State Health Care Update: Immigrants and Public Coverage Programs

On September 15 th 2009 Kim Simonian, from the Partners Patient Access and Community Benefits Program, spoke on the recent changes to state health care that affect certain immigrant populations’ access to health insurance.

Background

With the Federal Welfare Reform Act of 1996 (Personal Responsibility and Work Opportunity Reconciliation Act) immigrant access to public assistance including health insurance changed dramatically. A 5-year bar for certain qualified immigrants who entered the U.S. legally after 1996 was put in place for federal benefits such as SSI, Food Stamps, and non-emergency Medicaid, thus limiting access to health coverage for thousands of legal immigrants. Although immigrant access to federal public benefits is limited by this 5 year bar, states have the flexibility to fund programs for these populations with state-only dollars. Therefore, immigrant eligibility policies for health coverage programs vary state to state. Several programs exist in Massachusetts that provide public health coverage to lawfully present immigrants who are not otherwise eligible for federal programs such as comprehensive Medicaid (MassHealth) or Medicare because of the 5-year bar.

One such program was Commonwealth Care which, up until August 31 st, 2009, covered a particular class of legal immigrants called Aliens with Special Status (AWSS). Revised eligibility as a result of budgetary restrictions has eliminated Commonwealth Care coverage for AWSS immigrants in Massachusetts. The following article will summarize the changes in health coverage for this special category of immigrant (AWSS) and the new plan, Commonwealth Care Bridge, which will be implemented over the next several months.

Public Health Care Coverage for Immigrants in Massachusetts

In Massachusetts, for health coverage eligibility determination purposes, there are three major categories of immigrants: Federally eligible “Qualified” non-citizens, Special status immigrants (AWSS – a Massachusetts term), and undocumented immigrants.

“Qualified” non-citizens who meet categorical and financial criteria are eligible for all MassHealth coverage types. Examples of “Qualified” non-citizens include:

• Legal Permanent Residents who entered the country before August 22, 1996
• LPRs who have had status for more than 5 years, or held a prior exempt status.
• “ACARDS” – including refugees, asylees, and others regardless of entry date or when status was obtained.
• Parolees of at least one year with 5 years in status or who entered the U.S. before 8/22/96
• (see MassHealth eligibility page for more categories and definitions)

Aliens with Special Status (AWSS) is a term used in Massachusetts (not an immigration term) to describe a category of immigrant who would otherwise be eligible for comprehensive MassHealth (or federally funded programs), were it not for the mandatory 5 year bar. Prior to August 31, 2009 individuals in this category were eligible for Commonwealth Care.

Elderly and disabled individuals with this status were and are still currently eligible for MassHealth Essential/Limited if they meet financial criteria (<100% of the Federal Poverty Level). Those previously eligible for Commonwealth Care are automatically enrolled in MassHealth Limited and/or Health Safety Net, depending on situation and income. For those individuals who have lost their Commonwealth Care benefit on August 31st, 2009, a new program has been implemented called Commonwealth Care Bridge which is operated by a company called CeltiCare. The program will not have open enrollment, only those individuals who had their Commonwealth Benefits cut on August 31 st will be eligible to participate. See below Commonwealth Care Bridge section for more details.

Special group: children and pregnant women
On February 4, 2009, President Obama signed into law the Children's Health Insurance Program Reauthorization Act (CHIPRA) which reauthorizes the State Children's Health Insurance Program (SCHIP). CHIPRA includes the Legal Immigrant Children's Health Improvement Act (ICHIA), which gives states the option to use federal funding to lift the 5-year waiting period on new, legal immigrant children and pregnant women to make them eligible for Medicaid and the State Children's Health Insurance Program (now called CHIP). The law also eliminates barriers to health care for immigrant children and pregnant women with sponsors. (For more detail see accompanying article).

Undocumented immigrants are eligible for emergency Medicaid under MassHealth Limited, regardless of immigration status, if they meet categorical and financial eligibility requirements. MassHealth Limited covers emergency medical expenses only. Undocumented noncitizens can apply for MassHealth Limited without fear of deportation. MassHealth will not report your immigration status to USCIS.

If undocumented immigrants do not meet categorical eligibility requirements and are below 400% FPL, then they qualify for full or partial Health Safety Net.

Some factors may make noncitizens eligible for more comprehensive coverage than emergency Medicaid. One such example is the Healthy Start program for pregnant women regardless of immigrant status. Additionally, as mentioned above, any child less than 19 years of age, regardless of immigration status, is covered by MassHealth Family Assistance or Children’s Medical Security Plan.

Recent Changes to State Health Care Coverage: What will happen to those cut from Commonwealth Care Benefits?

Under Health Care Reform (the Massachusetts legislation requiring all residents to be insured), Commonwealth Care eligibility was extended to AWSS individuals. This was despite the fact that AWSS immigrants do not qualify under federal eligibility criteria for public health insurance. As AWSS immigrants were not eligible to be covered by federal funds, AWSS accepted into the Commonwealth Care program were covered solely by State funds, making them vulnerable to state budget cuts due to the sheer expense. In the FY10 budget, 130 million was cut from funding Commonwealth Care coverage for AWSS; 40 million of which was restored with the intent to cover this population with a new plan.

