In Feb 2022 CCA updated and published its Medical Necessity Guidelines for otherwise NonCovered Services (PDF is attached) & posted it here: https://www.commonwealthcarealliance.org/ma/wp-content/uploads/2023/01/N...
Thanks to Central West Justice Advocate, Catherine Ady-Bell, for sharing documents in a another successful appeal from CCA's denial of One Care coverage for a benefit not covered under the plan. This is her description of the case:
A CCA OneCare member needed a non-covered dental procedure: a bone graft and removal of an infected implant. CCA denied these procedures because they were non-covered services according to the CCA Dental Manual. We requested an expedited Level 1 appeal. We submitted the appeal packet attached and quickly followed it up with two additional supporting documents: a letter from the oral surgeon who submitted the Prior Authorization to do this work and a letter from our client’s therapist. Along with the appeal, we requested that the service be covered as a reasonable accommodation of the member’s disabilities, but the procedure was ultimately approved as an exception to the non-covered services rule.
Attached below is the Appeal packet she submitted, and the April 2022 favorable decision from CCA approving the service citing only the section in its Handbook that says member's who think the plan should pay for a service that is not covered can file an appeal. Congratulations Katie!
Last year, DLC advocate Matthew Steele supplied information about his 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.
Where to look for information on covered services in a CCA One Care Appeal:
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... We have posted the DST below.
CCA also posts a Member Handbook with detailed information on using the plan's coverage. The Member Handbook is posted under Member benefits on the CCA One Care Member page. 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). However, there is a reference to filing an appeal if a service is excluded, and this was the section cited in CCA's April 2022 decision (attached). The Section provides: "F. Benefits not covered by CCA One Care, Medicare, or Medicaid: This section tells you what kinds of benefits are excluded by the plan. “Excluded” means that the plan does not pay for these benefits. Medicare and MassHealth will not pay for them, either. The list below describes some services and items that are not covered by the plan under any conditions, and some that are excluded by the plan only in some cases. The plan will not cover excluded medical benefits listed in this section (or anywhere else in the Member Handbook) except under the specific conditions listed. If you think that we should pay for a service that is not covered, you can file an appeal. For information about filing an appeal, refer to Chapter 9"
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.
220.127.116.11. 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.