Commonwealth of Massachusetts
Executive Office of Health and Human Services
Office of Medicaid
600 Washington Street Boston, MA 02111 www.mass.gov/masshealth

MassHealth Eligibility Letter 127 October 15, 2004

TO:
MassHealth Staff

FROM:     Beth Waldman, Medicaid Director

RE:	Transition of the Children’s Medical Security Plan (CMSP) and the Healthy Start
Program (HSP) to MassHealth
MassHealth is changing the regulations in 130 CMR 522.000 to transition the Children’s Medical Security Plan and the Healthy Start Program to MassHealth.
The Children’s Medical Security Plan (CMSP) is a health insurance program that provides uninsured (except MassHealth Limited) children and adolescents access to primary and preventive services, regardless of family income.
The Healthy Start Program (HSP) promotes early, comprehensive, and continuous prenatal care for low-income, uninsured (except MassHealth Limited) pregnant women.
These regulations are effective November 1, 2004.
MANUAL UPKEEP

Insert
522.000 522.003
522.004 (1 of 3) 522.004 (2 of 3) 522.004 (3 of 3) 522.005

Remove
522.000 522.003

Trans. By
E.L. 41 E.L. 41

130 CMR: DIVISION OF MEDICAL ASSISTANCE
Trans. by E.L. 127

Rev. 11/01/04

MASSHEALTH OTHER DIVISION PROGRAMS

Chapter     522
Page	522.000

TABLE OF CONTENTS
Section
522.001:	Massachusetts Insurance Connection for Individuals with AIDS or HIV-Related Diseases
522.002:	Refugee Resettlement Program
522.003:	Adoption Assistance and Foster Care Maintenance
522.004:	Children’s Medical Security Plan (CMSP)
522.005:	Healthy Start Program (HSP)

130 CMR: DIVISION OF MEDICAL ASSISTANCE
Trans. by E.L. 127
MASSHEALTH
OTHER DIVISION PROGRAMS	Chapter     522
Rev. 11/01/04	Page	522.003
522.003:  Adoption Assistance and Foster Care Maintenance
Any child placed in subsidized adoption or foster care under Title IV-E of the Social Security Act is automatically eligible for medical assistance provided by the state where the child resides.
(A)	Children receiving state-subsidized adoption payments from a state that is a member of the Interstate Compact on Adoption and Medical Assistance (ICAMA) will be eligible for medical assistance provided by the state where the child resides if that state is a member of ICAMA.
(B)	Children receiving state-subsidized adoption payments from a state that is not a member of ICAMA, or any child receiving state-subsidized foster-care payments will only be eligible for medical assistance provided by his or her state of origin.
522.004:  Children’s Medical Security Plan (CMSP)
(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 under age 19 who do not qualify for any other MassHealth coverage type, other than MassHealth Limited, and who are not able to obtain primary and preventive health-care coverage. To apply for these benefits, an applicant must submit a Medical Benefit Request (MBR) as described in 130 CMR 502.001 and 502.002.
(C)	Eligibility Requirements. Children are eligible for CMSP if they are:

(1)	a resident of Massachusetts, as defined in 130 CMR 503.002;
(2)	under age 19; and
(3)	not otherwise eligible for any other MassHealth coverage type, other than MassHealth Limited.
(1)	
130 CMR: DIVISION OF MEDICAL ASSISTANCE
Trans. by E.L. 127
MASSHEALTH
OTHER DIVISION PROGRAMS	Chapter     522
Rev. 11/01/04	(1 of 3)    Page	522.004
(D) Premiums.
(1) The following premiums apply to those who are determined eligible for CMSP:

