MASSACHUSETTS HEALTH CARE REFORM
Commonwealth CareThis summer, a key part of Massachusetts’ health reform took shape. The Commonwealth Care program (the new state insurance program for that will replace Free Care) set enrollee benefits, co-pays, and premium contributions. The program will be rolled-out in two phases. Phase 1 starts October 1, 2006 and is for those with income at 100% Federal Poverty Level (FPL) or less. Phase 2 is expected to start January 1, 2007, and will include those between 100% and 300% FPL.
Eligibility
- Massachusetts Resident (6 months)
- Family income before taxes < 300% FPL
- Uninsured*
- a U.S. citizen/national, qualified alien, or alien with special status; AND
- age 19 or older (eligible persons under age 19 receive benefits though MassHealth)
*Uninsured - Individuals are NOT eligible to participate in Commonwealth Care if:
Enrollment
- during the last six months, the individual or a family member was working for an employer who provided health-insurance coverage (if the employer’s insurance plan covers at least 20% of the annual premium costs for a family plan or at least 33% of an individual plan); or,
- the individual accepted a financial incentive from their employer to not take the employer’s insurance plan.
Starting October 1, the state will convert about 50,000 people from Free Care, with goal of completing conversions by December 31, 2006. Free Care recipients should receive a letter from MassHealth listing the plan options from which they can choose. MassHealth helps the Connector determine who is eligible for the Commonwealth Care program. This is why letters about your eligibility will come from MassHealth. It is important for members to respond to any requests for information from MassHealth. In the interim, members will still have Free Care.
Those in Phase 1/at or below 100% of the federal poverty level (FPL) who do not choose a Commonwealth Care plan within 14 days after the enrollment packet is mailed, will be assigned to a plan. They can, however, call Commonwealth Care Customer Service to change plans within 60 days from the date enrolled. Once the health plan has been chosen and enrollment starts, members will have 60 days to change their health plan if they feel a different health plan may better meet their needs. After the 60-day period has passed, further changes would need to wait until the next open enrollment period, unless:
- the member moves and the new address is outside of the current health plan’s service area;
- the member demonstrate to the Connector that his/her health plan has not provided adequate to health-care providers that meet the members health-care needs over time, even after the member has asked the health plan for help; OR
- the member’s primary care provider is no longer part of the health plan or there is a significant change in the health plan’s group of providers.
The Commonwealth Care Customer Service Center will begin accepting calls for new applications or to choose a plan on October 2, 2006, at 8:00 A.M. The number is: 1-877-MA-ENROLL, (TTY: 1-877-623-7773), or on the web at www.mass.gov/connector
PlansCommonwealth Care health-insurance coverage will be offered through private insurance plans:
- Fallon Community Health Plan
- Network Health
- Neighborhood Health Plan
- Boston Medical Center HealthNet Plan
Not all plans are available in all areas. It is unclear at this writing whether or not MGH will have contracts with any/all of these plans.
Phase 1 (up to 100% FPL) Benefits and Co-Pays
- No premiums
- No deductibles
- inpatient hospital services
- outpatient services and preventive care
- prescription drugs
- inpatient and outpatient mental health and substance abuse services
- dental services, including preventive and restorative procedures and
- vision services
Co-payments for Commonwealth Care for this Phase/Income level are $1 for generic drugs, $3 for all other drugs, and $3 for using a hospital emergency department when it is not an emergency. The maximum co-payment within a calendar year is $200 for pharmacy services and $36 for other services.
Phase 2 (100.1% - 300%) Premiums, Benefits and Co-PaysThe second phase will begin on 1/1/07 for uninsured adults above 100%FPL.
Premiums : On September 1, the Connector approved a premium schedule higher than that originally proposed by the Board's Affordability Committee. This is the approved premium schedule, with the monthly premium per adult for each FPL bracket:
100.1%-150% $18
150.1%-200% $40
200.1%-250% $70
250.1%-300% $106
These premiums will be charged to people who enroll in the lowest cost plan in each region. If someone picks a higher cost plan, the premium will be increased accordingly.
Benefits & Co-Pays100 – 200% FPL: Maximum Annual Out-of-Pocket Expenses: Inpatient/OP Surgery $250, Pharmacy $250.
Individuals 100 to 200% (FPL) will have one plan option (details at www.hcfama.org/act/documents/CommowealthCare-100-200fplBenefits.pdf). Plans may add other benefits to the listed package.
