MassHealth Training Forum.rtf by tongxiamy


									MassHealth Training Forum
January 2009 Summary Notes
Summary notes supplement the presentations made in October’s MassHealth Training
Forums. Meeting materials can be accessed on the MTF website. These notes offer
presenter comments and Questions & Answers with meeting participants. Notes are
organized in the following sections. Click on any selection to jump to that section.
1. MassHealth Updates
2. MassHealth Q&A
3. Health Care For All Updates
4. Health Care For All Updates Q&A
5. NewMMIS Implementation
6. NewMMIS Implementation Q & A
7. MassHealth Premium Assistance Programs
8. MassHealth Premium Assistance Programs Q&A
9. Virtual Gateway Updates
10. Virtual Gateway Q&A
11. 2008 Health Care Reporting Requirements
12. 2008 Health Care Reporting Requirements Q&A
Member Education Mission and Goals The Member Education Unit’s goal is to
effectively educate our applicant/member’s regarding their potential for, and receipt of
MassHealth benefits. We accomplish this by:
• Participating in MassHealth Training Forums.
• Training the Trainers.
• Traveling out into the Community to give presentations.
• Attending Public Forums.
• Collaborating with Sister State agencies to provide training and or to attend
• Providing continued support and reinforcement as needed.
MassHealth has dedicated staff available to present at informational meetings and to
conduct on-site trainings. Please check the MTF website for a Presentation Request Form
m/MH_InSvcReq.pdf .
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MassHealth Policy - MassHealth Equality Bill On July 31, 2008, Governor Deval Patrick
signed into law a measure that allows and requires MassHealth to apply existing spousal
rules to determine eligibility for medical benefits for people in same-gender marriages.
MassHealth will recognize state marriage laws in assessing eligibility for all programs
determined by the MassHealth agency. MassHealth began implementation October 31,
2008. The definition of a spouse requires that persons be legally married. For MassHealth
eligibility determination purposes, any applicant or member who identifies his/her
relationship to another household member as spouse will be determined as such
regardless of gender. Spousal rules will apply equally to all married couples in the
eligibility process including the counting of income and assets, family group definitions,
transfer of assets, asset assessments and spousal impoverishment protections. MassHealth
Policy - MassHealth Eligibility Review
MassHealth has revised its regulations regarding the time standards for review of a
member’s eligibility. The time standard to return a review form has changed from 45 to
30 days. This change is for the MassHealth Waiver Population, Health Safety Net
recipients only, or a combination MassHealth Waiver Population, Health Safety Net and
or Commonwealth Care members (Mixed Households). There is no change for the
Traditional population over 65 who have 30 days to return the review and
Commonwealth Care –only households under 65 who have 45 days. This policy went
into effect December 15, 2008. The regulation can be found at CMR:130 502.007 in the
Member Regulation section of the MassHealth website at
Check the MTF Updates website page for the most recent status on this. MassHealth
Policy - MassHealth Copayments Copayments for most generic and over-the-counter
drugs are increasing from $1 to $2 for MassHealth members. Copayments for generic and
over-the-counter drugs used for diabetes, high blood pressure, and high cholesterol will
stay at $1. Copayments for brand-name drugs remain the same at $3. The MassHealth cap
for pharmacy copayments will remain at $200 per calendar year. MassHealth will send
the member a notice when the cap is met. It is good practice for members keep the
copayment cap met letter and also keep track of receipts for copayments paid during the
calendar year. Members will be mailed a notice regarding the changes to copayments.
Copayments for CMSP and the Healthy Start are not changing. This policy is going into
effect on February 1, 2009. MassHealth Policy - MassHealth Copayment Exemptions
You will not have to pay a MassHealth copayment for any service covered by
MassHealth if:
• You are under 19 years old;
• You are pregnant;
• Your pregnancy ended within 60 days of the service;
• You are getting benefits under MassHealth Limited (emergency MassHealth);
• You are getting a Medicare-covered drug at a pharmacy that is a certified provider for
Medicare and you are getting benefits under MassHealth Senior Buy-In (MassHealth and
Medicare) or under MassHealth Standard;
• You are getting EAEDC (Emergency Aid to the Elderly, Disabled and Children)
Program services, and are not covered under MassHealth Basic, Essential, or Standard; or
• You are getting hospice care.
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MassHealth Policy - MassHealth Copayment Exemptions Continued You also do not
have to pay a MassHealth copayment for:
• Pharmacy services while you are an inpatient in a hospital or an intermediate care
facility for the mentally retarded;
• Family-planning services;
• Mental health or substance abuse-related services provided by a hospital; or
• Emergency services.
MassHealth Operational Changes COLA (Cost of Living Adjustment)
• The Social Security Administration (SSA) has updated MassHealth member
information with the new 5.8% 2009 increase in the Cost of Living Adjustment (COLA)
• The MassHealth MA21 computer system now holds the new SSA COLA amounts.
• MA21 will continue to determined eligibility with the old 2008 amounts for the under
65 population.
• Members under 65 will be re-determined with the new amounts on March 1, 2009.
• Long term care members will have their Patient Paid amounts adjusted on January 1,
MassHealth Operational Changes 1099 HC Tax Form MassHealth will be mailing the
1099 HC tax form to members who have household incomes above 150% of the Federal
Poverty level to verify that they had health insurance coverage. The 1099 HC form must
be submitted with 2008 tax returns to prove an individual had health insurance.
MassHealth Operational Changes Massachusetts Commission for the Blind (MCB)
Eligibility Determination Effective December 1, 2008 MassHealth assumed
responsibility for eligibility determinations for (MCB) members. Eligibility functions
• Processing MBR and SMBR applications;
• Processing ERV and MER eligibility reviews;
• Performing Case maintenance;
• Processing Notice of Birth forms;
• Attending appeals related to eligibility;
• Customer Service Inquires.
