MASSHEALTH
All the information included here refers to MassHealth as falls under the Health Care Reform changes that only apply to those who are under age 65. MassHealth Over 65 will be covered in a future session. For the under 65 population to determine financial eligibility MassHealth only looks at income, not assets. Please note that there is currently a class-action lawsuit pending that argues that this practice is discriminatory as MassHealth uses an asset test for those over 65. Changes may follow.

Eligibility tip: one needs to have a Massachusetts address, but one is not required to prove residency. If mail is returned to the Division of Medical Assistance (DMA), however, they will disenroll the member.

MassHealth has several different programs with different eligibility criteria and benefits. Keep in mind that to be eligible one has to qualify not only financially, but also categorically. These two factors plus immigration status are what determine for which program one is eligible. The main programs are listed below (but there are additional smaller programs not listed).

MASSHEALTH PROGRAMS
Standard
This is the highest level of coverage, Edith calls it the "gold card". To qualify one must meet fairly strict immigration standards. For full details please see the MGH Community News special supplement - Immigrant Health Access, 10/2000. But in part, the regulations require that those who entered the U.S. on or after 8/22/96 as legal regular status immigrants (i.e., not refugees or asylees) be barred from receiving Federal aid for the first 5 years they are in the country. This summer is the five year anniversary of that date so Edith predicts we'll start seeing some people who were denied MassHealth Standard due to this provision who will be able to be upgraded to Standard. It is unclear if DMA will be seeking these people out or if we need to keep our eye out for them.

(Another example of when someone might be upgraded to Standard is if they were long-term unemployed (in which case they'd probably qualify for "Basic" coverage), and then become disabled. Judy Lynch, RN would then gather the necessary clinical information and a patient financial counselor would complete the disability supplement, which might lead to an upgrade.

CommonHealth
This program is aimed at helping working disabled adults. There is no income limit; but there is a one-time deductible and premiums based on income. Patients are responsible for paying the premium, so some do lose coverage for lack of payment. In this case, patients can be relatively easily reinstated, and Patient Financial Services staff can help.

Basic
This type of coverage is primarily for the long-term unemployed. This is defined as having not worked in the last 12 months or having earned less than approximately $3000. This amount is used as the cut-off because if one earned above this amount he/she would likely be eligible for Unemployment Compensation and the accompanying medical coverage through the Medical Security Plan. If the applicant is married she/he is not eligible if the spouse works more than 100 hours per month. Students are not eligible if they can get coverage through their college. NOTE: one can have unearned income such as a veterans pension as long as it is less than 133% of FPL.

Family Assistance
This type of coverage provides premium payments and certain other coverage for those who are offered insurance through an employer, but are unable to pay the premiums. To qualify parents have to have income of less than 133% of FPL, but their children might be eligible up to 200% of FPL.

This is the type of coverage now offered to those who are HIV positive, but not necessarily disabled.

Prenatal
This coverage is for a 60 day period to get women access to immediate prenatal care while they are in the process of applying for another type of MassHealth, verifying income and/or showing immigration status.

Limited
This is "emergency only" coverage for those who can't document an immigration status AND who also meet categorical criteria: under age 19, parents of children under age 19, pregnant women, disabled. There is not a "long-term unemployed" categorical eligibility under this coverage. Income is also a factor. It must be under 133% of FPL for adults, 150% for children and 200% for pregnant women.

Buy-In
People who are potentially eligible for these programs may be difficult to spot as they generally have health insurance. So they wouldn't generate an automatic referral to PFS. But if eligible, MassHealth would pay their premiums. Eligibility is similar to that under Basic - the person has not worked in more than one year, or not earned enough to collect unemployment; if spouse works it is less than 100 hours per month.

MASSHEALTH RENEWALS
MassHealth members will get notification of the need to renew their membership eligibility if they are undergoing a conversion from SSI to SSDI or TAFDC (such as when the last eligible child becomes of age).

There are also annual financial reviews. Please note that this financial review is different than a disability review. When the Disability Determination Service (DDS) initially declares someone disabled, they do so for a certain period of time, which may be greater than one year. At the end of this time period a member would need to verify the disability still exists - but this is done through the DDS.

