651 CMR 15.12 - Re-determination

(1) The Plan shall periodically conduct Member re-determination for the purpose of confirming a Member's eligibility and/or changing a Member's Membership Category and applicable Enrollment Fees, Co-payments and Deductibles.

(a) The Plan shall place a reminder telephone call and mail a written notice to each Member or his or her authorized representative informing him or her of the re-determination requirement.

(b) Each Member or his or her authorized representative is required to complete the redetermination process defined by the Plan and submit any required documentation to the Plan within 30 Business Days from receipt of the re-determination notice. If a Member or his or her authorized representative fails to complete the re-determination process and submit the required documentation within 30 Business Days of receipt of the notice, the Plan may terminate the Member's enrollment as of the first day of the following month.

(c) If a Member or his or her authorized representative fails to complete the redetermination process defined by the Plan and submit any required documentation within 20 Business Days from receipt of the re-determination notice, the Plan shall mail a reminder informing the Member or his or her authorized representative that the required information must be submitted to the Plan.

(d) Beginning January 1, 2006, if a Member who has been determined to be eligible for the Low-income Subsidy, but fails to re-apply for that subsidy as required by the Social Security Administration or fails to provide the Plan with verification of his or her reapplication for that subsidy, the Plan shall mail a written Notice informing the Member or his or her authorized representative that the required information must be submitted to the plan within 30 Business Days of receipt of the notification. In the event a Member or his or her authorized representative fails to submit a documentation of the re-application for the Low-income Subsidy within 20 Business Days from receipt of the first, the Plan shall mail a reminder informing the Member or his or her authorized representative that the required information must be submitted to the plan.

(e) If a Member or his or her authorized representative fails to submit required documentation of the Member's reapplication for the Low-income Subsidy within 30 Business Days of receipt of the Notice, the Plan may, prior to terminating the Member, reclassify the Member, as of the first day of the following month, in a Membership Category which offers the lowest supplemental assistance for Co-payments and Deductibles. Members or their authorized representatives shall have the right to seek Review of a termination of enrollment due to a failure to submit a complete re-determination form.

(f) Beginning January 1, 2020, Members shall apply for the MassHealth Buy-in or the MassHealth Senior Buy-in, as those coverages are defined in 130 CMR 519.000: MassHealth: Coverage Types, as a condition of completing the redetermination process and retaining their eligibility status.

(2) The Plan shall evaluate the information submitted by a Member or his or her authorized representative to confirm a Member's eligibility and/or adjust a Member's applicable Enrollment Fee, Co-payment levels, Deductibles, and Annual Out-of-pocket Spending Limit.

(3) The Plan will notify the Member in writing of the re-determination decision and the Member's Enrollment Fee (if applicable), Co-payments, Deductibles, and Annual Out-of-pocket Spending Limit.

Notes

651 CMR 15.12

Amended by Mass Register Issue 1327, eff. 12/2/2016. Amended by Mass Register Issue 1408, eff. 1/10/2020.