www.800ageinfo.com 1-800-age-info [email protected] one care medicare + masshealth important updates

www.800AGEINFO.com 1-800-AGE-INFO [email protected]

One Care Medicare + MassHealth

Important Updates


Key Updates for Counselors

• Eligibility Criteria • One Care Plans and County Guide• Enrollment Timeline and Types of Enrollment• Continuity of Care (Enrollment Process)• Grievances and Appeals• SHINE Counselors Role• MassHealth Contact Information• Additional Resources


Who is eligible?

• Dual eligibles with Medicare and MassHealth (Standard or CommonHealth) between the ages of 21-64*.

• Approximately 90,240 Massachusetts residents are included in this target population.

• Individuals enrolled in a SCO, PACE, Frail Elder Waiver or other Home and Community Based Service Waivers are not eligible.

• Eligible beneficiaries can opt-in, switch One Care Plans, or opt-out at any time by contacting MassHealth Customer Service. The above actions are effective the first day of the following month a change is requested.

* A One Care member turning 65 can stay in their One Care plan as long as they remain eligible for MassHealth.


One Care Plans

Three companies are offering One Care Plans in select counties in Massachusetts:

1) Commonwealth Care Alliance Contact: 1-866-610-2273, www.commonwealthonecare.org2) Fallon Total Care Contact: 1-800-879-0852, www.fallontotalcare.org3) Network Health Contact: 1-855-393-3154, www.chooseunify.com


Which Counties Will Have Access to One Care? CW Care

AllianceFallon Total

CareNetwork Health Subject to Auto-

Assignment # of One Care

Plans Available

Essex X 1

Franklin X 1

Hampden X X X 2

Hampshire X X X 2

Middlesex X 1

Norfolk X 1

Plymouth* X 1

Suffolk X X X 2

Worcester X X X X 3

* One Care is available in Plymouth County except for the following towns: Wareham, E. Wareham, W. Wareham, Lakeville, Marion and Mattapoisett

One Care is not available in Barnstable, Berkshire, Bristol, Dukes, and Nantucket County.


Types of EnrollmentEnrollment into One Care will vary depending on the county in which a beneficiary resides. All eligible beneficiaries will receive an Enrollment Guide from MassHealth in September.

•Self Selection (Voluntary Enrollment): Eligible duals living in Essex, Franklin, Middlesex, Norfolk, and parts of Plymouth County* can voluntarily enroll into One Care.

•Auto-Assignment (Automatic Enrollment): Eligible duals living in Hampden, Hampshire, Suffolk and Worcester County will be automatically assigned to a One Care plan if they do not take action to opt-in or opt-out.

*One Care is available in Plymouth County excluding the following towns: Wareham, E. Wareham, W. Wareham, Lakeville, Marion and Mattapoisett

Note: Only counties with 2 or more One Care plans are subject to auto-enrollments . This only effects Hampden, Hampshire, Suffolk and Worcester County.


Time Line of Important DatesDate

Activity

MassHealth Member Choice/Response

September, 2013

(Self-selection [voluntary] enrollment only)

Detailed letters and enrollment guides will be mailed by MassHealth only to the target population (between ages 21-64) of dual eligibles who reside in the counties in which a One Care plan is available.* The letter will describe their new health coverage choices and give them the option to join “opt-in” or not join “opt-out”. *One Care not available in: Barnstable, Berkshire, Bristol, Dukes or Nantucket County.

Opt-in Choice: If a MH member “opts-in”, coverage becomes effective on October 1, 2013. (Members can opt-in by returning the Enrollment Decision Form they receive with their letter or by calling MH Customer Service.) Opt-out Choice:If a MH member “opts-out”, their health care coverage does not change. They will continue to receive their coverage through Medicare and MassHealth. No Response:If a MH member does not respond, he/she will be subject to auto-assignment in November only if he/she resides in a county in which 2 or more One Care plans are offered.


Time Line Continued…

Date

Activity


October 1, 2013

One Care start date for self-selection enrollment only

Within the first 90 days of enrollment, a Personal Care Plan is developed. The member must approve the Personal Care Plan before it can be implemented. Until this happens, the member can continue to see current healthcare providers and the One Care plan will be responsible for payment. After the member has approved the Personal Care Plan, he/she will receive their health care from network providers only.