An eligibility memo and provider bulletin has been issued with detailed information
related to these changes. MassHealth Operational Changes Massachusetts Commission
for the Blind (MCB) Prior Authorization The MassHealth Prior Authorization (PA) Unit
assumed responsibility for processing the following PA requests:
• Private Duty Nursing (PDN)
• Personal Care Attendant (PCA)
• Durable Medical Equipment (DME)
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Contact the MassHealth Prior Authorization Unit600 Washington Street, Boston,
Massachusetts 02111 for written requests or go to for
electronic submission. All other services provided by MCB will not change and the
Central Register certification of legal blindness will not be impacted by this change.
Outreach and Enrollment Grant Update The grant funding is taking a two model
approach – network coordination grants and direct service grants.
• Network coordination grants – the lead organizations are responsible for coordination
and collaboration of outreach and enrollment activities currently underway. The
Executive Office of Health and Human Services is in the process of renewing network
coordination grants for activities to continue through the fiscal year.
• Direct Service Outreach and Enrollment Grants – are responsible for on the ground
direct outreach, enrollment, redetermination assistance.
• 45 FY08 grantees have been extended to continue outreach and enrollment activities
while an RFR process is taking place.
• The RFR process will be concluded and new grant recipients will be announced in
• Grant activities will include outreach and enrollment activities with a greater emphasis
on retention of benefits and post-enrollment assistance including assistance with the
annual review process, open enrollment processes, primary care physician enrollment,
wellness/preventative care education, and education on how to access health care
For more information on the location of grantees and functions they provide go to: New MMIS Has Delayed Implementation The New MMIS
(Medicaid Management Information System) implementation has been delayed. New
MassHealth Cards have been mailed out in batches to members beginning in October and
will continue being mailed through January 2009. Members should make certain that
MassHealth has their correct address on file. Members can report address changes by
calling 1-800-841-2900 or 1-888-665-9993. If a new MassHealth card has been returned
MassHealth will not close the case immediately, they will investigate and outreach to the
member and attempt to get a correct address on file.
Please check and for
further information.
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Can a transportation provider bill a client for a non-emergency ambulance ride? If the
member's eligibility coverage does not include non-emergency transportation, then the
transportation provider can bill the member directly.
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Can hospitals bill patients for non-emergency ambulance that are on Essential, Family
Assist or Basic? Ambulance services for Emergencies only are covered under the
Essential, Family Assistance and Basic coverage types. I spoke with a client that said she
is not getting her MassHealth mail. Her addresses is correct in MAPs but her name is not
on the mailbox - could that be the problem? Yes, that might be the issue. Undeliverable
mail will be returned to MassHealth so she should report that back to MassHealth. But
she should talk with the post office and put her name on the mailbox. Can you tell me
why the medical release forms are being returned to hospitals with hand written notes
saying that they have to be on one page, front and back? Yes, because of the HIPAA
compliance the written signature giving permission to release information has to be on
one piece of paper – a two sided document. We have a client that said they were
terminated because they no longer live in Massachusetts. When we checked on the case
further we found out she gave an Arizona license which is all she had. Your match is
being done around the country as someone who has been on public assistance. Can you
help me understand what that is about? Yes, there is something called the Paris match
which is done when someone is or receiving public assistance from another state.
Massachusetts needs to verify that the person we are giving benefits to lives in
Massachusetts. When a client does not have the ability to pay the pharmacy co-pay, how
long will the pharmacy attempt to collect? It’s up to the pharmacy. They can attempt to
collect as long as they want but they cannot stop providing the prescriptions. Can you
speak to the review form and the eligibility date? If the review form is suppose to be back
by February 1st but it doesn’t get returned until February 15th – will that be considered a
gap in coverage. For most coverage types eligibility would go back 10 days prior to the
date we received the renewal. Patients are reporting that their new cards are not working
at the pharmacy. How can the pharmacy process the prescription and get paid for it? The
pharmacy has the ability to look up the individual the same way you do (by name and
social security number). They just need to take that extra step. How can we get a copy of
the current co-pays for CMSP? There is a website for the Children’s Medical Security
Plan which is located at:
d=Eeohhs2. On this page there is a link to the “CMSP Premium and Copayment Chart”.
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The new cards have new numbers, but the current system has the old numbers. Should we
be using the new numbers now? You can still check by name or social security number.
You can try to add the number numbers into your process if you think it with help you
before the switchover. From the MTF meeting evaluations: Is there anyone from
Masshealth/Rep. available to come to a Latino population site and speak about the
different MassHealth benefits, co-payments, commonwealth connectors, healthcare tax
information? The requesting agency should fill out a “Member Education Presentation
Request form available on the MTF website to see if the request for MassHealth benefits
information can be accommodated. Does MassHealth automatically screen for new
applicants in the household for this type of assistance? MassHealth takes all of the
information listed on the applcation/review form and delivers an eligibility decision that
will supply the most complete coverage an individual qualifies for. When does coverage
begin for MassHealth standard or essential? Is there wrap around or retro coverage? If so,
how far back does it go? Essential coverage does not begin until a member enrolls in a
Managed care plan. Generally most MassHealth standard coverage will go back 10 days
for under 65, and up to 90 days for over 65. Would MassHealth cover dental care in the
future? The more comprehensive MassHealth coverage types provide MassHealth dental
care presently. Why can't we have separate phone # for providers/MCO to assist patients
at that time? Without more detail it is difficult to answer this question. The Menu Options
on MassHealth Customer Service (Option “1”) is available for Providers calling.
