First, some good news: The Exception process for Commonwealth Care has improved. HAN members confirmed that people who work under 100 hours a month are able to get approved for CommCare much faster, and that their Customer Service (1-800-MA-ENROLL) operation is now able to respond to Exception-related questions.
Outreach workers have also had success getting Medical Security Program (MSP) applications expedited for clients with specific, urgent medical needs. These applications can be expedited by emailing the MSP director or by writing "ACCESS TO CARE" on the top of the application and faxing it in. Contact us for more information.
But it can be difficult to do community outreach when your organization has an uncertain future. There is hope that the final state budget will include an outside section to guarantee 2.5 million dollars of outreach and enrollment funding from off-budget sources. But nothing is guaranteed. (CP Update 6/29/09: The outside section funding for outreach and enrollment was eliminated by the Governor's vetoes; see our policy updates for more information.)
HAN members are seeing an increase in clients who require extra help navigating health coverage systems. For example, seasonal employees on the Cape are once again entering the coverage gap between the Medical Security Program and Commonwealth Care. Clients are frustrated to be caught up in this cycle of coverage gaps, which they know they’ll go through again in 4-5 months. Some people have to cancel or postpone referrals for care as their coverage changes, and others are having trouble using the Health Safety Net to get their prescriptions filled.
There has also been a recent increase in elder and young disabled clients who are losing their MassHealth or Commonwealth Care eligibility and must enroll in Medicare. They are coming in just above the MassHealth income guidelines—sometimes due to Social Security Disability income—and must be referred to a SHINE counselor to navigate the complexities of a different coverage system.
At the time of this meeting, NewMMIS had been in action for only two days. HAN participants reported problems with checking eligibility but expected MassHealth would resolve glitches soon. One HAN member mentioned that people who used to show up as “Essential HSN” are showing up in NewMMIS as ineligible; MassHealth has instructed them to call in these cases so the member can enroll with a primary care clinician. (As other issues emerge, feel free to note them by commenting on this blog.)
Melissa Boudreault, Director of Commonwealth Care, visited this month’s meeting and gave HAN members the opportunity to ask questions. The first subject to arise was the relationship between the Medical Security Plan (MSP) and Commonwealth Care.
Q: MSP can pay COBRA premiums: why can’t it help with Commonwealth Care premiums, so people can avoid gaps in coverage?
MB: Using CommCare as a direct coverage plan would be creating a whole new program that was not carved out in the waiver. In other words, CommCare is designed to cover people who don’t have access to MSP (subsidized insurance), so we are not allowed to enroll people who can get MSP. DUA procures their direct coverage plan (it is currently Blue Cross) to provide coverage for their eligible members. However, CommCare and MSP are defined very differently in terms of who they can cover and the benefits provided. Here is some background:
MSP is part of the Medicaid waiver, so the state receives FMAP (Federal Medical Assistance Participation) reimbursement. MSP is bound by many Medicaid rules, but it has important differences. Eligibility goes up to 400% of the federal poverty guidelines (FPL), and income is determined very differently than for MassHealth.
The federal reimbursement rate is now above 50%. When the government made the decision to raise the rate, they wanted to be sure the money was being spent. To help make sure that happened, CMS implemented something called maintenance of effort and eligibility. It means any program operating on a waiver in any state—like CommCare and MSP—can’t adjust any program rules that relate to eligibility. Programs have to look just like they did on July 1, 2008 and stay that way until July 1, 2011. That’s why the time limit for returning ERVs and verifications went back to 45 days after we had changed it to 30 days. So when we try to problem-solve, we must consider these rules.
We would like to improve the exchange of information about people coming off of MSP who may be coming into CommCare. But MSP and CommCare cannot share data due to privacy rules, and the MSP staff are very busy and really only able to work with us after regular business hours. We’re making progress, but it’s going to take awhile longer. The result won’t have the look or feel of a different plan, but some operational issues can be straightened out in the background.
Q: We’ve heard that outreach workers should help clients apply simultaneously for MSP and for MassHealth through the Virtual Gateway, so that when they come off of MSP they’re already in the system. We’ve also heard that when people have done that, it’s created a contradiction in the system so that eligibility can be denied both ways. Is there another instruction?
MB: We do ask that you don’t submit MBRs for people you don’t think will be eligible for MassHealth or CommCare; but we understand that you sometimes submit MBRs in the hope they’ll get HSN while they’re waiting to be enrolled in MSP. If you submit the application before they’re approved for unemployment insurance (UI), and you check "no" in the "Are you receiving unemployment?" box, they will probably be approved for CommCare—they’re not going to go into the HSN. But once CommCare sees they’re on unemployment, they’ll be disenrolled. Meanwhile MSP can’t enroll them because they think they have CommCare. This is an unintended consequence: the system is working as designed, but the reality isn’t fitting the design. We have to intervene manually to correct this problem.
