A new MassHealth coverage type has been announced. It is intended to provide coverage for the 36,000 people, mainly the long-term unemployed, whose MassHealth Basic benefits were cut as of April 1, 2003. This program, called MassHealth Essential begins on October 1, 2003. This program is only authorized for one year. Benefits will terminate after September 30, 2004 unless the Legislature authorizes an extension. Given the cap and the temporary nature of funding for this program, providers should encourage individuals to complete a disability supplement when appropriate.

Eligibility

• Family group gross income less than or equal to 100% FPL
• Not eligible for MassHealth Basic (some DMH clients were kept on MassHealth Basic)
• Currently unemployed and hae been unemployed for more than one year
• Not eligible for unemployment compensation AND
• Meet certain other eligibility criteria

Benefits

The following services covered under Basic are NOT available under Essential:

• Home health services
• Audiologist service
• Chapter 766 home assessments and participation in team meetings
• Chiropractor services
• Hearing aid services
• Nurse-midwife services
• Orthotic Services
• Vision care services

MassHealth Essential Purchase of Medical Benefits
- for those with no health insurance:

Members must enroll with a primary care clinician (PCC). Under Basic they could choose this option or a managed care organization (MCO). Under Essential, the MCO option (such as NHP) is not available

Members will not pay premiums for coverage, but are required to pay co-pays for prescription drugs and non-emergency services provided in a hospital emergency room.

Members must enroll with a primary care clinician (PCC) before receipt of benefits.

If the member was previously enrolled with a PCC he/she will be automatically enrolled with same provider if possible. There is no need for this person to enroll with a PCC- benefits would start immediately upon the date of enrollment approval.

Those applicants who a) within the last year were enrolled in MassHealth but not with a PCC or b) have never been enrolled in MassHealth in the past year, have the following options:

• call the PCC enrollment line (1-800-841-2900) once the approval notice is received to begin coverage as of the date of the call (or hospitals can make that call if they have a signed Eligibility Representative Designation on file).
• fax a letter signed by the member outlining their PCC choice to begin coverage on date of receipt of fax.
• prepare the PCC enrollment notice to be submitted along with the MBR or after receipt of the approval notice. Coverage won't begin until that letter or notice is processed.

The Mass Hospital Association is urging hospitals to ask patients to complete Eligibility Representative Designation (ERD) Forms that will allow the hospital to request PCC enrollment on the patient's behalf. Since coverage does not begin until a primary care clinician is chosen by the member, this form ensures the individual does not have to wait to receive the enrollment packet from the Division of Medical Assistance (DMA) once his/her eligibility is confirmed. Instead, those with the ERD can call the provider enrollment number (1-800-841-2100) to enroll the member once eligibility is confirmed.

MassHealth Essential Premium Assistance
- for those with health insurance:

MassHealth will pay all or part of their health insurance premium provided the health insurance meets the Division's cost-effective analysis. This coverage begins in the calendar month following the verification of the member's health insurance information.

Enrollment Cap

The legislation authorizing this program does not allow the Division to exceed allotted expenditures. The Division will freeze enrollment as soon as 36,000 people are enrolled. After this time, those who otherwise qualify will be placed on a waiting list and will be processed in order of placement if and when enrollment allows. So it is important for applicants to complete their applications as soon as possible.

To ensure that Essential coverage is offered first to members who lost Basic coverage in April 2003, the Division identified approximately 34,000 adults who were former members and would be potentially eligible under the new rules and sent them an advance mailing in early September.

- Adapted from MassHealth Eligibility Operations Manual and updates from Kim Simonian, Program Manager, Medicaid and Uncompensated Care Programs, Partners Community Benefit Programs.