Premium Assistance Program

MassHealth

Premium Assistance Program

PremiumAssistanceandTPL

Programs

Topics

■Whatis Premium Assistance?

■Review of Eligibility Criteria

■Investigations,ConfirmedAccessandApprovals

■Whathappens when a memberdoesn’tenroll?

■PremiumBillingand PremiumAssistance

■Member benefits

WhatisPremium Assistance?

■MassHealthhelpseligiblemembers pay fortheir health insuranceby sendingthem monthly payments

■Eligibilityfor MassHealthPremiumAssistanceis determinedby theindividual’sMassHealthcoveragetype andthetypeof healthinsurancethat theindividualhas or has access to

■MassHealthPremium Assistanceprogramsare designed to provideMassHealtha costeffectivewayof delivering benefits toMassHealthmemberswhohavehealth insurance

EligibilityCriteriafor

PremiumAssistance

MassHealthcan providemembers with a Premium Assistance(PA) benefitwhenthemember and the health insurancepolicymeet certain criteria. MassHealthmay providea PApaymenttoaneligiblemember whenallof thefollowingcriteria aremet:

■Thehealth-insurancecoveragemeetstheBasicBenefitLevel(BBL)

■Thehealth-insurancepolicyholderiseitherinthePremiumBilling FamilyGroup(PBFG)orin certainsituationsthepolicyholder resideswith theindividualwhois eligible forthePAbenefit

■Thehealth-insurancepolicyis apolicythatMassHealthhas authorizationtopurchasebasedontheeligibilityoftheMassHealth memberscoveredbythepolicy

EligibilityCriteriaforPremium

Assistance

MassHealthmayprovidepremiumassistanceforthefollowingcategoriesof healthinsurance:

■EmployerSponsoredInsurance(ESI):Towhichtheemployercontributesatleast

50%towardthemonthlypremiumamount.

■OtherGroupInsurancePlans:Towhichanemployermaycontributelessthan50%towardthemonthlypremiumamount,COBRAcoverage,andothergrouphealthinsuranceaccess.

Thecategoriesof healthinsurancethat MassHealthhas authorizationto

providepremiumassistancefor by MassHealthcoveragetypeare:

MassHealthCoverageType / ESI50%
Plans / OtherGroup
InsurancePlans
•Standard(exceptBCCTmemberswithincomeover133%)
•CommonHealth
•CarePlus
•FamilyAssistanceChildrenatorbelow150%FPL,YoungAdults,
HIV+andDisabledAdults / Yes / Yes
•FamilyAssistanceChildrenbetween150%and300%FPL / Yes / Not eligibleforpremium
assistance

Insurance Investigations

■MassHealthperformsinvestigationstodetermineifmembers:

–HavehealthinsurancethatMassHealthmayhelppayfor;or

–HaveaccesstoESI in whichMassHealthwantstheindividualto enrollandforwhichMassHealthwillhelppayfor

■HIXprovidesinformationtothePremiumAssistanceUnitonMassHealthmemberswhohavereportedhealthinsuranceorwhohaveindicatedtheymayhaveaccesstoESI

■ThePremiumAssistanceUnitmaycontactthemember,theemployer,and/orthehealthinsurancecompanytodetermineiftheplan(s)availabletothemembermeettheMassHealthcriteriaforenrollmentincoverage

–Thepolicyholderandhis/heremployerwillneedtocompletea PremiumAssistanceApplicationthatincludesemployeeshareof premiumcostsanda SummaryofBenefitsofchosenplan

InvestigationsbyCoverageType

MassHealthCoverage
Type / Investigateself declared insurance? / InvestigateaccesstoESI and requireenrollmentin coverage?
Standard / Yes / Yes, allbutBCCTandHIV
CommonHealth / Yes / Yes
CarePlus / Yes / Yes
FamilyAssistance
•Children / Yes / Yes
•YoungAdultsbelow 150%FPL / Yes / Yes
•YoungAdultsabove 150% / No / No
•DisabledAdults / Yes / Yes
•AdultsandElders / No / No
Limited / No / No

Do membersneedto wait

foraninvestigation?

No!!!

■Membersareencouragedtocallandapplyforpremiumassistanceon theirowniftheyalreadyhavehealthinsurance

■AlleligibilityapprovalnoticesforStandard,CommonHealth,Family Assistance,andCarePlusthataregeneratedoutofHIXincludethe languagebelow:

–MassHealthmemberswhohavehealthinsurancefromajobmay beable togethelp payingforpartoftheirpremium.Thishealth insurancemustmeetcertainrules.Formoreinformationcontact theMassHealthPremiumAssistanceUnitat1-800-862-4840 (TTY:1-617-886-8102forpeoplewhoaredeaf,hardofhearing,or speechdisabled).

