Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid 600 Washington Street Boston, MA 02111 www.mass.gov/masshealth Eligibility Operations Memo 06-10 July 15, 2006 TO: MassHealth Eligibility Operations Staff FROM: Russ Kulp, Director, MassHealth Operations RE: Expansion of MassHealth Family Assistance Introduction The new health-care reform bill passed by the state legislature and signed into law by the Governor required the expansion of the State Children’s Health Insurance Program (SCHIP) to cover more children under MassHealth Family Assistance. Effective July 1, 2006, financial eligibility criteria for MassHealth Family Assistance for children will be expanded from 200% to 300% of the federal poverty level (FPL). Eligibility for Family Assistance Expansion For new applicants after July 1, 2006, the child must meet the following criteria: * have family group income above 200% FPL and less than or equal to 300% FPL; * be uninsured at the time of application; * if uninsured, the family group must not have dropped employer-sponsored health insurance within the previous six months; and * be a citizen or qualified alien. For current members whose income is above 200% FPL and less than or equal to 300% FPL, see “Existing CMSP Caseload” later in this memo. Presumptive and time-limited eligibility rules for Family Assistance apply to the new expanded group. (continued on next page) Eligibility for Family Assistance Expansion (cont.) If a new applicant was previously on MassHealth or CMSP within the past year, he or she will not be denied if they have or had other health insurance. This rule is in place because it is possible that the family group enrolled in a health plan through MassHealth. The eligibility determination will pend for a health- insurance investigation and follow the current investigation procedures. Family Assistance and COmmonHealth Premiums The Family Assistance premium tables have been updated to include the new 200% to 300% FPL. Disabled children eligible for CommonHealth who have income up to 300% FPL will pay the same premiums. The new premium chart is below. %FPL Premium cost or member share (per child) Premium cost or member share (family maximum) 100.1-150.0% $12 $15 150.1-200.0% $12 $36 200.1-250.0% $20 $60 250.1-300.0% $28 $84 Redetermination of Current Households Starting July 1, 2006, any household that currently pays a MassHealth premium and is affected by the new premium table above will be redetermined. A premium-change notice will be sent to each household with either the new premium amount or the amount MassHealth will pay toward their private health insurance. MassHealth calculates only one premium per family group. When the family group contains members with multiple premiums, the family group is responsible only for the higher premium amount. For instance, an adult getting CommonHealth and a child getting CommonHealth in the same family group with income at 205% FPL will pay the adult premium of $40.00 per month rather than both the adult premium of $40.00 and the child’s premium of $20.00 per month. Another example is a family group with income at 165% FPL with an adult getting CommonHealth ($20.00 per month premium) and three children getting Family Assistance ($36.00 per month premium). The family group would have a premium of $36.00 per month. (continued on next page) Existing CMSP Caseload Children currently eligible for CMSP whose family group income is between 200% and 300% FPL will be redetermined by MA21 after July 8, 2006. An advance notice that targets this population has been sent. This notice explains the change from CMSP to Family Assistance and provides some details to the change in benefits. A copy of this notice accompanies this memo. “Crowd-out” Provisions for Children Between 200% and 300% FPL “Crowd-out” describes a situation in which a person drops private health insurance to get MassHealth at less or no cost, especially at a time when public benefits are expanded to cover those without health insurance. One way to address this is to have crowd-out provisions, such as waiting periods for eligibility. MassHealth will not provide Family Assistance if the family had employer-sponsored group health insurance for applying children within the previous six months. Families who dropped their employer- sponsored group coverage will be subject to a six-month waiting period, from the date of loss of coverage before being allowed to enroll in Family Assistance. Exceptions from this waiting period will be made for situations in which: ? a child in the family group has special or serious health needs; ? the prior coverage was involuntarily terminated, including withdrawal of benefits by an employer, involuntary job loss, or COBRA expiration; ? a parent in the family group died within the previous six months; ? the prior coverage was lost due to domestic violence; ? the prior coverage was lost due to becoming self-employed; or ? the existing coverage’s lifetime benefits were reduced substantially within the previous six months or prior employer-sponsored heath insurance was cancelled for this reason. Children who are denied for Family Assistance because their family group’s employed-sponsored health insurance was dropped may be eligible for Children’s Medical Security Plan (CMSP) during their waiting period. On the day after the