Q: Another built-in complication is that there is no way for people to apply for HSN—which wraps MSP—except with an MBR, so it’s hard to avoid the glitch.
MB: One way to mitigate this is to make sure the MBR says they are receiving unemployment, if they are. But I see the reluctance: it may take 4-6 weeks to get approved for unemployment, and not everybody is approved; and I certainly support putting accurate info on the MBR.
The biggest difference between CommCare and MSP is that CommCare determines eligibility systematically, but MSP is all done by hand. MSP has many more nuances, a lot of different rules, and for many of their eligibles this requires a lot of education. They have this whole hardship waiver piece; they exercise a lot of judgment. Phone calls take longer. We speak a different language; they cannot imagine determining eligibility based on 2 pay stubs, and we can’t imagine looking at a whole year of income.
Q: I have a question about "crowd out." Many people coming to me are earning minimum wage. Their employer offers insurance and pays the required 25 or 33 percent, but there is no way my clients can afford it. If they refuse Employer Sponsored Insurance (ESI) and wait the six months, are they then eligible for CommCare?
MB: If you have access to ESI and it’s not affordable to you, your only option is the Health Safety Net. People often say, "If the state says I can’t afford ESI, why can’t I have CommCare?" That’s a very fair question. In theory, you can apply if you’ve turned it down. But the way the Exceptions process works, if we see that the employer offers insurance, you’re probably going to get denied. The six-month rule was really designed to dis-incentivize employers from paying employees to refuse their insurance.
We’ve considered other ideas to deal with this—for example, could people completely buy into CommCare. But our major focus right now is cost containment.
CommCare premiums for consumers have actually come down this year, in contrast to private insurance. Creating competition within the system, like bringing in CeltiCare, is what brings premiums down. Network adequacy is another challenge. If we oblige the plans to contract then providers have more leverage to say "this is what I want"; then rates can go up. More people are coming into the program. What’s critical to me now is to have funding to cover that growth. We didn’t increase co-pays or enrollee contributions this year. There’s a real tension between cost containment and program design that may be more prevalent this year than last year. We haven’t been affected by state budget cuts up to this point. We’ll have to see what happens.
Comment: Re-routing calls about Exceptions to 877-MA-ENROLL was a great improvement. They often take care of things within a week! Some folks still get stuck, but it’s much better.
MB: We’re glad we could do that.
Here’s a tip regarding NewMMIS—when you look at EVS, be sure you look closely. If it says they’re not eligible for CommCare, but they’re enrolled, that’s a red flag. We don’t want to get into a position where members are receiving services because providers think they’re covered, and they’re not. We don’t really have a way of addressing those issues. If it looks odd, go to MAP, or call us, do what you need to do. The NewMMIS implementation overall was incredibly successful; a lot of systems got bundled into one. Give it a few more days—but if something looks odd, please give us a call, because there will be some challenges aligning the eligibility and enrollment pieces for some people. (CP update 6/24 – Melissa informs us that NewMMIS is working much more smoothly now.)
Q: I work at a hospital, and our problem is the relationship between CommCare and CommonHealth.
MB: Oh, yes. The CommonHealth population is in a difficult paradigm. They can’t hit the spend-down while they’re on CommCare. It’s been a long-standing frustration. Robin and I had a plan for getting these folks into MassHealth, and then we hit the reality of the budget.
Q: Will CeltiCare will be the default insurance for people who are auto-enrolled in Plan I?
MB: There may be some instances where they’re in an area but we’re not auto-assigning, and that’s because they’ve met the contract standard, but we may want more from them in that particular area. The plans are all comfortable with that. And we really want people to select a plan so we can avoid auto-assignment.
We’ve never published auto-assigning algorithms, but maybe we can this year so people will know what they are.
Q: This year some people have premiums as low as $1.85 a month. Is there any minimum amount of arrears people have to accumulate before they go into the termination process?
MB: No, there’s no minimum amount of arrears people have to meet. We are trying to create a culture of insurance, get people used to paying a premium. If a Plan IIA member stops paying their premium, we disenroll them from that plan and enroll them to the no-cost plan.
Q: Is CommCare considering letting people pay online?
MB: Online payments are an area where we are going to have a lot of discussion. It makes sense especially with initial payments, but it won’t be something we do this calendar year. Our premium billing system meets our members’ needs well, but not the back office needs; we’re exploring whether to enhance the current system or bring in a new one. It doesn’t make sense for us to do online payments until we know what system we want, but it’s still something we really want to do.
MB: Things to keep an eye open for:
Thank you all for who you are and what you do. We are very, very grateful. Feedback is critical. The Exceptions process would not have been improved without feedback from the outreach community. We try to be super-accessible—and if we’re not accessible enough, let us know. We need your input.
For notes on the presentations about Network Standards in Commonwealth Care and Policy Updates from Health Care For All, please see these additional May 28 Boston HAN meeting notes.
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