10- 144 C.M.R. ch. 103, § IV-4.2
As a condition of eligibility, recipients must cooperate with the Department in providing the information necessary for the Department to determine cost effectiveness.
The Department's criteria for determining cost effectiveness include, but are not limited to, the following:
- administrative feasibility,
- comparison of benefits,
- review of deductible and co-pay requirements, and
- amount of employer contribution.
The Department may pay either the insurer or the employer on behalf of the Program recipient. The Department will make payments on a monthly basis. Payments will be made prospectively only.
In the event the Department is unable to pay the insurer or employer, the Department may reimburse the recipient. Recipients may be required to submit documentation that they paid the premium, e.g., pay stubs, to the Department monthly. Payment will be made retroactively except, if good cause exists, the Department shall provide a one time advance payment at the time a recipient is required to enroll in an employer plan. Good cause will be established by the Bureau of Medical Services Third Party Liability Unit.
The Department will discontinue paying premiums when a recipient is no longer eligible to participate in the Program except the Department may continue premium payments for a one month grace period once the recipient ceases to be eligible for the Program.
10- 144 C.M.R. ch. 103, § IV-4.2