When one of our patients contacted me to tell me about his loss of the Commonwealth Care coverage that he'd had for about three months, I was surprised, to say the least. It was the middle of the month, so it wasn't a technical coverage cut-off; he had paid his premium, was undergoing treatment with the Visiting Nurses Association (VNA) and getting medication from the pharmacy. You can imagine his surprise, among other emotions, when the VNA and the pharmacy told him that his coverage was no longer active and they couldn't help him.
He finally figured out that the ONE thing he had done differently that month was to start, but not complete, an application for EAEDC (Emergency Assistance) through his local Department of Transitional Assistance office (DTA). This patient was not afraid to contact his State Representative, and their office called me to ask if there was anything we could do to help. Our billing office called their Commonwealth contact who had helped in the past; this time, the office was told 'They know it's a problem, but they don't know how to fix it. He will have to wait until the first of the month to resume his coverage.' This patient was on a waiting list for surgery. If he was informed that the hospital could perform his surgery, should he ask them to put it off until the first of the month when his insurance would be re-instated?!
Have other outreach workers or health centers seen this situation? Were you able to resolve or work around it? Here is a patient who needs surgery and subsequent daily care and medication; he's paid for his insurance; but when he needs it most, his insurance coverage is suspended. Why does this happen? What can we do to prevent this? Where is the accountability? Who is responsible for tackling these system collisions?
This problem was identified
This problem was identified in this very blog a few months ago. I checked back with someone at MassHealth operations who said they thought they had fixed this; and passed his number on to Cameron to find out what's wrong with the fix. Stay tuned ...
This problem happens because EAEDC applicants are entitled to certain medical benefits right away. This just messes up people on ComCare but is a valuable benefit for those with no other coverage.
For your patients with no other coverage it may be helpful to know more about the EAEDC-medical benefit. Applicants for EAEDC are eligble for a temporary paper MassHealth card that gives them access to a limited EAEDC-medical benefit until they are either denied EAEDC or granted EAEDC and enrolled in Basic.
EAEDC medical does not show up in REVS but MassHealth regs instruct providers to bill with a copy of the Temporary ID. DTA staff are sometimes helpful in explaining this to providers. Pharmacists are supposed to fax the Temp. ID along with a form to the vendor for the pharmacy payment system who will then be able to authorize payment through the pharmacy payment system.
The EAEDC-medical benefit covers physicians, pharmacy & CHC visits & some other services but not hospital services. Applicants often need it to get the medical evidence to show they meet the EAEDC disability standard.
For people who like to look things up in the regulations (like me), the services covered by the EAEDC medical benefit are described in 130 CMR 450.106; the regulations about the temporary card and how providers are to use it are described in 130 CMR 502.010; 516.009 and 450.107 and Pharmacy Billing Guide 11.00.
Vicky Pulos
Mass. Law Reform Institute
We have seen the same thing
We have seen the same thing here at the hospital. We work hard to get a patient on and then because they are trying to get on their feet they are kicked off until EAEDC has made their decision. What's up anyway, aren't we all suppose to be working together to get the folks of Massachusetts the best possible health care. It is no wonder our patients and outreach worker are frustrated.
For me there are two things
For me there are two things that jump out from your post Cameron. First and foremost, people facing situations that require medical services, and have paid a premium, can still find themselves in a gap where coverage is not possible. The goal of health care reform is to create systems that improve health and reduce cost. It seems there are currently structural barriers to this happening. The second point is important too as we reflect on implementation to date: "What entity is responsible for the big picture?" Is there an agency that can make sure the various systems that are in place are working to promote a continuum of coverage or care? If there is, I'm not aware of one.
No wonder our state
No wonder our state representatives are confused, and the people responsible for handling the situations are having a hard time carrying out their mission to protect our vulnerable seniors. And OUR MEDICAIRE, MEDICAID Dual coverage is a puzzle to those who need Health Care and competent service
Mary Leddy "Another
Mary Leddy "Another difficult interface is between MassHealth and Medicare Part D. I have never had a smooth transition for a newly dual eligible. It's never clear who is supposed to enroll the person in Part D or who to call that would know."