Temporary ID's - if MH denies claim as MBR not found, how would HSN recognize
these members? An MBR would need to be completed in its entirety before a decision for
HSN would show up on the computer.
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Health Care for All is a non-profit advocacy and health information organization, seeking
to make quality and affordable health care accessible to Massachusetts’ residents.
• HCFA has a helpline (1-800-272-4232) staff with multiple language capability
(English, Portuguese, and Spanish). The helpline staff can also fill out MBRs on paper by
phone and then the completed form can be mailed to the individual for signature.
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• HCFA’s legal assistance group, Health Law Advocates (1-617-338-5241), staffs 8
attorneys who assist clients with healthcare related legal issues at no cost. Visit the
Health Care for All website at .
Fiscal Concerns Top Agenda Governor announced $300 million MassHealth 9(c) cuts in
October. MassHealth provider rates are generally frozen. The Outreach grants were
reduced to $1M in state funds. However, funding from other sources preserved funding at
$3.5M. Program changes: Generic drug co-pays are going up from $1.00 to $2.00. There
will also be no non-emergency ambulance service available for MH Essential, Family
Assistance, and Basic. MassHealth will reduce the redetermination response time from 45
days to 30 days. Fiscal Concerns – Help Possible Congress is considering a temporary
increase in Federal Medicaid Assistance Percentage (FMAP). The FMAP increase would
function as economic stimulus by improving health, preserving jobs, and increasing
spending. Policymakers are to decide if additional funds will be used to reverse health
cuts. Fiscal Concerns – Long term Cost Control is a top priority on the agenda for state
policy makers. The state has commissioned an outside group of experts to write a report
showing options to reduce health cost growth which is due in late February. A Payment
Reform Commission will look at recommending radical changes on how we pay for
health care in Massachusetts. Right now hospitals and doctors are paid by the visit or by
the procedure. This has created a great economic incentive to do more procedures and
have more visits. If we can introduce payments for preventive care – to keep people
healthy – maybe we can lower overall costs. There are also new regulations on gifts from
drug companies to doctors and other prescribers. By eliminating these gifts the
expectation is the drug costs will go down. There will also be hearings on cost drivers
which will hopefully help us understand why the cost of health care is so high in
Massachusetts. There will also be limits and a harder review process for new facilities.
Health Care Quality and Cost Council New Web Site
The Health Care Quality and Cost Council created a new web site and its URL is: This site will allow you to compare the quality
and cost of different hospitals for the same procedure. The goal is to make consumers
more informed so they can make better choices in where they want to go for health care.
New Year for Health Policy There will be a new House Co-Chair of the Health Care
Financing Committee which is a key post in the House. The Connector Small Business
Contributory coverage plan pilot starts in January. This will allow small businesses to
give their workers a broad range of Connector approved Commonwealth Choice plans.
The new Minimum Creditable Coverage (MCC) standards go into effect which will
include requirements for:
• Drug coverage required,
• Pre-deductible preventive care, and
• Cap on deductibles, out-of-pocket costs.
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New Year – Upcoming Issues
• The State budget – House 1 from Governor due January 28, 2009 and will have a new
round of 9C cuts. Then the budget goes to the House for its version approval sometime in
March, then it goes to the Senate in April or May, and the final budget is expected to be
out in mid to late June for the fiscal year that starts July 1, 2009.
• The Connector has to decide on which Managed Care Organizations (MCOs) in be in
Commonwealth Care. The HCR law said that the first three years of Commonwealth Care
the four Medicaid MCOs will be the four Commonwealth Care MCOs. Now that the first
three years are over, the field is open for other insurers to offer Commonwealth Care
coverage. Any new MCO offerings will be available July 1, 2009.
• The Commonwealth Care premiums schedule is also up for renewal. There should not
be significant premium increases this year.
• The Affordability Schedule for the individual mandate is up for renewal.
New Numbers The DHCFP survey of insurance coverage as of December 2008 is as
follows: Insured 97.4% and Uninsured 2.6%. Numbers – Uninsured by Income The
following statistics provides information on the uninsured by income: The Total
Uninsured Population is 2.65%, less than 150% of FPL is 5.4%, 150-299% of FPL 5.1%,
300-499% of FPL is 1.9%, and 500% of FPL and Higher is 0.3%. Numbers –Uninsured
by Race, Ethnicity The following statistics provides information on the uninsured by race
and ethnicity. The Total Population is 3.7%, White, Non-Hispanic is 3.0%, Other Race,
Non-Hispanic is 4.5%, and Hispanic is 13.1%. Get Involved! Following is a list of HCFA
Health Reform Implementation:
Children’s Health:
Health Quality:
Oral Health:
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On the MCC, how does that apply if a person works in Massachusetts but their insurance
is from an out-of-state carrier? The insurance in order to meet the mandate still has to
meet the MCC standards. The Connector has provided a waiver process for companies
that have out-of-state carriers where it is good coverage but it doesn’t meet the MCC
criteria exactly. The employer or the insurance carrier can go to the Connector and get an
opinion that this coverage is close enough.
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What are the caps and out-of-pocket limits? For an individual, the deductible cap can’t be
more than $2,000 and for a family it can’t be more than $5,000. The total out-of-pocket
for an individual is $5,000 and for a family is $10,000. If MCC is now a requirement,
what about Free Care Partial and high deductibles? MCC is looking at commercial
insurance carriers. What does 2.6% translate into numbers? I believe that may be
approximately 180,000. If someone just has Medicare A & B, will they be penalized for
not having drug coverage? No.
