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New Pool Regulations Will Impose Co-Payments, Restrict Services

New Pool Regulations Will Impose Co-Payments, Restrict Services

August 2, 2005

Yesterday the Romney administration released proposed new regs for the Free Care Pool. The regs would impose new copayments on free care patients, and impose many new restrictions on hospitals and health centers treating free care patients. The new regs are due to take effect on October 1, 2005. A public hearing on them will be held on September 8 at UMass Boston.

Among the proposed changes:

1. New co-pays for services provided to Pool patients
$3 per community health center visit.
$5 per hospital visit or inpatient admission.
$5 for brand name drugs;
$3 for generic drugs.

Studies have found that even very modest co-payments imposed on low-income families can impact health. A Minnesota study found that more than half were unable to get prescriptions at least once in the last six months because of copayments of $3 for brand name drugs or $1 for generic drugs. A third of the patients who failed to get medications had subsequent emergency room visits and hospital admissions for related disorders. The inability to afford copayments had serious health consequences and led to use of more expensive medical care. A good summary of research on this issue is available here.

2. A patient will no longer be eligible for the Pool if the patient is terminated from MassHealth for failure to pay premiums or deductibles. In 2003, MassHealth began imposing premiums on many families with incomes as low as 114% of the poverty level ($10,900 for an individual). These premiums have resulted in many people losing coverage for failure to make a monthly payment on time.

3. A patient will no longer be eligible for the Pool if the patient is eligible for MassHealth’s premium assistance program for employer sponsored insurance but fails to enroll or apply for employer sponsored insurance.

4. The Pool will reimburse for costs going back 60 days before the date of application. Currently, the pool pays retroactive claims for up to 6 months. This will snag many patients who believe they have health coverage, but turn out to be uninsured. The new regs allow hospitals to bill a Pool-eligible patient if the patient applies more than 60 days after a service is provided.

5. Pool patients using hospital pharmacies will have coverage only for drugs that are on the MassHealth list. The exceptions policy available to MassHealth patients, which allows a doctor to prescribe a drug not on the approved list, will not be available to patients using hospital pharmacies.

Complete analysis and links to information on the hearing and the text of new regulations can be found on our website.