Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid 600 Washington Street Boston, MA 02111 www.mass.gov/masshealth Eligibility Operations Memo 06-14 December 15, 2006 TO: MassHealth Eligibility Operations Staff FROM: Russ Kulp, Director, MassHealth Operations RE: Health Care Reform Implementation: Commonwealth Care Health Insurance Program-Phase II Commonwealth Care Health Insurance Program The Commonwealth Care Health Insurance Program, commonly referred to as Commonwealth Care, was introduced in EOM 06-11, issued in November 2006. Commonwealth Care is not MassHealth, but is provided in coordination with the Office of Medicaid. Financial eligibility is dependent on an individual’s family group gross monthly income. Health insurance coverage will be through managed care organizations (MCOs), subject to state law and approved by Commonwealth Care. This memo covers Phase 2 of the Commonwealth Care program, for those with income greater than 100% of the FPL to at or below 300% of the FPL. The Connector An independent public authority called the Commonwealth Health Insurance Connector Authority (the Connector) has been created to manage the program. The Connector is overseen by a separate board of 11 private and public representatives, including the Medicaid Director. Overview of Commonwealth Care Eligibility Requirements Commonwealth Care members have the same rights and responsibilities as MassHealth members. Eligibility requirements for Commonwealth Care are detailed on the Commonwealth Care Connector Web site at www.mass.gov/connector. MassHealth will determine eligibility for Commonwealth Care, after the applicant has been determined ineligible for MassHealth. An abbreviated list of the general rules for Commonwealth Care was provided in EOM 06-11. The eligibility requirements for residence, age, and family remain the same in Phase 2. The Commonwealth Care eligibility requirements that differ in Care Eligibility Phase 2 follow: Income — The individual’s family group income must be less than or equal to 300% of the FPL. Persons with family group income greater than 300% of the FPL are not eligible for Commonwealth Care. Eligibility Limitations — Persons are considered uninsured and eligible for Commonwealth Care if they do not have health insurance or they are: * insured under the Consolidated Omnibus Budget Reconciliation Act (COBRA); * paying a full premium in the nongroup commercial insurance market; or * in a waiting period before becoming eligible under an employer- provided health plan for which their employer covers at least 20% of the annual premium cost for a family plan or at least 33% of the annual premium cost for an individual. Individuals will be considered insured and not eligible for Commonwealth Care if they have, or are eligible for, other government- funded or state- authorized health insurance programs. These include, but are not limited to: * MassHealth and Medicare o aliens with special status and persons permanently living in the United States under color of law (PRUCOLs) who are eligible for MassHealth Limited (those who have gross family group income below 133% of the FPL) may receive MassHealth Limited and Commonwealth Care; or o individuals denied MassHealth because they did not comply with MassHealth administrative requirements; * TRICARE, the Department of Defense health-care program for active military service families, retirees and their families, and other beneficiaries; * Massachusetts Fisherman’s Partnership, Inc.; * Student Health Insurance Program, available full-time or part-time students enrolled in public or independent institutions located in Massachusetts; or * Massachusetts Division of Unemployment Assistance Medical Security Program. Crowd-out Provisions Individuals will not be considered uninsured and will be ineligible for Commonwealth Care if either of the following crowd-out provisions applies: * the employer provided health insurance within the previous six months and contributed at least 20% of the annual premium for family plan or 33% of the annual premium for an individual plan; or * the individual accepted a financial incentive from the employer to decline the employer’s subsidized coverage. The Connector may waive ineligibility based on the crowd-out provisions if the employer complies with Section 110 of Chapter 175, Section 8½ of Chapter 176A, Section 3B of Chapter 176B, or Section 7A of Chapter 176G of the Massachusetts General Laws (MGL). Managed Care Enrollment and Premiums Start Date When an applicant with income above 100% of the FPL to 300% of the FPL is approved for Commonwealth Care, he or she will be sent an “introduction letter.” The approved applicant can call Commonwealth Care Customer Service and request an enrollment package or go to www.macommonwealthcare.com and enroll online. Commonwealth Care Customer Service will send the appropriate enrollment package based on the member’s geographic location and category of assistance. The enrollment package contains information about the available managed- care plans. The cost of the plans is based on the individual’s income. When the member selects a plan, an invoice is sent to the approved applicant. If the invoice