DEPARTMENT OF HEALTH CARE POLICY AND FINANCING Medical Services Board FINANCIAL MANAGEMENT OF THE CHILDREN’S BASIC HEALTH PLAN 10 CCR 2505-3 [Editor’s Notes follow the text of the rules at the end of this CCR Document.] 50 DEFINITIONS 50.1 “Applicant” shall mean a person applying or re-applying for benefits on behalf of a child and/or themselves.

50.2 “Benefit Year” or “Plan Year” shall mean the term of the employer sponsored insurance as determined by the employer.

50.3 “Child” means a person who is less than nineteen years of age.

50.4 “Cost sharing” shall mean payments, such as copayments or enrollment fees that are due on behalf of the enrollee.

50.5 “Department” shall mean the Colorado Department of Health Care Policy and Financing.

50.6 “Effective Date” shall mean the first day of the employer sponsored insurance, or ESI, benefit year.

50.7 “Employer contribution” shall mean the amount of the employer sponsored insurance premium that is paid by the employer.

50.8 “Employer Sponsored Insurance” or “ESI” shall mean a medical benefit plan provided by an employer that meets the minimum required benefit coverage required by the Department.

50.9 “Enrollee” shall mean an eligible person who is enrolled in the Children’s Basic Health Plan including the premium assistance program.

50.10 “Essential Community Provider” means a healthcare provider that:

A. Has historically served medically needy or medically indigent patients and demonstrates a commitment to serve low-income and medically indigent populations who make up a significant portion of its patient population, or in the case of a sole community provider, serves medically indigent patients within its medical capability; and B. Waives charges or charges for services on a sliding scale based on income and does not restrict access or services because of a client's financial limitations.

50.11 “Evidence of Coverage” or “EOC” shall mean any certificate, agreement, or contract issued to an enrollee from time-to-time by an MCO setting out the coverage to which the enrollee is or was entitled under the Children’s Basic Health Plan.

50.12 “Family” shall mean a group of people who are related by blood, marriage or other legally recognized domestic relationship, live in the same household and receive at least 50% of their support from the household.

50.13 “Grievance Committee” shall mean a conference with the Department or its Designee in which a contested decision regarding an applicant or enrollee is reexamined.

50.14 “Managed Care Organization” or “MCO” shall mean:

A. A carrier which meets the definition in §10-16-102 (8), C.R.S. with which the Department contracts to provide health care or dental services covered by the Children’s Basic Health Plan; or, B. Essential community providers and other health care and dental service providers with whom the Department contracts to provide health care services under the Children’s Basic Health Plan using a managed care model.

50.15 “Opt-in” shall mean an eligible person’s election to enroll in the premium assistance program.

50.16 “Opt-out” shall mean an eligible person’s election to disenroll from the premium assistance program.

50.17 “Premium Assistance” shall mean a component of Children’s Basic Health Plan, under which the Department pays part of the insurance premium for a Children’s Basic Health Plan eligible enrollee’s employer sponsored insurance, ESI.

50.18 “Presumptive Eligibility” shall mean children and pregnant women who have applied and appear to be eligible for the Children’s Basic Health Plan shall be presumed eligible and may receive immediate temporary medical coverage.

50.19 “Primary Beneficiary” shall mean the employer sponsored insurance, or ESI, policy holder.

50.20 “Subsidy” shall mean the amount paid by the Department to assist a Children’s Basic Health Plan eligible person in purchasing coverage under an eligible health plan available through another coverage entity, including employer sponsored insurance, ESI.

50.21 “Woman” shall mean a female age 19 or over.

100 ELIGIBILITY 110 INDIVIDUALS ASSISTED UNDER THE PROGRAM 110.1 To be eligible for the Children’s Basic Health Plan, an eligible person shall:

