Massachusetts Health Care Reform: Frequently Asked Questions

These FAQs are provided for educational purposes and should not be construed as legal advice. Readers with specific legal questions should consult with a private attorney.

Commonwealth Care is a subsidized health insurance program in Massachusetts for individuals who meet certain eligibility requirements and whose income is below 300% of the Federal Poverty Level (FPL). Commonwealth Choice is a non-subsidized insurance program for Massachusetts residents and small employers. Commonwealth Care and Choice are administered by the Commonwealth Health Insurance Connector Authority (the Connector). For more information about the Commonwealth Care Health Insurance Program, visit the Health Insurance Connector website at www.mass.gov/connector.

General

1. What is Commonwealth Care?

Commonwealth Care is a health insurance program for low-income residents of Massachusetts. It is administered through the Connector. Coverage under Commonwealth Care is through a choice of private health insurance plans. The Connector helps eligible individuals choose and enroll in a health plan that works for them. Once enrolled, individuals will become a member of the health plan they select.

For additional information about Commonwealth Care, including guidance on determining eligibility and applying as well as an extensive list of FAQs prepared by the Connector, please call 1-877-MA-ENROLL or visit www.macommonwealthcare.com.

2. What is Commonwealth Choice?

Administered through the Connector, Commonwealth Choice is a health insurance program for Massachusetts residents and small employers. Individuals will be able to choose from a variety of private health insurance options and small employers will either contribute to and make available health insurance plans to their employees or allow for pre-tax premium deductions for health insurance through the Connector. The Connector assists eligible individuals and employers choose and enroll in a health plan that works for them. 

3. What is the difference between Commonwealth Care and Commonwealth Choice?

Commonwealth Care is a subsidized insurance program for uninsured individuals who must meet income eligibility requirements. It is currently available to those who qualify.

Commonwealth Choice is a non-subsidized insurance program for Massachusetts residents and small employers.

4. What is a Commonwealth Care Plan Type?
 
A Plan Type is a scope of health benefits that is available to a group of eligible individuals based on income level. 

Commonwealth Care has four Plan types:  

  • Plan Type 1 is available to those under 100% FPL.
  • Plan Type 2a is available to those greater than 100% FPL but at or below 150% FPL.
  • Plan Type 2b is available to those greater than 150% FPL but at or below 200% FPL.
  • Plan Type 3 is available to those greater than 200% FPL but at or below 300% FPL.

Each Plan Type has a certain list of health benefits and co-payments. Upon enrollment, individuals receive benefits which include: doctor office visits, inpatient hospital care, pharmacy benefits, mental health and substance abuse services, and vision. Members in Plan Type 1 also receive dental care. There is no monthly premium for Plan Type 1, and members in Plan Types 2 and 3 have sliding premiums based on income. All members must pay a fee (co-payment) for some benefits.

5. How do I contact the health plans regarding billing and contracting issues?
 
Providers interested in Provider enrollment and Provider billing should contact the Managed Care Organization (MCO) directly:

  • Fallon Community Health Plan - 1-866-ASK-FCHP (866-275-3247)
  • Network Health - (888) 257-1985 
  • Neighborhood Health Plan - (800) 462-5449 
  • Boston Medical Center HealthNet Plan - (888) 566-0008

Eligibility/Enrollment/Coverage

6. How do I check a patient's eligibility?
 
Effective October 1, 2006, the Recipient Eligibility Verification System (REVS) will display new messages when an individual is enrolled or is determined to be eligible to enroll in one of the four MCOs.

Once an individual is enrolled, he/she is considered a member and will receive an MCO identification card.

More information is available at the Connector website www.mass.gov/connector. Patients with questions about Commonwealth Care can contact Commonwealth Care Customer Service Center at  1-877-MA-ENROLL (1-877-623-6765) Monday to Friday from 8 a.m. to 5 p.m.
 
7. What if my patient's income changes?
 
It is the member's responsibility to inform  Commonwealth Care of any income changes. A pay check stub is required as proof and the member will be re-enrolled at the proper level depending on the change in income or unenrolled if the income goes over 300% FPL.
 
8. How can a provider find out what co-payment amount my patient will need to pay?
 
The provider should check the member's MCO identification card, and contact the MCO plan directly for this information if there are any questions. Note: Co-pay information is not listed on the Recipient Eligibility Verification System (REVS).
 
Co-payments for all Commonwealth Care products:

A member's plan benefits and co-payments will vary depending upon two factors:

  1. Income
  2. The Plan in which the individual is enrolled.

Outlined below are the generic benefits and co-payment requirements for the various products.3 Benefit plan design summaries are available by contacting the MCOs directly.

