MAP Similar Benefit Policy

Policy 6 Similar Benefits

Purpose: To determine the appropriate eligibility funding source for the Medical Access Program when other alternatives exist.

Central Health is the payer of last resort.  Therefore, all clients are screened for other coverage/benefits.  Those who have or are potentially eligible for similar benefit(s) are considered for MAP as follows:

I.  Active Similar Benefits

A client who has any of the below active coverage does not qualify for MAP:

a.  Supplemental Security Income (SSI) with Medicaid

b.  Medicaid

c.  Medicare

d.  Children’s Health Insurance Program (CHIP)

e.  Children with Special Healthcare Needs (CSHCN)

f.  Private Health Insurance or Employer-sponsored health insurance coverage

A client who has any of the below active coverage may be considered for the MAP Dental benefits when all other MAP criteria is met.

a.  Qualified Health Plans through the Health Insurance Marketplace.

II.  Potentially Eligible for Similar Benefits

A client who is determined to be potentially eligible for a similar benefit will be considered for MAP as follows:

A.  Medicaid/Children’s Health Insurance Program

1.  If the client is potentially eligible for any Medicaid program or CHIP and does not currently receive benefits, they will be denied for MAP and a Medicaid application should be submitted on the client’s behalf.

2.  If a client has been previously denied for Medicaid or CHIP for a valid reason (i.e. non-compliance is not a valid reason), they may reapply for MAP if the denial letter is less than 60 days old and there are no status changes.

3.  If a client has been previously denied for Medicaid or CHIP and the denial letter is more than 60 days old and they again screen eligible for Medicaid or CHIP, they will be denied for MAP and a Medicaid application should be submitted on the client’s behalf.

B.  Qualified Health Plan (QHP) through the Health Insurance Marketplace

1. If a client is potentially eligible to receive premium subsidies through the Health Insurance Marketplace, they will be issued short-term MAP coverage and will be referred to the Health Insurance Marketplace, except in the following two cases:

A.  Clients who will reach their 5-year Legal Permanent Residency anniversary date within the first 5 months of the coming coverage year may apply for MAP and will not be referred to the Health Insurance Marketplace.

B.  Clients who have been declared disabled through SSA and are over 100% of the FPL and whose Medicare begins within 3 months of the coming coverage year may apply for MAP and will not be referred to the Health Insurance. Marketplace.

2.  If a client cannot receive subsidies through the Health Insurance Marketplace, they may apply for MAP.

3.  If a client cannot apply for a QHP through the Health Insurance Marketplace due to open enrollment being closed and does not have a qualifying event, they may apply for MAP.

4.  If a client has a qualifying event and is potentially eligible to receive premium subsidies through the Health Insurance Marketplace, they will be issued short-term MAP coverage and will be referred to the Health Insurance Marketplace.  Examples of qualifying events are change in income, change in family size including marriage, divorce, birth of a child, loss of insurance, or gaining status as a citizen, national, or lawfully present individual in the U.S.

C.  Supplemental Security Income (SSI) with Medicaid

1. Clients determined to be potentially eligible for SSI/Medicaid, including those in the process of transferring their SSI benefits from another state to Texas, may be eligible for full MAP benefits when all other MAP criteria is met.

D.  Veteran’s Administration Coverage

1. Clients determined to be potentially eligible for or who have medical benefits through the Veteran’s Administration may be eligible for full MAP benefits when all other MAP criteria is met.

E.  Medicare

1. Clients determined to be potentially eligible for Medicare part A or B are not eligible for MAP

 IV.  Documentation Required

a.  Medicaid Card or proof from HHSC

b.  Medicare Card or proof from SSA

c.  CHIP Card or proof from HHSC

d.  CSHCN Letter

e.  Health Insurance Card

f.  Medicaid/CHIP Denial Letter

g.  Health Insurance Marketplace Enrollment Letter