% of Federal Poverty Level	Premium	
Less than or equal to 150%	No monthly charge	
Above 150% to 200%	$10.50 per child per month; family group maximum $31.50 per month	
Above 200% to 400%	$45.32 per family group per month	
Above 400%	$52.50 per child per month	
(2)	Failure to pay the applicable monthly premium will result in termination from CMSP.
(3)	Premiums for CMSP are determined by comparing the gross family group income to the applicable income level. A family group includes all children under age 19, including unborn children, living in the household and their parents or guardian. A parent may be a natural, step, or adoptive parent.
(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 income at or below 200% of the federal poverty level (FPL);
(b)	$4 for members with income above 200% to 400% FPL; and
(c)	$6 for members with income above 400% FPL.
(3)	The copayments for medical (non-preventive visits) and mental health services are:
(a)	$2 for members with income at or below 200% FPL;
(b)	$5 for members with income above 200% to 400% FPL; and
(c)	$8 for members with income above 400% FPL.
(F) Medical Coverage Date. Except as provided at 130 CMR 522.004(H), coverage begins on the date of the final eligibility determination.

130 CMR: DIVISION OF MEDICAL ASSISTANCE
Trans. by E.L. 127
MASSHEALTH
OTHER DIVISION PROGRAMS	Chapter     522
Rev. 11/01/04	(2 of 3)    Page	522.004
(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)	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;
(5)	prescription drugs up to $200 per 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 not to exceed 20 visits per fiscal year;

(10)	durable medical equipment, up to $200 per fiscal year, with an additional $300 fiscal per year for equipment and supplies related to asthma, diabetes, and seizure disorders only;
(11)	dental health services, up to $750 per 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.

130 CMR: DIVISION OF MEDICAL ASSISTANCE
Trans. by E.L. 127
MASSHEALTH
OTHER DIVISION PROGRAMS	Chapter     522
Rev. 11/01/04	(3 of 3)    Page	522.004
(H) Enrollment Cap. MassHealth may limit the number of children who can be enrolled in CMSP. When MassHealth imposes such a limit, applicants will be placed on a waiting list when their eligibility has been determined. When MassHealth is able to open enrollment for CMSP, MassHealth will process the applications in the order they were placed on the waiting list.
522.005: Healthy Start Program (HSP)
(A)	Regulatory Authority. The Healthy Start Program (HSP) is administered pursuant to Chapter 26 of the Acts of 2003 and M.G.L. c. 118E, §10E.
(B)	Overview. To lower the infant mortality rate, HSP provides payment for health-care benefits to eligible low-income pregnant women, providing them with early, continuous, and comprehensive prenatal, postpartum, and maternity care. To apply for these benefits, an applicant must submit a Medical Benefit Request (MBR) as described in 130 CMR 502.001 and 502.002.
(C)	Eligibility Requirements.
(1)	Pregnant women and their unborn children are eligible for HSP if their family group
gross income is less than or equal to 200% of the federal poverty level and they are:
(a)	a resident of Massachusetts, as defined in 130 CMR 503.002;
(b)	not otherwise eligible for any other MassHealth coverage type, other than MassHealth Limited; and
(c)	not insured for medical care, or have health-care insurance that does not cover all medically necessary care offered by HSP.
(2)	A family group includes all children under age 19, including unborn children, living in
the household and their parents. A parent may be a natural, step, or adoptive parent.
(D)	Period of Eligibility.
(1) For those determined eligible, coverage begins on the 10th day before the date a completed MassHealth Benefit Request (MBR) is received at the Central Processing Unit (CPU). If a Request for Information is needed to complete an MBR, all verifications must be received within 60 days of the date of the Request for Information.

130 CMR: DIVISION OF MEDICAL ASSISTANCE
Trans. by E.L. 127
MASSHEALTH
OTHER DIVISION PROGRAMS	Chapter      522
Rev. 11/01/04	Page	522.005
(2) Except when the member is no longer a resident of Massachusetts, benefits for an eligible member will continue throughout the pregnancy, and postpartum care continues for 60 days following the termination of the pregnancy plus an additional period extending to the end of the month in which the 60-day period ends. A temporary absence from the state will not cause loss of coverage.
(E)	Calculation of Financial Eligibility. Financial eligibility for HSP is determined by comparing
the family group’s gross monthly income with the applicable income standard.
(F)	Benefits Provided. Benefits provided include all medical care necessary to maintain health
during the course of the pregnancy and delivery, including newborn hospital care, all medically
necessary postpartum obstetric and gynecological care, and newborn care, including one
postpartum pediatric ambulatory visit.