Other States laws/regulations;

OLR Research Report

September 1, 1998 98-R-1058

FROM: John Kasprak, Senior Attorney

RE: Massachusetts' Children's Medical Security Plan

You asked for information on the Massachusetts Children's Medical Security Plan.



The Massachusetts Children's Medical Security Plan (CMSP) provides access to preventive and primary care services for eligible children through a health insurance program administered by the Community Health Plan (CHP) and John Hancock Insurance Company. Legislation establishing the plan passed in 1993; it was subsequently amended in 1994 and 1995 (see Massachusetts General Laws, Title 118F 17B). The fiscal year 1997 state budget act transferred CMSP to the state Department of Public Health (DPH). Program eligibility was expanded by a 1996 law to cover children from birth to age 18.

Children under age 19 residing in Massachusetts who are (1) without public or private health insurance for primary and preventive services or (2) not eligible for Medicaid, are eligible for CMSP. Families at or under 200% of poverty can receive coverage free of charge; families between 201 to 400% of poverty are charged a reduced premium rate ($10.50 per child, per month with a $32.50 family cap); and families over 400% of poverty are charged the full cost of the provision per month ($52.50 per month).

Benefit Package

CMSP's benefits package includes 100% coverage with non co-payments for routine well-child check-ups, immunizations, and smoking prevention information and materials. It also provides 100% coverage after co-payment of doctor acute care office visits, minor office surgical procedures, outpatient surgery for hernias or inserting ear tubes, medically necessary eye exams, laboratory services, x-rays, and specialty consultations ordered by the provider.

CMSP provides limited coverage for emergency care ($1,000 per benefit year), prescription drugs ($100 per benefit year with co-pay—$3 generic, $4 brand names), durable medical equipment ($200 per benefit year) and outpatient mental health services (13 visits per benefit year with co-pay). Laboratory tests and mental health services are available only through specific network providers. Co-payments are $1.00, $3.00, or $5.00 based on family income guidelines.

Services Not Covered

CMSP does not pay for over-the-counter drugs; ambulance and hospital in-patient services; dental care; therapeutic services such as chemotherapy, hemodialysis, occupational and physical therapy; and any services not medically necessary for the diagnosis, treatment, or prevention of illness or injury (children in the plan may be eligible to review full or partial in-patient hospital coverage through the state's free care pool.)

Administrative Issues

CHP provides administrative services for the plan in Berkshire, Franklin, and Hampshire counties while John Hancock administers the plan in all other counties.

CMSP relies on a primary care physician model for service delivery; each enrollee chooses a designated primary care physician from a network of providers. Reimbursement for providers through John Hancock is on a fee-for-service basis. Provider reimbursement through CHP is partial capitation and fee-for-service. Each plan is under contractual arrangement to provide a range of administrative services such as a toll-free customer service telephone number; determining client eligibility; annual recertification and disenrollment; processing applications; handling claims payment; and providing the state health department with periodic management reports, member data, claims and utilization reports, consideration of benefits reports, and grievance reports.

Eligibility Determinations, Relationship To Medicaid

Eligibility determinations are the responsibility of the plan administrators and regulated by contract language. John Hancock and CHP must pre-screen applicants for Medicaid eligibility. Applicants meeting the state's Medicaid eligibility criteria will not be enrolled in CMSP unless the applicant presents proof of ineligibility for Medicaid or unless otherwise directed by the health department.

John Hancock and CHP are responsible for determining family income and performing annual reverification of applicant eligibility.

Relationship Of CMSP To Massachusetts' Children Health Insurance Expansion

The 1997 federal Balanced Budget Act provides a significant amount of money to the states for the State Children's Health Insurance Program (SCHIP). (In Connecticut, this has resulted in the creation of the “HUSKY Plan.”) Under SCHIP, states have three options for providing health insurance for children—a Medicaid expansion, a separate health insurance program, or a combination.

On May 31, 1998, the federal Department of Health and Human Services (HHS) approved Massachusetts' plan to expand health insurance to uninsured children under SCHIP. Under the plan, children under age 19 in families with incomes up to 200% of the federal poverty level (FPL) will be provided health insurance by the state. The state plan will:

1. expand MassHealth (Medicaid) standard coverage for children through age 18 in families with incomes up to 150 percent of the FPL,

2. implement a new MassHealth Family Plan for uninsured children through age 18 in families with incomes between 150 percent and 200 percent of the FPL. Families with incomes above 150 percent of the FPL would be required to contribute between one percent and two percent of their income to the cost of the coverage,

3. limit the eligibility for the Children's Medical Security Plan (CMSP) to children who are ineligible for MassHealth programs,

4. provide presumptive MassHealth eligibility to children for a limited duration to cover health care services required while their MassHealth application is processed, and

5. expand MassHealth coverage for pregnant women from 185 percent to 200 percent of the FPL.