January 21 Eligibility and Enrollment Update

Tomorrow the Governor releases his proposed budget for the next fiscal year.  Meanwhile, the health coverage landscape gets ever more confusing. Attached and reprinted below is our best effort to describe the Jan 1 transition with links to information from MassHealth & the Connector providing more information & identification of some of the advocacy issues presented by clients and patients to date.

MLRI’s Mid January Eligibility & Enrollment Update

1.  300,000 adults formerly on Basic/Essential/CommonwealthCare/Heath Safety Net transferred to MassHealth CarePlus (Standard or Family Assistance) on Jan 1

a) Who went to MH Standard (US ciizens & Qualified non-US citizens only)?

• 19 & 20 year olds ≤150% FPL
• 21-64 ≤133% FPL & eligible for Dept. of Mental Health services
• 21-64 ≤133% FPL & HIV+
• Pregnant women ≤200% FPL formerly in Healthy Start
• Certain Basic/Essential members who had been getting post-homeless housing support services or post-detox peer counseling services through the Partnership in the PCC Plan

b) Who went to MH CarePlus (US citizens & Qualified non US citizens only)?

• 21-64 ≤133% FPL who didn’t go to Standard

c) Who went to MH Family Assistance (certain non US citizens only)?

• Adults ≤100% FPL “Aliens with Special Status (AWSS)”& disabled (19-64) or EAEDC recipients, or elderly (65 or older) & formerly in MH Essential

More information on CarePlus: Regulations at 130 CMR § 505.008; “Additional Important information about MassHealth coverage changes” – fact sheet about CarePlus updated Jan 15, 2014 including telephone numbers of CarePlus MCOs and summary table of continuity of care obligations: http://www.mass.gov/eohhs/docs/masshealth/aca/provider-update-on-aca-coverage-changes.pdf

Link to table showing CarePlus MCOs by region: https://www.masshealthmtf.org/sites/masshealthmtf.org/files/Pages%20from%20MassHealth%20MCOs%20by%20Region_January%202014_1pages.pdf

2. Only about 400 individuals have been determined eligible and enrolled in new subsidized coverage through the Connector on January 1

• Over 120,000 individuals in programs slated to end on December 31 were notified to reapply for new subsidized coverage through the Connector between Oct 1 and December 23 in order to be insured Jan 1 in ConnectorCare or in Qualified Health Plans (QHPs) with Advance Premium Tax Credits. An outreach campaign also got the word out to uninsured individuals about new options for coverage January 1.
• The new HIX/IES computer system that was supposed to facilitate application, eligibility verification and determination and plan selection is not working. Applications can (sometimes) be completed on-line & this saves a step for MassHealth, but eligibility for MassHealth or subsidized coverage is then being determined manually by MassHealth staff, and those eligible for subsidized Connector programs are manually enrolled by Connector staff.
• By January 1, about 4,000 people had successfully enrolled in unsubsidized plans but only about 400 more were enrolled in ConnectorCare or QHPs with tax credits.
• There is a new version of the ACA paper application and Member Booklet dated 01/14 that is an improvement on the 10/13 version. The state is still encouraging people to try to apply using the on-line system if they can.

More information about ConnectorCare: Regulations at 956 CMR 12.00; “ConnectorCarePlans: A new way to help you pay for health insurance” –fact sheet about ConnectorCare including Plan Type income limits; minimum premium charges, benefit and copays, and names of the 7 participating MCOs: http://bettermahealthconnector.org/wp-content/uploads/2013/11/ConnectorCare_Overview_FINAL.pdf

Also see links for sample ConnectorCare letters to members: https://www.masshealthmtf.org/news/important-update-masshealth-connectorcare-eligibility-plus-tufts-health-plan-direct-letter [Editor's Note: Link is no longer active]

3. 124,000 adults in coverage slated to end on December 31 had their coverage extended until March 31, 2014

• Commonwealth Care, the Medical Security Program (MSP) and the Insurance Partnership are closed to new enrollment, but most individuals enrolled in these programs as of December 31 who did not qualify to transfer to MassHealth have had their coverage extended until March 31, 2014.
• Unemployed workers who were having their COBRA premiums reimbursed by MSP did not have this program extended. Instead they were given a time-limited option to enroll with the MSP MCO (Network Health Forward) 
• Individuals now have until March 24, 2014 to apply for coverage through the Connector (if they haven’t already done so), select a health plan and pay any premium due in order for new coverage to be in place by April 1.