 Service

 Plan Type 1

 Plan Type 2

Plan Type 3  

 PCP/SP

 Covered in full

 $10/$18

 $15/$22

 Outpatient MH/SA

 $0

 $10

 $15

 Abortion

 Covered in full

 $50

 $100

 Outpatient surgery

 Covered in full

 $50

 $125

 X-rays/labs

 Covered in full

 Covered in full

 Covered in full

 Rx

 $1/$3

 $10/$20/$40

 $10/$20/$40

 Emergency care

 $0

 $50

 $100

 Inpatient care

 Covered in full

 $50*

 $250*

 Wellness benefit

 Covered in full

 $0-$10

 $0-$20

 * Co-payment waived if transferred from another inpatient unit. . 
Source: Commonwealth Connector

9. Are Commonwealth Care members covered for out-of-state services?
 
MCOs provide coverage for out-of-state emergencies and urgent care services. Routine care, follow-up care, or care that could have been foreseen prior to leaving Massachusetts is not covered.  
 
10.  Can a member change health plans after the 60-day window?  

After a Commonwealth Care member's enrollment starts, that member will have 60 calendar days to change health plans for any reason. After the 60-day period has passed, the member may only change health plans if:

  • The member moves and the new address is outside of the health plan's service area;
  • The member demonstrates to the Connector that the health plan has not provided access to health-care providers that meet that member's health-care needs over time, even after asking the health plan for help; or
  • The member's primary care provider is no longer part of the health plan or there is a significant change in the health plan's group of providers.

If the Connector agrees that the member meets one of the reasons above and there is at least one business and one calendar day left in the month, the effective date of the new plan will be the first day of the month following the date of the change. 

Billing

11. If a patient's coverage changes will a provider still receive reimbursement?
 
Yes, while a patient is transitioning to a new coverage type due to eligibility changes, the provider will still be paid under the patient's most recent coverage during the month that the change occurs. An important basic tenet of Commonwealth Care enrollment operations is that enrollment always starts on the first day of a month and ends on the last day. Coverage will always be provided during these time frames, so appropriate claims should be processed for care provided during the month of the eligibility change.
 
12.  Can a provider collect co-payments? 
 
Yes, providers may collect co-payments for Commonwealth Care members. Commonwealth Care has developed a schedule for co-pays based on the Plan Type and service(s) provided. Providers may either collect the co-payment at the point-of-service or bill the member for the co-payment.  

Outlined below are the generic benefits and co-payment requirements for the various products.4 Benefit plan design summaries are available by contacting the MCOs directly.

 Service

 Plan Type 1

 Plan Type 2

Plan Type 3  

 PCP/SP

 Covered in full

 $10/$18

 $15/$22

 Outpatient MH/SA

 $0

 $10

 $15

 Abortion

 Covered in full

 $50

 $100

 Outpatient surgery

 Covered in full

 $50

 $125

 X-rays/labs

 Covered in full

 Covered in full

 Covered in full

 Rx

 $1/$3

 $10/$20/$40

 $10/$20/$40

 Emergency care

 $0

 $50

 $100

 Inpatient care

 Covered in full

 $50*

 $250*

 Wellness benefit

 Covered in full

 $0-$10

 $0-$20

 * Co-payment waived if transferred from another inpatient unit. 
Source: Commonwealth Connector

13.  What if a patient does not pay?
 
Certain providers may have the right to refuse to provide a service to a member who does not pay the co-payment. If, however, the provider decides to provide the service, that member will still owe the provider for the co-payment.

This right to refuse does not apply to all providers. For example, hospitals, out-patient clinics, and entities owned or operated by a hospital may not refuse services for failure to pay a co-payment. Additionally, in an emergency, services can not be refused based on non-payment of a co-payment.

Providers may use any legal method to collect the money owed.  
 
14. Will reimbursement be retroactive when a patient switches health plans?
 
No, there should be no need for retroactive reimbursement, since Commonwealth Care enrollments are always prospective, with enrollments always beginning on the first of a month and ending on the last day of a month. Therefore, reimbursement should be made based on the patient's enrollment status at the time of service.

Contracting

15. Do I need to sign a new contract with each health plan to participate in Commonwealth Care?
 

Maybe; providers with questions should contact the MCO directly because provider contracting is handled separately by each of the MCOs. The MCO may have different coverage areas for MassHealth and the subsidized Commonwealth Care products. Providers should check with the MCO if they are interested in being part of that MCO's Commonwealth Care network.
 
16. If I sign a new contract how quickly can I be enrolled as a provider and will the new contract require credentialing?


Provider enrollment processes may vary among the MCOs, so providers must contact each MCO directly for details. All providers are required to be credentialed prior to becoming providers for the MCOs.  
 
17. Are out-of-network providers covered? For example, if a provider sees a patient in the hospital or as an out-patient that is covered by a plan in which the provider is not a contracted provider?
 
Commonwealth Care MCOs must offer a provider network sufficient to provide access to all Commonwealth Care covered benefits. In the event an MCO is unable to provide access to a certain benefit with its existing network, the MCO must have in place protocols to address the situation, which may include use of out-of-network providers.  Providers should contact each MCO directly for details. In addition, if providers are not a contracted provider for a member's MCO, they should not be routinely seeing patients in a hospital or other setting.  
 
18. Does Commonwealth Care work like MassHealth in regards to closing a panel? For example, if I close my practice to new patients I must close it to all new patients?

Yes, similar to MassHealth, participating MCOs must prohibit their providers from closing or otherwise limiting acceptance of Commonwealth Care members as patients unless the same limitation applies to all MassHealth or commercially insured persons.

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