You are here

Health Access: What did you do last summer?

A lot has been going on this summer

See earlier health announcements for good news on changes in MassHealth MCO standards for approving drugs that can cure Hepatitis C (effective August 1) and a new state law mandating MassHealth (and insurance) coverage for lipodistrophya side effect of early HIV treatments (effective November 1).

And now for more news not all of it good.

Health Safety Net (HSN)

Earlier health announcements described restrictions in HSN eligibility that took effect in June 2016 for new applicants (including upper income limit cut from 400% FPL to 300% FPL and deductibles that used to start at 200% FPL now starting at 150% FPL). The new rules will be applied to current HSN beneficiaries at renewal.

HSN Renewal/Reapplication Notices August 2016 Deadlines September 30, 2016

Starting in mid-August the Office of Medicaid will begin sending out notices to 56,000 households with HSN who are overdue for an annual renewal. They will need to reapply to get into the new (HIX) eligibility system and when they reapply, the new more restrictive June 2016 HSN rules will be applied to them. They will have until Sept 30 to submit a reapplication or they will get a notice terminating HSN effective Oct 19. (People age 65 and older and people with only Medicare and HSN will not be part of this group).

A sample copy of the August notice to reapply is attached.

MassHealth has scheduled 4 enrollment events in late September in Lawrence, Boston, Holyoke and Brockton for more convenient in-person enrollment help for people who need to reapply/renew.A flyer on these events in English and Spanish is attached.

PCA Over-Time Hours restricted effective September 1, 2016

MassHealth has issued amended regulations for the PCA program limiting overtime hours by PCAs. This is a big change roiling the community of severely disabled people who use PCAs. Approximately 7300 PCA users will be directly affected. Although the number of hours that a PCA consumer is approved for is not changing, the limitation on overtime may leave consumers without access to adequate services. At the public hearings on this proposal, consumers repeatedly expressed deep concern about not being able to find attendants under the proposed cap.

A copy of the notice that went out to affected members is attached. It explains the process for seeking an exception to the cap. MassHealth can authorize more than 40 hours to maintain continuity of care while people seek to hire an additional PCA, and for live-in PCAs.

For now, any PCA user who will be harmed by this change should talk to their PCM Agency about submitting a request for approval of needed over-time hours. The form itself is posted on line.

In the long term more advocacy may be needed. Implementation of across-the-board caps risks violating the ADA if the caps do not account for the needs of individuals with disabilities and consequently places them at serious risk of institutionalization or segregation. People who need more overtime hours than can be obtained through the request form or who are denied a request should seek legal help.

New Option: MassHealth Premium Assistance for Student Health Insurance (June 2016)

This summer MassHealth is also piloting a premium assistance program for college students already enrolled in MassHealth. Over 20,000 college students waived out of student insurance last year because they had MassHealth –they can still do that but now they have another option. Students with MassHealth will be given the option by the school system of signing up for student health insurance as their primary coverage with MassHealth paying the premium and providing wraparound coverage. The initial pilot applies to the 9 State Universities, 15 Community Colleges and Quincy College and the entire University of Massachusetts system. See the attached flyer for more information. Students considering this option should be aware that with MassHealth secondary, MassHealth will not pick up their copayments unless the providers they see participate in MassHealth (not just the Partnership or one of the MassHealth MCOs).

Managed Care Lock-In: Early notice in August, change coming in October 2016

On August 10, 2016 the comment period closed on a proposed rule to limit the times in which MassHealth members required to participate in either Managed Care Organizations (MCOs) or the Primary Care Clinician/Partnership (PCC Plan) can change plans. Currently, people can change MassHealth plans at any time of year. Under the proposed rule, people will have a 90 days plan selection period in which they can freely change plans, followed by a fixed enrollment period in which they can only change plans with approval from MassHealth for cause. Despite opposition, MassHealth is moving quickly towards implementation.

During the last week in August 2016, households with at least one member in an MCO or PCCP will be getting an early warning notice. The first plan selection period will be October 1 to December 31, 2016 and the first fixed enrollment period will be from January 1 to September 30, 2017. People who become eligible after October 1, 2016 will get the full 90 day selection period whenever the dates fall. Going forward from October 2017, the lock-in will be 12 months from the point of an individual's initial managed care enrollment.

Under the current free choice system, people could avoid many access problems by simply changing plans. They could vote with their feet. Under the proposed lock-in system, there will likely be more coverage disputes and a greater need for individual advocacy.

The proposed changes to the MCO lock-in and changes to PCCP referral rules are posted here.

The changes are also described starting on p. 19 of this PowerPoint from MassHealth Training Forum:

Delivery System Reform-1115 Waiver: Comments to CMS by Sept. 3, 2016

MassHealth has submitted a request to CMS to amend and extend the current 1115 demonstration waiver. The proposal is a mixed bag of positive changes like expanded Substance Use Disorder services, a few negative changes like a cut in PCC Plan benefits described below, and complex changes in the way MassHealth providers are organized and paid via Accountable Care Organizations with consequences that are difficult to assess. Overall the proposal, if approved, will provide significant new federal revenue for the state. The request is posted on-line along with all the comments submitted on the proposal before its submission to CMS.  There is a second opportunity to comment directly to CMS by September 3, 2016.

The state's application to CMS along with comments on the proposal prior to its submission to CMS are posted here:

Information on how to comment to CMS by Sept. 3, 2016 is here:

One feature of the request we at MLRI strongly oppose is eliminating coverage of orthotics, eyeglasses, hearing aids and chiropractic services for people who choose to stay in the PCC Plan rather than an MCO or a new Accountable Care Organization (ACO). We expect the ACOs like the MCOs will have to restrict networks to save costs, and for some enrollees that would mean losing access to essential providers, not just high cost hospitals, but primary care clinicians who choose not to join an ACO. This kind of punitive policy should not be part of the ACO roll out.