Model Massachusetts CommonHealth separately from the shared working-disabled buy-in schema

[daphnehanse11]

Follow-up to #8493 and narrower successor to closed #8465. Massachusetts CommonHealth should be modeled separately from the first shared working-disabled buy-in schema because it is a state coverage type for disabled children, disabled adults, disabled working adults, and disabled young adults, not only a simple disabled-worker buy-in row.

Why this is separate from the shared schema

MassHealth CommonHealth has several features that do not fit neatly into a first-pass shared working-disabled buy-in parameter table:

• It covers multiple disabled groups, not just working disabled adults.
• Disabled working adults have a specific work-hours rule: at least 40 hours per month, or at least 240 hours in the six months before application or review if working fewer than 40 hours/month.
• The disability definition for working adults ignores substantial gainful activity, but the person must be permanently and totally disabled.
• Disabled adults who are not working can qualify through a one-time deductible route, or with HIV-positive status and income up to 200% FPL.
• There are separate rules for disabled working young adults, disabled young adults, disabled 18-year-olds, and disabled children.
• Applicants and members must use available health insurance, including employer-sponsored coverage and Medicare, when MassHealth requires it and premium assistance applies.
• CommonHealth premiums use MassHealth premium billing family group rules, full vs supplemental premium formulas, and premium assistance offsets.
• CommonHealth members can have extended coverage for up to three calendar months after terminating employment if premiums are paid timely.

This should probably feed into the shared WORKING_DISABLED_BUY_IN category only for the working-disabled subpopulation, while preserving a Massachusetts-specific CommonHealth implementation for the broader coverage type.

Source details

130 CMR 505.004 says MassHealth CommonHealth is available to disabled children, disabled adults, and disabled working adults.

Disabled working adults must:

• be age 21 through 64;
• be employed at least 40 hours per month, or if employed less than 40 hours/month, have been employed at least 240 hours in the six-month period immediately before application or eligibility review;
• be permanently and totally disabled, except for engagement in substantial gainful activity;
• be a U.S. citizen or qualified noncitizen;
• be ineligible for MassHealth Standard;
• comply with health-insurance-use requirements.

Disabled adults who are not in the working-adult group must:

• be age 21 through 64;
• be permanently and totally disabled;
• be ineligible for MassHealth Standard;
• be a citizen or qualified noncitizen;
• either meet a one-time deductible or have Disabled Adult household MAGI at or below 200% FPL and verify HIV-positive status.

Other CommonHealth groups include disabled working young adults, disabled young adults, disabled 18-year-olds, and disabled children under 18.

Disability can be established by:

• certification of legal blindness by the Massachusetts Commission for the Blind;
• SSA disability determination; or
• Disability Evaluation Services determination.

Premium and insurance rules:

• CommonHealth members may be assessed premiums under 130 CMR 506.011(B)(2).
• The MassHealth premium rule applies to Standard, CommonHealth, and Family Assistance members with income above 150% FPL.
• Premiums are calculated using premium billing family group rules.
• For CommonHealth young adults/adults above 150% FPL, the full premium formula starts at $15 above 150% FPL and increases by FPL brackets, continuing above 1000% FPL.
• A supplemental premium formula applies when members have other health insurance to which MassHealth does not contribute.
• If MassHealth determines a member has employer-sponsored insurance available and it meets premium-assistance criteria, the member generally must enroll; failure to enroll can cause loss or denial of eligibility.
• The regulation provides hardship waiver and delinquent-payment rules.

Implementation notes

• Do not force all of CommonHealth into working_disabled_buy_in if Model working-disabled Medicaid buy-in as one Medicaid category with state-specific parameters #8493 only models working-disabled buy-in eligibility.
• Create Massachusetts-specific CommonHealth variables, then expose a working-disabled CommonHealth sub-result to the shared WORKING_DISABLED_BUY_IN category where appropriate.
• Treat disabled working adult eligibility separately from disabled adult deductible eligibility.
• Model or document the employment test:
  • 40 hours/month; or
  • 240 hours in the preceding six months.
• Decide whether the first implementation approximates the six-month work-history rule using current annual/monthly employment inputs.
• Model CommonHealth premiums in a premium framework rather than as a flat KFF value.
• Add source comments around premium assistance/employer coverage requirements, because these may be hard to observe in CPS.

Acceptance criteria

• A Massachusetts disabled working adult age 21-64 who is ineligible for MassHealth Standard and satisfies the work test qualifies through CommonHealth.
• A disabled working adult does not fail merely because their work would otherwise indicate substantial gainful activity.
• A disabled adult who is not working is not incorrectly classified as a working-disabled buy-in case solely because CommonHealth exists.
• The working-disabled CommonHealth path maps to the shared WORKING_DISABLED_BUY_IN category from Model working-disabled Medicaid buy-in as one Medicaid category with state-specific parameters #8493, while leaving room for broader CommonHealth coverage modeling.
• Tests cover:
  • age boundary for adult working eligibility;
  • 40-hour/month work test;
  • premium above 150% FPL if premiums are in scope;
  • a non-working disabled adult case to prevent overclassification.

Sources

• MassHealth CommonHealth, Mass.gov: https://www.mass.gov/info-details/masshealth-commonhealth
• 130 CMR 505.004, MassHealth CommonHealth: https://www.law.cornell.edu/regulations/massachusetts/130-CMR-505-004
• 130 CMR 506.011, MassHealth Premiums and CMSP Premiums: https://www.law.cornell.edu/regulations/massachusetts/130-CMR-506-011
• MassHealth Premium Information for Members: https://www.mass.gov/info-details/masshealth-premium-information-for-members

Related: #8493, #8465, #8102, #8497.