SECTION 9C. Medical insurance reimbursement programs; definitions; eligibility; expenditures; submission of plans

[Text of section effective as provided by 1997, 47, Sec. 36 as amended by 2003, 9, Sec. 37.]

Section 9C. (1) For purposes of this section, the following words shall have the following meanings:—

''Eligible employer'', (i) an individual or an unincorporated business that employs one or more residents of the commonwealth, (ii) a corporation, including a foreign corporation, other than a governmental entity, that employs at least one or more residents of the commonwealth, or (iii) a corporation or an unincorporated entity that is exempt from taxation under the provisions of section 501(c) of the Internal Revenue Code of the United States, as amended and in effect for the taxable year; provided however, that to be eligible said employer employs no more than 50 employees and meets the eligibility requirements set forth in this section and in regulations promulgated by the division; and provided, further, that the method of determining the number of employees an employer has and the amount and types subsidies available to an eligible employer based upon employee family status shall be determined by the division.

''Eligible employee'', an employee: (i) who is employed by an eligible employer; (ii) who resides in the commonwealth; (iii) who has not attained age 65; (iv) whose employer or family member's employer has not in the last 6 months provided insurance coverage for which the individual is eligible; and (v) who meets the financial and other eligibility standards set forth in regulations promulgated by the division, if the gross family income standard does not exceed 300 per cent of the federal poverty level.

''Eligible self-employed single individual'', a person with or without dependents (i) who receives any gross income from self-employment; (ii) who resides in the commonwealth; (iii) who has not attained age 65; and (iv) who meets the financial and other eligibility standards set forth in regulations promulgated by the division, provided that the gross family income standard shall not exceed 300 per cent of the federal poverty level.

''Eligible self-employed husband and wife'', a married couple with or without dependents (i) where either spouse receives any gross income from self employment; (ii) where both spouses reside in the commonwealth; (iii) where neither spouse has attained age 65; and (iv) who meets the financial and other eligibility standards set forth in regulations promulgated by the division, provided that the gross family income standard shall not exceed 300 per cent of the federal poverty level.

''Qualified medical insurance'', shall mean ''qualified medical insurance'', ''qualified individual medical insurance'', ''qualified two-person family medical insurance'' and ''qualified family medical insurance'' as defined in regulations promulgated by the commissioner of insurance pursuant to section 3C of chapter 175.

(2) The division may, subject to the provisions of this section, establish an insurance reimbursement program for certain employees and employers for the purpose of reducing or eliminating the amount of contributions or payments made by such employees and employers toward the cost of qualified medical insurance and which shall consist of the following three programs:

(A) an employee subsidy program to assist eligible employees with reducing or eliminating their contribution to premiums or other employment-based costs of qualified medical insurance provided by an eligible employer for which said employer pays not less than 50 per cent of said premium or cost; and provided, further, that the amount of said subsidies may vary with the contribution of said employees to the cost of their qualified medical insurance, and with the income of said employees and their families, in accordance with one or more sliding fee schedules set forth in regulations promulgated by the division and may be paid directly to or on behalf of said eligible employees; and, provided further, that the amount of the subsidy shall not be greater than that of the subsidy the employee would have received if enrolled in the subsidized insurance program under chapter 118H.

(B) a subsidy program to assist the self-employed single individual and the self-employed husband and wife with reducing the cost of premiums or other costs of purchasing qualified medical insurance; provided, however, that the amount of said subsidies may vary with the income or insurance costs of said persons and their families under 1 or more sliding fee schedules set forth in regulations promulgated by the division and may be paid directly to or on behalf of said persons; and provided further, that the amount of the subsidy shall not be greater than that of the subsidy the employee would have received if enrolled in the subsidized insurance program under chapter 118H.