waiting period ends, MA21 will automatically redetermine the case. (continued on next page) Systems Changes New MA21 Event The new Insurance Coverage Dropped (ICD) event in MA21 will be used to record crowd-out and dropped health insurance information. Only the Family Assistance Program staff and MEC and CPU supervisors and managers will have access to the ICD event. Other staff will have query access only. Information from this event will be used to calculate the waiting period for Family Assistance. See the following example of the ICD event screen. MA21 Noticing Children who are denied Family Assistance because of the crowd-out provisions will receive a new type of CMSP notice that explains why they were denied Family Assistance. A separate notice will accompany the CMSP notice that lists the exceptions to the crowd-out provisions. This notice also has the earliest date on which a child may be eligible for Family Assistance. If the child meets one of these exceptions, the notice will be filled out and returned to the address for the Family Assistance Program that is listed on the notice. Copies of the new CMSP notice and the exceptions notice are attached to this memo. The Family Assistance Program staff will be responsible for collecting and entering into the ICD event the information that is on the returned exceptions notice. (continued on next page) Eligibility Operations Memo 06-10 July 15, 2006 Page 5 MEC and CPU Responsibilities When staff at the MECs and at CPU enters health-insurance information into the HIN event, they need to be sure to indicate the correct type. In the HIN event, there are five types of health insurance from which to choose. “Medical Insurance” is the only type that will deny a new applicant for Family Assistance if their family group income is between 200% and 300% FPL. If the member sends the exceptions notice to a MEC or CPU, a supervisor or manager can enter the information into the ICD event. The notice should then be forwarded to: Family Assistance Program P.O. Box 9212 Chelsea, MA 02150 Attachments This memo includes the following attachments: ? the new CMSP notice; ? the “Notice About Your MassHealth Benefits” that accompanies the new CMSP notice; and ? the advance notice to current CMSP household whose family group income is 200% to 300% FPL. Questions If you have any questions about this memo, please have your MEC designee contact the Policy Hotline. REVERE OFFICE 300 OCEAN AVENUE, SUITE 4000 REVERE MA 02151-3675 Tel: (800) 322-1448 TTY: (888) 665-9997 Fax: (781) 485-3400 550/APPR JIM CMSP 1 MAIN ST BOSTON MA 02111-0000 Date: 05/25/2006 Notice: 1376219 SSN: 601-23-1111 Dear JIM CMSP The MassHealth Agency has decided that the following members of your family can get benefits. Benefit Name Coverage Effective SSN/DOB Type Date CMSP, JIMJR Children's Medical 05/25/2006 601-24-1111 Security Plan Children who are eligible for CMSP may be eligible for more benefits under the Family Assistance program. It is important that you read the message about your MassHealth benefits that came with this notice. Follow the instructions on that notice if you think you may be eligible for Family Assistance. CMSP is an insurance program that provides primary and preventative health care for children though the age of 18. Call the CMSP customer service center at (800) 909-2677 for help in finding a CMSP doctor or for questions on what non-emergency services are covered by CMSP. You will soon get a CMSP card; your CMSP card will be mailed to you separately. You need to show your card to your doctor and the pharmacy when getting medical services. For free good foods and help with healthy eating, call WIC - the Women, Infant and Children nutrition program. WIC serves pregnant women, children under five, and new mothers. You and your children may be eligible for WIC services. Call the WIC Hotline at 1-800-942-1007. You may be able to get additional services from a hospital or community health center that are not covered by a MassHealth program. These services may be paid for by the Uncompensated Care Pool. For more information, call 1-877-910-2100. Call the phone number at the top of this notice if you have any questions about this notice. If you don't have a copy of the MassHealth booklet, please call to request one. It has important information about MassHealth coverage and rules. For information about appealing our decisions, see the other side of this notice. _______ Office Commonwealth of Massachusetts MEC Street Address Executive Office of Health and Human Services MEC City, State, Zip Division of Medical Assistance This is an important message about your MassHealth benefits. Based on the information you gave us about your income and family size, the benefit you could get would be Family Assistance. But the MassHealth agency has information that you recently had health insurance from an employer. At your family’s income level, you cannot get MassHealth Family Assistance if you had health insurance from an employer within the past six months. You will have to wait six months from the date of loss of this coverage before you may be able to get Family Assistance. The earliest date you may be eligible for Family Assistance is listed below: Name SSN/DOB Date Smith, Jim 601-10-1111 12/01/2006 You may get Family Assistance right away if you meet one of the