More information about the extension to March 31, 2014: Information posted by the Connector http://bettermahealthconnector.org/health-connector-pathways-to-coverage-update/ Information about the Medical Security Program extension: https://www.masshealthmtf.org/sites/masshealthmtf.org/files/03%20MSP.pdf and the Insurance Partnership extension: https://www.masshealthmtf.org/sites/masshealthmtf.org/files/2014Dec30_Insurance%20Partnership%20transition%20info.pdf Links to sample letters to members regarding the extensions https://www.masshealthmtf.org/sites/masshealthmtf.org/files/Sample%20AA%20extension%20letter%20-%20061614.pdf

4. 28,000 individuals were enrolled in temporary coverage on January 1

• 28,000 individuals who applied for new subsidized coverage between Oct 1 and December 31 and were not already enrolled in a program that was being extended and for whom notimely eligibility decision could be made were enrolled in temporary coverage on Jan 1.
• Temporary coverage is equivalent to MassHeath Standard fee for service coverage and will continue until an eligibility determination can be made.

More information about temporary coverage: All Provider Bulletin 240 (December 2013) “Temporary Coverage for Applicants for Subsidized Health Insurance” describes temporary coverage and includes sample notice to members: https://www.mass.gov/files/documents/2016/07/rz/all-240.pdf Alsosee information posted by the Connector https://www.mahealthconnector.org/

5. Advocacy issues in the transition

• Continuity of care for CarePlus members formerly in the Primary Care Clinician Plan with the Partnership (PCCP).
  • About 65,000 Basic & Essential members were enrolled in the PCC Plan in December. They could see any MassHealth provider for medical care and received behavioral health care through the Partnership. CarePlus does not offer the PCC Plan as a managed care option. Therefore these members had to switch to an MCO. Many did not choose a plan and were auto-assigned. Due to a glitch in the autoassignment process, most were assigned to CeltiCare. (There may be a later reassignment to more equitably distribute members who have not selected a plan for themselves).
  • There are several options for members experiencing problems whose ongoing medical care was disrupted by the change in plans and providers:
    • All the MCOs have certain continuity of care obligations. MassHealth lays them out in the CarePlus fact sheet (see link above). Complaints should be raised first with the MCO, and then with MassHealth. We are hearing that MCOs have been responsive.
    • CarePlus members can change MCOs effective on the first of the following month at any time.
    • CarePlus members can change MCOs for cause effective right away. Examples of cause include: moving to a different service area, or lack of access to covered services or providers able to deal with member’s health care needs. The regulation is 130 CMR 508.002(E).
    • CarePlus members with certain special health care needs (also referred to as “medically frail”) can upgrade to MassHealth Standard coverage. Special health needs include medical, mental health, or substance abuse conditions that limit your ability to work or go to school. Individuals are directed to call the MEC to identify themselves and ask for this option. We are hearing that Customer Service is not well-trained about this and giving out inaccurate information about it. The regulation is 130 CMR 505.008 (F). It is also described on p. 13 of the Jan 2014 Member Booklet and in the CarePlus eligibility notices mailed in December.
• Individuals who have filed an ACA application and have not yet received a notice.
  • About 60,000 new ACA applications for subsidized or unsubsidized coverage to begin January 1 were submitted between October 1 and December 31. As of January 10, MassHealth had not yet “touched” 14,000 applications and an additional 6,000 were waiting to be entered into the new computer system before they could be enrolled in temporary coverage (retroactive to January 1).
  • MassHealth tells us that they are still providing “expedited” processing to individuals with urgent medical needs. The request for expedited processing of applications can be made to Customer Service, the MEC or via email to masshealthhelp@state.ma.us We are hearing that people are having very uneven results with requests for expedited services, but it does sometimes work. (MassHealth is still allowed 45 days from the date of application to make an eligibility determination).
• Individuals determined eligible for Commonwealth Care but unenrolled.
  • People found eligible for Commonwealth Care had to take affirmative steps to enroll in a plan for coverage to begin. They had 12 months to enroll without having to reapply but Health Safety Net (HSN) coverage ended for them after 90 days. Since enrollment was only effective on the 1st of the month, HSN was reinstated in the time between plan selection and enrollment. Because Commonwealth Care was slated to end Dec 31, November 24 was the last day someone could enroll in Commonwealth Care. There have been transition problems for some of the people who were Commonwealth Care eligible but unenrolled in December 2014.
    • About 8,000 individuals determined eligible for Commonwealth Care in November and December who could not enroll and should have automatically transferred to CarePlus or temporary assistance were left out. MassHealth is working on a fix for everyone in this group that will be retroactive to Jan. 1.
    • MassHealth has reinstated HSN coverage for all the Commonwealth Care unenrolled for the period from November 19 to December 31, 2013 –but the HSN coverage does not appear in EVS (the system used by providers to confirm eligibility). The reinstatement of HSN to Dec 31 is described here
      https://www.mass.gov/files/documents/2016/12/pz/secondary-elements-on-hsn-secondary-claims.pdf
    • Individuals who are also eligible for Limited on Jan 1 –and that includes all adults under 133% FPL who do not have an eligible immigration status for CarePlus—will be eligible for HSN without an expiration date & this HSN coverage will appear in EVS

For questions or comments about this update, contact Vicky Pulos, vpulos@mlri.org