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General Laws

Section 16C. (1) There is hereby established the child health insurance program, which shall provide medical assistance or medical benefits to infants, children and adolescents to age 18, inclusive, whose financial eligibility as determined by the division does not exceed 300 per cent of the federal poverty level, pursuant to and in conformity with the provisions of Title XXI, the terms and conditions of the demonstration project authorized by section 9A of this chapter, or a combination thereof.

(2) Medical benefits under said program shall be available to all such infants, children and adolescents qualifying for enrollment in said program pursuant to clauses (b) and (c) of subsection (2) of said section 9A. To the extent authorized by federal law or by the terms and conditions of the demonstration project authorized pursuant to said section 9A, the division is hereby authorized to grant presumptive eligibility for up to 60 days to children and adolescents applying for enrollment in said program. The division may deny eligibility for medical benefits under said program pursuant to the provisions of subsection (3) of said section 9A.

(3) The amount, duration and scope of medical benefits provided under said program for eligible beneficiaries whose financial eligibility, as determined by the division exceeds 133 per cent of the federal poverty level but does not exceed 300 per cent of the federal poverty level, shall be established by the division; provided however, that medical benefits provided under said program shall be both consistent with the benefit levels required under the provisions of said Title XXI and comparable to the benefit levels offered under private insurance plans, shall include early and periodic screening, diagnostic and preventive services and shall include other medical services to the extent that such services are covered medical benefits under said plan.

(4) The costs of said program may be offset by copayments and deductibles to the extent permitted by Title XXI. The division shall require the payment of premiums by households eligible for said program whose household income as determined by said division exceeds 150 per cent of the federal poverty level. Such premiums shall be deposited in the Children’s and Seniors’ Health Care Assistance Fund established pursuant to the provisions of section 2FF of chapter 29. The failure to pay premiums for more than two consecutive months shall constitute grounds for terminating a household’s eligibility to participate in said program of benefits; provided, however, that the commissioner of medical assistance may allow continued participation in said program despite such nonpayment of premiums or otherwise waive the payment of any or all premiums for any particular household in the event that such payment of premiums constitutes an extreme financial hardship for such household.

(5) Eligibility for and the medical benefits provided under said program shall not give rise nor be construed as giving rise to enforceable legal rights for any party or an enforceable entitlement to such eligibility or medical benefits other than to the extent that such rights or entitlements exist pursuant to the regulations of the division, the terms and conditions of the demonstration project established in said section 9A or this section. The provisions of this section shall not establish any rights or entitlements that exceed the rights or entitlements established by Title XIX in the absence of this program, or impose any obligations upon the commonwealth’s administration or financing because of implementation of said program would exceed obligations established by Title XIX.

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