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NewMMIS Update The NewMMIS implementation date has been rescheduled for May
26, 2009. MassHealth will continue internal testing to ensure that the new system
functions as designed. This delay will also give MassHealth providers additional time to
prepare for the transition to NewMMIS. Additionally, as a result of the rescheduled
implementation, the start date for issuing the new MassHealth Member ID Cards as
indicated in Bulletin 176, has changed. The distribution of the new ID cards to all
MassHealth Members began 10/6/08. NewMMIS Provider Registration Process
MassHealth mailed registration letter & provider ID & service location (PID/SL) to all
MassHealth Providers (non-dental) & submitters who currently have a legacy number on
file on February 23, 2009. The PIN letter envelope will be marked in RED with the words
“MassHealth NewMMIS-Critical Information Enclosed, Please Read!” Providers and
billing entities must begin to identify staff within your organization who will require
access, and/or who will perform services on your organization’s behalf. The Provider
Online Service Center will be open for PIN registration only, beginning March 23, 2009.
Determine how your organization will manage the registration process, and assign access
& permissions for your users. Organizations that conduct business on your behalf will
need to link their NewMMIS User IDs to your provider number. An e-Learning course
will be posted to educate on how to register the primary user. The provider registration
process is outlined in All Provider Bulletin 181. NewMMIS Trading Partner Testing
MassHealth began Trading Partner Testing in August 2009. We are testing with 1,200
direct submitters - 300 are doing Compliance/Comprehensive testing and 900 are doing
Compliance testing. To date approximately 150 have passed compliance testing. If you
are a direct submitter, have been called by CST and have not tested, call 1-888-824-3484
or email If you currently submit electronic claims and do not
complete trading partner testing, you will not be able to submit electronic claims in
NewMMIS. Please complete trading partner testing!
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Cost associated with not completing TPT: Your revenue stream will be interrupted if you
are not prepared to submit batch transactions on Day 1, or utilize the paper or DDE
options to submit claims. Your operations will be impacted if you have not coordinated
resources within your organization to support alternative claim submission options prior
to implementation (paper, DDE). You may have to seek the services of a billing
intermediary to support your operations if the alternative claim submission methods that
are available are not viable options for your organization. NewMMIS Internet Access
NewMMIS is a Web based application which will require access to the internet to
conduct business with MassHealth. There will be no more eligibility operator. Providers
will need to verify eligibility using the Provider Online Service Center. NewMMIS e-
Learning MassHealth NewMMIS Implementation phase: e-Learning courses have been
available since the beginning of October 2008. These are designed to educate providers
how to use and navigate NewMMIS to conduct business with MassHealth through the
Provider Online Service Center. The e-Learning modules are:
• Now available via link on NewMMIS website under “Current MassHealth NewMMIS
Provider Training” link.
• Taken at your convenience and with no limit to the number of times a course can be
• Available with a walk through, practice and job aid.
It is strongly suggested that key staff complete all courses applicable to your MassHealth
business before the implementation of NewMMIS. NewMMIS e-Learning Take
advantage of the extra time to assess staff training progress and identify courses or areas
that may need additional practice. Learn, acclimate and practice, practice, practice… Be
sure to print the course job aids associated with the various e-Learning courses as they
can be used as a step-by-step desk reference to supplement exercises. NewMMIS E-
Learning Here is the list of e-Learning Courses:
• Provider Portal Information and Navigation (This course must be completed first)
• Provider Profile Maintenance
• Eligibility Verification
• Pre-Admission Screening
• Prior Authorization
• Management Minutes Questionnaire
• Referrals
• Submitting Institutional & Professional Claims
• Batch Claims
• Edit Claims Post Submission
• Set Up Security Access
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NewMMIS Provider Bulletins MassHealth will continue to issue bulletins regarding
NewMMIS. Bulletin content will outline the steps that should be taken now to prepare for
the coming days, weeks or months. MassHealth will issue a bulletin on the move from
REVS to the Provider Online Service Center. Provider Readiness Following is a list of
Do and Do Not. Do:
• Do continue submitting paper claims on the applicable MassHealth proprietary claim
forms until MassHealth instructs you to stop.
• Do continue to submit claims via PCSS.
• Do continue to submit electronic claims to the Customer Web Portal.
• Do continue to submit paper adjustments and voids in the current (legacy) system.
• Do continue to use the Claim Attachment Forms (CAF) process.
• Do review the applicable billing and companion guides.
• Do continue to submit prior authorizations using APAS.
Do Not:
• Do not use the new12 digit member ID for billing.
• Do not begin submitting paper claims on the UB-04 (except for hospitals) or the CMS-
• Do not use NewMMIS UB-04 billing instructions.
Available Resources
• Check our web site for the most up-to-date information:
• Use the e-Learning modules.
• MassHealth provider bulletins.
• For TPT call 1-888-824-3484 or email
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We have a hospital and a Professional group, how many primary users should we have?
You will only have one Primary User for each MassHealth provider number. We’ve tried
using the E-Learning portal but we have experienced the screen freezing (45 minutes).
How are we supposed to use the training tool if we have these types of issues?
MassHealth has issued an updated version of the e-Learning courses. One of the updates
was to improve the timing in the larger courses. You need to let us know when you have
these issues so we can troubleshoot why this is happening and fix the issue. Make sure
your pop-up blocker is off.
