium assistance payment amount is less than the SBE maximum premium assistance amount, the MassHealth agency sets the actual premium assistance payment amount at the estimated premium assistance payment amount.

(b) If the estimated premium assistance payment amount is equal to or greater than the SBE maximum premium assistance amount, the MassHealth agency sets the actual premium assistance payment amount at the SBE maximum premium assistance amount. The policy holder is responsible for payment of the remainder of the health-insurance premium, if any.

(3)Example. An adult applies for MassHealth and is determined eligible for SBE premium assistance. The adult has access to employer-sponsored insurance (ESI) that meets the requirements set out in 130 CMR 506.013(B). The adult has enrolled in ESI coverage from the employer.

(a) The total monthly cost of the health-insurance premium = S.

(b) The monthly contribution amount for an employer that a person covered by this plan is eligible for = T.

(c) The MassHealth required member contribution toward the monthly health-insurance premium = U.

(d) Calculating the estimated premium assistance payment amount:

S = (total cost of premium)

- T = (employer's share of the cost)

V = (employee's share of the cost)

- U = (the MassHealth SBE required member contribution)

W = (estimated premium assistance payment amount)

SBE premium assistance maximum contribution amount: X = $150 times the number of adults covered by the employer-sponsored plan in the PBFG, not to exceed two adults.

Actual SBE premium assistance amount: W is compared to X.

If W is less than X, the MassHealth agency sets the actual premium assistance payment amount at W.

If W is equal to or greater than X, the MassHealth agency sets the actual premium assistance payment amount at X.

(E)MassHealth SBE Premium Payment Administration.

(1)SBE Premium Assistance Payments.

(a) The MassHealth agency makes only one SBE premium assistance payment per policy.

(b) SBE premium assistance payments are made directly each month to the policyholder.

(c) Proof of health-insurance premium payments may be required.

(d) SBE premium assistance payments begin in the month of the MassHealth Premium Assistance eligibility determination or in the month that health-insurance deductions begin, whichever is later.

(e) Each monthly SBE premium assistance payment is for health-insurance coverage in the following month.

(f) MassHealth reviews the SBE maximum contribution amount and the cost of the member's health insurance at least once every 12 months.

(2)Change in SBE Premium Assistance Calculation.

(a) The SBE premium assistance amount is recalculated when the MassHealth agency is informed of changes in the federal poverty level, health-insurance premium, employer contribution, and whenever an adjustment is made in the premium assistance payment formula.

(b) Members whose SBE premium assistance amount changes as the result of a reported change or any adjustment in the SBE premium assistance payment formula receive the new SBE premium assistance payment beginning with the calendar month following the reported change.

(3)Termination of Premium Assistance Payments.

(a) If a member's health insurance terminates for any reason, the MassHealth SBE premium assistance payments end.

(b) If there is a change in the services covered under the policy such that the policy no longer meets the BBL requirements, the SBE premium assistance payments end.

(c) Members who become eligible for a different coverage type in which they are not eligible to receive an SBE premium assistance benefit receive their final SBE premium assistance payment in the calendar month in which the coverage type changes.

(d) If a member voluntarily withdraws his or her MassHealth application for benefits, the MassHealth SBE premium assistance payments end.