Code of Massachusetts Regulations › 651 CMR - EXECUTIVE OFFICE OF ELDER AFFAIRS › Title 651 CMR 15.00 - Prescription Advantage Program › Section 15.12 - Re-determination

Current through Register 1525, July 5, 2024
(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.