10- 144 C.M.R. ch. 332, § 5.5-11

Current through 2024-51, December 18, 2024

Section 144-332-5.5-11 - ADMINISTRATIVE HEARINGS

Rules regarding hearings are identified in Part 1, Section 7; except as they differ for Cub Care as identified in this section. A hearing may be requested for an adverse action taken during the enrollment period, but benefits will not be continued beyond the enrollment period pending the hearing decision. For coverage to continue beyond the enrollment period, the individual must file a reapplication and be found eligible without a penalty. If for some reason a household's premium is increased during the enrollment period due to adding a child to Cub Care and the increase is appealed, the increased premium will be effective when the child is added to Cub Care coverage pending the hearing decision. The household's increased premium is due in accordance with the policies of this section and any unpaid premium is subject to a penalty of ineligibility.

If a household appeals a penalty period being imposed at the time of reapplication, the penalty will be imposed pending the hearing decision.

If the hearing decision reverses the Department action, any penalty imposed will be lifted and any increased premiums that have been paid will be returned to the household.

SECTION 12: PREMIUMS

Section 12.1 G eneral

Except for Alaska Natives and Native American Indians who are members of a Federally recognized Tribe, individuals who are eligible for Cub Care must pay a premium. Chart 8.5 identifies the amount of the premium that is due basedon household income and the number of children covered under Cub Care.

The premium for the twelve month enrollment period does not change except to reflect the number of children being covered.

Any change in premium is effective the month the child's coverage begins or ends.

Section 12.2 C overage for the Current Enrollment Period

I. Premiums are due on the first day of each month for coverage for that month. When a premium is not paid by the first of the month in which it is due, the Department will give notice of non-payment.

Note: Notice will also be given at the beginning of the 12^th month of the twelve month enrollment period for any premiums that are still unpaid.

II. There is a grace period for non-payment of premiums. For the first through the eleventh months of the twelve month enrollment period, the grace period extends through the last day of the twelve month enrollment period.

The individual will also be notified that coverage will end at the end of the 12^th month without further notice if a reapplication is not received.

For example, if the enrollment period is 11/08 through 10/09, the individual has until 10/31/09 to pay his/her premiums for month one through eleven.

The grace period for payment of the premium due in the 12^th month is the 15^th of month number thirteen.

For example, if the twelve month enrollment period is 11/'08 to 10/09, the individual has until 11/15/09 to pay his/her premium for month twelve.

If the 1^st or the 15^th fall on a weekend or holiday, the premium is then due on the next workday.

Section 12.3 Nonpayment of Premiums

A. Following a current enrollment period, there may be a period of ineligibility because premiums have not been paid or not paid when they are due. Pemiums are due on the first day of every month.

B. At the beginning of the 12^th month of the enrollment period, notification will be given if any premiums for the enrollment period have not been paid when due. The individual will also be notified of the penalty incurred because of the nonpayment.

The penalty will be lifted immediately if the payment is subsequently received by the Department within the grace period.

C. Premiums can be paid monthly, for more than one month at a time, or they can be paid in advance for the twelve month enrollment period. Payments will be credited to the earliest months of coverage first, during the current enrollment period.

Example:

A monthly premium of $8.00 is due during a twelve month enrollment period from January to December and the first payment for $40.00 is received on June 1^st. Months one through five will be credited with a premium paid. The June payment is overdue.

D. There is a month of ineligibility for each month a premium was due, coverage was received, and a premium payment was not made when due.

The maximum period of ineligibility is three months.

The penalty periods start in the first month following the end of the enrollment period in which the premium was due.

Example

If no premiums are paid for the twelve month enrollment period of 1/08 through 12/08, the child is ineligible for Cub Care for the months of 1/09, 2/09, and 3/09.

E. If the twelve month enrollment period is shortened due to a withdrawal from Cub Care, a penalty will be imposed for each month Cub Care coverage was received and a premium was due and was not paid by the end of the enrollment period.

Example

An enrollment period of July through December ends on August 31^st due to a withdrawal from the program. If the premiums due for July and August have not been paid by August 31^st there will be a penalty period of two months, starting on September 1^st when the individual is not eligible for Cub Care.

F. Any penalty under Cub Care will run concurrently with Medicaid coverage. For example, if a child is denied coverage under Cub Care due to nonpayment of a premium for July and August, but the child is eligible for Medicaid during those months, Medicaid would be granted. The child is then potentially eligible for Cub Care in September.

If a child under penalty due to nonpayment of a premium reapplies and is found to be otherwise eligible for Cub Care, the penalty period will be imposed for up to the first three months following the end of the enrollment period in which the premium was due. Coverage will be granted for the remaining months.

Example

During a January to June enrollment period, no premiums were paid. A reapplication is filed and the children are financially eligible. July, August, and September are penalty months and eligibility exists for October, November, and December.

G. If a child moves from a household where a penalty has been imposed for nonpayment of a premium to a household where there is no penalty, the child is potentially eligible for Cub Care.

The penalty stays with the adults responsible for the premium payment.

H. Good cause for nonpayment exists and no penalty is imposed if premiums are not paid or not paid when due because of the following reasons:

(1) mail delay;

(2) illness of the child's responsible relative; or

(3) unanticipated emergency beyond the control of the responsible relative.

Section 12.4: Refunds

A refund is due if:

A. a premium has been paid due to Department error,

B. a payment is received after the grace period. This payment, at the option of the family, will be:

(1) refunded to the family;

(2) credited to past due premiums; or

(4) credited to future premiums due.

10- 144 C.M.R. ch. 332, § 5.5-11