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If several people are trying to access the E-learning modules at the same time, is that
affecting the slowness? That should not be an issue at this point. In the fall, changes were
made to increase the capacity to avoid delays due to high traffic. But please call us and
we will troubleshoot to help resolve the issues. For billing purposes, are we still suppose
to use the 10 digit number and not the new one? Yes, still use the 10 digit number until
the NewMMIS system is implemented. When members received their new cards, the
letter they received told them to throw away their old cards. When new recipients come
in with their new cards, it is slowing down our registration process. This is becoming a
real issue. You can put the new number into REVs and we can give you the 10 digit
number. We understand this issue is causing a slowdown in the registration and billing
flow process and we will take this back. The screens shots on the E-learning modules are
very small and hard to see. The letters are very small and it’s difficult to see what is on
the screen. Is there anything being done to resolve this? If you upgrade to Internet
Explorer 7, there is a magnifying option glass in the bottom right corner on the status bar.
You may have to go to the menu and select View - Status Bar in order for it to be
displayed. If you increase the zoom level, it will make the e-Learning text larger. You can
also Right Click on the e-Learning module and select Zoom In which also increases the
text size.
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MassHealth offers five distinct Premium Assistance programs. All of these programs
have two goals, the first goal is to expand coverage and the second is to save the state
money. These goals are achieved by helping low income, Massachusetts residence that
are eligible for MassHealth enroll into employer-sponsored insurance (ESI). Many of
these people cannot afford the employer sponsored health insurance so the Premium
Assistance program helps to pay for these employers sponsored plans by sending checks
out to most members each month to help them afford the cost of their employer
sponsored health insurance. In certain cases Premium Assistance helps small employers
offer comprehensive, affordable health insurance to their employees by paying a subsidy.
How money is saved, we take advantage of the employer sponsorship in that health
insurance. By doing this, the expense to the state is reduced by the amount the employer
is paying. By taking advantage of ESI, certain premium assistance programs save the
state millions of dollars it otherwise would spend on direct MassHealth coverage.
MassHealth Standard, CommonHealth Premium Assistance (MSCPA)
This program provides premium assistance to MassHealth Standard and CommonHealth
members who have access to commercial health insurance. This is done by sending
premium assistance payments (a month in advance) to members minus the appropriate
contribution amount required of the member. This program also provides the member
with “wrap” benefits
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for MassHealth so the member will never see a reduction in coverage and in a lot of cases
what we see is an expansion in coverage because people are opened up to a wider
network or they get coverage from their private insurance for treatments that MassHealth
may not pay for. MSCPA Eligibility Criteria MSCPA is based on a member’s category of
aid, rather than income. The member must have access to commercial health insurance
that is group sponsored (including COBRA). The health insurance must be cost effective,
and meets the MassHealth basic benefit level. Family Assistance The Family Assistance
program provides premium assistance on behalf of eligible children in families with
incomes between 150%-300% of the FPL. If a parent is working and they have access to
ESI, the parent will be asked to enroll in a family plan which will cover all family
members. When this coverage was expanded from 200% to 300% of the FPL, there was a
crowd out that had to be put into place. This means that someone applying that is
between 200% to 300% of the FPL and they already have health insurance they will be
denied. Someone between the same level that is not currently insured but has access to
employer sponsored insurance would be eligible. Premium assistance payments are sent
one month in advance to member minus the appropriate contribution amount required of
the member. This program does not provide “wrap” benefits.Family Assistance
Eligibility Criteria The gross family income must be between 150%-300% of FPL for
families with children. The family must have access to commercial health insurance, and
the employer contributes 50% or more of premium cost; is cost effective; and meets the
MassHealth basic benefit level Insurance Partnership The Insurance Partnership is a
unique premium assistance program that pays subsidy to a qualified small employer to
provide health insurance. This program also provides premium assistance to adults (with
or without children) with incomes at or below 300% FPL who work for a qualified
employer. Premium assistance payments are sent to the employer on behalf of employees
minus the appropriate contribution amount required of the employee. Insurance
Partnership Eligibility Criteria The “member eligibility” requirements are that the
employee work for a qualified, small employer; their gross family income below 300%
FPL; and they must be a resident of Massachusetts under 65 years old. “Employer
eligibility” states they must employ no more than 50 full-time employees; offer
comprehensive health insurance to employees; contribute at least 50% of the cost of that
insurance; and agree to adjust withhold of employee to reflect premium assistance
payments. MassHealth Essential Premium Assistance
This program provides premium assistance to members who qualify (see criteria below)
and are enrolled in group or non-group commercial health insurance plans. People who
might qualify
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for this program need to contact MassHealth Essential Premium Assistance. This
program sends premium assistance payment to member and it does not provide “wrap”
benefits. MassHealth Essential Eligibility Criteria A member must be unemployed for a
year or more; or if employed, has not earned enough in the previous year to collect
unemployment compensation; if married, member’s spouse must work less than 100
hours per month; and have a gross monthly income at or below 100% FPL. The member
must have access to commercial health insurance that is cost effective; and meets the
MassHealth basic benefit level. HIV Premium Assistance Massachusetts was the first
state to extend Medicaid eligibility based on an HIV+ diagnosis. This program provides
premium assistance to MassHealth members who have verified an HIV+ diagnosis to
avoid high cost claims by helping people to continue to carry private health insurance.