The Division is now getting much stricter about following through on these. A letter is sent out, then after 30 days a reminder is sent, after 45 days there is a second notice. All correspondence from DMA includes a message in multiple languages stating that this is important and how to get materials translated into other languages. If people do not respond within 60 days they will lose their coverage. The member will get a post-renewal response from DMA only if the renewal results in a change of coverage.

PFS can help with redeterminations. This is the most likely point to catch something like someone now being able to move from Limited to Standard based on having been in the country since just after 8/22/96.

FREE CARE
Free Care is the common name for the Uncompensated Care Pool into which hospitals, insurers and the Commonwealth contribute each year to cover the costs of care provided to the uninsured or underinsured.

Free Care covers medically necessary hospital services as deemed necessary by a clinician. Our physician's organization (MGPO) honors Free Care in that IF they accept Free Care they won't bill the patient. But each MGPO practice/physician is able to decide if they will accept Free Care.

Massachusetts residency is a requirement to qualify for Free Care. Residency is defined as "someone who is living in Massachusetts with the intention of remaining in the state indefinitely". This is not dependent on immigration status, and receipt of Free Care will not put someone at risk of being viewed as a "Public Charge". (For more information on Public Charge see the Resource Wall on FH2 or the MGH Community News, June 1999). Non-Massachusetts residents are only eligible for emergency or urgent care.

There are officially three types of Free Care:

• Full Free Care- when the person's income is less than or equal to 200% of FPL (see chart). (Note: When an adult lives with adult children the children's income is not counted.) This requires proof of income and Massachusetts residency.
• Partial Free Care- when the income is between 200% and 400% (see chart) of FPL. This requires the same proofs, but additionally the applicant must meet a yearly deductible based on their income. The deductible can only be met with medically necessary hospital charges, physicians charges are not countable for partial Free Care. Once the deductible is incurred (though not necessarily paid) they can utilize full Free Care for medically necessary services for the remainder of their eligibility period (PFS doesn't actually change their status to Full Free Care, but the patient will no longer be billed for medically necessary services).
• Medical Hardship Free Care- for anyone who has allowable medical expenses exceeding 30% of gross family income and whose available assets are insufficient to cover allowable medical expenses over this amount. So assets are considered in addition to all proofs listed under Partial Free Care. In demonstrating "Medical Hardship" all types of medical expenses including prescriptions, physician bills from other hospitals, etc., are allowable.

The MGH uses 3 additional categories for Free Care:

Medicare Free Care- is primarily an accounting term; staff look at assets to see if the patient qualifies for a federal indigent program ("Medicare bad debt") vs. the uncompensated care pool to determine to which program to write-off the care. Medicare patients who are over asset for the federal program, but otherwise income eligible for Free Care, will be able to access Free Care.

Limited Free Care- non-Massachusetts residents who financially fit into one of the categories of Free Care can get that level of coverage only for emergency services. This does not cover prescriptions (unless directly related to an emergency admission) and does not cover any scheduled services as that is not considered emergency services.

Administrative Free Care- this is the use of MGH funds to cover costs for non-Massachusetts residents seeking care for non-emergent/urgent services. This is approved on a case-by-case basis based on financial eligibility and a clinical approval process at the hospital administration level.

Advocacy tip- although Free Care is to be the "payor of last resort" and patients are to be encouraged to apply for MassHealth or other coverage for which they may be eligible, they may refuse to do so and then apply for Free Care. Some patients may opt to do this for example rather than apply for the Commonwealth's new Prescription Advantage program, which would require those at higher incomes to pay a premium.

Thanks to Edith Kenneally for her very informative presentation, her dedication to patients and all her help to us over the years. Edith will be moving on to a new job at Brigham and Women's hospital. We wish her the best of luck, but we'll miss her. Stay tuned for information on the status of rescheduling what was to be her next presentation on MassHealth Over 65 and Long Term Care.

Family Size	200%	400%
1	$17,180	$34,360
2	$23,220	$46,440
3	$29,260	$58,520
4	$35,300	$70,600
Each additional member	$6,040	$12,080