is paid by the 20th day of the enrollment month, the medical start date will be the first day of the next calendar month. If the payment is received after the 20th of the enrollment month, the medical start date will be the first day of the month following the month after the enrollment month. Example: An individual applies on January 5, 2007, and is approved on January 8. An enrollment package is sent, and the new enrollee chooses a health plan on January 11. The enrollee is sent an invoice and the payment is received on January 18. Coverage will begin on February 1, 2007. If the payment had been received on January 21, the coverage would begin on March 1, 2007. Important: Until the member is enrolled in a managed care organization (MCO) and the premium is paid, he or she will not have coverage. The member will have an open Commonwealth Care segment on MA21 and MMIS, but MassHealth Enrollment Center (MEC) staff must check the TPL screen to see if the enrollment is active. Coverage End Date — When Commonwealth Care coverage is terminated, the coverage will end on the last day of the month of termination. Reenrollment after Reopening There will not be any autoenrollment into MCOs in Phase 2, except for members whose eligibility is closed due to their failure to pay their premiums (more about terminations later in this memo). If the premium is paid within 30 days of the eligibility closing date, the payment will be applied to the arrears and these members will be automatically reenrolled into the same MCO (the enrollee will be without coverage for one month). If the payment is received after 30 days, the payment will be applied to the arrears and the Commonwealth Care Customer Service will contact the enrollee to solicit enrollment into a health plan. An invoice will be generated and, if the payment is received by the 20th of the month, coverage will begin on the first day of the following month (the enrollee will be without coverage for one month). If payment is received after the 20th day of the month, coverage will begin the first of the month following the month after enrollment (the enrollee will be without coverage for two months). There are four MCOs, but plan availability depends upon where the member resides. The four plans are: Fallon Community Health Plan, Network Health, Neighborhood Health Plan, and Boston Medical Center HealthNet Plan. MCO Benefits for Phase 2 The following are the benefits available to members enrolling in Commonwealth Care Phase 2: * inpatient services; * outpatient services and preventive care by participating providers; * prescription drugs; * inpatient and outpatient mental health and substance abuse services; and * vision care. Phase 2 plans do not include dental coverage. Questions about the plans should be referred to the Commonwealth Care Customer Service at 1-877-MA-ENROLL (1-877-623-6765) (TTY: 1-877-623-7773 for people with partial or total hearing loss). Premiums Commonwealth Care enrollees with income above 100% of the FPL will be assessed an enrollee contribution (premium) based on their gross family group income and which plan type they enroll in. Plan options will vary based on geographic location and category of assistance. Plan Types III and IV have varying copayment and deductible amounts. Plan Type Income Monthly Premium Plan Type I income below 100% of No enrollee the FPL contribution Plan Type II income above 100% of $18 the FPL up to 150% of the FPL Plan Type II income above 150% of $40 the FPL up to 200% of the FPL Plan Type III income above 200% of $70 the FPL up to 250% of the FPL Plan Type IV income above 250% of $106 the FPL up to 300% of the FPL Note: These amounts are the minimum amounts that can be charged. Some plan types have different options. Enrollee contribution amounts will vary depending on the options that the member chooses. Financial Hardship Waivers Extreme financial hardship means that the enrollee has shown to the satisfaction of the Connector that the enrollee: * is homeless, or is more than 30 days in arrears in rent or mortgage payments, or has received a current notice of eviction or foreclosure notice; * has a current shut-off notice, or has been shut off, or has a current refusal to deliver essential utilities (gas, electric, oil, water, or telephone); * within the 12-month period immediately preceding the date of the waiver application, has non-cosmetic medical and/or dental out-of- pocket expenses (exclusive of premium payments), totaling more than 7.5% of the individual’s or family’s gross annual income that are not subject to payment by a third party. In this case, the “non-cosmetic medical and/or dental out-of-pocket expenses” must be incurred by the individual or family for services rendered while enrolled in a Commonwealth Care plan; or ? has incurred a significant, unexpected increase in essential expenses within the last six months resulting directly from the consequences of: o domestic violence ; o the death of a spouse with primary responsibility for child care; o the sudden responsibility for providing full care for an aging parent or other family member, including the major, extended illness of a child that requires a working parent to hire