A. 1. Be less than 19 years of age; or

1. 2. Be a pregnant woman

B. Meet one of the following categories:

1. 1. A citizen or national of the United States, the District of Columbia, Puerto Rico, Guam, the United States Virgin Islands, the Northern Mariana Islands, American Samoa, or Swain's Island; or 2. An alien or immigrant who entered the United States at least five years prior to the date of application and who is:
   1. a. Lawfully admitted for permanent residence under the U.S. Immigration and Nationality Act; or b. Paroled into the United States for at least one year under Section 212(d)(5) of the U.S. Immigration and Nationality Act; or c. Granted conditional entry under Section 203(a)(7) of the U.S. Immigration and Nationality Act; or
2. 3. An alien who arrived in the United States on any date who is:
   1. a. Lawfully residing in Colorado and is an honorably discharged military veteran; or
      1. 1. A spouse of such military veteran; or 2. An unremarried surviving spouse of such military veteran; or 3. An unmarried dependent child of such military veteran.
   2. b. Lawfully residing in Colorado and is on active duty in the United States Armed Forces, excluding military training; or
      1. 1. A spouse of such individual; or 2. An unremarried surviving spouse of such individual; or 3. An unmarried dependent child of such individual.
   3. c. Granted asylum under Section 208 of the U.S. Immigration and Nationality Act; or d. Refugee under Section 207 of the U.S. Immigration and Nationality Act; or e. An individual with deportation withheld:
      1. 1. Under Section 243(h) of the U.S. Immigration and Nationality Act, as in effect prior to September 30, 1996; or 2. Under Section 241(b)(3), as amended by P.L. 104-208 of the U.S. Immigration and Nationality Act.
   4. f. A Cuban or Haitian entrant, as defined under Section 501(e)(2) of the U.S. Refugee Education Assistance Act of 1980; or g. An individual who:
      1. 1. Was born in Canada and possesses at least 50 percent American Indian blood; or 2. Is a member of an Indian tribe, as defined in 25 U.S.C. Section 450(b)e.
   5. h. Admitted into the United States as an Amerasian immigrant under Section 584 of the U.S. Foreign Operations, Export Financing, and Related Programs Appropriation Act of 1988, as amended by P.L. 100-461; or i. A lawfully admitted, permanent resident, who is a Hmong or Highland Lao veteran of the Vietnam conflict; or
3. 4. An alien who was admitted in the United States on or after December 26, 2007 who is an Iraqi Special Immigrant under section 101(a)(27) of the Immigration and Nationality Act (INA); or 5. An alien who was admitted in the United States on or after January 28, 2008 who is an Afghan Special Immigrant under section 101(a)(27) of the Immigration and Nationality Act (INA); and

C. Be a resident of Colorado; and D. Have family income less than or equal to 250% of the Federal Poverty Level, adjusted for family size.

E. Failure to complete an application or to provide required documentation in Section 130 will result in the denial of the incomplete application or individual applicant (s). 120 INSUFFICIENT ACCESS TO OTHER HEALTH COVERAGE 120.1 To be eligible for the Children’s Basic Health Plan, an eligible person shall not:

A. Be covered under a group health plan or under health insurance coverage excluding Consolidated Omnibus Budget Reconciliation Act (COBRA); or B. Have had within the three months prior to application, comparable (as defined in Title XXI of the Social Security Act, Section 2103) health coverage through an employer where the employer contributes at least fifty percent of the premium cost for the individual unless the individual lost health coverage due to a change in or loss of employment, or the employer no longer offers coverage; or C. Be a member of a family that is eligible for health benefits coverage under a State health benefits plan on the basis of a family member's employment with a public agency in the State of Colorado; or D. Be eligible to receive assistance under Title XIX of the Social Security Act; or E. Be an inmate of a public institution or a patient in an institution for mental diseases. 130 DOCUMENTATION 130.1 To be eligible for the Children’s Basic Health Plan, an eligible person shall provide the following:

A. Verification of earned income for the family of the applicant if money has been earned within 30 days of the date of application. Verification may include one of the following:

1. 1. Current wage stubs; or 2. A written document from an employer; or 3. A phone call to an employer (if permitted by applicant); or 4. Self-employment section of application, ledgers or receipts for self-employed applicants; or 5. Self-declaration, verified through the Colorado Department of Labor and Employment or the Income and Eligibility Verification System (IEVS).

B. Citizenship and Identity documentation as required in 10 CCR 2505-10-8.100.3.H.

140. REDETERMINATION 140.1 Eligibility shall be redetermined when twelve (12) months have passed since the last eligibility determination.

A. A redetermination form is not required to be sent to the client if all current eligibility requirements can be verified by reviewing information from another assistance program, verification system, and/or CBMS. When applicable, the eligibility site shall redetermine eligibility based solely on information already available. If verification or information is available for any of the three months prior to redetermination month, no request shall be made of the client and a notice of the findings of the review will go to the client. If not all verification or information is available, the eligibility site shall only request the additional minimum verification from the client. This procedure is referenced as Ex Parte Review.

B. The only verification that can be required at redetermination is the minimum verification needed to complete a redetermination of eligibility. The redetermination form shall direct clients to review current information and to take no action if there are no changes to report in the household. Eligibility sites and CBMS shall view the absence of reported changes from the client at this redetermination period as confirmation that there have been no changes in the household. This procedure is referenced as automatic reenrollment.

1. An eligibility site may redetermine eligibility through telephone, mail, or electronic means. The use of telephone or electronic redeterminations should be noted in the case record and in CBMS case comments.