This program sends premium assistance payment to member minus the appropriate
contribution amount required of the member. This program also provides member with
“wrap” benefits. HIV Premium Assistance Eligibility Criteria Member must have gross
monthly income at or below 200% FPL, be under the age of 65, provide verification of
HIV+ diagnosis and not be institutionalized, not be eligible for MassHealth Standard or
CommonHealth, and have access to commercial health insurance that is cost-effective
and meets the MassHealth BBL. Premium Assistance Programs
For a visual comparison of the premium assistance programs, please view Slide 14 in the
MassHealth Premium Assistance Programs Ensuring Medicaid is the Payor of Last
Resort January 2009 Power Point presentation found here:
um%20Assistance.pdf. Spending Per Month The following is an example of saving the
state money and how many people can be covered with just one MassHealth member. If
there is one disabled child or adult in the house hold, Premium Assistance can purchase
the family plan health coverage that the employer offers for the entire family instead of
covering just the one MassHealth member. Rather than having just one MassHealth
member covered and the other family members uninsured, we would have all family
members insured with comprehensive health insurance. Premium Assistance & IP
Program Net Savings The Premium Assistance and IP Program savings in FY08
generated a net savings of $61,074,548. There are approximately 52,000 covered lives in
these programs which is a 15% increase over FY07. Programs & Contact Numbers
Family Assistance (888) 291-4464(617) 451-1332 MSCPA (800) 862-4840; (617) 451-
1332 Premium Billing (800) 841-2900 Medicare Buy-In (800) 462-1120 (Opt. 6)
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Medicaid Essential (800) 862-4840 (Opt. 2); (617) 451-1332 HIV Program (800) 862-
4840 (Opt. 2); (617) 451-1332 Insurance Partnership (800) 399-8285 MH Customer
service (800) 841-2900 Third Party Liability (888) 628-7526; (617) 357-7604 Essential
or Basic – Medicaid essential
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If someone wants to apply for one of these programs, would they call MassHealth
directly rather than going through the Virtual Gateway site? Anyone who applies, even
going through the Virtual Gateway, will get picked up for these programs. If someone is
asked if their employer offers them insurance, would that automatically discount them for
these programs? No, and in a lot of cases it makes it easier to identify the access right
away and get the person on the health insurance. Someone can apply even when they are
on health insurance. Their case would be investigated to determine if they qualify for a
premium assistance program, what their health insurance is and start reimbursing them
for it before they can’t afford it any longer or drop the health insurance. A parent and
college student over 19 and is given Premium Essential, does the payment go to the
parent or the student? We would have to look at the specific case before providing an
answer. If someone is between 200% and 300% of the FPL and they are already enrolled
in health insurance, would they qualify for Family Assistance? If they don’t qualify but
are in jeopardy of losing their insurance, is there any program that can provide them
assistance? In the Family Assistance program there is a “crowd out” provision that was
put in when coverage was expanded from 150% to 200% out to 300% of the FPL and this
provision states that when a family applies and they are between 200% to 300% of the
FPL, they need to be uninsured at the time they apply in order qualify for the program.
There are several exemptions in place in the regulations which allow people to not be
“crowded out”. Is there an income level for the employer in order for them to participate
in the Insurance Partnership program? No, there is no income level for the employer to
qualify – it is based on the employee’s eligibility. There are employer eligibility
guidelines and to be a qualified employer they would need to employ less than 50 full
time employees (40 hours per week), offer comprehensive health insurance benefits,
contribute at least 50% towards the cost of those benefits, and agree to adjust the
employee’s withholdings. Are there Insurance Partnership “crowd out” provisions? Yes
and the IP crowd out provision is stricter. It states that if the applicant is already insured
or has been offered health insurance within the past six months they will not be eligible
for the program no matter what their income level is.
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If a long-term unemployed person makes less than $3,000 within the past year, what
program would they qualify for? In order to qualify for Essential you have to have earned
less that the amount needed to qualify for unemployment compensation in the last 12
months which currently is $3,300. If someone has a health plan at work and it’s going to
cost them more than what MassHealth, would the family still be reimbursed? We would
never ask someone to incur a cost which is going to be higher than what they would have
to pay to participate in direct coverage MassHealth. For example, someone who is
Standard will not pay a premium. So if Premium Assistance can only pay $329.00
towards the cost of health insurance and it’s going to cost them $500.00, we would not
ask them to enroll in that health insurance because they will be incurring a cost above
what they would if they were participating in direct coverage MassHealth. We may,
however, be able to reimburse a family the “cost effective” about if they want to do this.
There are also exceptions to the rules where there is a “cost effective” amount but if we
pull a specific member’s claims and if it is determined that the member is an extremely
“high cost” case, it may make sense to pay a few hundred dollars towards purchasing the
health insurance. From the MTF meeting evaluations: Are letters sent advising of all
these different types of Premium Assistance? Yes, MassHealth Approval notices advise
members of potential access to premium assistance provided they have potential or self-
declared access to employer sponsored health insurance. Are Families automatically
screened for different types of premium assistance when MassHealth Application is
submitted? Yes, when families approved form MassHealth and they have potential or
self-declared access to health insurance they are automatically referred for investigation
for Premium Assistance.
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To see what was presented at the session, please click here. What is My Account Page
(MAP) / Interactive Voice Response (IVR)?
The MAP IVR announcement and handout are available at:
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Can you make a change even if you are not the facility that started the application? If the
person is physically present and they are willing to sign a Permission to Share
Information for your organization, if one is not already on file with MassHealth, then yes.
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Do changes entered on the Change Form update the MA21 system? Yes – in most cases
immediately. There are some exceptions, however. For example, these Virtual Gateway
Change Form changes will not cause an immediate change in MA21, but will trigger a
manual process due to the unusual circumstance:
• The household is in an active ERV profile;
• No household ID is found on MA21;
• No person ID is found in the MA21 household;
• A new person ID is found in the MA21 household;
• The change of residential or mailing address is an out-of-state address;
• The residential or mailing address city does not match one that MA21 recognizes;
• For a new pregnancy, the household member is under the age of 19;
• There is an event or household change since the change form was submitted;
• Any household member is closed with an administrative reason.