Members whohaveaccess toESI that meets MassHealth criteria must enrollincoverageuponrequest:

■AdeterminationisdoneinHIXandwill generatea noticeadvising

thememberoftheneedtoenrollin theESI planwithin 60days

■Additional notificationis senttotheindividualwhohasaccess informingthemofwhichESI plan(s)offeredbytheiremployermeet thecriteriaforMassHealthPremiumAssistance

■MembersmustcontacttheMassHealthPremiumAssistanceUnit uponESIplan selectionandenrollmentinordertobeginreceiving premiumassistancepayments

Formembers whothePremium AssistanceUnithas confirmed accesstoESI butmember failsto enrollwithin the60 daytimeframe:

Uponexpirationofthe60daydeadlinetoenrollintohealthinsurance,HIXwillperformaneligibilitydeterminationandterminatecoverageforallexceptthefollowingmembers:

• PregnantwomeninStandardorCommonHealth

• ChildrenoryoungadultsreceivingStandardor CommonHealth

Aterminationnoticewillbesent

PremiumAssistance

Approval

■Aneligibilitynoticewillbesentinformingthepolicyholderofthepremiumassistanceapprovalandthepremiumassistancepaymentamount.

■Thepolicyholderwillreceivethepremiumassistancepaymentsmonthlyforthefollowingmonth’shealthinsurancepremium.

■PremiumassistancepaymentsbegininthemonthoftheMassHealthPremiumAssistanceeligibilitydeterminationorinthemonththathealthinsurancedeductionsbegin,whicheverislater.

■Membersareencouragedtosignupfordirectdepositoftheirpremiumassistancepayment

■Memberswhohavebeenpayinga premiumbill to MassHealthfor theircoveragearestillrequiredtocontributethatamountwhenthey becomeeligible forpremiumassistance.

■Inmostcasesthememberspremiumbillingamountwillbecometheir requiredmembercontributionwhichwillbedeductedfromtheir premiumassistancepayment.

–Example:ThomasBrady is eligibleforMassHealthFamily Assistance

•AtanFPLof 152%heis chargeda billof$12/monthfor this coverage

•Thomas’mother Mary has HarvardPilgriminsuranceavailableto her throughher employer,MarketBasket. Theinsurancecosts

$250/month

•Uponpremiumassistanceapproval,Marywillreceive$238/monthto cover Thomas onher insurance

■Insomeinstancesamember’spremiumbill amountis higherthanthe costoftheirhealthinsurancecoverage.This usuallyonlyhappensfor CommonHealthmemberswithhigh incomes.Ifamembermeetsthe criteriaforPremiumAssistance,thePremiumAssistancemonthly paymentwilloffsettheMassHealthpremiumbill.Thesememberswill stillbe responsibleforpayingthisnewoffsetamounttoMassHealth

–Example:SusanneSmith is eligiblefor MassHealthCommonHealth

•With anFPLof800%,her monthlybillfor MassHealthis $646/month

•SusanneworksatMGH andhas TuftsInsuranceavailableto her ata

cost of $300/month

•Susanne’spremiumbillforMassHealthis greater thanthecostof her ESI

•Uponpremiumassistanceapproval,hermonthlyMassHealthbillwill

bereducedto$346/month13

ESI andPremium Assistance

MassHealthmembersoftenhaveamisconception thattheydonotneedtoenrollinhealthinsurancethattheyhaveaccesstobecausetheyalreadyhaveMassHealth.Infact,enrollingintoaffordablecoveragewithPremiumAssistancecanbenefitmembersforthereasonsbelow:

■PremiumAssistanceeligiblemembersreceivereimbursementtowardthecostoftheirprivatehealthinsurance–inmostcasestheirESIwillbeatnocosttothemember.

■ObtainingaprimaryinsuranceinadditiontoMassHealthcoveragewillprovidethememberwithagreaternetworkofservices,andbetteraccessthecaretheyneed.

■ManyMassHealthmembers withESIwillbeeligibletoreceivethewrapofco-

payments,deductibles,andcoinsurance.

■NonMassHealtheligiblefamilymembers(usuallyparents)cangethealthinsurancecoverage(ESI)atlowtonocostwhenotherfamilymembersareMassHealthmembers.

■Ifahousehold’sincomeincreasesovertheMassHealtheligibilitythreshold,thefamilywillbeabletoretaincontinuityofcarewiththealreadyexistingprivateinsurance,andwillnotneedtoscrambletoenrollintotheirESIorgowithouthealthcoverageforanyperiodoftime.

ContactUs

Premium AssistanceHotline:

1-800-862-4840

Fax:

617-451-1332

MailingAddress:

Premium AssistanceUnit

POBox 9212

Chelsea,MA02150