150 CALCULATION OF FAMILY INCOME 150.1 Income includes all employment, self-employment, and unearned income, with the following exceptions:

A. College grants and scholarships;

B. Grants from non-profit, tax-exempt, charitable foundations specifically for cost sharing;

C. Child support and foster care payments;

D. Food stamps and Women, Infants, and Children (WIC) payments;

E. Assistance provided by non-profit organizations, if the assistance is need-based (i.e. the cost of meals at a soup kitchen);

F. Settlements;

G. Stipends;

H. College loans;

I. Medical care provided for free or if a third party made the payments;

J. Payments by credit life or disability insurance;

K. Proceeds of a loan;

L. Disaster relief assistance;

M. Tax refunds;

N. Moving expenses paid by employer for relocation;

O. Income of children less than 19 years of age; and P. Children’s Basic Health Plan premium assistance program payments Q. All wages paid by the United States Census Bureau for temporary employment related to decennial U.S. Census activities.

R. The additional unemployment compensation of $25 a week enacted through the American Recovery and Reinvestment Act of 2009.

150.2 Verification of earned income may be provided through the submission of documents as described in section 130.1 A. Verification of earned income shall be provided for the month of application or the month prior to the month of application, if the verification is not yet available for the application month. Estimated income may be used to determine eligibility if the applicant provides income verification for any part of the application month. The most recent income verification shall be used.

150.3 The following are allowable deductions to income for the same month income is provided:

A. Day and elder care expenses;

B. Expenses for medical services, prescriptions or durable medical equipment;

C. Child support payments;

D. Alimony payments; and E. Health insurance premiums.

160 PREMIUM ASSISTANCE 160.1 To be eligible for the Children’s Basic Health Plan premium assistance program, an eligible person shall meet all eligibility requirements for the Children’s Basic Health Plan program, as described in Section 110, Individuals assisted under the program and Section 120, Insufficient access to other health coverage.

160.2 To be eligible for the Children’s Basic Health Plan premium assistance program, an eligible person shall submit documentation required for enrollment in the Children’s Basic Health Plan as described in Section 130, Documentation. An eligible person shall also submit the following prior to premium assistance enrollment;

A. Employer sponsored insurance form; and B. United States Internal Revenue Services Form W-9: Request for Taxpayer Identification and Certification; and C. Verification of employer sponsored insurance enrollment.

160.3 To be determined eligible for the Children’s Basic Health Plan premium assistance program, an eligible persons’ employer shall contribute to the employer sponsored insurance premium at a level determined to be cost effective by the Department.

160.4 Eligibility for the Children’s Basic Health Plan premium assistance shall be redetermined consistent with section 140, Redetermination, based on employer benefit year.

160.5 A person who has applied for the Children’s Basic Health Plan premium assistance program and is determined ineligible shall use the eligibility appeals process as described in section 600, Appeals Process.

170 PRESUMPTIVE ELIGIBILITY 170.1 An eligible person may apply for presumptive eligibility for immediate temporary medical services through designated presumptive eligibility sites.

To be eligible for presumptive eligibility, an applicant household's declared income shall not exceed 250% of federal poverty level and he/she shall be a United States citizen or a documented immigrant of at least five years.

Presumptive eligibility sites shall be certified by the Department of Health Care Policy and Financing to make presumptive eligibility determinations. Sites shall be re-certified by the Department of Health Care Policy and Financing every 2 years to remain approved presumptive eligibility sites.

The presumptive eligibility sites shall attempt to obtain all necessary documentation to complete the application within ten business days of application. The presumptive eligibility site shall forward the application to the county within five business days of being completed. If the application is not completed within ten business days, on the eleventh business day following application, the presumptive eligibility sites shall forward the application to the appropriate county.

The presumptive eligibility period will be no less than 45 days. The presumptive eligibility period will end on the last day of the month following the completion of the 45 day presumptive eligibility period. The county or medical assistance (MA) site shall make an eligibility determination within 45 days from the date of application. The effective date of eligibility will be the date of application. A presumptive eligible person may not appeal the end of a presumptive eligibility period.

170.2 Presumptively eligible clients may appeal the county or medical assistance (MA) site's failure to act on an application within 45 days from date of application or the denial of an application. Appeal procedures are outlined in Section 600.

180 Express Lane Eligibility Express Lane Eligibility will allow for automatic initiation of Medical Assistance enrollment by using available data and findings from other programs as listed below.

180.1 Free/Reduced Lunch Program

A. Recipients of the Free/Reduced Lunch Program who have submitted a Free/Reduced Lunch application at a participating school district

1. 1. Families who are potentially eligible will be given the option to opt out of Medical Assistance coverage.
2. 2. Children who meet all necessary eligibility requirements as outlined in this volume will be automatically enrolled.
3. 3. Children who meet all necessary eligibility requirements except verification of U.S. citizenship and identity will receive 30 days of eligibility while awaiting this verification.
4. 4. Any additionally required verification will be requested from the client through CBMS prior to being automatically enrolled.
5. 5. Eligibility is based on income declared on the Free/Reduced Lunch application as well as eligibility requirements outlined in section 150.
6. 6. Families who are found ineligible for a medical program will receive an Application for Medical Assistance in order to reevaluate eligibility for Medical Assistance.