a full-time caretaker for the child; or o a fire, flood, natural disaster, or other unexpected natural or human-caused event that led to substantial household or personal damage for the enrollee. If the Connector determines that the requirement to pay a premium results in extreme financial hardship for the enrollee, the Connector, in its sole discretion, may waive payment of the premium or reduce the amount of the premium assessed to a particular individual or family. In the case of an enrollee whose annual income is at or below 100% of the FPL, if the Connector determines that the payment of a copayment results in extreme financial hardship for the enrollee, the Connector, in its sole discretion, may waive payment of copayment for a particular individual or family. Hardship waivers will be authorized for up to six months. The six-month period begins in the month after the documented hardship waiver is granted. An enrollee that is granted a hardship waiver will be assigned to the lowest cost coverage type that is available in the enrollee’s service area. At the end of the six-month period, the enrollee may submit another request for a hardship waiver. Requests for enrollee premium or copayment relief should be made through the Commonwealth Care Customer Service Center at 1-877-MA-ENROLL (1-877-623-6765) (TTY: 1-877-623-7773 for people with partial or total hearing loss). Terminations Nonpayment of Premium If the monthly payment is not received within 60 days of the date of the bill, the enrollee’s eligibility will be terminated. The enrollee will be sent a notice of termination 14 days before the date of the termination. This notice will provide appeal rights and the Connector will handle these appeals. The enrollee’s eligibility will not be terminated if, before the date of termination, the enrollee: * files an appeal; * pays all the amounts due; * submits an application for financial hardship waiver; or * establishes a payment plan that is acceptable to the Connector. If a payment plan is approved, the enrollee must make all payments in accordance with the plan. Any questions about Commonwealth Care premiums and billing should be referred to Commonwealth Care Customer Service at 1-877-MA-ENROLL (1-877-623-6765) (TTY: 1-877-623-7773 for people with partial or total hearing loss). Voluntary Withdrawal If an enrollee wishes to voluntarily withdraw from Commonwealth Care, he or she must notify the Connector by phone or, preferably, in writing. Coverage continues through the end of the month of the withdrawal. Enrollees are responsible for payment of premiums up to and including the month of withdrawal. Connector Administrative Action Reasons C1 and C2 The Connector will be responsible for the process of establishing and removing Commonwealth Care Action Reasons C1 and C2 in MA21. C1 is the Commonwealth Care action reason used to identify nonpayment of Commonwealth Care premiums. C2 is the Commonwealth Care action reason to identify voluntary withdrawal from a Commonwealth Care benefit. MEC staff will not have security access in MA21 for these action reasons and must refer callers to Commonwealth Care Customer Service at 1-877-MA-ENROLL (1-877-623-6765) (TTY: 1-877-623-7773 for people with partial or total hearing loss). Conversion Process Beginning on January 8, 2007, through March 2, 2007, MA21 will perform weekly conversions for all active Uncompensated Care Pool (UCP) households and AWSS individuals who are on MassHealth Limited. These conversion notices will be mailed each Monday (or on Tuesday if Monday is a holiday). Conversions notices will be sent to households, not individuals. There are 75,000 members to be converted. MassHealth Role and Responsibility It is important to note that Commonwealth Care is neither a MassHealth program nor a MassHealth coverage type. MassHealth will process Commonwealth Care eligibility determinations, including issuing system-generated eligibility notices through MA21 for Commonwealth Care applicants and members. MassHealth is responsible for: * processing applications at intake; * performing annual Commonwealth Care eligibility reviews and case maintenance activities through MA21; * verifying family income and other information used in the Commonwealth Care eligibility determination when the member provides MassHealth with the information by phone, mail, or in person; * answering basic questions about Commonwealth Care eligibility; * explaining eligibility notices; * complying with the Health Insurance Portability and Accountability Act (HIPAA) by processing Permission to Share Information (PSI) and Eligibility Representative Designation (ERD) forms; * referring Commonwealth Care applicants and members to Commonwealth Care Customer Service as needed at 1-877-MA-ENROLL (1-877-623-6765) (TTY : 1-877-623-7773 for people with partial or total hearing loss); and * coordinating with the Connector on fair-hearing requests. Commonwealth Care Eligibility Determinations All Commonwealth Care applicants and members must be screened for MassHealth eligibility before a Commonwealth Care-eligibility determination can be made. In Phase 2, the income level has increased, but the process to determine Commonwealth