Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid 600 Washington Street Boston, MA 02111 www.mass.gov/masshealth MassHealth Transmittal Letter ALL-153 October 2007 TO: All Providers Participating in MassHealth FROM: Tom Dehner, Medicaid Director RE: All Provider Manuals (Revised Appendix Y) This letter transmits revisions to Appendix Y in all provider manuals. Appendix Y lists the active REVS codes and their respective service-restriction messages. Providers accessing REVS to verify a member’s eligibility before providing medical services will receive one or more of the restriction messages listed in this appendix. As of October 1, 2007, the program formerly called the Uncompensated Care Pool (UCP), or Free Care, is now called the Health Safety Net (HSN). The Health Safety Net is a fund set up to help pay for health services at participating hospitals and community health centers for certain low-income individuals with household incomes at or below 400% of the federal poverty level. Health Safety Net coverage is not a MassHealth coverage type, but MassHealth determines eligibility for HSN. HSN is not comprehensive. Individuals who have HSN coverage only may be subject to tax penalties under the state mandate for Massachusetts adults to have insurance. Effective November 1, 2007, the Recipient Eligibility Verification System (REVS) will begin to reflect a number of changes related to Commonwealth Care, Health Safety Net, and MassHealth coverage types. In addition to new coverage types, modified and new restrictive messages will also appear relative to these new coverage types. Commonwealth Care is administered by the Commonwealth Health Insurance Connector Authority (the Connector) and is a program that provides subsidies toward the purchase of private health insurance on behalf of enrolled Massachusetts residents who are not eligible for MassHealth benefits (other than MassHealth Limited), and who have household incomes at or below 300% of the federal poverty level. Commonwealth Care coverage is not a MassHealth coverage type, but MassHealth determines eligibility for Commonwealth Care. Changes to the coverage types, listed in the table on the following page, mainly reflect changes to HSN rules, limiting the time frames and circumstances when individuals can get HSN coverage. Please read this document carefully to ensure that you understand all the changes that may impact you. If you have any questions about the information in this transmittal letter please contact MassHealth Customer Service at 1-800-841-2900, e-mail your inquiry to providersupport@mahealth.net, or fax your inquiry to 617-988-8974. More information about Commonwealth Care is available on the MassHealth Web site at www.mass.gov/masshealth and the Connector Web site at www.mass.gov/connector. NEW MATERIAL (The pages listed here contain new or revised language.) All Provider Manual Pages Y-1 through Y-6 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) All Provider Manual Pages Y-1 through Y-6 — transmitted by Transmittal Letter ALL -148 Coverage types that have changed or are new are listed in the following table. Old Coverage Type New Coverage Type When Coverage Type will appear on REVS FULL UCP HLTH SAFETY NET Member is eligible to receive services by a participating hospital or community health center. PARTIAL UCP HSN PARTIAL Member is eligible to receive services by a participating hospital or community health center, with an associated HSN deductible. RETRO UCP RETRO HSN Member may be eligible to receive services by a participating hospital or community health center, as determined by HSN regulations. RETRO PARTL UCP RETRO PARTL HSN Member may be eligible to receive services by a participating hospital or community health center, with an associated HSN deductible, as determined by HSN regulations. COMMONWLTH CARE COMMCARE/HSN Two circumstances where this coverage type may be used are 1. when a member is eligible for Commonwealth Care coverage but is unable to receive Commonwealth Care benefits because they have not yet enrolled in an MCO; and 2. when a member is eligible for Commonwealth Care and has selected an MCO, but the coverage is not effective until the first day of the next month. During these times, individuals with this coverage type may be eligible to receive services by a participating hospital or community health center, as determined by HSN regulations. COMMONWLTH CARE COMMCARE/UNENRL Members are eligible for Commonwealth Care coverage but are unable to receive Commonwealth Care benefits because they have not yet enrolled in a managed care organization (MCO) and HSN time-limited coverage period has ended, as determined by HSN regulations. COMMONWLTH