B. Recipients of the Free/Reduced Lunch Program who were not required to submit a Free/Reduced Lunch application at a participating school district

1. 1. Families who are automatically enrolled Free/Reduced Lunch recipient children will not be forwarded to the Department for Express Lane Eligibility in compliance USDA confidentiality guidelines.
2. 2. These families must apply for Medical Assistance in order to give consent for request of benefits.

200 BENEFITS PACKAGE 210 The following are covered benefits including any applicable limitations:

A. Emergency Care and Urgent/After Hours Care;

B. Emergency Transport/Ambulance Services;

C. Hospital/Other Facility Services Including:

1. Inpatient;

2. Physician;

3. Outpatient/Ambulatory;

D. Medical Office Visits Including:

1. Physician;

2. Mid-Level Practitioner;

3. Specialist;

E. Diagnostic Services;

F. Preventative, Routine and Family Planning Services Including:

1. Immunizations;

2. Well-child visits;

3. Health maintenance visits;

G. Maternity Care Including:

1. Prenatal;

2. Delivery and inpatient well-baby care;

3. Postpartum care H. Mental Illness Treatments such as:

1. Neurobiologically-based mental illness including:

1. a. Schizophrenia;
2. b. Schizoaffective disorder;
3. c. Bipolar affective disorder;
4. d. Major depressive disorder;
5. e. Specific obsessive compulsive disorder;
6. f. Panic disorder;

2. Mental disorders including:

1. a. Post traumatic stress disorder b. Drug and alcohol disorders c. Dysthymia d. Cyclothymia e. Social phobia f. Agoraphobia with panic disorder g. General anxiety h. Anorexia Nervosa exclusive of residential treatment i. Bulimia exclusive of residential treatment

3. All other mental illness;

1. a. Inpatient coverage;
2. b. Outpatient coverage;

I. Physical Therapy, Speech Therapy and Occupational Therapy shall be limited to 30 visits per diagnosis per year. Effective November 1, 2007, Physical, Speech and Occupational Therapy services shall be unlimited for children from birth up to the child’s third birthday.

J. Durable Medical Equipment shall be limited to the lesser of the purchase price or rental price for medically necessary durable medical equipment that shall not exceed two thousand dollars per year.

K. Transplants must be medically necessary and are limited to:

1. Liver;

2. Heart;

3. Heart/lung;

4. Cornea;

5. Kidney;

6. Bone marrow which shall be limited to the following conditions:

1. a. Aplastic anemia;
2. b. Leukemia;
3. c. Immunodeficiency disease;
4. d. Neuroblastoma;
5. e. Lymphoma;
6. f. High risk stage ii and iii breast cancer;
7. g. Wiskott aldrich syndrome;

7. Peripheral stem cell support which shall be limited to the following conditions:

1. a. Aplastic anemia;
2. b. Leukemia;
3. c. Immunodeficiency disease;
4. d. Neuroblastoma;
5. e. Lymphoma;
6. f. High risk stage II and III breast cancer;
7. g. Wiskott aldrich syndrome;

M. Home health care;

N. Hospice care;

O. Prescription medication;

P. Kidney dialysis shall be excluded only if the member is also eligible for Medicare;

Q. Skilled nursing facility care must be provided only when there is a reasonable expectation of measurable improvement in the members' health status.

R. Vision services shall be limited to:

1. Vision screenings for age appropriate preventative care;

2. Referral required for refraction services;

3. Maximum fifty dollar benefit for eyeglasses;

S. Audiology services shall be limited to:

1. Hearing screenings for age appropriate preventative care;

2. Hearing aids without financial limitation for enrollees age 18 and under no more than once every five years unless medically necessary including:

1. a. A new hearing aid when alterations to the existing hearing aid cannot adequately meet the needs of the child b. Services and supplies including, but not limited to, the initial assessment, fitting, adjustments, and auditory training that is provided according to accepted professional standards.