The Transition: Commonwealth Care Bridge

As of 8/31/09, the 31,000 legal immigrants with AWSS status who were enrolled in Commonwealth Care were either downgraded to MassHealth Limited or Health Safety Net depending on their situation and income. The Commonwealth Care Bridge operated through CeltiCare will be offered as a transitional program to the select legal immigrants who were affected by the Commonwealth Care cut. This group will have “protected eligibility” meaning that they will not undergo eligibility review once they are enrolled in the Bridge plan until 6/30/10. As previously mentioned, this plan is only open to those 31,000 legal immigrants who were previously enrolled in Commonwealth Care. Individuals who will be eligible for Commonwealth Care Bridge will receive a notice from the state informing them when they are fully enrolled in the new program. Until then, they will remain on either MassHealth Limited or the Health Safety Net. Enrollment for Commonwealth Care Bridge will begin according to the following schedule:

• 10/1-Boston region residents
• 11/1-Northern and Southern region residents
• 12/1-Central and Western region residents.

Commonwealth Care Bridge Coverage

Key details of the plan:

• The Commonwealth Care Bridge will offer similar coverage to Commonwealth Care including inpatient rehabilitation (up to 100 days per year) and home health services, but with some key exclusions (see below).
• Skilled nursing, vision, dental, and hospice services are NOT covered.
• Monthly premiums will be assessed at the same levels as Commonwealth Care, including a premium hardship waiver process for individuals who have difficulty paying.
• Co-pays in some cases are steep - such as a $50 co-pay for non-generic drugs or $100 for three months via mail-order (with no limit on out-of-pocket costs), $25 for outpatient mental health and substance abuse visits, $25 for an office visit to a specialist, $100 for an emergency room visit that doesn’t lead to inpatient hospitalization, etc. See more detail on Co-Pays.
• Co-payments are the same for all members of the Commonwealth Care Bridge, regardless of income.
• CeltiCare, the mother company of Commonwealth Care Bridge, is planning to grow its provider network in order to meet the needs of this population. Specific details have not been worked out yet although Partners sites are expected to be in the network.

Commonwealth Care Bridge and Health Safety Net

• If someone is eligible for this plan, they cannot choose to disenroll and go onto HSN. This will work the same way Commonwealth Care does; if someone disenrolls who is eligible, they will be ineligible for other coverage, including HSN.
• HSN will wrap this plan for dental and vision services if they are available at community health centers and hospitals.
• HSN will not wrap this plan for out-of-network services.
• HSN will not wrap this plan for co-pays.

Advocacy Tips/Impact on MGH patients

Many questions exist regarding how this change in coverage will directly impact MGH patients. To help patients cope with this transition it is best to:

• Advise patients to wait for their enrollment information from the state which, depending on where the individual lives, could be anytime in the next three months.
• Assure patients that they should be able to continue to receive primary and specialty care at Partners sites.

Will Partners be in the Commonwealth Care Bridge/CeltiCare network?

There are obviously lots of questions circulating as to whether these patients may continue to be seen at Partners sites. As of September 30th, Partners and CeltiCare had not yet reached an agreement, but are still working hard on this and expect some resolution very soon.

How should Partners staff provide care to patients on this new plan?

Beginning October 1, there is a 90 day transition period during which time we will be paid Medicaid rates if we see patients on this plan. Until further guidance is available, staff at Partners sites should provide care to patients on Commonwealth Care Bridge in the following ways:

• If patients show up as walk-ins or for scheduled appointments, they should be seen.
• If patients call to schedule appointments because they are in current treatment of any kind then providers will need to call CeltiCare to get authorization for that patient to be seen in our system. For example, this would apply to a patient who requires inpatient care; who calls his current PCP because he feels ill; who calls his current cardiologist to make an appt; or who is scheduled to come in for chemotherapy or any type of ongoing care. CeltiCare is committed to preventing disruptions in active treatment. If you are denied, please let me know and I will work with the Partners Contracting staff on finding a positive resolution.
• We are not yet certain how to respond to patients calling to schedule routine primary care appointments or elective non-emergent procedures. For now, staff should inform these patients that we are not yet participating in this health plan.

How should Partners staff contact CeltiCare for authorizations?

CeltiCare's medical management dept can be reached at 1-866-895-1786 ext. 65292.

Although Commonwealth Care Bridge recipient AWSS are “protected” from being downgraded or dropped from the plan until 6/30/10, they may be eligible for upgrades. Staff should watch closely for such cases. For example, it will be important to report instances where someone passes his/her 5 year bar, becomes disabled, or faces a decline in income. In those cases, financial counselors (Patient Financial Services) can contact the Connector Customer Service line at 1-877-MA-ENROLL to process an upgrade.

For patients who are unable to pay the $50 co-pay for brand name drugs, the MGH pharmacy will uphold prior policy requiring payment at the pharmacy in the same way that privately insured patients are expected to pay. Patients should be encouraged to ask their doctors about changing their prescription if generics are available.

Although CeltiCare’s product, “ Commonwealth Care Bridge”, is expected to be accepted at Partners, it is not to be confused with the existing CeltiCare Commonwealth Care, a program centered around the Caritas Hospitals.

Stay tuned for more details regarding the implementation of Commonwealth Care Bridge’s plan as enrollment begins and the provider network finalized.

-Thanks to Kim Simonian, MPH for her clear, concise and highly informative presentation, update e-mails, and her help with this article.

 

9/09