What is MassHealth? You have MassHealth, now what?
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1 You have MassHealth, now what? Vicky Pulos Massachusetts Law Reform Institute Ext What is MassHealth? 1.8 million members $15 billion budget Mostly federal-state Medicaid Also federal-state non- Medicaid Children s Health Ins. Progr. (CHIP) Small number in stateonly program 2
2 MassHealth Single state agency: Executive Office of Health and Human Services (EOHHS) Day to day administration: Office of Medicaid Long term services & supports -Dept. of Elder Affairs & Office of Medicaid G.L. c. 118E 130 Code of Mass. Regs (CMR) Website: mass.gov/masshealth 3 4
3 What you get with MassHealth Access to health care providers who accept MassHealth rates as payment in full less any allowed copayment Range of covered services that vary by coverage type Delivery system includes managed care and fee for service 5 MassHealth coverage types 130 CMR 505 &519 (eligibility) (benefits) 5 Types of MassHealth MassHealth Standard the good MassHealth MassHealth CarePlus-for childless adults under Affordable Care Act since Jan. 1, 2014 MassHealth CommonHealth-for people with disabilities & income too high for Standard MassHealth Family Assistance-includes CHIP for children in families with income too high for Standard MassHealth Limited-emergency care for those not eligible for Standard/CarePlus due to immigration eligibility rules 6
4 Benefit Tables included in on-line materials 7 8
5 9 Premium Assistance Eligible for MassHealth (exc. Limited) Access to other insurance If cost-effective, MassHealth requires enrolling in other insurance MH pays full premium cost for Standard/CarePlus; varies with income Family Assistance/CommonHealht MH secondary coverage for cost sharing & added services See on line materials on Premium Assistance & Student Health Insurance Premium Assistance 10
6 Mandatory managed care MassHealth is your only coverage No Medicare, employer-sponsored insurance or other coverage You are under age 65, living in community, and Eligible for MH Standard, CarePlus, CommonHealth, or Family Assistance 11 Voluntary managed care Individuals aged 65 or older with or without Medicare (Senior Care Options, SCO) Individuals age 55 or older with Medicare (PACE) Individuals with disabilities age at enrollment with Medicare (One Care) Certain children & youth: DCF/DYS; Kaileigh Mulligan Program; adoption assistance People enrolled in home & community based waiver services 130 CMR
7 MassHealth Delivery System today Fee for Service (FFS) MassHealth pays participating providers directly Managed Care Organizations MH pays MCO & MCO pays providers in its network Primary Care Clinician Plan-for medical services, MassHealth pays participating providers directly, for behavioral health, MassHealth pays the Partnership and it pays providers in its network 13 MassHealth MCOs (2017) Tufts Health Together Neighborhood Health Plan BMC Health Net Fallon Community Health Health New England CeltiCare (CarePlus only) 14
8 How MCOs work Show both MCO card and blue MassHealth card MassHealth card for some services e.g. dental, PCA, nonemergency transportation MCO card for all other services For MCO services, must see providers in MCO network Complaints & appeals go first to MCO, then to MassHealth fair hearing 15 Primary Care Clinician (PCC)Plan Beneficiary chooses a primary care practice participating in PCCP Medical benefits through MassHealth Behavioral health benefits through the Partnership PCC referral needed to see certain specialists; complex care case management from Partnership 16
9 MassHealth Changes March 1, 2018 Returning managed care options: Tufts HealthTogether BMC Health Net PCC Plan & the Partnership Not returning as the same MCO in 2018 Fallon Health New England Neighborhood Health Plan CeltiCare New Accountable Care Organizations (ACOs): ACO Partnership Plans 13 (4 w. BMC, 4 w. Tufts, 3 w. Fallon, 1 w. Health New England, 1 w. Neighborhood Health Plan) Primary Care ACOs Community Care Cooperative (C3) Partners HealthCare Choice Steward Health Choice MCO-contracted ACO Lahey Health (with Tufts or BMC MCO) 17 18
10 19 Transitions for over 1 million people Of those in managed care on Oct 15, ,000 had a PCP who joined an ACO & were specially assigned to that ACO on March 1 200,000 had a PCP who did not join an ACO & can stay with same MCO (Tufts or BMC) or PCC Plan 100,000 have to change plans by March 1 and were not specially assigned All sent green stripe letter in Nov-Dec 20
11 What is an ACO? An ACO is a type of managed care plan ACO Partnership Plans are like MCOs MassHealth pays ACO PP and it pays a network of providers Primary Care ACOs are like the PCC Plan MassHealth pays medical providers directly, MassHealth pays the Partnership and it pays behavioral health providers in its network, some medical services require referral from PCP ACOs & MCOs have their own cards & websites 21 What is an ACO? ACOs are a new way of organizing and paying for health care services to try to reach better results at lower cost MassHealth is giving ACOs more resources and information to provide better coordinated care MassHealth is holding ACOs accountable by paying them more or less depending on how they perform on savings and quality 22