following exceptions. Please put a checkmark (?) in the space next to the letter (A, B, C, D, E, or F) of the exception that you think you meet. Also, the head of household must sign below. Return this form to the address below. You will receive another letter if MassHealth makes a new decision. ( ) A. A child in the family group has special or serious health-care needs. ( ) B. The prior coverage was involuntarily terminated, including withdrawal of benefits by an employer, involuntary job loss, or loss of COBRA benefits. ( ) C. A parent in the family group died in the previous six months. ( ) D. The prior coverage was lost due to domestic violence. ( ) E. The prior coverage was lost due to becoming self-employed. ( ) F. The existing coverage’s lifetime benefits were reduced substantially within the previous six months, or prior employer-sponsored health insurance was cancelled for this reason. Signature of Head of Household Return this signed form to: Family Assistance Program P.O. Box 9212 Chelsea, MA 02150 Commonwealth of Massachusetts EOHHS Office of Medicaid May 2006 Dear CMSP Member, Parent, or Caretaker: We are pleased to tell you that because of a new state law, your child may get better health-insurance coverage than he or she is now getting from the Children’s Medical Security Plan (CMSP) or the Uncompensated Care Pool (UCP). (UCP is also called Partial Free Care.) Based on your family income, your child may soon get more complete benefits under MassHealth Family Assistance. During July and August, we will send letters to the homes of all children who move from CMSP to MassHealth with the date MassHealth coverage will start. On the date that MassHealth coverage starts, your child will no longer be eligible for CMSP. Instead, your child will get more benefits through MassHealth. Below is some basic information about this new MassHealth coverage and important information about what you will need to do to make sure your child gets this new coverage. Help with health-insurance premiums If your employer offers family health-insurance coverage that you have not been able to afford, MassHealth may be able to help you pay the premiums for this coverage instead of providing benefits to your child directly. You will be required to enroll in qualifying employer-sponsored insurance that is offered to you at your job. Signing up for family health-insurance coverage at your job is a great way to get health insurance for parents and children. We will send you more information about this in the future if we receive information that your child can get qualified health insurance through your employer. MassHealth will cover your child directly for a period of time while you make arrangements at your job to enroll in family health-insurance coverage. More complete benefits MassHealth provides Family Assistance direct coverage for children when employer-sponsored health insurance is not available. This coverage includes all the benefits now covered by CMSP and UCP, and many more benefits if they are medically necessary services, including: Inpatient and outpatient hospital coverage: MassHealth includes inpatient hospital coverage that CMSP does not. And, unlike UCP, MassHealth has no deductibles. You will not have to worry about hospital bills for your child! Dental coverage: MassHealth does not limit dental benefits to $750 the way CMSP does. Full pharmacy coverage: MassHealth does not limit pharmacy benefits to $200 the way CMSP does. Mental health and substance abuse treatment CMSP-AN (05/06) services: MassHealth does not limit these services the way CMSP does. MassHealth provides eyeglasses, medical supplies and equipment, and more. No copayments: Unlike CMSP, MassHealth does not charge copayments for any benefits for children and, unlike UCP, MassHealth has no deductibles or coinsurance for children. Choice of health plans MassHealth offers a choice of health plans if you cannot get health insurance from your employer. Under these health plans, children have access to thousands of health-care providers across the state, including primary-care physicians, specialists, hospitals, community health centers, and more. MassHealth premiums You will not have to pay any copayments or deductibles for MassHealth direct coverage, but you will be charged a monthly premium. Depending on your family income, you will be charged either $20 per child per month (up to a maximum of $60 per month for three or more children) or $28 per child per month (up to a maximum of $84 per month for three or more children). The letter you will get from MassHealth will tell you what your monthly premium amount will be. If at times you cannot pay your monthly premiums, MassHealth has payment plans. There are also waivers of premium payments if you have a hardship. You will receive more information about MassHealth premiums in future letters from MassHealth. What you need to do now Continue to pay CMSP premiums until your child’s new MassHealth coverage begins. Respond to any requests for information or redeterminations from CMSP. Tell MassHealth if you move. Important: If your child loses CMSP coverage because premiums are not paid or because you did not respond to information requests, MassHealth will not be able to automatically enroll your child in Family Assistance and your child will not be able to reenroll