T. Intractable pain;

U. Autism;

V. Case management is covered only when medically necessary;

W. Dietary counseling/nutritional services shall be limited to:

1. Formula for metabolic disorders;

2. Total parenteral nutrition;

3. Enterals and nutrition products;

4. Formulas for gastrostemy tubes;

X. Dental services are limited to:

1. Those dental services described in the Evidence of Coverage provided to enrollees aged 18 and under by the MCO (or its designee) with which the Department has contracted for the applicable plan year to provide such dental services;

2. Orthodontic and prosthodontic treatment for cleft lip or cleft palate in newborns (covered as a medical service in accordance with 10-16-104, C.R.S.); and 3. Treatment of teeth or periodontium required due to accidental injury to naturally sound teeth (covered as a medical service in accordance with 10-16-104, C.R.S.). A physician or legally licensed dentist must perform treatment within 72 hours of the accident.

Y. Therapies covered shall include:

1. Chemotherapy;

2. Radiation;

X. The following are not covered benefits:

1. Acupuncture;

2. Artificial conception;

3. Biofeedback;

4. Storage Costs for umbilical blood;

5. Chiropractic care;

6. Convalescent care or rest cures;

7. Cosmetic surgery;

8. Custodial care;

9. Domiciliary care;

10. Duplicate coverage;

11. Government institution or facility services;

12. Hair loss treatments;

13. Hypnosis;

14. Infertility services;

15. Maintenance therapy;

16. Nutritional therapy unless specified otherwise;

17. Elective termination of pregnancy, unless the elective termination is to save the life of the mother or if the pregnancy is the result of an act of rape or incest;

18. Personal comfort items;

19. Physical exams for employment or insurance;

20. Private duty nursing services;

21. Routine foot care;

22. Sex change operations;

23. Sexual disorder treatments;

24. Taxes;

25. TMJ treatment;

26. Other therapies and treatments which are not medically necessary;

27. Vision services unless specified otherwise;

28. Vision therapy;

29. War-related conditions;

30. Weight-loss programs;

31. Work-related conditions;

220 PREMIUM ASSISTANCE 220.1 The benefit package as described in section 210 shall not apply to Children’s Basic Health Plan premium assistance enrollees.

220.2 An employers’ health benefits plan shall meet minimum health coverage standards that includes, but is not limited to:

A. Preventive health services (including well-baby/well-child examinations);

B. Immunizations;

C. Inpatient hospital services; and D. Emergency care.

220.3 A Children’s Basic Health Plan premium assistance program enrollee shall receive benefits limited to those covered by the employer sponsored insurance plan. The enrollee shall not receive wrap around benefits.

220.3 If a Children’s Basic Health Plan premium assistance program enrollee does not agree with the employer sponsored insurance benefit coverage decisions, the enrollee shall use the employer sponsored insurance (ESI) grievance and appeals process. 300 ENROLLMENT FEES AND COPAYMENTS 310 ANNUAL ENROLLMENT FEES AND DUE DATE 310.1 For eligible children, the following annual enrollment fees shall be due prior to enrollment in the Children's Basic Health Plan:

A. For families with income, at the time of eligibility determination, less than 151% of the federal poverty level, the annual enrollment fee shall be waived.

B. For families with income, at the time of eligibility determination, between 151% and 250% of the federal poverty, the annual enrollment fee shall be:

1. 1. Twenty-five dollars for a single eligible child; and 2. Thirty-five dollars for two or more eligible children.
2. 3. Waived for families who include an eligible pregnant woman.

310.2 If the required enrollment fee is not received with the application for the Children's Basic Health Plan, the Department or its designee shall notify the applicant:

A. That applicable enrollment fees are a requirement for enrollment;

B. That fees shall be due within thirty (30) days of the date of notification;

C. Of effective date of enrollment if payment is received; and D. That the application shall be denied if payment is not received by the due date indicated.

310.3 The application shall be denied if payment is not received by the due date indicated on the notification.

310.5 Once enrollment has occurred, the annual enrollment fee is non-refundable. 320 COPAYMENTS 320.1 The following copayments shall be due for enrollees at the time of service:

A. For families with income, at the time of eligibility determination, less than 101% of the federal poverty level, all copayments shall be waived, except for emergency and urgent/after hours care, which shall be three dollars per use.

B. For families with income, at the time of eligibility determination, between 101% and 150% of the federal poverty level, the copayment shall be:

1. 1. Two dollars per office visit;
2. 2. Two dollars per outpatient mental health or substance abuse visit;
3. 3. One dollar per prescription;
4. 4. Two dollars per physical therapy, occupational therapy or speech therapy visit;
5. 5. Two dollars per vision visit;
6. 6. Three dollars per use of emergency care and urgent/after hours care.

C. For families with income, at the time of eligibility determination, between 151% and 200% of federal poverty level, the copayment shall be:

1. 1. Five dollars per office visit;
2. 2. Five dollars per outpatient mental health or substance abuse visit;
3. 3. Three dollars per generic prescription;
4. 4. Five dollars per brand name prescription;
5. 5. Five dollars per physical therapy, occupational therapy or speech therapy visit;
6. 6. Five dollars per vision visit;
7. 7. Fifteen dollars per use of emergency care and urgent/after hours care.