12 Other features of ACOs coming soon June 1, 2018 Community Partners to help members access behavioral and long term services and supports June 1, 2018 an independent Ombudsman program to help members resolve problems 2019 ACO programs designed to address housing and nutrition issues affecting health Will also apply to MCOs 23 Transition problems People unaware of change Difficulty finding out which plan a PCP joined or which plan a provider accepts Some people will be unable to find a new plan that includes the same PCP and specialists they have in their current plan PCP exclusivity: a primary care practice can only belong to one ACO. To keep a PCP in an ACO, you must join that ACO but that ACO may not cover your town or may not include your other providers. 24
13 Unaware of change After Mar 1, you present Neighborhood Health Card at Pharmacy & told you don t have NHP anymore What shouldn t happen: you leave without medicine What should happen: Pharmacy checks EVS/MMIS to see where you are enrolled & bills appropriate plan 25 Continuity of Care Continuity of care for 30 days from March 1 New plan will pay for previously scheduled service from current providers (including out of network) Prior authorization info shared between plans ID of complex care members for individual assistance to avoid break in service during & after 30 days 90 days continuity for ABA for children with autism Lines of communication clarified Point of contact at plans & MassHealth Escalation process if problems not addressed at Customer Service level by plan/masshealth 26
14 Continuity of Care: other contract provisions Prior authorizations will be honored thru PA period or if modified/terminated, treated as an adverse action with appeal rights (aid pending) Existing drug refills will be honored unless RX requires PA, then at least 72 hour supply while PA obtained Pregnant women can remain with out of network Ob/Gyn thru delivery & 6 weeks post-partum Trouble getting info needed to select a plan Which plan has my primary care doctor? MassHealth info is by practice E.g. Community Health Center or Physician Group Individual Dr. shown only if not part of a larger practice PC Practice in an ACO is exclusive to that ACO PCP for 2018 are fixed for the year In which plan are my other providers? Hospitals shown in Enrollment Book Specialists not fixed, being added on on-going basis 28
15 MassHealthChoices.com 29 PCP joined ACO that doesn t cover your town Options: Change your PCP or Apply to MassHealth for a waiver to join a Plan that does not cover your town & keep your PCP Call customer service for the form You must live in a town next to one of the towns covered by the Plan, The travel time/distance to requested provider is not more than that to comparable provider in your service area, & Medical benefit of care from provider in service area is outweighed by benefit of requested provider 130 CMR (A)(2) 30
16 13 ACO Partnership Plans 31 Specialists & PCP not in same Plan Options: Change your PCP but keep your specialists Four plans will include all participating MassHealth hospitals and specialists for medical care and the Partnership network for behavioral health PCC Plan Community Care Cooperative (C3) Partners HealthCare Choice Steward Health Choice Join your PCP s MCO or ACO PP and Ask your specialists to try to join the MCO or ACO PP, or Ask your MCO or ACO PP to authorize out of network care/single case agreement with your specialists 32
17 Example I live in Brockton & have a child with a disability on MassHealth. His primary care doctor joined the BMC Signature Alliance ACO. He sees specialists at Boston Children s Hospital. The BMC Plans do not include Children s in their hospital networks. His doctor is only in BMC Signature Alliance ACO Plan Options for Brockton Family BMC MCO & 2 BMC ACO PP 3 Primary Care ACOs: C3, Steward & Partners* PCC Plan* Wellforce (with Fallon) ACO PP 3 Tufts ACO PP with Atrius, BIDCO, & Boston Children s* *Plans that include Children s Hospital. To join need to find new PCP with open panel in one of these plans. 34
18 Grounds: Out of Network Services Provider Network is unable to provide an Enrollee with appropriate access to ACO Covered Services due to lack of a qualified Network Provider within reasonable travel time of the Enrollee s residence Source: pp of Model Contract MCO denial of out of network service subject to appeal and fair hearing 35 Other relief If MassHealth agrees no managed care provider physically accessible to person with disability or No available & affordable transportation to managed care provider Then Medical fee for service & Partnership or MCO/ACO outside service area 130 CMR (B) 36
19 Changing plans (n/a PCC Plan) Plan selection period for 90 days from enrollment For those enrolled on March 1 plan selection period ends May 31, 2018 Fixed enrollment period for next 9 months For those enrolled on March 1-fixed enrollment ends Feb 28, 2019 During fixed enrollment, can only change plans for cause per MassHealth rules; right to appeal if denied (130 CMR (C)(3) 37 On line resources MassHealthChoices.com Enrollment Book (mailed & on line) MassHealth Provider Directory Websites for each plan* Provider directory (MCO & ACO PP) Evidence of Coverage/Summary of Benefits (MCO & ACO PP) Info on Customer Service, Grievance & Appeal 38
20 Help In-Person or by Telephone MassHealth Customer Service: Customer Service for each Plan* MassHealth Enrollment Events* Enrollment Assisters and Navigators Legal assistance *See training materials on-line 39
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