Care eligibility and for MA21 case maintenance is the same as in Phase 1 (see EOM 06-11). Commonwealth Care Application Process Like individuals applying for MassHealth benefits, Commonwealth Care applicants will use a Medical Benefit Request (MBR), Senior Medical Benefit Request (SMBR), or an electronic Medical Benefit Request (eMBR) through the Virtual Gateway. Once the information has been entered or imported into MA21, the system makes a determination for MassHealth and requests verifications as needed. MA21 is now programmed to send verification requests to all individuals with income at or below 300% of the FPL, even if they are not categorically eligible for MassHealth. If the verifications are submitted within MassHealth time standards, MA21 performs a final determination for a MassHealth program. If the applicant is ineligible for MassHealth (other than MassHealth Limited), MA21 will determine eligibility for Commonwealth Care and MA21 will send the appropriate notice. If the verifications are not submitted within MassHealth time standards, MA21 will perform a final determination (ineligible for MassHealth, Commonwealth Care, and UCP due to failure to verify) and MA21 will send the appropriate denial notice. Commonwealth Care Notices If MA21 approves eligibility for Commonwealth Care, an appealable notice will be sent advising of the approval and will include an explanation that coverage is contingent upon enrollment in a Connector-approved MCO and receipt of the initial payment by the Commonwealth Care Customer Service Center. The materials describing available plans and enrollment procedures will be sent separately. The notice will include the Commonwealth Care Customer Service telephone number to enroll in an MCO. A denial for MassHealth will also be in the notice, or if the applicant is eligible for MassHealth as an AWSS, an approval for MassHealth Limited. If MA21 denies eligibility for Commonwealth Care, it will send a notice to applicants advising them of the denial for MassHealth and Commonwealth Care and the reasons. Uncompensated Care Pool (UCP) Commonwealth Care members are able to get care through the Uncompensated Care Pool (UCP) for services provided by the UCP until MCO enrollment. The Commonwealth Care approval notice serves as the UCP approval pending MCO enrollment. Once enrolled in an MCO, members will receive services through Commonwealth Care. Health Insurance Cards The MCO will issue health insurance cards to Commonwealth Care members to identify member plan participation. A MassHealth card will be issued only to Commonwealth Care members who are also approved for MassHealth Limited as an AWSS. Systems: MA21, MMIS, and REVS MA21 MA21 screens have been updated to determine eligibility for Commonwealth Care. MA21 Benefit Codes and MMIS Category Codes The benefit and category codes for Commonwealth Care members are as follows: Description MA 21 Benefit Code MMIS Category Code US Citizens and CC Qualified Aliens Income at or below CN 100% of the FPL Income above 100% CQ to 150% of the FPL Income above 150% CS to 200% of the FPL Income above 200% to CU 250% of the FPL Income above 200% CW to 250% of the FPL AWSS State-funded Commonwealth CC Care Not eligible for CP MassHealth Limited Income above 100% to 150% CR of the FPL Income above 150% to 200% CT of the FPL Income above 200% to 250% CV of the FPL Income above 200% to 250% CX of the FPL AWSS Eligible for Commonwealth Care LC BB with Limited State funded – income at or below 100% of the FPL Income above 100% to 133% BD of the FPL Action Reasons There are two new actions reasons: * C1 — failure to pay Commonwealth Care premiums; and * C2 — voluntary withdrawal from Commonwealth Care. These action reasons will be used only by Commonwealth Care Customer Service. When you see either of these action reasons on a case, refer the memberto the Commonwealth Care Customer Service at 1-877-MA-ENROLL (1-877-623-6765) (TTY: 1-877-623-7773 for people with partial or total hearing loss). When a Commonwealth Care case is closed, a UCP benefit will remain open. If a member requests that their UCP benefit be closed, the member should be referred to the Commonwealth Care Customer Service. The MA21 Eligibility Result for an Individual Screen (Snapshot Screen) Effective January 1, 2007, the MA21 Eligibility Results for an Individual screen (Snapshot screen) was updated to include information on Commonwealth Care. The highlighted sections were added. Snapshot Screen: Screen 1 Snapshot Screen 1 has been updated to reflect if the applicant/member was eligible for Commonwealth Care in the previous year. The indicator will be Y (Yes) or blank. A Y indicates Commonwealth Care eligibility currently or in the last year. Snapshot Screen 2 Snapshot screen 2 has been updated to reflect information about the availability of employer insurance. The Employer Insurance Available section will be used for Commonwealth Care eligibility determinations. The indicators are Y (Yes), N (No), or blank. A Y means the individual or family member worked for an employer who offered comprehensive health insurance in the last six months, and that the individual does not qualify for Commonwealth