D. For families with income, at the time of eligibility determination, between 201% and 250% of federal poverty level, the copayment shall be:

1. 1. Ten dollars per office visit;
2. 2. Ten dollars per outpatient mental health or substance abuse visit;
3. 3. Five dollars per generic prescription;
4. 4. Ten dollars per brand name prescription;
5. 5. Ten dollars per physical therapy, occupational therapy or speech therapy visit;
6. 6. Ten dollars per vision visit;
7. 7. Twenty dollars per use of emergency care and urgent/after hours care. 330 COST SHARING LIMITATIONS

330.1 American Indians and Alaskan Natives shall be exempt from cost sharing requirements. American Indian shall mean a member of a federally recognized Indian tribe, band, or group, or a descendant in the first or second degree of any such member. Alaskan Native shall mean an Eskimo or Aleut or other Alaska Native enrolled by the Secretary of the Interior.

330.2 The maximum yearly cost sharing requirements for families of enrollees shall be 5% of income.

330.3 No copayments shall apply to preventive services. For the purpose of this section, preventive services shall mean:

A. All healthy newborn and newborn inpatient visits, including routine screening whether provided on an inpatient or outpatient basis;

B. Routine examinations;

C. Laboratory tests;

D. Immunizations and related office visits; and E. Routine preventive and diagnostic dental services.

340 PREMIUM ASSISTANCE 340.1 Sections 310 Annual enrollment fees and due date, 320 Copayments, 330 Cost sharing limitations shall not apply to the Children’s Basic Health Plan premium assistance enrollees.

340.2 A Children’s Basic Health Plan premium assistance program enrollee shall be responsible for paying all copayments, coinsurance, premiums, and deductibles required by the employer sponsored insurance plan regardless of any maximum cost-sharing limits established by the Children’s Basic Health Plan.

340.3 If a Children’s Basic Health Plan premium assistance program enrollee does not agree with the employer sponsored insurance cost sharing requirements, the enrollee shall use the employer sponsored insurance appeals process.

400 ENROLLMENT 400.1 An applicant found eligible for Children’s Basic Health Plan can elect to be enrolled in either, A. Children’s Basic Health Plan; or B. Children’s Basic Health Plan premium assistance as described in section 160, Premium Assistance.

410 SELECTION OF A MANAGED CARE ORGANIZATION 410.1 A. An applicant shall select, at the time of application, a participating MCO in the county of the eligible person’s residence. If there is only one participating MCO available in the county of the eligible person’s residence, the eligible person shall be enrolled in that MCO.

B. In the event the Department contracts with an MCO to provide dental services to CBHP enrollees, an enrollee automatically will be enrolled with such MCO. No separate MCO election will be required.

410.2 APPLICATIONS WITH NO MCO SELECTION

A. If the applicant has not chosen a participating MCO at the time of application, the applicant’s eligibility shall be determined and put in a pending status, if approved. The Department or its designee shall attempt to contact the applicant for selection of a participating MCO the date the eligibility determination is made. If the applicant fails to choose an MCO within ten (10) business days from the date of the eligibility determination, the Department or its designee may deny the application. In areas of the state where there is only one participating MCO available, the Department shall select that MCO and enroll the eligible person.

B. For renewal applications, if the applicant has not chosen a participating MCO at the time of renewal, the Department or its designee shall reassign the eligible person to the participating MCO the applicant approved for the previous enrollment period.

410.3 In counties in which a participating MCO as defined in section 50.14.A is not available, the eligible person shall be enrolled in an MCO as defined in section 50.14.B.

410.4 Once an enrollee is enrolled in an MCO, the enrollee shall remain enrolled in that MCO for the remainder of his/her eligibility period, unless the eligible person meets any of the disenrollment criteria set forth in section 440.

410.5 An eligible person shall have an opportunity to change to a different MCO serving the eligible person’s geographic region, if one is available, during the applicant’s annual redetermination period.

420 ENROLLMENT OF ALL ELIGIBLE PERSONS IN A FAMILY 420.1 If one eligible child from a family is enrolled in the Children’s Basic Health Plan, all eligible children in that family must be enrolled in the Children’s Basic Health Plan.

420.2 All eligible children in a family must be enrolled in the same MCO.

430 ENROLLMENT DATE 430.1 If determined eligible, an eligible person’s date in the Children’s Basic Health Plan shall be the received date of an application by a delegated entity.

A. If determined eligible, the enrollment span of a pregnant woman shall begin on the date the application is received by a delegated entity and shall end 60 days after the birth of the child or termination of the pregnancy.

