Children’s Medical Security Plan (CMSP)

(A) Regulatory Authority. CMSP is administered pursuant to M.G.L. c. 118E, § 10F. (B) Overview. CMSP provides coverage to uninsured children younger than 19 years of age who do not qualify for any other MassHealth coverage type, other than MassHealth Limited, and who do not have physician and hospital healthcare coverage. To apply for these benefits, an applicant must submit an application as described in 130 CMR 502.001: Application for Benefits and 502.002: Reactivating the Application. (C) Eligibility Requirements. Children are eligible for CMSP if they are (1) a resident of Massachusetts, as defined in 130 CMR 503.002: Residence Requirements; (2) younger than 19 years of age; (3) not otherwise eligible for any other MassHealth coverage type, other than MassHealth Limited. Children who are otherwise eligible, and who are not receiving MassHealth coverage as a result of not complying with administrative requirements of MassHealth, are not eligible for CMSP. Children who lose eligibility for MassHealth Family Assistance as a result of nonpayment of premiums, or as a result of not enrolling in employer-sponsored health insurance through Premium Assistance, are not eligible for CMSP; and (4) uninsured. An applicant or member is uninsured if they (a) do not have insurance that provides physician and hospital healthcare coverage; (b) have insurance that is in an exclusion period; or (c) had insurance that has expired or has been terminated. (D) Premiums. The premium schedule and payment policies for CMSP are described in 130 CMR 506.011: MassHealth and the Children’s Medical Security Plan (CMSP) Premiums. (E) Copayments. Members are not required to pay copayments for any covered services. (F) Medical Coverage Date. Except as provided at 130 CMR 522.004(H), coverage begins on the date of the final eligibility determination. The time standards for determining and redetermining eligibility are described at 130 CMR 502.005: Time Standards for an Eligibility Determination and 502.007: Continuing Eligibility. (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) office visits, first-aid treatment, and follow-up care; (4) provision of smoking prevention educational information and materials to the parent, guardian, or person with whom the enrollee resides, as distributed by the Department of Public Health; (5) prescription drugs up to $200 per state fiscal year; (6) urgent care visits, not including emergency care in a hospital outpatient or emergency department; (7) outpatient surgery and anesthesia that are 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, including substance-use treatment services, not to exceed 20 visits per fiscal year; (10) durable medical equipment, up to $200 per state fiscal year, with an additional $300 per state fiscal year for equipment and supplies related to asthma, diabetes, and seizure disorders only; (11) dental health services, up to $750 per state 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. (H) Enrollment Cap. The MassHealth agency may limit the number of children who can be enrolled in CMSP. When the MassHealth agency imposes such a limit, applicants will be placed on a waiting list when their eligibility has been determined. When the MassHealth agency is able to open enrollment for CMSP, the MassHealth agency will process the applications in the order in which they were placed on the waiting list.