Care. An N means the individual or family member did not work for an employer who offered comprehensive health insurance in the last six months, and the individual qualifies for Commonwealth Care. If the indicator is left blank, no entry was made on the EHI screen for Question 2 (other possible health insurance). REVS and the MassHealth Card With the exception of AWSS on MassHealth Limited, Commonwealth Care members will not be issued any type of health-insurance card through MassHealth. A MassHealth card from previous eligibility will not be valid. Commonwealth Care-eligible individuals will be eligible for UCP benefits until the MCO medical coverage date is in effect. Providers will see UCP eligibility until the third-party-liability (TPL) message changes to the applicable MCO. REVS Messages Upon Commonwealth Care approval, but before the individual has enrolled in an MCO, the REVS message will identify the member as eligible for UCP or MassHealth Limited, if AWSS. The UCP message advises that the individual has been approved for Commonwealth Care and must call the Connector to enroll in an MCO. After enrollment in an MCO, the REVS message will identify the member as managed-care enrolled and provide the MCO information. Connector Fair Hearing Appeals MassHealth will coordinate with the Connector about fair-hearing requests. The Board of Hearings will be responsible for fair hearings that involve initial eligibility determinations as well as reviews of eligibility, including appeals of financial eligibility determinations. Hearings will be pursuant to the fair hearing regulations at 130 CMR 610.000. MA21-generated eligibility notices will include the standard Request for a Fair Hearing appeal form. The MECs will be responsible for providing representation at hearings on eligibility determinations and reviews of eligibility. Hearings on other Commonwealth Care issues will be conducted by Commonwealth Care using the state’s administrative procedure and policy regulations at 801 CMR 1.00 and 956 CMR. Commonwealth Care will have exclusive authority to hear appeals about the following issues: * enrollment and plan assignment for Plan Type 1 enrollees; * disenrollment of enrollees for failure to pay premiums; * disenrollment on enrollees based on the discretion of Commonwealth Care; * denial of hardship waiver applications; and * copayment maximum limits. Commonwealth Care Contacts The Commonwealth Care Customer Service Center can be reached at 1-877-MA-ENROLL (1-877-623-6765) (TTY: 1-877-623-7773 for people with partial or total hearing loss). The Connector Web site is at www.mass.gov/connector. There is a link to the Connector on the MassHealth Web site in the News and Updates box on the home page. Attachments This memo includes the following sample notices: * Commonwealth Care approval with premium; * Commonwealth Care denial-over income (UCP approved) * Commonwealth Care termination-failure to pay premium; * Commonwealth Care termination-over income (UCP approved); * change in premium; and * MassHealth Limited with Commonwealth Care with premium. The bolded sections on the sample MassHealth approval and denial notices indicate changes. Questions If you have any questions about this memo please have your MEC designee contact the Policy Hotline. Commonwealth Care approval with premium REVERE OFFICE 300 OCEAN AVENUE, SUITE 4000 REVERE MA 02151-3675 550/DENY Tel: (800) 322-1448 TTY: (888) 665-9997 Fax: (781) 485-3400 CW LIMITED 1 MAIN BOSTON MA 02111-0000 Date: 08/02/2006 Notice: 1380577 SSN: 602-39-1111 Important! This health-care benefits notice tells you the decisions we have made about the programs that you may be eligible for. Please read the whole notice to find out about these health-care benefits. ********************** COMMONWEALTH CARE *********************** Dear CW LIMITED The MassHealth Agency has decided that the following individuals listed below are eligible to enroll in a health plan from the Commonwealth Care Health Insurance Program. Your benefits begin after you have enrolled. Names and ss# Coverage Type Benefit CW LIMITED Effective Date 602-39-1111 Commonwealth Care 8/02/06 Commonwealth Care is a program run by the Commonwealth Health Insurance Connector (the Connector). Commonwealth Care is not a MassHealth program, but the MassHealth agency determines who is eligible for the Commonwealth Care program on behalf of the Connector. Commonwealth Care is an insurance program that offers health care coverage through certain health plans. The Connector will help Commonwealth Care members join a health plan and find providers that meet your needs. These plans offer services like preventive care, prescription drug coverage, hospitalization, and emergency room services. You will soon get a package in the mail that explains your choices and tells you and how to sign up. Call the Customer Service Center at 1-877-623-6765 (1-877-MA–ENROLL) as soon you get that package. They can help you choose the right plan for you. Based on the information you gave us about your income, you have to pay a premium before you are enrolled into a health plan. You will soon receive a premium bill from the Connector. Before you enroll into Commonwealth