COMMONWEALTH CARE PROVIDER FAQS
What happens to people who are awaiting their disability determination for MassHealth? Will they get Commonwealth Care?
The waiting period for disability determination for MassHealth is 90 days. Individuals awaiting their decision receive Free Care, but are not Commonwealth Care eligible.
What documents are required to prove 6-month residency for Commonwealth Care?
The state is not requiring any documentation to show that someone has resided in MA for 6 months. At this time, it appears as though this requirement will not be in effect.
Are undocumented immigrants eligible for Commonwealth Care?
No.
What about those legal immigrants who are barred for a 5-year period from receiving federal assistance and are in that time period?
Legal Permanent Residents who got their green card less than 5 years ago will be eligible for Commonwealth Care.
What happens if mail that is sent out to homeless patients gets return undeliverable?
If the homeless indicator is checked off in the Virtual Gateway, then even if mail gets returned, members are not terminated from their coverage.
Can you get Commonwealth Care as a wraparound for services not covered under private insurance?
No, you must be uninsured to be eligible for Commonwealth Care.
Why have some individuals under 100% of FPL not received letters from the Connector yet?
Individuals under 100% of FPL who have not yet received a letter from the Connector will receive one by mid January 2007.
Those who have access to employer coverage are not eligible for Commonwealth Care. Does having access to COBRA render them ineligible?
No, the Connector Board has decided that someone who is eligible for COBRA may qualify for Commonwealth Care. (Also, individuals who are now paying for their own coverage, or who are not yet eligible for employer coverage due to a waiting period are eligible for Commonwealth Care.)
Are college students eligible for Commonwealth Care?
No, the Connector Board is excluding students who are eligible for coverage through their college or university. (Other groups who areineligible include those eligible for the state’s Medical Security Plan or the Fisherman’s Partnership.)
Patients who are determined eligible for Commonwealth Care have Free Care during the interim period before their plan becomes effective. Will the 6 months Free Care retroactivity be in place for that patient?
Yes, those patients who were converted or who are new applicants have 6 months Free Care retroactive.
Do patients need to pick a PCP when they call the Connector to select a plan?
No, patients should not be required to choose their PCP when they call the Connector to select a plan. They should select a plan, and then once they receive member materials from their plan they may call the plan directly to choose their PCP. (See accompanying story.)
Is Commonwealth Care the same as the Commonwealth Care Alliance?
No, Commonwealth Care Alliance is an existing MassHealth “Senior Care Options” plan for dual eligibles (individuals with MassHealth and Medicare).
Is it possible for providers to seek exceptions to the 60-day limit for members to switch plans?
( For example, a patient is auto-assigned to a plan, perhaps they don’t understand that their existing MD needs to be on that plan’s panel, and the patient does not have an appointment during that 60-day period which might uncover the problem. Is there any possibility for an exception to the rule for patients who might have longstanding primary care or critical specialty care relationships that are important to preserve?)
No, the 60- day rule is part of the Commonwealth Care regulations and not something from which the state may deviate.
If someone is above 100% FPL and not eligible for MassHealth, what happens if they apply with the Virtual Gateway prior to January 1? Are they held on a waiting list for the new plans available on January 1 st for those between 100% and 300% FPL?
This person will get on Free Care for now, and because they would already be in the system, they will receive a notice about Commonwealth Care in January when the new plans are available.
Are seniors eligible for Commonwealth Care?
Yes, as long as they are not eligible for Medicare (some seniors do not have the work history to qualify for Medicare) and otherwise qualify.
Is it possible for a provider to fast-track a patient’s conversion to Commonwealth Care from Free Care, in cases where a patient requires services he can’t get on Free Care?
Yes, the state has agreed to put a process in place to fast-track these requests in critical cases. Providers should not file another application for the patient, but should instead call the Connector and explain the situation.
Outstanding Questions for the State:
It’s still unclear how Free Care will interact with Commonwealth Care in many situations:
- Will Commonwealth Care members be able to use their Free Care as wrap-around for their Commonwealth Care co-pays? For non-covered services?
- Will patients be able to choose Free Care over enrolling in Commonwealth Care?
- Will patients who are terminated from Commonwealth Care for failure to pay their premiums be allowed to stay on Free Care?
- Will providers be able to write off visits to the Free Care Pool for patients who go outside their network?
- Will Commonwealth Care members have the option to have their premiums automatically withdrawn from their bank accounts so that they don’t need to write a check and mail it in each month?
Outstanding Questions for the Health Plans:
- Will providers know a Commonwealth Care member’s income eligibility level? If not, how will providers know a member’s level of co-pays and covered benefits?
- What will the Commonwealth Care member cards from the 4 Medicaid Managed Care Organization plans look like? Will they contain information about a member’s co-pays and covered benefits?
- After a 60-day period during which Commonwealth Care members may switch plans, members are locked into their plan until an annual open enrollment period. Even though Commonwealth Care members will be locked into their plan in this way, will they be able to switch their primary care site at any time during the year?
- Will there be a grace period for providers to get up to speed with billing under the new Commonwealth Care products? Providers are concerned that denials will be high initially while they are learning the new plan requirements.
- If a Commonwealth Care member’s status changes and they become eligible for MassHealth, what will prompt their conversion over to MassHealth from Commonwealth Care? For example, a woman who becomes pregnant.
Policy and Operational Concerns:
How should practices handle situations where patients come in for scheduled visits and they’ve lost their Commonwealth Care due to failure to pay premiums? Or they have been auto-assigned to a plan outside the PHS system? Should practices make efforts to rectify the situation and make sure the patient’s coverage is active before seeing them? What resources can practices utilize in these situations?
How will the state and health plans help to educate Commonwealth Care members about their new responsibilities under the plans (paying premiums, getting referrals, paying co-pays, etc)? In the past, a lot of patient education has fallen to the providers. What role can the state play in building awareness of these new options and rules associated with them?
-Adapted from “Commonwealth Care Health Insurance Program: Provider Questions and Concerns”, November, 3, 2006, by Kim Simonian, MPH, Partners Community Benefits
11/06