Time Line Continued…Date

Activity


November, 2013

First round of auto-assignment of members who did not respond (opt-in or opt-out) to the September mailing. Only impacts members who live in counties with 2 or more One Care plans – Hampden, Hampshire, Suffolk and Worcester counties.

Auto Assignment:Member will receive a notice that they have been enrolled into a One Care plan to be effective on January 1, 2014. These auto-assigned members can: 1.Stay with the One Care plan to which they have been assigned;2.Contact MassHealth to switch to a different One Care plan;3.Contact MassHealth to opt-out of One Care altogether.

January 1, 2014

Effective date for 1st round of auto-assigned members

See above for member options

April 1, 2014

Effective date for 2nd round of auto-assigned members


July 1, 2014

Effective date for 3rd round of auto-assigned members



Process for Voluntary and Automatic Enrollments

• Enrollment in One Care is effective the first day of the following month in which the enrollment is submitted.

• Within 90 days of enrollment, a Personal Care Plan is developed to ensure the member’s range of needs are identified, addressed, and supported by the plan. Before the Personal Care Plan is implemented, the member must approve it. During this 90 day period, the member can continue to see their current healthcare providers and One Care will be responsible for payment. Members will not be denied access to covered services during this time.

• Once the member approves the Personal Care Plan, the plan is implemented and the member must receive care from network providers only.


Personal Care Plan

• Each One Care member will have an individually designed Personal Care Plan outlining their various physical, mental health, and long-term care needs.

• The Personal Care Plan will be developed by the member along with the help of their assigned care team. The care team will consist of a care coordinator in a addition to providers, long-term support coordinator, family members or any combination of advocates the member would like involved.

• Before the Personal Care Plan is implemented the member must approve it. Before approval, the member will have awareness of plan providers and coverage information.


Process for Opting Out

When an individual wants to opt-out of One Care: •Action is required. The beneficiary should complete and return the Enrollment Decision Form or call MassHealth Customer Service to officially opt-out. •The member will revert back to their Medicare and MassHealth benefits.

•Upon opting-out, the beneficiary will not be subject to future auto-assignments.


Grievances and Appeals

• Appeals: Members have the right to file an appeal to dispute changes made to coverage such as: denials, terminations, reduced services, or delayed access to coverage. Instructions on how to file an appeal will be available in the plan’s One Care Member Handbook.

• Grievances: Members have the right to file a grievance to report issues related to quality of care, customer service concerns or failures to uphold patient rights. Instructions on how to file a grievance will be available in the plan’s One Care Member Handbook.

• Ombudsperson: There will be an independent Ombudsperson role developed to impartially resolve disagreements, problems with service plans, and denials of service. The contact information for this resource will be made available in fall 2013.

Depending on the situation, appeals may be handled by Medicare, MassHealth, or One Care. Contact the One Care Plan first for specific instructions.


Role of SHINE Counselor

• Assist eligible beneficiaries to understand what One Care is, review choices, check provider networks, check drug formularies and describe the enrollment process.

• Complete the client contact form, including new data fields, as required by CMS


MassHealth Contact Info

To opt-in, opt-out, or switch plans, members will call MassHealth directly or submit their Enrollment Decision Forms by fax or mail.

MassHealth Customer Service : 1-800-841-2900; TTY 1-800-497-4648

MassHealth Fax number : 617-988-8975

MassHealth Mailing Address:One CarePO Box 1200Boston, MA 02112


Additional ResourcesVisit the One Care Website: www.mass.gov/masshealth/onecare•One Care Introduction Webinar •One Care Member Booklet•One Care Consumer Brochure•One Care FAQ

Visit the SHINE Counselor Website: shinecounselor.800ageinfo.com•One Care Fact Sheet for SHINE Counselors•One Care Time Line of Important Dates•One Care List of Covered Services

www.800ageinfo.com 1-800-age-info [email protected] one care medicare + masshealth important updates

Documents

care member

care plans available

fallon total care contact

types of enrollment

enrollment guide

worcester county

eligible duals

nantucket county