B. If determined presumptively eligible, a pregnant woman’s presumptive eligibility enrollment span shall be from the date of presentation at the presumptive eligibility site up to 60 calendar days.

430.2 An eligible person’s enrollment date in the selected MCO shall be no later than:

A. The first of the month following eligibility determination and MCO selection if eligibility is determined on or before the 21st of the month.

B. The first of the second month following eligibility determination and MCO selection if eligibility is determined after the 21st of the month.

430.3 Upon birth, a child born to an eligible woman age 19 and older in the Children’s Basic Health Plan shall be automatically enrolled for twelve months.

440 DISENROLLMENT

440.1 An enrollee shall be disenrolled from an MCO for the following reasons:

A. Administrative error on the part of the Department, the Department’s designee, or the MCO, including but not limited to enrollment of a person who does not reside in the MCO’s service area; or, B. A change in the enrollee’s residence to an area not in the MCO’s service area; or, C. When an enrollee’s coverage is terminated as described in section 430.1.A.

440.2 If an enrollee is disenrolled from an MCO for any of the reasons stated in section440.1 and there is another participating MCO available in the enrollee’s county of residence, the enrollee shall be allowed to select a new MCO.

440.3 If the enrollee is enrolled in a MCO as defined in section 50.14 B and a MCO as defined in section 50.14 A becomes available in the child’s county of residence, the enrollee will be disenrolled from the MCO as defined in section 50.14 B and enrolled in the MCO as defined in section 50.14 A.

440.4 An enrollee may be disenrolled from both an MCO and/or the Children’s Basic Health Plan for the following reasons:

A. Fraud or intentional misconduct, including but not limited to knowing misuse of covered services, knowing misrepresentation of membership status; or, B. An enrollee’s receipt of other health care coverage; or, C. The admission of an enrollee into any federal, state, or county institution for the treatment of mental illness, narcoticism, or alcoholism, or into any correctional facility; or, D. Ineligibility for the program, based on the guidelines set forth in the Children’s Basic Health Plan eligibility rules; or, E. Failure to comply with cost sharing requirements (annual enrollment fees and copayments) set forth in the Children’s Basic Health Plan cost sharing rules; or, F. There is not another participating MCO as defined in section 50.14 available in the enrollee’s county of residence.

440.5 If an eligible person or an eligible person’s family displays an ongoing pattern of behavior that is abusive to provider(s), staff or other patients; or, disruptive to the extent that the provider’s ability to furnish services to the child or other patients is impaired, the eligible person may be disenrolled from his/her managed care organization. If there is another participating MCO available in the eligible person’s county of residence, the Department may allow the eligible person to select a new MCO. If there is not another MCO available in the eligible person’s county, the eligible person may be disenrolled from the Children’s Basic Health Plan. 450 PREMIUM ASSISTANCE 450.1 Section 410, Selection of a Managed Care Organization shall not apply to an applicant found eligible for Children’s Basic Health Plan who elects to be enrolled in the Children’s Basic Health Plan premium assistance program. The person shall be enrolled in their guardian’s employer sponsored insurance, or ESI, plan.

450.2 Section 420, Enrollment of All Eligible Persons in a Family shall apply to any applicant found eligible for Children’s Basic Health Plan who elects to be enrolled in the Children’s Basic Health Plan premium assistance program.

450.3 Annually the Department shall evaluate the subsidy amount to determine its cost effectiveness. The subsidy shall not exceed the cost of coverage under the existing Children’s Basic Health Plan.

450.4 The subsidy shall be paid to the primary beneficiary and shall not exceed their total out-of-pocket premium contribution amount.

450.5 If an eligible person elects to enroll in the premium assistance program and their employer’s health benefits plan, the enrollee may opt-out of the employer’s health benefits plan at any time during the plan year and enroll in a Children’s Basic Health Plan MCO. 500 FINANCIAL MANAGEMENT 500 Financial Management The Children’s Basic Health Plan, being a non-entitlement program, must manage to its legislative appropriation. The Department shall track expenditures, caseload, and other financial information to make informed decisions on spend ing its appropriation. Expenditures may exceed State appropriations with approval of the Governor, but any General Fund overexpenditure shall be limited to $250,000. 510 The Department shall make quarterly assessments of projected expenditures. If it appears the program may overspend its appropriation due to changes in enrollment, health care costs, funding, legislation, or other factors, the Department shall consider if adjustments to the program are necessary . The program may use, but is not limited to, any of the following financial management tools: waiting lists, adjustments of eligibility criteria and/or levels, instituting open enrollment periods, or temporary closure of the program. 600 APPEALS PROCESS 600.1 Applicants shall be notified of any action regarding the eligibility and enrollment status and cost sharing requirements for the enrollees’ participation in the Children’s Basic Health Plan and appeal rights regarding those actions by the Department or its designee.

