CRC Info Session: Patient Financial Services

At the November CRC Info. Session, Joe Ianelli, Administrative Manager, MGH Financial Services brought his management leadership team, Jennifer Chu, Kathryn “Katie” Johnson, Derek Nisula and Cathy Devitto, to answer “Social Work’s top 10 questions about Financial Counseling”.

Joe Ianelli manages a team that includes staff who work primarily with commercial insurers to obtain authorization for hospitalization or treatment. These are folks that are less likely to interact with social work than the remaining staff who work primarily with the uninsured and underinsured to access health care coverage and whose work is discussed here.

The Basics

1. Patient Financial Services (PFS) staff work in all areas of the hospital- in and outpatient and work with patients and their families in a collaborative process. Inpatients can visit the office in the Gray building, or staff will come to patient care floor. There are also offices in Yawkey and the Wang building for outpatients.
2. The PFS staff list, including contact information, is on the staff access area of our website here.
3. PFS staff recommend that all of our patients who need to apply for MassHealth apply through them. The benefits of applying through PFS include:
   1. Applying via the computer system called the “virtual gateway” can shave 2-3 weeks off application time.
   2. The virtual gateway application serves as an automatic “release of information” allowing MassHealth to speak with our staff allowing them to follow-up on the application and to trouble-shoot problems.
   3. PFS staff receive copies of correspondence from MassHealth so they can stay on top of potential problems.
   4. PFS staff can make and keep copies of verifications which makes it easier to resubmit them when they get lost (unfortunately not an uncommon occurrence).
4. On a daily basis PFS gets census of all self-pay and health safety net inpatients and their exact insurance status. Those without insurance are designated for a visit by PFS staff. Not all insurance issues will be caught by this method. The expectation for PFS staff to see an inpatient is 1-2 days from time of referral.

Staff Questions

1. How does Patient Financial Services help patients over age 65, who do not have comprehensive benefits?

A common scenario in the “Over 65” population is someone with Medicare A & B, but who cannot afford secondary coverage (like a Medigap plan) to fill the gaps. PFS can help these people apply for Health Safety Net (HSN- formerly Free Care) – they must meet an income and asset test. The state makes the ultimate decision. If they are determined eligible, HSN would cover pharmacy and 20% co-pay.

PFS staff would also encourage the patient to apply for Medicare D and will help her to apply taking into consideration the medications that she takes.

This elicited an audience question about whether HSN helps in the Medicare D “donut hole”- the period after basic benefits are exhausted and before one reaches the “catastrophic” threshold. HSN does help during the Medicare D donut hole, but they would in this case likely refer to Prescription Advantage (PA). PA is a state program which would allow the patient to obtain their drugs at participating pharmacies rather than having to get them here. Before one can receive PA assistance one must apply for the Medicare D low-income subsidy. Due to recent PA cuts, they can only assist in this type of situation- when someone is in the donut hole. (--This section corrected 12/3/08).

PFS might also educate the patient about Medicare Advantage plans (Medicare HMOs)which include pharmacy coverage. These are a less attractive option for those who travel frequently or “snow birds” as they are state-specific. MGH accepts the Harvard-Pilgrim Medicare Advantage Plan and Blue Cross/Medex, but not currently the Tufts Medicare Advantage plan.

2. Can Patient Financial Services help patients apply for out-of-state Medicaid?

   Yes. PFS can help patients apply for Medicaid in any state, they have the applications on file. They have particularly close relationships with the New England offices and are knowledgeable about their disability requirements, and other policies and procedures. Each state has its own residency requirements, but they can help minimize any waiting time one moving from MA to another state might have.

   For inpatients who already have out of state Medicaid they will also get authorization for treatment. For outpatients this responsibility falls to the practices.

3. Is there an expedited track for inpatients applying for MassHealth?

There is no official expedited process. Because of our close relationship with MassHealth, Joe can, on rare occasion ask for a favor. He has done this in the past in cases where someone can’t be discharged without homecare or a rehab. placement and needs MassHealth to obtain the needed service. It is important to keep in mind that this is only in very special circumstances and Joe must be careful not to “go to the well” too often.