Care, you may be able to get services from a hospital or community health center. These services may be paid for by the Uncompensated Care Pool. For more information, call 1-877-910-2100. If you have any questions about your eligibility for Commonwealth Care, please call the number at the top of this notice. ********************** MASSHEALTH *********************** The MassHealth Agency has decided that the following members of your family are not eligible for MassHealth for the following reasons. Name SSN/DOB LIMITED,CW 602-39-1111 Reason and Manual Citation You do not meet the immigration requirements for any benefits other than MassHealth Limited, and you do not meet the requirements to get MassHealth Limited because your family income is too high or because you do not meet MassHealth disability rules, or you are not under age 19, or you are not a parent of a child under 19. 130 CMR 501.001 504.002 505.002 505.008 Call the phone number at the top of this notice if you have any questions about this notice. If you don't have a copy of the MassHealth booklet, please call to request one. It has important information about MassHealth coverage and rules. For information about appealing our decisions, see the other side of this notice. Commonwealth Care denial-over income (UCP approved) REVERE OFFICE 300 OCEAN AVENUE, SUITE 4000 REVERE MA 02151-3675 550/DENY Tel: (800) 322-1448 TTY: (888) 665-9997 Fax: (781) 485-3400 DENY CCHIP 1 MAIN BOSTON MA 02111-0000 Date: 10/17/2006 Notice: 1381177 SSN: 602-47-1111 Important! This health-care benefits notice tells you the decisions we have made about certain programs that you may be eligible for. Please read the whole notice to find out about your health-care benefits. Dear DENY CHIP The MassHealth Agency has decided that the following members of your family are not eligible for MassHealth for the following reasons. Name SSN/DOB CCHIP, DENY 602-47-1111 Reason and Manual Citation Your family's income is over 200% of the federal poverty level; you do not meet MassHealth disability rules; and you do not meet MassHealth Standard rules for the cervical or breast cancer treatment program. 130 CMR 506.007 501.001 The MassHealth booklet describes the rules for MassHealth. It explains why members of your family are not eligible. It describes the income standards and other rules for MassHealth. Call the phone number at the top of this notice if you have any questions about this notice. If you don't have a copy of the MassHealth booklet, please call to request one. It has important information about MassHealth coverage and rules. For information about appealing our decisions, see the other side of this notice. ********************* UNCOMPENSATED CARE ********************* MassHealth has decided that the Uncompensated Care Pool may be able to pay for services that the individual(s) listed below got at a Massachusetts hospital or community health center. You must pay co-pays and deductibles but you will not have to pay bills for the services you got. Name Coverage Family Benefit Other SSN Type Deductible Effective Date CCHIP,DENY Uncompensated n/a 10/17/2006 *3 602-47-1111 Care *3 You are not eligible for the Commonwealth Care Health Insurance Program because your family’s income is over 300% of the federal poverty level (see 956 CMR 3.04). Please get in touch with your hospital or community health center to find out what services you can get without having to pay bills. You must tell MassHealth about certain changes within 10 days or as soon as possible. These include any changes in income, family size, employment, disability status, health insurance, address, and immigration status. This will let MassHealth determine the most complete coverage you qualify for. If you have questions about this Uncompensated Care Pool decision, please call the number at the top of this notice. If you do not agree with this Uncompensated Care Pool decision, you may contact the Massachusetts Division of Health Care Finance and Policy, Grievances, Two Boylston Street, Boston, MA 02116, or you can call them at 1-877- 910-2100. You may also call 1-877-910-210 for any questions you have about the Uncompensated Care Pool. Commonwealth Care termination-failure to pay premium REVERE OFFICE 300 OCEAN AVENUE, SUITE 4000 REVERE MA 02151-3675 550/DENY Tel: (800) 322-1448 TTY: (888) 665-9997 Fax: (781) 485-3400 CW LIMITED 1 MAIN BOSTON MA 02111-0000 Date: 10/17/2006 Notice: 1380577 SSN: 602-39-1111 Important! This health-care benefits notice tells you the decisions we have made about the programs that you may be eligible for. Please read the whole notice to find out about these health-care benefits. Dear CW LIMITED The MassHealth Agency has decided that the following members of your family are not eligible for MassHealth for the following reasons. Name SSN/DOB LIMITED,CW 602-23-1111 Reason and Manual Citation You do not work for a small business; you do not meet the definition for long-term unemployment; you do not meet Division disability rules; you are not under age 19 or a parent of a child under 19. 