(C) an employer health care incentive program for the purpose of reducing the cost to said employers of providing or maintaining qualified medical insurance for their eligible low-income employees; provided, however, that said eligible employer pays 50 per cent or more of the premium cost of such qualified medical insurance; and provided, further, that the division may limit payments under this program, using a reasonable methodology, in relation to the participation of said employer's employees in the subsidy program provided for in paragraph (A). No payments authorized under this paragraph shall be made to a self-employed individual or a self-employed husband and wife.

(3) The subsidy programs described in paragraphs (A) and (B) of subsection (2) shall constitute additional medical benefits to expansion beneficiaries in accordance with the terms and conditions of a demonstration project as defined in subsection (1) of section 9A. The division may, subject to the terms and conditions of said demonstration project, include in the demonstration project the program described in paragraph (C) of subsection (2); provided, however, that the division may implement said program if it is not included within said demonstration project.

(4) The amount of payments for each employer under paragraph (C) of subsection (2) shall be as follows: (i) $400 for each eligible employee for whom the eligible employer pays 50 per cent or more of the cost of qualified individual medical insurance; (ii) $800 for each eligible employee for whom the eligible employer pays 50 per cent or more of the cost of qualified two-person family medical insurance, and (iii) $1,000 for each eligible employee for whom the eligible employer pays 50 per cent or more of the cost of qualified family medical insurance; provided that the division may use any reasonable data sources in determining the number of eligible employees of an eligible employer qualifying for such payments under clauses (i), (ii) and (iii).

[There is no subsection (5).]

(6) The division may require, as a condition for receiving benefits under this section and solely for the purposes of determining the eligibility of any employee, self-employed single individual, or self-employed husband and wife, the consent of any applicant to the disclosure to the division and to the United States Department of Health and Human Services pursuant to subsection (10) of prior year's tax information and any other information demonstrating the income level of such persons. The division may employ additional eligibility criteria to ensure, where appropriate, that no person or employer receives payments or assistance under more than one category of persons or employers eligible for payment or assistance.

(7) The income and other eligibility requirements for the programs provided under subsection (1) may be modified from time to time to ensure that projected expenditures for such benefits are within the amounts available and within the amounts projected to be available. The division shall set forth in regulations changes in eligibility requirements, including changes necessary to ensure compliance with the budget neutrality requirements of section 9B.

(8) The division may, in lieu of cash payments or otherwise, issue to individuals vouchers or other documents certifying that the division will pay a specified amount for medical insurance under specified circumstances.

(9) If, during the term of the demonstration project as it pertains to programs authorized under this section, the division proposes modifications to the demonstration project which require approval by the Secretary, the division may implement said modifications upon the Secretary's approval, subject to the terms of that approval, and, if required, the enactment of authorizing legislation.

(10) Data and information obtained by the division pursuant to subsection (6) to determine eligibility under this chapter shall be available for inspection by the Secretary or his delegate for the specific purpose of substantiating expenditures made under this section.

(11) The division may implement the provisions of this section through arrangements with other agencies of the commonwealth, including the department of revenue, as provided in subsection (11) of section 9A.

(12) The provisions of this section shall not give rise to, nor be construed as giving rise to, enforceable legal rights for any party or an enforceable entitlement to benefits other than to the extent that such rights or entitlements exist pursuant to the regulations of the commissioner of insurance and the regulations of the commissioner of revenue under the provisions referenced in subsection (1), the regulations of the division, or the terms and conditions of the demonstration project.

(13) Expenditures under this section shall, subject to appropriation, be funded by the MassHealth insurance reimbursement program account. Aggregate expenditures made by the division for said insurance reimbursement program shall not exceed $120,000,000 in any fiscal year, nor exceed $56,000,000 in the fiscal year when said program commences and shall be further subject to the requirements of the budget neutrality plan established by section 9B.

(14) Ninety days prior to implementing one or more of the programs under this section, the division shall provide a plan or plans for implementing said programs to the committee on health care and to the house and senate committee on ways and means. Said programs may be offered separately and implemented at different times, and a plan relative to each program may be submitted separately.