4. If an individual is receiving HSN and eligible for a Commonwealth Care plan are they required to enroll?

Yes. The process to apply for HSN involves applying to the state and the state chooses the most appropriate plan for the applicant based on a number of factors including age, family size, income, availability of employer-sponsored coverage and citizenship status. While a Commonwealth Care application is pending, one can access HSN for a 10-day retroactive period from the date of application. If eligible for Commonwealth Care then one gets 90 days of HSN coverage during which one must enroll in a Commonwealth Care plan. If one is not required to pay a premium for Commonwealth Care, and the patient does not pick a plan, the state will chose for the patient. The patient does have an option to pick another plan withion 2 weeks of the one chosen for her. Those who are required to pay a premium would not get this extra time; coverage does not begin until that premium is received and HSN will NOT cover.

Who is subject to a Commonwealth Care premium? Those who have incomes over 150% of FPL/FPG. Commonwealth Care members can have income up to 300% FPL/FPG.

5. What is the application process for Commonwealth Care, CommonHealth, HSN, and MassHealth; and can you choose what insurance to apply to?

This question requires a bit of clarification as there may be some confusion with program names. Commonwealth Care is the state’s insurance for those with incomes up to 300% of poverty who do not have access to insurance through any other means. CommonHealth is one type of MassHealth. As noted in previous question, no, you can’t chose. The state makes this determination. It used to be that under “Free Care” you could chose to stay on Free Care rather than apply for MassHealth. As part of the state’s Health Care Reform that created HSN, this was changed so that only those ineligible for other programs could remain on HSN. Patients should know though, that Commonwealth Care, though it may require a premium, does offer better coverage than HSN. It includes vision and access to services such as rehabilitation if needed, and those under 100% poverty also get dental coverage.

6. What rights do patients have to appeal a MassHealth decision, i.e., a denial or revocation of benefits?

Denial letters are required to include instructions about how to appeal. One has 30 days to initiate an appeal. PFS staff can accompany patients to the appeal, particularly if the grounds for denial is related to disability status. Our disability determination nurse- currently Judy Lynch may go along with the PFS counselor.

7. If an individual has access to COBRA, but is unable to pay for it, when is the best time to apply for MassHealth?

As soon as possible! It makes a huge difference if it is before one loses COBRA because of failure to pay premiums; once COBRA has lapsed one’s options become limited. One should apply to MassHealth while still on COBRA. MassHealth may be able to help through premium payment assistance. This takes about two months to process. In some instances, the applicant might even receive some reimbursement for past COBRA payments.

8. What is the process for assisting special population patients (i.e., victims of trauma, abuse, homelessness) in receiving public health benefits such as MassHealth?

For trauma patients PFS staff work with family members to get documents/verifications needed for applications.

They have a special “confidential” MassHealth application that can be used for Domestic Violence victims/survivors. This makes the application inaccessible to other hospitals/providers through the virtual gateway. MassHealth also does not require information about the abusers’ income- the victim applies using only her own income information.

There is a homeless check-box on the MassHealth application that, when checked, keeps the MassHealth active even if mail is returned.

9. How long do MassHealth applications typically take to go through?

If it is based on age, or caretaker status or other categorical status other than “disabled” it normally takes 30 to 45 days from the date the application is complete (i.e., all verifications are in). If a disability review is required this usually takes about 90 days in the meantime they usually are covered by the HSN and there may be retroactive coverage.

10. A patient has Commonwealth Care and is now eligible for Medicare. If applies he will lose Commonwealth Care. What should he do?

Commonwealth Care is designed for those with no access to other health insurance. Once he is eligible for Medicare he cannot continue on Commonwealth Care.

This does mean that he will now have less comprehensive coverage. His Commonwealth Care eligibility tells us that he has income below 300% of poverty and was not previously eligible for MassHealth. Once he is on Medicare he may eligible for MassHealth’s CommonHealth plan (for disabled adults) after a deductible and a spend-down. He is legally responsible to pay for the spend-down, but for purposes of MassHealth eligibility, MassHealth only requires that he has accrued the expense, not that he has paid it.

11/08