FREE CARE CHANGES

On July 16 th, the state issued proposed regulations that sought to change where Free Care services could be delivered and how Free Care eligibility would be determined. NOTE: These changes to the Free Care eligibility process do NOT pertain to patients age 65 or older. The state expects that seniors will be folded into the new process within the year.

The regulations went into effect on October 1 st, but the state is revising them based on feedback received at the public hearing on August 24 th and via written comments, and has not released the final regulations yet.

• The main changes have been outlined in previous articles in this newsletter (July and Ausgust).

One of the key provisions is to move primary care out of hospital settings and to community health centers in the hopes of saving money. Only patients of “such high acuity that care cannot be appropriately provided in a community setting” (i.e., “critical access” situations) or when “ the visit is for emergent care, urgent care or maternity services” will the patient be allowed to continue to receive outpatient primary care in a hospital campus. Hospitals will be exempt if there was not a community health center within 5 miles. The unofficial word is that this provision will be delayed 3 months until January 1 st, 2005. Physicians will decide whether a patient’s acuity is such that he/she should remain on the hospital main campus for care.

Among other changes from the last newsletter article include the restoration of patient protections related to billing and collection.

How Free Care Eligibility Is Determined

As of October 1 st, the state has taken over the responsibility for the Free Care eligibility determination process from providers. Free Care eligibility is now integrated with the Mass Health application process. In other words, all applicants are now required to submit an MBR (MassHealth application) to apply for Free Care. Providers will use an MBR to submit a single application for MassHealth and Free Care. The state will begin reviewing all MBRs for MassHealth first, and then for Free Care.

• If applicants are found to be eligible for MassHealth, they will receive a notice from the state that they are enrolled in MassHealth, and they will automatically have Free Care also as a secondary payer. (There will be no mention of Free Care in their notice of MassHealth eligibility, but after October 1, everyone on MassHealth is “assumed” to have Free Care as a secondary payer.)
• If applicants are not eligible for MassHealth, but still qualify for Free Care, then will receive a notice from the state that they have been designated as a Low Income Patient and are eligible for either Full or Partial Free Care depending on their income status. These categories will show up in REVS, along with the amount of any applicable partial free care liability.
• If applicants are not eligible for MassHealth or Free Care, they will receive a notice stating that they are not eligible for these programs.
• Patients will only need to apply once for Free Care, which then can be accessed from any site. For example, a patient may apply for Free Care at BMC, if that patient shows up at a Partners hospital or health center, the provider will be able to look that patient up in a database. The patient will no longer have to file separate Free Care applications at each site.
• Only Massachusetts residents will be eligible for Free Care. College students and nursing home residents may also be eligible, if they are state residents. (This is a change from the proposed regulation, which considered all college students and nursing home residents to be “non-residents.”) Proof of residency will be self-declared, just as it is today for the MassHealth application process.
• Patients will have 6 months after services are delivered to apply for Free Care (currently patients have 1 year, but the proposed regulations gave only a 60 day retroactive period, so this is a compromise).

Critical Access Services – Where Free Care Services Can Be Delivered

Partners will begin holding meetings with main campus and health center providers throughout the system to consider strategies for redirecting new Free Care patients to health centers, and to consider whether there are existing patients for whom health centers could be an option.

Issues:

Following are some of the main concerns that the new system raises for providers:

• There will be a loss of provider control over the Free Care process. Providers will no longer be able to quickly get a patient onto Free Care while his/her MassHealth application is being processed. Since applicants must apply for Free Care with an MBR, and all MBRs must first be screened for MassHealth, there is the potential for the process to slow down considerably if Medicaid’s Central Processing Unit (CPU) has problems keeping up with the volume. The state has informed Partners that they have reorganized the CPU and have added staff to accommodate the additional volume, but this remains a prominent concern.
• Providers anticipate extreme reluctance on the part of immigrant patients who are asked to complete an MBR in order to get Free Care. Public charge and deportation fears may prevent patients from applying with an MBR and visits for those patients may become bad debt. The state has not been able to put anything in writing to reassure patients that their information will not be shared with other government agencies. However, they have agreed to develop a Virtual Gateway communication piece, designed to allay patient fears.
• The new regulations do not allow Limited Free Care after October 1 st.
• There is the potential for increasing numbers of uninsured patients, if sites see a significant undocumented immigrant population or non-Massachusetts residents. Sites will need to engage the patients proactively and provide guidance on the completion of an MBR for all Massachusetts residents. Discussions regarding how to approach the expected increase in low- income patients who will not qualify for Free Care are in process at many levels of the organization.
• In the past, a site could do a quick Free Care eligibility determination on a patient whose MassHealth application was pending, in order to cover the date of service. Moving forward, that will no longer be possible, and sites will need to decide how they will provide services to patients before they have a MassHealth/Free Care determination from the state.

- Adapted from updates from Kim Simonian, MPH, Health Access and Community Partnerships, Community Benefit Programs, Partners HealthCare.

Please note: Joe Ianelli, Director of Patient Financial Services will come to speak to staff on these changes at the time regularly scheduled for staff meeting- October 28 th in the O’Keeffe.

09/2004