Can you add a gender choice for new born babies to the change form? Thank you for the
idea – it’s a good one. We will take it back. If a person submitted an ERV, will
MAP/IVR indicate when it will be processed? There will be a date of receipt for the
“application” indicated but it will not specify the turnaround time. Will exception letters
that people send back ever show up in MAP? Currently MAP does not provide
information on the status of an Exceptions Letter. When I go to MAP I can’t see the non-
payment of premiums. Can this be added? Look at the “notices”: The MassHealth notices
will identify if a member has been denied or terminated for non-payment of premium.
When someone calls the MAP IVR and it tells them that they are eligible for
Commonwealth Care, does it give them any additional information that they need to
enroll? Currently MAP-IVR does not alert a member who has been approved for
Commonwealth Care of the need to enroll in a MCO, however the Commonwealth Care
approval notice does advise the member of the need to enroll in a plan. I have a client that
has his mail delivered “in care of” someone, where do you put that? If an individual has
mail delivered in "care of" someone, the "care of" address should be reported in the
"mailing address" section of the application. Currently, MassHealth systems do not have
the capability to list the "care of" name- only the street address. (NOTE: The individual
must report their residential address.) If a patient’s name is John but the gender in Revs
indicates “female”, can we go on VG and change female to male? You cannot use the VG
to do this at this time.
If the person is in profile status, can we enter (change, job updates) information? Yes, but
please be aware the change entered on the Change Form will not be immediately
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imported into MA21. It requires an eligibility worker to actually process the form
manually after the ERV profile period has ended. Why can I not use the change form to
update an address once a case is closed? You can submit a Change Form to update an
address once a case is closed. When a change of address is received via the Change Form
for a household that is closed for undeliverable mail, it is processed by changing the
address, removing the closing code and determining the household. Can the job update
form be added to MAP? The job update information comes from DOR so it can’t be
posted on MAP. Why can we change the address but we can’t change the name? That
type of change needs to be processed by an eligibility worker and the client must be
present to ensure the correct spelling is provided. If you do not have a PSI on file can you
not make a change? Correct. Why does the link to Streamlined Renewals go away 30
days before the due date? Just before the due date and immediately after is when we need
it the most. There is actually an important policy reason for this, however, we do
understand your concerns and are looking into whether it can be feasibly addressed. On
the Virtual Gateway, why is my organization not seeing any links on the review forms?
Currently, only Commonwealth Care-only households will generate a Streamlined
Renewal link in MAP. So, it may be that your organization has few if any
Commonwealth Care patients/clients. If you do have Commonwealth Care clients and are
not seeing the link at all, ever, please contact Howard – we may need to investigate
whether you were ever given access to Streamlined Renewals. This can be resolved, if
this is the case. We have people calling me saying they are calling the 24/7 telephone
access and saying they are not getting anywhere. Is there a known issue with the phone
system? We did identify recently a small glitch which was affecting a small number of
individuals in trying to connect to the service. It has since been corrected. Please let us
know if you encounter any further difficulties. Will Streamlined Renewals be rolled out
for MassHealth and Health Safety Net? There has been a delay. But yes, we will notify
everyone eventually when this is about to happen.
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Massachusetts passed comprehensive Health Care Reform legislation in April 2006. The
law is based on a set of shared responsibilities for individuals, employers, and the
government. The Commonwealth has provided support through expanded access to
MassHealth and the creation
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of Commonwealth Care and Commonwealth Choice programs. With expanded access to
affordable health insurance came the individual mandate. Health care reform seems to be
working. We know that 440,000 people who were uninsured in 2006 now have health
insurance. The Division of Health Care Finance and Policy (DHCFP) released a survey in
late 2008 showing that roughly 2.6% remain uninsured. Around the same time, DOR
released a report on its first year experience with the individual mandate which showed
that 95% of adult tax payers indicated to DOR that they had health insurance as of
December 31, 2007. The DHCFP survey result are actually more comprehensive than
DOR’s because it includes data on children and people who do not have a requirement to
file taxes or who have a requirement but abate DOR. Individual Mandate requires
residents of the Commonweatlh 18 years of age and over with access to affordable health
insurance to obtain it. Penalties enforced by the Department of Revenue through income
tax returns. Individual Mandate Requirements for 2008 states that individuals must have
coverage for all 12 months. Penalties apply only to adults deemed able to afford health
insurance. There is no penalty for individuals with incomes up to 150% FPL. The
penalties are up to 50% of least costly health insurance available for each month (the
premiums are based on the Commonwealth Connector premiums). Gaps of three
consecutive months are permitted (i.e., no penalty) in 2008 recognizing the economy, that
people may be between jobs, and people may have lapses in coverage due to
circumstances beyond their control. Multiple and distinct lapses are permitted throughout
the year such as two three month lapses throughout the year – as long as each distinct
laps is three months or less there would be no penalty. Individuals with gaps of four or
more consecutive months may be subject to the penalty if health insurance is deemed
affordable (first three months penalty-free). Exemptions to Individual Mandate Taxpayers
who do not have health insurance are exempt from the penalty if insurance is deemed not
affordable, if the individual has a religious exemption or objection to purchasing health
insurance, or an individual obtained a “Certificate of Exemption” in advance from the
Connector stating that no health insurance product was affordable. Important Note: even
individuals for whom health insurance is deemed affordable may claim a hardship for an
exception to the penalty. “Deemed Affordable” The Connector creates the affordability
standards and the Connector board must annually publish a schedule of amount of
“income which an individual could be expected to contribute toward purchase of health
care.” Schedule HC – Health Care Information The Tax Filing Process for 2008 includes
the following. Taxpayers must file a Schedule HC “Health Care Information” with their
income tax returns. Insurance carriers and certain employers must issue a Form MA
1099-HC to the subscriber of the plan by 1/31/2009. The MA 1099-HC will list spouse
and dependent information and the months covered by insurance. Taxpayers will use the
MA 1099-HC to complete the Schedule HC. Every MA 1099-HC issuer must send an
electronic report to DOR which will be used to verify the health insurance information
reported by the taxpayer on the return.