130 CMR 505.002 505.006 505.005 501.001 Call the phone number at the top of this notice if you have any questions about this notice. If you don't have a copy of the MassHealth booklet, please call to request one. It has important information about MassHealth coverage and rules. For information about appealing our decisions, see the other side of this notice. ********************* UNCOMPENSATED CARE ********************* MassHealth has decided that the Uncompensated Care Pool may be able to pay for services that the individual(s) listed below got at a Massachusetts hospital or community health center. You must pay co-pays and deductibles but you will not have to pay bills for the services you got. Name Coverage Family Benefit Other SSN Type Deductible Effective Date LIMITED, CW Uncompensated n/a 10/17/2006 *1 602-23-1111 Care *1 The Connector is ending your Commonwealth Care health insurance because you did not pay your monthly Commonwealth Care premium (see 956 CMR 3.11). Call Commonwealth Care Customer Service at 1-877-MA–ENROLL (1-877-623-6765) or TTY-1-877-623-7773 (for people with partial or total hearing loss) if you: - have made a recent payment; - need more information about your premium bill; - want to start a payment plan; or - want to apply for a waiver or temporary reduction of your premium because you are having a hard time paying your bills. Please get in touch with your hospital or community health center to find out what services you can get without having to pay bills. You must tell MassHealth about certain changes within 10 days or as soon as possible. These include any changes in income, family size, employment, disability status, health insurance, address, and immigration status. This will let MassHealth determine the most complete coverage you qualify for. If you have questions about this Uncompensated Care Pool decision, please call the number at the top of this notice. If you do not agree with this Uncompensated Care Pool decision, you may contact the Massachusetts Division of Health Care Finance and Policy, Grievances, Two Boylston Street, Boston, MA 02116, or you can call them at 1-877- 910-2100. You may also call 1-877-910-210 for any questions you have about the Uncompensated Care Pool. Commonwealth Care termination-over income (UCP approved) REVERE OFFICE 300 OCEAN AVENUE, SUITE 4000 REVERE MA 02151-3675 550/TERM Tel: (800) 322-1448 TTY: (888) 665-9997 Fax: (781) 485-3400 TERM CCHIP 1 MAIN BOSTON MA 02111-0000 Date: 10/17/2006 Notice: 1381177 SSN: 602-47-1111 Important! This health-care benefits notice tells you the decisions we have made about certain programs that you may be eligible for. Please read the whole notice to find out about your health-care benefits. Dear TERM CHIP The MassHealth Agency has decided that the following members of your family are not eligible for MassHealth for the following reasons. Name SSN/DOB CCHIP, TERM 602-47-1111 Reason and Manual Citation Your family's income is over 200% of the federal poverty level; you do not meet MassHealth disability rules; and you do not meet MassHealth Standard rules for the cervical or breast cancer treatment program. 130 CMR 506.007 501.001 The MassHealth booklet describes the rules for MassHealth. It explains why members of your family are not eligible. It describes the income standards and other rules for MassHealth. Call the phone number at the top of this notice if you have any questions about this notice. If you don't have a copy of the MassHealth booklet, please call to request one. It has important information about MassHealth coverage and rules. For information about appealing our decisions, see the other side of this notice. ********************* UNCOMPENSATED CARE ********************* MassHealth has decided that the Uncompensated Care Pool may be able to pay for services that the individual(s) listed below got at a Massachusetts hospital or community health center. You must pay co-pays and deductibles but you will not have to pay bills for the services you got. Name Coverage Family Benefit Other SSN Type Deductible Effective Date CCHIP,TERM Uncompensated n/a 10/17/2006 *2 602-47-1111 Care *2 The Connector is ending your Commonwealth Care health insurance because your family’s income is over 300% of the federal poverty level (see 956 CMR 3.04). Call Commonwealth Care Customer Service at 1-877- MA–ENROLL (1-877-623-6765) or TTY-1-877-623-7773 (for people with partial or total hearing loss) if you have any questions about the Commonwealth Care Health Insurance Program. Please get in touch with your hospital or community health center to find out what services you can get without having to pay bills. You must tell MassHealth about certain changes within 10 days or as soon as possible. These include any changes in income, family size, employment, disability status, health insurance, address, and immigration status. This will let MassHealth determine the most complete coverage you qualify for. If you have questions about this Uncompensated Care Pool decision, please call the number at the top of this notice. If you do not agree with this Uncompensated Care Pool decision, you may contact the Massachusetts Division of Health Care Finance and Policy, Grievances, Two Boylston Street, Boston, MA 02116, or you can call them at 1-877- 910-2100. You may also call 1-877-910-210 