April Western HAN: new systems, new challenges

• Attendance and agenda, Western Health Access Network, 4-4-08

Making sure people who apply for Commonwealth Care are able to get and keep their coverage was on the minds of outreach workers at the Western Massachusetts HAN meeting in April, which featured a presentation by the Director of Commonwealth Care, Melissa Boudreault.

Commonwealth Care issues
Since the beginning of CommCare, people who have missed the 20th of the month deadline through no fault of their own have asked “can I get on retroactively?” Consistently the answer has been no. However, it was reported at the HAN meeting that a lawsuit filed by Health Law Advocates changed this for one person. HLA filed suit on behalf of a client whose cancer surgery fell in the gap between her Prior Approval and the date her Commonwealth Care coverage later took effect (delayed by an administrative error by the program). Though she was initially told she could not be reimbursed for the surgery, Commonwealth Care agreed to retroactively enroll her in the health plan after the lawsuit was filed. Unfortunately, there is no regular mechanism in place for others in similar situations.

Melissa Boudreault shared information on a variety of CommCare issues. She reminded people that there will be an open enrollment period for CommCare starting on May 1. People will be getting customized packets explaining the process and their options. Starting July 1, newly approved premiums and co-pays for CommCare will take effect, along with new “out-of-pocket” maximums. There is not yet a mechanism to track members’ out-of-pocket payments, but the Connector is working with the health plans to have something in place for July 1. Members will be sent invoices in May for their anticipated July premiums, so they can call to make plan changes that would take effect July 1. In addition, people in Plan Type 4 will no longer have that option – this plan will be merged with Plan Type 3.

Niki Conte informed people that the Connector’s websites have been consolidated. The CommCare information is now available at www.mahealthconnector.org, including open enrollment materials.

Mechanisms for coping with Exceptions Notices
Melissa also clarified the redetermination and Exceptions Letter processes. According to state law, only the MassHealth Enrollment Centers can handle eligibility issues. Therefore, MassHealth generates the Exceptions Letters and processes annual eligibility reviews (ERVs) for Commonwealth Care. However, though the Exceptions Letters are sent out by MassHealth, they must be returned to a non-MassHealth address: Exceptions Department, P.O. Box 9212, Chelsea, MA 02150. Once received by this Chelsea P.O. Box, each Exceptions Letter is processed by a core member of the Connector staff.

According to the Connector, an Exceptions Letter will be generated if an applicant answers “yes” or leaves blank any of the questions about employer-sponsored insurance (ESI) on page 5 of the MBR. However, it is also possible that an Exceptions Letter could be sent if there is old data in the system regarding a previous employer.

After some dialogue at the HAN meeting, we came to an understanding of what to do for members who receive an Exceptions Letter and don’t have access to other insurance, but whose circumstances don’t fit with any of the choices given on the Letter. In these cases, one should (1) write in an answer, in the margins of the Exceptions Letter, that explains the individual’s situation and (2) call the Masshealth Enrollment Center (MEC) to give them updated employment data. Ignoring the Exceptions Letter, even if it does not seem relevant, will mean being deemed ineligible.

Outreach workers raised a few questions that Melissa said she would look into. HAN members asked whether we could pro-actively avoid the whole Exceptions Letter process by including an official letter from the employer with the MBR, explaining they don’t have access to ESI. The answer to this suggestion is not yet clarified. Other HAN members suggested making the questions that could trigger an Exceptions Letter required fields on the Virtual Gateway, so that blank responses would no longer be an issue. Melissa said this was a good idea and that the Connector was indeed looking into it.

Community Updates
Outreach workers expressed concern that some health plans may be confusing people by calling members about their ERVs before the forms are received through the mail. Eric Goldstein from BMC HealthNet clarified during the meeting that the health plans are notified on the day that plan members get sent ERVs - but not in advance - and that BMC HealthNet then makes calls to let people know to look out for and expect their ERV.

Another HAN member pointed out that Commonwealth Choice, being an unsubsidized plan, can be used in conjunction with the Insurance Partnership. This would subsidize the cost of insurance. This applies mainly to self-employed people, since Commonwealth Choice does not currently offer group plans. Another HAN member pointed out that people who are only briefly disenrolled from CommCare (i.e. their plan ends on March 31, and they are re-enrolled as of April 1) still have to choose a plan and doctor over again in order to avoid a break in coverage.

Finally, there was continued discussion and concern about the lack of primary care providers, given the demands created by health care reform. Melissa indicated that there would be network expansions for CommCare as of July, but nothing was reported about what health plans are doing to increase the provider base.

Members also shared useful resources for Western and Central Massachusetts.