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MassHealth and Commonwealth Care Members Members with incomes above 150%
FPL at any point in 2008 will receive a MA 1099-HC from MassHealth or
Commonwealth Care by 1/31/2009. The MA 1099-HC will provide detailed information
about months covered. Individuals with incomes at or below 150% FPL are not subject to
any penalty and thus will not receive MA 1099-HC. Toll free numbers are available in
the Schedule HC instructions for members who did not receive a MA 1099-HC but wants
or needs one. Affordability Determination Taxpayers without Health Insurance or gaps in
coverage of four or more consecutive months need to determine if insurance was
affordable for them in 2008. First they have to determine if they had access to affordable
employer sponsored health insurance. If they did not, then they need to determine if they
were eligible for government subsidized health insurance. If they did not, then they need
to determine if they were able to afford private health insurance on their own. If the
answer is “no” to all of three questions, health insurance is not affordable to them and
they are not subject to any penalty. If the answer is “yes” to any one of the three
questions, then they are subject to the penalty. Penalty Worksheet To determine the
penalty amount, the taxpayer must complete the penalty worksheet in the Schedule HC
instructions. Penalties are based on an individual’s family size and income. For
individuals under 300% FPL there is a phased in penalty schedule for individuals with
income between 150% to 200%, 200% to 250%, and 250% to 300%. For people above
300% FPL there are two tiers of penalties, (1) for individuals between ages 18 and 26 and
(2) for people 27 and above. The maximum penalty for someone 27 and above with
incomes above 300% FPL is $76 for each month of non-compliance or $912 for an entire
year of non-compliance. Health Care Appeals Taxpayers who have been deemed able to
afford health insurance may appeal the penalty. The appeals will be heard by the
Connector and an individual may be required to attend a hearing. A penalty is not
assessed if the individual is filing an appeal. A penalty will only be assessed if their
appeal is denied or dismissed. If someone decides to take the penalty, the amount would
come out of their tax refund. For someone who appeals and their appeal is denied or
dismissed by the Connector, DOR will then issue them a bill. The penalty is treated like
any other tax due to the Commonwealth and is subject to interest if not paid on time.
There are steps that people need to take to perfect an appeal. People who request an
appeal on their tax return will get a letter from DOR and they will have 30 days to
respond. They will be asked to provide supporting documentation to support their appeal.
Examples of hardship documentation are: a house foreclosure notice, utility shut-off
notice). Failure to respond to the DOR letter will result in the dismissal of the appeal.
For more information, including an online affordability calculator and Schedule HC
video presentation, visit
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How does DOR fine people who lose their jobs, are on unemployment, who are on
waiting periods with new jobs? INDIVIDUALS DEEMED ABLE TO AFFORD
CAUSED A HARDSHIP. If someone is getting a tax refund that is less than the tax
penalty, will they be billed for the difference? Yes, they will get a bill. Will DOR taken
into consideration someone’s employment history – someone working two months, lose
their job, work another few months then lose their job again, or may not qualify for
insurance due to not working long enough? Yes, that is one of the reasons why DOR
extended the 63 day lapse period to three months in 2008 given the economic conditions,
people losing jobs, and that they may be in waiting periods with new employers. Through
unemployment people might be eligible for Medical Security Program or Premium
Assistance. If these programs do not help the individual, they should appeal. Will the
penalty worksheet be on-line?
DOR has created an on-line affordability calculator and it is available on-line. For people
who are subject to the penalty, there is also an on-line penalty calculator. There is also a
Schedule HC Virtual Highlights video that provides a step-by-step guide to help tax
payers figure out how to fill out the Schedule HC. Schedule HC Virtual Highlights video
is located here:
Ador&b=terminalcontent&f=dor_HC_Tour-2008&csid=Ador If a client thinks they have
been denied by MassHealth but what in fact happened was the client failed to send in the
proper documentation, could that be seen as a “denial” and therefore the client would not
be accessed the penalty? For these purposes, denial means that the applicant was "not
eligible" for Commonwealth Care or MassHealth vs. denied for "administrative reasons"
for failure to return forms necessary to determine eligibility. Regarding the appeal, some
people are sending information to DOR regarding hearings by the Connector. Who
should they call if there are any questions? The Connector should be called for an appeal
hearing. DOR has offered to process the appeals paperwork for the Connector, the appeal
is entered into a database that the Connector has access to. It is the Connector’s
responsibility to administer and hear the appeals.
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If determination is pending due documentation and this process is taking two to three
months, or if there is an incorrect determination, how should an individual handle this
when filling out their taxes? This is one of the reasons why DOR extended the lapse
period from two to three months recognizing there are some people who lack insurance
through no fault of their own due to the processing of paperwork. This is a good example
of when an appeal would be appropriate. Where are the appeals conducted? The
Connector hears appeals in Boston only. The Connector can be contacted directly
regarding specific appeals. If someone is an immigrant and they have a Social Security
Number and they are doing a tax return (they do not have a green card so they are not
eligible for MassHealth or Commonwealth Care), they don’t have insurance but they fall
between 150% to 300% FPL, would they still face a penalty? Generally speaking, they
would likely fall into the “not affordable” category because if they are not eligible for
government subsidized health insurance and if they don’t have employer sponsored
insurance available to them it is unlikely that they can afford to buy it on their own. Is
there a way to tell an immigrant that they are not eligible for Commonwealth Care
because they are not a RESIDENT? In the government subsidized question - if you are an
illegal immigrant, you are not eligible for government subsidized insurance.
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