Thanks to DLC advocate Matthew Steele for sharing information about a recent (2021) successful appeal from an adverse coverage determination in a One Care CCA case. CCA denied the request for a back up generator. A redacted copy of the adverse coverage determination is attached -it summarizes a 2018 document called the "Commonwealth Care Alliance Decision Support Tool for Non-Covered Benefit (DST #134)" . After the internal appeal, the denial was appealed to the Board of Hearings and CCA assembled a lengthy case file. Included in the case file was the complete Decision Support Tool (which states that it applies to both One Care and SCO). Matthew submitted an affidavit from his client addressing all of the criteria in the DST and CCA reversed its decision without a hearing. Congratulations to Matthew for the win & to his colleague Linda Landry for alerting us to the existence of this document.
CCA posts medical necessity guidelines on its website and a few are called Decision Support Tools, but the DST for Non-Covered Benefits does not appear to be posted with the other guidelines (note each Guideline/DST states if it is applicable to only One Care, SCO or both) . https://www.commonwealthcarealliance.org/ma/providers/medical-policies/m...
CCA also posts a Member Handbook with detailed information on using the plan's coverage. This is the One Care Member Handbook for 2021 We couldn't find any reference to a general exceptions process for non-pharmacy services that are not covered in Medicare, Medicaid or not specifically shown as covered in the Handbook See (Chapter 3 starting on p. 31), Covered Services and (Chapter 4 Section D starting on p. 53) (Appendix of Covered Services). There is an exception process for drugs.
However, this policy pasted below is from the Three Way Model Contract and Memorandum of Understanding for One Care (Eff April 2019) & posted here. Amendments and CCA & Tufts specific contract pages are posted here.
126.96.36.199. The Contractor has discretion to cover other community-based services not listed in Appendix B if the Contractor determines that such authorization would provide sufficient value to the Enrollee’s care, considering the Enrollee’s entire ICP. Value shall be determined in light of the full range of services included in the ICP [Individualized Care Plan], considering how the services contribute to the health and independent living of the Enrollee in the least restrictive setting and with reduced reliance on emergency department use, acute inpatient care and institutional long-term care. (p 129 of 351 of 2019 Model Contract)
Please let us know about any other cases in which advocates were successful in obtaining coverage for non-covered benefits in One Care or SCO.