1-03MassHealthCuts

MassHealth Cuts

As of January 1, 2003 several MassHealth changes went into effect as a result of budget cuts. The most significant are highlighted below.

Covered Services For Adults (age 21 or older)

The following services are no longer covered:

Chiropractor services
Eyeglasses, eyeglass parts, eyeglass dispensing, contact lenses, and other visual aids, except for visual magnifying aids used by members who are both diabetic and legally blind (visual magnifying aids do not included eyeglasses or contact lenses.) In this exception the doc-tor must clearly state that the member is both diabetic and legally blind on the prior authorization.
Prosthetics and orthotics, except in hospital settings (Orthotic shoes for members with severe diabetic foot disease continue to be covered in all settings. The doctor must give the podiatrist or shoe provider written certification of this condition on his or her office letterhead. This certification must state that these services are medically necessary for life and safety.)
Dentures and related services, except for members who qualify for "special circumstances" defined in regulations at 130 CMR 420.410(D)- to qualify for special circumstances, a dentist must request prior authorization, and the adult member must have:

1. a severe, chronic mental and/or physical impairment and be unable to maintain oral hygiene; or
2. a clinical condition such that oral disease may be life threatening.

If MassHealth approved a prior authorization (PA) request for an adult member on or before October 25, 2002, and the request was for any of the services listed, then MassHealth will continue to pay for those services through the authorized period.

In addition, MassHealth may institute new prior authorization rules or change the current PA rules for therapy services including physical, occupational and speech therapy. MassHealth may also set up certain limits on the amount of these services that MassHealth will cover for adult members.

Member notice- services no longer covered: http://www.state.ma.us/dma/whatsnew/memb-notice_OptionalServiceCutsEng-11-02.pdf

FAQs: http://www.state.ma.us/dma/questions/faq_cuts.html

Prescription Co-Pay Increase

The co-pay has increased from 50 cents to $2.00 for each prescription for adults in all categories of MassHealth.

The following PERSONS are exempt from paying a pharmacy copayment:

MassHealth members under 19 years old;
MassHealth members who are pregnant;
MassHealth members for the 60 days following the month their pregnancy ended;
MassHealth Limited (emergency MassHealth) members;
MassHealth Senior Buy-In (MassHealth and Medicare) members or MassHealth Standard members for Medicare-covered medicines only, when filled at a pharmacy that is a certified Medicare provider;
MassHealth members who are inpatients in hospitals, nursing facilities, chronic-disease or rehabilitation hospitals, or intermediate-care facilities for the mentally retarded; and
Persons getting Emergency Aid to the Elderly, Disabled and Children (EAEDC) covered services, if they are not getting MassHealth Basic or MassHealth Standard.

The following SERVICES are exempt from a pharmacy copayment:

family-planning services and supplies;
emergency services; and
hospice-care services.

Advocacy tips:

If a person is exempt she/he needs to inform the pharmacy, the pharmacy most likely will not have this information.
Pharmacies, by federal law, cannot refuse to fill prescriptions because a customer cannot afford to pay for the medicine or copayment, even if the person owes the pharmacy many co-payments. However, the money is still owed to the pharmacy and it may continue to bill for the unpaid copayment(s) and use any legal means to collect the money owed.

Notice to consumers: http://www.state.ma.us/dma/whatsnew/Copays-ES-1102.pdf

FAQ: http://www.state.ma.us/dma/questions/faq_pharmacy.html

Reductions in Protection for Community Spouses

The MassHealth asset limit for spouses of nursing home residents applying for coverage has been increased to $90,660. But many "community" spouses will no longer get this amount. Under new rules, community spouses will no longer be able to keep all of the couple's countable assets up to this limit. Now they may only keep half up to this limit, with a floor of $18,132 or the total of the assets if less than this amount.

If a couple has:

$100,000 in countable assets, the community spouse may only keep $50,000. Under the rules in effect through December 31, she could keep $90,660.
$30,000 in countable assets, half would be $15,000, but the community spouse could keep $18,132. Under the old rules she could keep $30,000.
$15,000 in countable assets, the community spouse could keep $15,000.

Obviously, this will have the greatest effect on lower-income community spouses. Those with countable assets over $181,320, can keep $90,660 under both the new and old rules.

Advocacy Tip: In some cases asset allowances can be increased if the community spouse needs additional assets to generate sufficient income to remain in the community (as determined by the Division). This can only be done on appeal after the institutionalized spouse has applied and received a notice of approval or denial. Representation by an elder law attorney at this point is recommended.

See the regulations 130 CMR 520.016 and 520.017: http://www.state.ma.us/dma/masshealthinfo/regulations_eligibility/regs_memb_520.pdf

-This section adapted from: ElderLaw News, a bi-weekly e-newsletter from Margolis & Associates.

MassHealth Basic Update

As previously reported the long-term unemployed who are under 65 will be cut from MassHealth Basic and MassHealth Buy-In. The implementation date of this change is currently scheduled for April 1, 2003, but may be changed to as early as February 1. Exempted from this cut are those who are:

identified by DMH to the Division as receiving services or as being on a waiting list to receive services from the DMH; are "long-term unemployed," and have income at or below 100% of the Federal Poverty Level (currently $8,868 annually for an individual)

receiving Emergency Aid to the Elderly, Disabled and Children (EAEDC) through the Dept. of Transitional Assistance.

Special Status Aliens (generally PRUCOL and members of some groups who arrived on or after August 22, 1996- call the CRC if you have a specific case).

Some people currently receiving MassHealth Basic may be eligible for other MassHealth plans and should apply for the adjustment as soon as possible. Examples include pregnant women, parents or "caretaker relatives" of children under age 19, those who are HIV positive, and those who are disabled. Those who have submit-ted a disability supplement and it has been sent to Disability Evaluation Services (DES) at the time of termination of services will continue to receive services pending the determination of disability by DES.

Those on Basic who are not exempt should receive notice that includes the "MassHealth Eligibility Update Form" that specifically asks questions that might lead to upgrading to another MassHealth coverage type. DMA was to have started mailing these letters on January 3, 2003. These packets also include a multilingual notice and the disability supplement form. Members will receive a 2nd notice 14 days prior to the effective date of their MassHealth Basic ending, (either 14 days before the end of the MassHealth Basic program or after DES determines them non-disabled if they've filed a Disability Supplement). This second notice will include the right to a Fair Hearing, which will include the right to receive coverage pending the appeal determination if DMA receives the appeal before the actual date of the MassHealth closing.

01/03