600.2 The Department or its designee shall notify the applicant within ten (10) business days of a decision regarding eligibility , enrollment and cost sharing. The notice shall:

A. Be in writing;

B. Be in his/her primary language, to the extent practicable;

C. Describe to the applicant the reasons for the decision;, D. Document the authority for the decision (e.g. rule citation); and E. Inform the applicant of his/her rights and responsibilities regarding the decision.

600.3 An applicant who disagrees with a denial regarding eligibility, enrollment, or cost sharing requirements may appeal in writing to the Children’s Basic Health Plan (CBHP) Eligibility Vendor within thirty (30) calendar days of the date of the notification of denial of eligibility, enrollment, or cost sharing. The appeal shall be reviewed and processed within thirty (30) calendar days of receipt and the results of the appeal shall be communicated to the applicant within ten (10) business days of the review. The following guidelines shall apply to the appeal process:

A. The CBHP Eligibility Vendor will coordinate the appeals process with the county or Medical Assistance site that determined the initial eligibility, enrollment, or cost sharing decision within ten (10) business days after receipt of the appeal.

B. The county or Medical Assistance site that determined the initial eligibility, enrollment, or cost sharing decision shall:

1. 1. Review the data entry of the application in the Department’s eligibility system for accuracy and completeness within ten (10) business days after receipt of the appeal from the CBHP Eligibility Vendor;
2. 2. Correct or complete information in the Department’s eligibility system if it is found to be incomplete or incorrect and re-run eligibility;
3. 3. Maintain the original denial, if the information in the Department’s eligibility system is complete and correct; and 4. Notify the applicant and the CBHP Eligibility Vendor in writing once the review is complete with the results of the data entry review and the option of forwarding the appeal to the Grievance Committee.

600.4 If the applicant disagrees with the results of the appeal, the applicant may have their appeal reviewed by the Grievance Committee. The Grievance Committee’s decision shall be final.

A. The Grievance Committee shall be conducted by an independent panel appointed by the Executive Director of the Department. The panel shall include at least three people from the Department or its designee not previously involved with the grievance. A person previously involved with the grievance may be present at the conference and appear before the panel to present information and answer questions, but shall not have a vote. The Department shall ensure that those appointed to the panel have sufficient experience to make an informed decision regarding the grievance under review.

B. The applicant may attend the Grievance Committee in person or by telephone.

C. The applicant may be represented by the person of the applicant’s choice (i.e. legal counsel, friend, family member, etc.) during the Grievance Committee.

D. The applicant may have access to documents that were used by the Department or its designee in making the decision under appeal.

600.5 If an eligible person is enrolled in the Children’s Basic Health Plan, the eligible person shall remain enrolled in the program pending the decision of the appeal.

600.6 An enrollee who disagrees with a denial of benefits shall submit an appeal to the MCO he/she is enrolled in and shall follow the MCO’s appeal process.

610 PREMIUM ASSISTANCE 610.1 A person who has applied for the Children’s Basic Health Plan premium assistance program and is determined ineligible shall use the appeal process described in this section; this section shall not apply to enrollment or cost sharing appeals.

___________________________________________________ Editor’s Notes History Entire Rule eff. 07/30/2007.

Section 210 emer. rule eff. 11/01/2007.

Section 210 eff. 12/30/2007.

Sections 50.17 – 50.21, 100 – 110.1E, 150.3 – 150.3E, 170 – 170.2 emer. rule eff. 01/01/2008. Sections 50.17 – 50.21; 100 – 110.1E; 150.3 – 150.3E; 170 – 170.2 eff. 03/30/2008. Section 500 – 510 eff. 11/30/2008.

Section 210 eff. 12/30/2008.

Section 110 eff. 03/30/2009.

Section 150 emer. rule eff. 04/10/2009.

Section 150 eff. 06/30/2009.

Sections 110.1(B)(4-5), 150.1(Q-R) eff. 11/30/2009.

Section 130.1.B emer. rule eff. 01/01/2010; expired 03/11/2010. Section 130.1.B eff. 03/30/2010.

Sections 110.1(D), 150.3, 170.1, 310.1(B), 320.1(D) emer. rule eff. 05/01/2010; Section 110.1(D) expired 08/07/2010.

Section 140.1 emer. rule eff. 06/11/2010.

Sections 150.3, 170.1, 310.1(B), 320.1(D) eff. 06/30/2010. Sections 110.1(D), 140.1 eff. 08/30/2010.

Section 110.1.B (4-5) eff. 10/30/2010.

Section 130.1A, 150.2 eff. 12/30/2010.

Section 140.1.B emer. rule eff. 09/09/2011.

Section 180 emer. rule eff. 10/14/2011.