for any questions you have about the Uncompensated Care Pool. Change in premium REVERE OFFICE 300 OCEAN AVENUE, SUITE 4000 REVERE MA 02151-3675 550/DENY Tel: (800) 322-1448 TTY: (888) 665-9997 Fax: (781) 485-3400 MR CCHIP 1 MAIN BOSTON MA 02111-0000 Date: 08/22/2006 Notice: 1381177 SSN: 602-47-1111 Important! This health-care benefits notice tells you the decisions we have made about certain programs that you may be eligible for. Please read the whole notice to find out about your health-care benefits. ********************** COMMONWEALTH CARE *********************** Dear MR CCHIP The Connector has decided that the following member(s) no longer have to pay a premium for Commonwealth Care health insurance because of a change in your family’s circumstances (see 956 CMR 3.11). Call Commonwealth Care Customer Service at 1-877-MA–ENROLL (1-877-623-6765) or TTY-1-877-623-7773 (for people with partial or total hearing loss) if you have any questions about the Commonwealth Care Health Insurance Program. Name SSN/DOB CCHIP, MR 602-47-1111 If you have any questions about your eligibility for Commonwealth Care, please call the number at the top of this notice. ********************** MASSHEALTH *********************** The MassHealth Agency has decided that the following members of your family are not eligible for MassHealth for the following reasons. Name SSN/DOB CCHIP,MR 602-47-1111 Reason and Manual Citation You do not work for a small business; you do not meet the definition for long term unemployment; you do not meet MassHealth disability rules; you are not under age 19 or a parent of a child under 19. 130 CMR 505.002 505.006 505.005 501.001 Call the phone number at the top of this notice if you have any questions about this notice. If you don't have a copy of the MassHealth booklet, please call to request one. It has important information about MassHealth coverage and rules. For information about appealing our decisions, see the other side of this notice. MassHealth Limited with Commonwealth Care with premium REVERE OFFICE 300 OCEAN AVENUE, SUITE 4000 REVERE MA 02151-3675 550/APPR Tel: (800) 322-1448 TTY: (888) 665-9997 Fax: (781) 485-3400 CW LIMITED 1 MAIN BOSTON MA 02111-0000 Date: 08/02/2006 Notice: 1380577 SSN: 602-39-1111 Dear CW LIMITED The MassHealth Agency has decided that the following members of your family can get benefits. Benefit Name Coverage Effective SSN/DOB Type Date Other LIMITED, CW Limited pending 07/23/2006 602-39-1111 Commonwealth Care MassHealth Limited coverage lets members get care for the medical services described in the MassHealth booklet under MassHealth Limited. This includes treatment for cancer that is considered to be emergency care. MassHealth Limited also covers emergency care for all other conditions and pays for labor and delivery. Organ transplants are not covered under MassHealth Limited. Commonwealth Care is a program run by the Commonwealth Health Insurance Connector (the Connector). Commonwealth Care is not a MassHealth program, but the MassHealth agency determines who is eligible for the Commonwealth Care program on behalf of the Connector. Commonwealth Care is an insurance program that offers health care coverage through certain health plans. The Connector will help Commonwealth Care members join a health plan and find providers that meet your needs. These plans offer services like preventive care, prescription drug coverage, hospitalization, and emergency room services. You will soon get a package in the mail that explains your choices and tells you how to sign up. Call the Customer Service Center at 1-877-623-6765 (1-877-MA–ENROLL) as soon you get that package. They can help you choose the right plan for you. Based on the information you gave us about your income, you have to pay a premium before you are enrolled into a health plan. You will soon receive a premium bill from the Connector. Members who get MassHealth Limited before their enrollment into a Commonwealth Care health plan will continue to receive emergency care from Commonwealth Care after you enroll, unless you receive a written notice that MassHealth Limited is ending. Before you enroll into Commonwealth Care, you may be able to get services from a hospital or community health center. These services may be paid for by the Uncompensated Care Pool. For more information, call 1-877-910-2100. You will soon get a MassHealth card if there are newly eligible MassHealth members in your family. They must use this card whenever they get medical services. Eligible members may use the card right away. MassHealth members who are eligible only for MassHealth Premium Assistance will not get a MassHealth card. MassHealth members may get more benefits under other MassHealth coverage types if they send us proof of their immigration status or if they change their immigration status. The MassHealth booklet describes these coverage types. Call the phone number at the top of this notice if you have any questions about this notice. If you don't have a copy of the MassHealth booklet, please call to request one. It has important information about MassHealth coverage and rules. For information about appealing our decisions, see the other side of this notice.