CARE COMMCARE/PARTIAL (Commonwealth Care and partial HSN coverage - Due to system limitations, this is how the coverage type will appear.) For an individual with income that is between 200-300% FPL, there are two circumstances when this coverage type may be used. They are 1. when a member is eligible for Commonwealth Care coverage but is unable to receive Commonwealth Care benefits because they have not yet enrolled in an MCO; and 2. when a member is eligible for Commonwealth Care and has selected an MCO, but the coverage is not effective until the first day of the next month. During these times, individuals with this coverage type may be eligible to receive services by a participating hospital or community health center, after the deductable has been met, as determined by HSN regulations. ESSENTIAL* ESSENTIAL/HSN Members are eligible for Essential coverage but are unable to receive Essential benefits because they have not yet selected a primary care clinician (PCC.). During this time, they may be eligible to receive services by a participating hospital or community health center, as determined by HSN regulations. ESSENTIAL* ESSNTL/UNENROLL Member is eligible for Essential coverage but is unable to receive benefits because they have not yet selected a primary care clinician (PCC) and HSN time-limited coverage period has ended, as determined by HSN regulations. BASIC* BASIC/HSN When members are eligible for Basic coverage but are unable to receive Basic benefits because they have not yet enrolled in an MCO or selected a PCC. During this time they may be eligible to receive services by a participating hospital or community health center, as determined by HSN regulations. BASIC* BASIC/UNENROLL Members are eligible for Basic coverage but are unable to receive benefits because they have not yet selected an MCO or a PCC and HSN time-limited coverage period has ended. * These coverage types will still appear if a member has selected a PCC or MCO. To reflect the changes from the Uncompensated Care Program to the Health Safety Net, the following restrictive message has been changed in REVS. Message No. Old Message New Message 621 MEMBER ALSO ELIGIBLE FOR COMMONWEALTH CARE. ENROLLED WITH PLAN. COVERAGE TO BEGIN . MEMBER ENROLLED WITH PLAN. COVERAGE TO BEGIN . The following restrictive messages are new messages in REVS, reflecting changes for the Health Safety Net and Commonwealth Care. New Restrictive Messages: Message No. Restrictive Message When it will appear 633 HSN IS FOR CERTAIN HOSPITAL AND CHC SERVICES ONLY. MEMBER HAS SUBMITTED AN MBR AND IS NOT ELIG FOR MASSHEALTH. CALL 1-877-910-2100. Member may be eligible to receive certain services by a participating hospital or community health center, with an associated HSN deductible, as determined by HSN regulations. 634 MEMBER MUST ENROLL IN COMMCARE TO RECEIVE THESE BENEFITS. MEMBER MUST CALL 1-877-MA-ENROLL (1-877-623-6765). Member is eligible for Commonwealth Care but has not yet selected an MCO. 635 HSN AVAILABLE Member has secondary coverage with the HSN. 636 MEMBER IS ALSO ELIGIBILE FOR HSN SECONDARY. SEE 114.6 CMR 13.00 FOR INFO ON HSN REQS. This appears for certain members who do not have comprehensive MassHealth coverage. 637 MEMBER IS HSN SECONDARY. BILL MEMBER’S PRIVATE HEALTH INSURANCE. SEE 130 CMR 450.316- 317 FOR INFO ON TPL REQS. Appears if a member’s coverage type appears on REVS as Health Safety Net or HSN partial, and the member has other insurance (third party liability.) 638 PARTIAL HSN AVAILABLE. MEMBER WITH 200-250 PERCENT FPL. HSN DEDUCTIBLE IS $41. Member is eligible for partial HSN secondary. Member must pay associated deductible. 639 PARTIAL HSN AVAILABLE. MEMBER WITH 250-300 PERCENT FPL. HSN DEDUCTIBLE IS $2,083. Member is eligible for partial HSN secondary. Member must pay associated deductible. 640 HSN NOT AVAILABLE. Member is not eligible for HSN. 641 PARTIAL HSN AVAILABLE. Member is eligible for partial HSN secondary. Member must pay associated deductible. 642 PARTIAL HSN DENTAL AVAILABLE. MEMBER WITH 200-250 PERCENT FPL. HSN DEDUCTIBLE IS $41. Member is enrolled in Commonwealth Care plan type 3 or 4 and is also eligible for partial HSN dental. Member must pay associated deductible. 643 PARTIAL HSN DENTAL AVAILABLE. MEMBER WITH 250-300 PERCENT FPL. HSN DEDUCTIBLE IS $2,083. Member is enrolled in Commonwealth Care plan type 3 or 4 and is also eligible for partial HSN dental. Member must pay associated deductible. 644 HSN DENTAL AVAILABLE. Member is enrolled in Commonwealth Care plan type 2 and is also eligible for HSN dental. 645 PARTIAL HSN DENTAL AVAILABLE. Member is enrolled in Commonwealth Care plan type 3 or 4 and is also eligible for partial HSN dental.