Current through Register 1531, September 27, 2024
(A)
Regulatory
Authority. The Children's Medical Security Plan (CMSP) is
administered pursuant to M.G.L. c. 118E, § 10F.
(B)
Overview. CMSP
provides coverage to uninsured children younger than 19 years old who do not
qualify for any other MassHealth coverage type, other than MassHealth Limited,
and who do not have physician and hospital health-care coverage. To apply for
these benefits, an applicant must submit an application as described in
130 CMR
502.001: Medical Benefit Request
(MBR) and 502.002: Reactivating the Medical Benefit
Request.
(C)
Eligibility Requirements. Children are eligible for
CMSP if they are
(1) a resident of
Massachusetts, as defined in
130 CMR
503.002: Residence Requirements ;
(2) younger than 19 years old;
(3) not otherwise eligible for any other
MassHealth coverage type, other than MassHealth Limited. Children who are
otherwise eligible and who are not receiving MassHealth coverage as a result of
not complying with administrative requirements of MassHealth are not eligible
for CMSP. Children who lose eligibility for MassHealth Family Assistance as a
result of nonpayment of premiums or as a result of not enrolling in
employer-sponsored health insurance through Premium Assistance are not eligible
for CMSP; and
(4) uninsured. An
applicant or member is uninsured if he or she
(a) does not have insurance that provides
physician and hospital health-care coverage;
(b) has insurance that is in an exclusion
period; or
(c) had insurance that
has expired or has been terminated.
(D)
Premiums. The
premium schedule and payment policies for CMSP are described in
130
CMR 506.011: MassHealth and the
Children's Medical Security Plan (CMSP) Premiums.
(E)
Copayments.
Members are required to pay copayments for certain covered services. There are
no required copayments for preventive and diagnostic services. No member will
be exempt from copayment requirements.
(1) The
copayments for prescription drugs are
(a) $3
for each generic drug prescription; and
(b) $4 for each brand-name drug
prescription.
(2) The
copayments for dental services are
(a) $2 for
members with modified adjusted gross income of the MassHealth MAGI household
equal to or below 199.9% of the federal poverty level (FPL);
(b) $4 for members with modified adjusted
gross income of the MassHealth MAGI household between 200.0% to 400.0% FPL; and
(c) $6 for members with modified
adjusted gross income of the MassHealth MAGI household equal to or greater than
400.1% FPL.
(3) The
copayments for medical (nonpreventive visits) and mental health services are
(a) $2 for members with modified adjusted
gross income of the MassHealth MAGI household equal to or below 199.9% FPL;
(b) $5 for members with modified
adjusted gross income of the MassHealth MAGI household between 200.0% to 400.0%
FPL; and
(c) $8 for members with
modified adjusted gross income of the MassHealth MAGI household equal to or
greater than 400.1% FPL.
(F)
Medical Coverage
Date. Except as provided at 130 CMR 522.004(H), coverage begins on
the date of the final eligibility determination. The time standards for
determining and redetermining eligibility are described at
130 CMR
502.005: Time Standards for an
Eligibility Determination and 502.007: Eligibility
Review.
(G)
Benefits Provided. Benefits provided are described at
M.G.L. c. 118E, § 10F. Included benefits are
(1) preventive pediatric care;
(2) sick visits;
(3) office visits, first-aid treatment, and
follow-up care;
(4) provision of
smoking prevention educational information and materials to the parent,
guardian, or the person with whom the enrollee resides, as distributed by the
Department of Public Health;
(5)
prescription drugs up to $200 per state fiscal year;
(6) urgent care visits, not including
emergency care in a hospital outpatient or emergency department;
(7) outpatient surgery and anesthesia that is
medically necessary for the treatment of inguinal hernia and ear tubes;
(8) annual and medically necessary
eye exams;
(9) medically necessary
mental-health outpatient services, including substance-abuse treatment
services, not to exceed 20 visits per fiscal year;
(10) durable medical equipment, up to $200
per state fiscal year, with an additional $300 per state fiscal year for
equipment and supplies related to asthma, diabetes, and seizure disorders only;
(11) dental health services, up to
$750 per state fiscal year, including preventive dental care, provided that no
funds will be expended for cosmetic or surgical dentistry;
(12) auditory screening;
(13) laboratory diagnostic services; and
(14) radiologic diagnostic
services.
(H)
Enrollment Cap. The MassHealth agency may limit the
number of children who can be enrolled in CMSP. When the MassHealth agency
imposes such a limit, applicants will be placed on a waiting list when their
eligibility has been determined. When the MassHealth agency is able to open
enrollment for CMSP, the MassHealth agency will process the applications in the
order they were placed on the waiting list.
