One Care Medicare MassHealth

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• One Care Medicare MassHealth
• Important Updates

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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

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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.

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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.org
• 2) Fallon Total Care
• Contact 1-800-879-0852,
  www.fallontotalcare.org
• 3) Network Health
  
  
• Contact 1-855-393-3154,
  www.chooseunify.com

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Which Counties Will Have Access to One Care?
  CW Care Alliance Fallon Total Care Network 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.
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Types of Enrollment

• Enrollment 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.
• 
  
  

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Time Line of Important Dates
Date   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.
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Time Line Continued
Date   Activity   MassHealth Member Choice/Response
  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.  
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Time Line Continued
Date   Activity   MassHealth Member Choice/Response
  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   Stay with the One Care plan to which they have been assigned Contact MassHealth to switch to a different One Care plan 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 See above for member options
  July 1, 2014   Effective date for 3rd round of auto-assigned members See above for member options
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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 members 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.

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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.

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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.

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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 plans
  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 plans
  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.

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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

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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 Care
• PO Box 1200
• Boston, MA 02112

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Additional Resources

• Visit the One Care Website www.mass.gov/massheal
  th/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