E Premiums During 12-Month Guarantee and Appeals Process

Policy

A child who is eligible solely due to the 12-month guarantee period is counted in the premium calculation.

1)    12-Month Guarantee Premium Amount

When a child is eligible due to the guarantee period, the premium amount is recalculated based on the number of children who remain either KidsCare eligible or who are eligible under the guarantee period.  One premium amount is calculated for all children in the case.  When the income budgeted exceeds the limit, the maximum premium amount is used.

2)    12- Month Guarantee Letter

A KidsCare Guarantee Letter is sent indicating that benefits are continuing under the guarantee period and the revised premium amount.

3)    Non-Payment

For non-payment of premiums during the 12-month guarantee period see MA1204C.

4)    Premiums During Appeal

When a customer wants to have KidsCare continued during the appeal process, the customer must:

·         Request a hearing prior to the effective date of discontinuance;

·         Pay the full monthly premium amount prior to the date of the discontinuance; and

·         Continue to pay the full monthly premium amount each month during the hearing process.

When the payment is not received by the end of the month, coverage is stopped for the remainder of the fair hearing period.

5)    Appeal Due to Premium Increase

When a customer appeals an increase in the KidsCare premium and the hearing request is received prior to the effective date of the premium increase, restore the premium amount to the lower amount until a hearing decision is made.  The customer must pay the premium throughout the hearing process.

Definitions

Legal Authority