CommonHealth Members Now Required
To Join Managed Care
MassHealth has revised their managed care regulations effective July 1, 2010. The revisions require MassHealth CommonHealth members who are eligible for managed care to receive services through either a MassHealth Primary Care Clinician (PCC) Plan or a MassHealth-contracted managed care organization (MCO) like NHP, Network Health, Fallon or BMC HealthNet. Historically, such members could choose to receive all services on a fee-for-service basis. Those eligible are under age 65 and do not have Medicare. Exceptions include the terminally ill and those in institutions. Additional exemptions are in the regulations below.
Additional revisions
- allow members in the following MassHealth programs to enroll in a MCO or PCC Plan if they meet other managed care eligibility requirements: Essential members, Standard members who have breast or cervical cancer, and Family Assistance members who are HIV positive to enroll. Historically, such members could only enroll in the PCC Plan. If any of these members have other insurance plans in addition to their MassHealth, they are not eligible for managed care of any kind and will remain in fee-for-service MassHealth. These changes do not affect that rule.
- allow MassHealth members who are Native Americans or Alaskan Natives who are enrolled in an MCO to choose to receive services through an Indian provider, even if that provider is not part of the managed care network.
For many years, the MassHealth managed care plans have been the same - NHP, Network Health, Fallon, and BMC HealthNet. Beginning in July, Health New England will become a 5th MassHealth managed care plan in Massachusetts, but will operate primarily in the western part of the state.
The state is now requiring all of the plans to offer complex care management to disabled members.
-From MassHealth Eligibility Letter 200, June 1, 2010, and“MassHealth changes to managed care; transportation” e-mail, from Kim Simonian, MPH, Associate Director, Patient Access, Partners HealthCare Community Benefit Programs, June 24, 2010.
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Addendum: Partners-Specific Guidance
Patients who are on CommonHealth will now be on PCC Plan, which MGH accepts, OR one of the managed care plans (NHP, Network Health, BMC, or Fallon). We take NHP and Network Health.
Unresolved questions- What is the notification process for patients? Will patients just have to pick a plan at their annual redetermination period or will the state auto-enroll this population into plans? If auto-enrolled, some may end up on BMC, which we don't take (they would not autoassign to Fallon in our geographic area)? Even so, members just need to call and switch their plan if they show up at MGH on BMC, they are not locked-in. (Note: notification and auto-assign issues were clarified- see MassHealth Managed Care Update, MGH Community News, July/August 2010.)
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More Information/Regulations:
130 CMR: DIVISION OF MEDICAL ASSISTANCE
508.001: MassHealth Managed Care Requirement
Member Participation.
(1) MassHealth members who are under age 65, except those MassHealth members who are receiving services from the Department of Children and Families (DCF) or the Department of Youth Services (DYS) or who are receiving Title IV-E adoption assistance described in 130 CMR 522.003, must enroll in the Primary Care Clinician (PCC) Plan or a MassHealth-contracted managed care organization (MCO), unless excluded from participation as described in 130 CMR 508.004.
(2) MassHealth Standard and CommonHealth members who are under the age of 21 and who are excluded from participation in the PCC Plan or a MassHealth-contracted MCO under 130 CMR 508.004(A) or (B) must enroll with the MassHealth behavioral-health contractor
508.004: Members Excluded from Participation in the Primary Care Clinician Plan or a MassHealth Managed Care Organization
The following members are excluded from participation in the MassHealth Primary Care Clinician (PCC) Plan or a MassHealth-contracted managed care organization (MCO):
(A) a MassHealth member who has Medicare;
(B) a MassHealth member who has or has access to other health insurance that meets the basic-benefit level as defined in 130 CMR 501.001;
(C) a MassHealth member who is aged 65 or older, except such member may voluntarily enroll in a senior care organization in accordance with the requirements at 130 CMR 508.008;
(D) a MassHealth member in a nursing facility, chronic disease or rehabilitation hospital, state school for the mentally retarded, or a state psychiatric hospital for other than a short-term rehabilitative stay;
(E) a MassHealth member who is eligible solely for
(1) MassHealth Limited;
(2) MassHealth Prenatal;
(3) Children’s Medical Security Plan (CMSP); or
(4) Healthy Start;
(F) a MassHealth Standard or CommonHealth member who is receiving hospice care through MassHealth, or who is terminally ill as documented by a medical prognosis of a life expectancy of six months or less;
(G) a member who is receiving medical services through the Emergency Aid to the Elderly, Disabled and Children Program pursuant to 130 CMR 450.106;
(H) a MassHealth member who has presumptive or time-limited eligibility;
(I) a MassHealth member who is enrolled in the Kaileigh Mulligan Program described at 130 CMR 519.007(A);
(J) a MassHealth member who is enrolled in a home- and community-based services waiver; and
(K) a MassHealth member who is a refugee described at 130 CMR 522.002.
Eligibility Letter: http://www.mass.gov/Eeohhs2/docs/masshealth/el2010/el-200.pdf
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