Supposedly the Medicaid program is supposed to notify Social Security and Medicare that the person receives (1) Medicaid and Medicare (2)Social Security Supplemenatal (SSI and different from SSD or Social Security Disability or (3) the state pays the Medicare B premium - the 3 things that make them automatically eligible for Part D assistance. That can, however, mean a fairly long wait for the computer systems to catch up and the person to be entered into the Soc. Sec. or Medicare computers as automatically elgible for Part D assistance.
You could try to speed up the process by contacting the local Soc. Sec. office once they have the Medicaid or Part B premium (different from Part D) assistance award letter.
The 2nd thing is that the person MUST PICK A PART D PLAN. If they do not,they will be enrolled in one willy-nilly which may or may not cover the medications they need. All Part D plans are not the same as to what drugs they cover or what pharmacies accept which plans.
Go here : http://www.medicare.gov/MPDPF/Public/Include/DataSection/Questions/MPDPFIntro.asp?version=default&browser=IE%7C6%7CWinXP&language=English&defaultstatus=0&pagelist=Home&ViewType=Public&PDPYear=2007&MAPDYear=2007&MPDPF%5FMPPF%5FIntegrate=N
Do the 'find plan' thing and then once the plan is sleceted,they could try enrolling online. At one point in the process it asks if they qualify for help and asks whether they have received a letter. For the purposes of identifying the possible plans, click 'yes.'
It may or may not let them actually enroll if they don't have the letter from Soc. Sec./Medicare.
The client should NEVER jsut accept whatever plan they are auto-enrolled in without checking to make sure their meds are covered.
Another example of systems'
Another example of systems' lack of coordination is when someone has MassHealth through DSS. Their caseworker will tell them that they want to close their case so they have to go apply for MassHealth before they will close it. They already have MH so they can't apply so it goes around in circles. If this is 2 state agencies, why can't they make this transfer internally?? Another difficult interface is between MassHealth and Medicare Part D. I have never had a smooth transition for a newly dual eligible. It's never clear who is supposed to enroll the person in Part D or who to call that would know.
My Mother-in-law is 64 years
My Mother-in-law is 64 years old with terminal breast cancer. A very rare and fast spreading form of cancer (IBC). She has been 100% disabled for over two years. She was given only five years to live if that. Right now, three years later she is in remission. Now being disabled over two years she is forced to pick up Medicare A, B with Commonhealth as her secondary health insurance. Okay, thats great she gets more insurance to help her fight this horrible disease. However, as of 01/01/08 and trying to fill her medications she was told by the pharmacy she had no prescription coverage. Little did we know she was required to pick up a Medicare D plan. It is now 01/30/08 and still no prescription coverage. I have been on the phone "everyday" with Medicare, MassHealth and Social Security as to what she needs to do. Medicare states they have no updates that she is covered under MassHealth Commonhealth and cannot give us a plan until thier files are updated. MassHealth says that it is a Medicare issue to update thier files and Social Security has no idea why I would be calling them to update the file. Okay now a disabled person who has worked three jobs at one time almost her whole life hoping someday to enjoy retirement. Gets a terminal form of cancer before she was ready to retire. Gets help for the first couple of years, is fighting and beating the odds of this awful disease and wakes up one morning for someone to say, sorry our computers are not updated and you cannot get the medication that is helping you survive. Not to mention she has other health issues such as type II diabetes, controlled by medication and COPD which she was recently released from the hosptial from. She has had to cancel on of her surgerys with a Boston Doctor that is related to the disease because of this issue. On 01-29-08 she fell from feeling dizzy and loss of balance. Upon me making my daily call to Medicare to see if the files were updated. I explained her falling and low and behold I was told she was able to pick up a 14 day supply of her medication. A quick fix. She still needs to get a Medicare D plan and cannot do that until Medicare files are updated. I was told there would be a 30 day waiting period on the prescriptions from date of enrollment. So she gets to take her medication, go off of it for 30 days, go back on it for 14 days and then who knows how long until these files are updated and wait another 30 days after that. And did I mention she's not even 65 years old yet. That will happen in 7 months. And everything will change again and we have to do this all over again. This poor lady is living a slow, sad death sentance. I work in the medical billing field and I am confused. Imagine these other people who have noone to help them with this mess.
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