200 - 300%FPL: Will have two plan options. A lower premium option will have the same services and higher co-pays. Those higher co-pay levels for the 200.1%-300% low premium option plans are available at www.hcfama.org/act/documents/CommowealthCare-200-300fpl-LowPremium-Benefits.pdf. Enrollees can choose a higher premium option with lower co-pay levels - the same as the co-pays available for those in the 100%-200% FPL group. Maximum Annual Out-of-Pocket Expenses: Inpatient/OP Surgery $500, Pharmacy $500, DME/ Prosthetics/Oxygen and Respiratory Therapy Equipment $500. Total limit on Out of Pocket Expenses by Special Request $750.
What’s Next?Remember the underlying goal of this plan is to have universal health coverage. To this end there will be a statewide open-enrollment period in March 2007 including both Commonwealth Care and whole insurance market. Beginning on July 1, 2007 all Massachusetts residents will be required to have health insurance. Enforcement mechanisms include requiring an insurance policy number on state tax return. Failure to have health insurance would lead to a loss of personal tax exemption for tax year 2007 and then a fine for each month without insurance equal to 50% of affordable insurance product cost for tax year 2008.
Q and A
- What happens re: prescription drugs- will people still get scripts filled here? Will pharmacies be required to fill scripts if patient says she/he can't pay co-pay?
The MGH pharmacy will be contracted to take the Commonwealth Care plans for patients on Commonwealth Care. We actually don't know yet how Free Care will work as a wrap around - the state has given conflicting info on whether Free Care may still be used for co-pays or non-covered Rx, for example. Pharmacies will be trying to collect co-pays. Not sure they'd actually turn patients away, but co-pays will be expected. (For the plans beginning Oct 1, these are the MassHealth level co-pays of $1 and $3).
- What happens to those who aren't eligible – like those who are between 300 and 400% FPL who in the past would be eligible for partial Free Care, will they still get Free Care or will it be eliminated?
Free Care remains in place until Oct 1, 2007 for those populations. It's unclear what the eligibility rules will be after that point for "Free Care." We need to advocate for the continuation of some safety net, especially for undocumented immigrants (who were eligible under Free Care but not under Commonwealth Care).
- How will Commonwealth Care work for those who currently have Free Care as a secondary payer?
Those with insurance are ineligible for Commonwealth Care- so Commonwealth Care will never be a secondary payer. For now they will stay the same – with Free Care as a secondary payer. After October 1, 2007, they will likely be on their own.
- If someone chooses the Cambridge Network Health option and they get their primary care here, can they receive mental health services here? Yes
- For new applicants, will our Patient Financial Services staff choose whether to apply for MassHealth or Commonwealth Care based on their knowledge of eligibility, or will they apply for both?
They have to go through the MassHealth process first - the state will first look to see if someone qualifies for MassHealth, then Commonwealth Care, then Free Care -all through the Virtual Gateway computer system.
- The insurance card will be from the plan, will it identify the patient as having Commonwealth Care?
The cards will likely say Commonwealth Care, although we haven't seen any cards yet, so it's not clear. At the very least, the MassHealth REVS system (and presumably EDI) will show Commonwealth Care plus the plan (NHP, etc).
- Will the hospital be holding any hallway information tables?
Marketing materials from the plans will be available in the coming weeks, and I assume providers will be approached by the plans about patient outreach opportunities like this. The state has been talking about creating a speaker's bureau, where providers could call to get someone to come out and do a patient session. We'll need to see what's offered and whether we need to try to fill in the gaps...
The Commonwealth Care Customer Service Center will begin accepting calls for new applications or to choose a plan on October 2, 2006, at 8:00 A.M. The number is: 1-877-MA-ENROLL, (TTY: 1-877-623-7773), or on the web at www.mass.gov/connector
-Thanks to Kim Simonian for assistance with preparing this article, especially the Q&A. This article was adapted from materials from:
http://www.mass.gov/?pageID=hichomepage&L=1&L0=Home&sid=Qhic
www.mass.gov/Eeohhs2/docs/masshealth/memlibrary/commonwealthcare-faqs.pdf,
www.hcfama.org/_uploads/documents/live/Connector Board Meeting 20060607.pdf
www.hcfama.org/_uploads/documents/live/MA Health Reform Law.pdf
9/06