MassHealth Managed Care Rules Updates

 

As reported last month, MassHealth has revised its managed care rules (“CommonHealth Members Now Required To Join Managed Care” MGH Community News, June 2010). Not only are certain CommonHealth members (those under age 65 who don’t have other coverage) now required to join managed care, but certain other groups now have the option of joining a MassHealth-contracted Managed Care Organization (MCO), where before they could only access Primary Care Clinician (PCC) plans. Some new details, primarily about member notification, have become clear.

Notification

MassHealth Basic members, MassHealth Essential members, MassHealth Family Assistance members who are HIV positive, and MassHealth Standard members with breast or cervical cancer are those that historically had been eligible only for the PCC Plan, but not for the MCOs. They were notified in a letter, sent July 1, that they could choose an MCO, but that they would continue on the PCC Plan if they did not respond to the mailing.

On July 1, MassHealth sent a mailing to 13,500 CommonHealth members to notify them, and those who did not select a plan within 14 days were auto-assigned to either the PCC Plan or an MCO. If possible these members are assigned to a plan with which they have a history. If they have no plan history, then auto-assignments are done by equal distribution among the plans available in the member's service area. MCOs must honor existing Prior Authorizations for any members who are switching plans.

In late August, MassHealth will send notices to all managed care-eligible MassHealth members, summarizing the new MCO options and changes. Since MassHealth members can switch plans at any time, there isn't an "open enrollment" period.

New MCO Plan

The state just completed a procurement process for their managed care organization (MCO) program, which resulted in 5 participating MCOs as of July 1, 2010: The four incumbent MCOs are still participating: BMC HealthNet, Network Health, NHP, and Fallon. There is one new entrant: Health New England (in the western part of the state only)

New MCO Required Services

The state will be requiring the MCOs to add some activities as part of this contract, including: health risk assessments, complex care management, and coordination of care for members who are served by multiple state agencies.

Effect on Our Patients

As reported previously, most Partners sites accept MassHealth members on Network Health and NHP. NSMC, North Shore Physicians' Group, and McLean also accept MassHealth members on BMC HealthNet.

-From “MassHealth managed care updates” e-mail, from Kim Simonian, MPH, Associate Director for Patient Access, Partners HealthCare Community Benefit Programs, July 27, 201.

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