in CMSP. Questions If you have any questions, please call the MassHealth Customer Service Center at 1-800-841-2900 (TTY: 1-800-497-4648 for people with partial or total hearing loss), Monday through Friday, 8 AM to 5 PM. MassHealth–a better plan for your child. Commonwealth of Massachusetts EOHHS Oficina de Medicaid Mayo, 2006 Estimado afiliado de CMSP, padre o guardián: Tenemos el placer de informarle que debido una nueva ley del estado, su hijo puede tener una mejor cobertura de seguro médico que la que hoy tiene a través del Plan de seguridad médica para niños [Children’s Medical Security Plan (CMSP)] o del Fondo no común no compensado para servicios médicos de Cuidado [Uncompensated Care Pool (UCP)]. (UCP también se conoce como Cuidado parcial gratuito o Partial Free Care). Basado en sus ingresos familiares, su hijo podrá pronto obtener beneficios más completos a través de MassHealth Family Assistance. Durante julio y agosto, enviaremos cartas a las casas de todos los niños que se transfieren de CMSP a MassHealth con la fecha en que comenzará la cobertura de MassHealth. En la fecha en que comience la cobertura de MassHealth su hijo ya no será elegible para CMSP. En su lugar, su hijo recibirá más beneficios a través de MassHealth. A continuación hay alguna información básica sobre esta nueva cobertura de MassHealth e información importante sobre lo que usted debe hacer para asegurar que su hijo tenga esta nueva cobertura. Ayuda con las primas del seguro médico Si su empleador ofrece un seguro médico de cobertura familiar que usted no ha podido pagar, es posible que MassHealth pueda ayudarle a pagar sus primas para esta cobertura en lugar de proveer directamente beneficios a sus hijos. Usted tendrá que afiliarse a un seguro calificado que sea patrocinado por su empleador y ofrecido en su lugar de trabajo. El afiliarse a una cobertura de seguro médico familiar en su trabajo es una gran manera de tener seguro médico para padres e hijos. Le enviaremos más información sobre esto en el futuro si recibimos información de que su hijo puede recibir un seguro médico calificado a través de su empleador. MassHealth cubrirá a su hijo directamente por un período mientras que usted hace las gestiones necesarias en su trabajo para enrolar su familia en un seguro médico familiar. Beneficios más completos MassHealth provee cobertura directa a través de Family Assistance para niños cuando no existe por parte del empleador un seguro médico. Esta cobertura incluye todos los beneficios que hoy día cubren CMSP y UCP, y muchos otros beneficios si fueren médicamente necesarios, tales como: Cobertura hospitalaria para pacientes hospitalizados y ambulatorios: MassHealth incluye cobertura hospitalaria para pacientes hospitalizados CMSP-AN (SP) (05/06) que CMSP no provee. Al contrario que UCP, MassHealth no tiene deducción de gastos. ¡Usted no tendrá que preocuparse sobre las facturas del hospital para sus hijos! Cobertura dental: MassHealth no limita los beneficios dentales a $750 como hace CMSP. Cobertura total para la farmacia: MassHealth no limita los beneficios de farmacia a $200 como hace CMSP. Servicios para la salud mental y tratamiento del abuso de substancias: MassHealth no limita estos servicios como hace CMSP. MassHealth provee gafas, suministros y equipos médicos y mucho más. No hay copagos: Al contrario que CMSP, MassHealth no impone copagos en los beneficios para niños y, al contrario que UCP no tiene deducciones de gastos o coseguro para los niños. Elección de planes médicos MassHealth ofrece una selección de planes médicos si usted no puede recibir un seguro médico a través de su empleador. A través de estos planes médicos, los niños tienen acceso a miles de proveedores de cuidados para la salud en todo el estado, incluyendo médicos de cabecera, especialistas, hospitales, centros de salud comunitarios y muchos más. Primas de MassHealth Usted no tendrá que efectuar copagos o tendrá deducciones en la cobertura directa por MassHealth, pero se le cobrará una prima mensual. Dependiendo de sus ingresos familiares, se le cobrarán $20 al mes por niño (hasta un máximo de $60 al mes por tres o más niños) o $28 al mes por niño (hasta un máximo de $84 al mes por tres o más niños). La carta que recibirá de MassHealth le dirá cual será su prima mensual. Si hay momentos en que usted no pueda pagar sus primas mensuales, MassHealth tiene planes de pago a plazos. Existen también exenciones del pago de la prima mensual si usted pasa por un momento difícil. Usted recibirá más información en cartas futuras sobre las primas de MassHealth. ¿Qué tiene usted que hacer ahora? Continúe pagando las primas de CMSP hasta que comience la nueva cobertura de MassHealth para su hijo. Conteste a cualquier petición de información o determinación de CMSP. Notifique a MassHealth si se muda. ¡Importante! Si su hijo pierde la cobertura de CMSP debido a que las primas no se pagaron o porque usted no respondió a peticiones de información, MassHealth no podrá enrolar a su hijo automáticamente en Family Assistance y su hijo no podrá reinscribirse en CMSP. Preguntas Si usted tiene alguna pregunta, llame al Centro de servicios al cliente de MassHealth: 1 800 841 2900 (TTY: 1 800 497 4648 para personas con sordera total o parcial) de lunes a viernes, de 8 de la mañana a 5 de la tarde. MassHealth–el mejor plan para su hijo.