10- 144 C.M.R. ch. 332, § 5.5-8

Current through 2024-51, December 18, 2024

Section 144-332-5.5-8 - CHANGES

A. The child remains eligible for Cub Care throughout the twelve month period without regard to changes in household income. However, coverage can be ended if the child no longer meets any of the other eligibility requirements identified under "basic eligibility requirements."

B. The child must be moved to Medicaid coverage if s/he withdraws from Cub Care and the child becomes Medicaid eligible due to a change in circumstances and the change is expected to last for a full calendar month. The change to Medicaid will be made effective the month the change occurred as long as this change is reported within ten days of its occurrence; otherwise, it is effective the month the change is reported.

If the family withdraws from Cub Care, this will end the twelve month enrollment period. If coverage continues under Cub Care or Medicaid, this starts twelve months of continuous Medicaid coverage.

C. A child can be added to Cub Care when some members of the household are already covered by Cub Care.

For example:

If a child moves into a household, the child can be added to Cub Care; If a child becomes ineligible for Medicaid, the child can be added to Cub Care.

When a child is added, the premium will be based on the household income already established for the current enrollment period.

Household income will not be recalculated even if the child being added has income of their own.

The child can be added effective the month the change occurred as long as the change is reported within ten days of its occurrence; otherwise, the child is added effective the month the change is reported.

A premium is due for each month a child is open for Cub Care coverage unless exempted from payment.

D. When a child is covered by Medicaid and becomes ineligible, coverage will be reviewed for Cub Care. A ten day notice will be given when a child moves from Medicaid to Cub Care coverage.

SECTION 9: ELIGIBILITY PERIODS

A. Coverage under Cub Care is determined for a twelve month enrollment period for all members of a household, beginning with the month of application or, if ineligible for that month, coverage starts in the following month. There is only one enrollment period for a household.

B. Eligibility is determined for a twelve month period by projecting household income over that twelve month period, including the month of application. The child remains eligible for the twelve month period without regard to changes in household income.

In some instances, the individual is not eligible for coverage during the month of application but is eligible for the following month. In this situation, the twelve month eligibility period begins with the month following the month of application.

C. Premiums are set at the beginning of the twelve month enrollment period and do not change regardless of household income. Any household income changes must be reported when the child reapplies for coverage.

Changes affecting eligibility must be reported within ten days of their occurrence. Examples of such changes include: an eligible child no longer resides in the household, or s/he is covered by health insurance. "Occurrence" is the date the change takes place.

The individual may withdraw from Cub Care and end his/her twelve month enrollment period if s/he becomes Medicaid eligible (See Section 7 of this Part).

D. Reapplications

The individual must reapply and be found eligible in order for coverage to continue beyond a twelve month enrollment period.

The individual will be sent a reapplication before the twelve month enrollment period ends. In order for coverage to continue for the next twelve months, premiums that have been due must be paid, the child must be otherwise eligible, and there are no penalties in effect.

If, by the 15^th of the 12^th enrollment month, a completed reapplication and all needed documentation is received by OFI, coverage can continue uninterrupted as long as there is financial eligibility and premiums that were due have been paid.

E. A child who has been covered by Cub Care and whose household income exceeds 208% of the Federal Poverty Level (See Chart 6.5) at the end of the twelve month enrollment period will be provided notice for possible extended coverage through the Health Insurance Purchase Option (HIPO). Refer to Chapter 335 Health Insurance Purchase Option (HIPO) in this manual. (10-144 CMR Chapter 335)

SECTION 10: NOTICES

A. Eligibility or Ineligibility

Individuals will be notified in writing as soon as eligibility is determined. If some of the individuals applying for medical coverage are eligible and some are not, the notice must specify who is or is not eligible and the reasons for each individual's ineligibility.

Individuals whose eligibility begins after the month of application must be sent a denial notice for the months of ineligibility.

When an individual is determined to be ineligible, the notification will contain:

(1) a statement that the application has been denied;

(2) the specific reason(s) for the denial;

(3) the manual citations which support the decisions; and

(4) an explanation of the individual's right to request a hearing;

B. Adverse Action

In situations when the intended action is to discontinue eligibility or to reduce services, timely and adequate notice must be given to the recipient. However, coverage will not be continued beyond the enrollment period pending a hearing decision. Also, as long as a child is open for Cub Care coverage, a premium will be due and unpaid premiums will incur a penalty.

"Timely" means that the notice must be mailed fifteen days before the intended change would be effective (ten days for notice plus five days for mail).

"Adequate" means a written notice which includes a statement of:

(1) the action the Department intends to take;

(2) the reasons for the intended action;

(3) the regulations supporting such action; and

(4) an explanation of the rights to request a hearing.

C. Denials

If a child is not eligible for Medicaid but eligible for coverage under Cub Care, s/he needs to be informed of his/her eligibility for Cub Care, and that Medicaid has been denied.

If an application is denied for MAGI- Related Medicaid and Cub Care, notification will be given that other coverage may be available if the household has large medical bills or a child has a disabling condition.

D. Closings

If coverage under Cub Care is ended for a reason other than the enrollment period has ended, the individual will be given adequate and timely notice. When the child is granted coverage for the twelve month period, s/he will be informed that coverage will automatically end at the end of the twelve month period.

10- 144 C.M.R. ch. 332, § 5.5-8