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Massachusetts health care – wonky with a dose of reality

December 23, 2013

Connector Executive Director Jean Yang called it “a backup to the backup” in a Boston Globe article about plans in process to prevents gaps or delays in coverage despite major dysfunction in the state's online eligibility and enrollment processing system. On late Friday, MassHealth and the Connector released more information about the temporary coverage plan:

We recently informed you of the coverage extensions that apply to members enrolled in Commonwealth Care, Medical Security Program or the Insurance Partnership program allowing members to retain their current coverage through at least March 31, 2014.  As you know, the priority of the Health Connector and MassHealth is to ensure that everyone seeking insurance coverage has access to coverage without gaps or delay. We are currently experiencing some delays in processing applications through our new system, and are aware that some applicants who are not currently enrolled in any subsidized health insurance program may need access to health care coverage starting on January 1. We are working to process those applications and prioritizing applications from those who are not currently enrolled in any subsidized health program. Please be advised that any individuals not currently enrolled in any subsidized health program who have applied for subsidized coverage, and whose applications we have not been able to process, will have access to temporary coverage until we are able to process their applications and make final eligibility determinations. Individuals whose applications were submitted prior to December 31, 2013, will receive this temporary coverage starting January 1, 2014. In an effort to provide further clarification on this temporary coverage option for you and those applicants you assist, we have prepared and attached the following materials:

Individuals receiving temporary coverage or providers with questions about this option can call MassHealth Customer Service at 1-800-841-2900 (TTY: 1-800-497-4648) for more information.

 

December 20, 2013

HPC 2013 Accomplishments

The Health Policy Commission met Wednesday December 18, for its 11th full meeting. The bulk of the meeting focused on a presentation of the preliminary findings of the 2013 Cost Trends Report and an update on the Cost and Market Impact Review of the acquisition of South Shore Hospital and Harbor Medical Associates by Partners HealthCare.  The slide deck is here, and our full report is on the backside:

December 19, 2013

Re-Reforming Reform Part 2 coverIt's re-re-reforming reform. A part II sequel, like Revenge of the Nerds II: Nerds in Paradise. (We're not going to say Attack of the Clones).

What it is an updated, comprehensive, readable, understandable guide to all the changes happening to health coverage in Massachusetts due to the ACA. Today the Blue Cross Foundation released Re-forming Reform Part 2, by Elisabeth Rodman of the Foundation staff.

Re-Reforming Reform Part 2 coverage chartThe report looks at the changes to subsidized coverage for low income people, new eligibility and enrollment policies, altered regulations affecting private insurance, and also includes some payment reform initiatives.

If your reading this blog, you'll probably like this report. Get it here. -Brian Rosman

 

December 18, 2013

The Health Policy Commission’s (HPC) Quality Improvement and Patient Protection Committee held a hearing Monday on proposed amendments to 958 CMR 3.000, the Office of Patient Protection (OPP) regulation governing health plan internal and external appeals procedures.  The proposed amendments follow a listening session that OPP convened over the summer, and include consumer-friendly changes required by the Affordable Care Act (ACA) and Massachusetts state laws, as well as changes to provide additional clarifications and protections for consumers.

For example, some positive changes prompted by the ACA include a faster turnaround time for both expedited and non-expedited external reviews; more detail and clarity for information provided in consumer notices; allowing patients with urgent medical needs to file both expedited internal and external appeals simultaneously; and requiring refunds to consumers of the external review fee if the consumer wins the review.  And those are just a few of the improvements.

During the hearing, the Committee heard oral testimony from InterQual/McKesson Health Solutions, National Association of Social Workers (NASW), Massachusetts Association of Health Plans (MAHP), Health Law Advocates (HLA) and Health Care For All (HCFA), and Massachusetts Association of Behavioral Health Systems (MABHS).  Here are some of the points raised:

  • Jacqueline Mitus, Senior VP of Clinical Development and Strategy for McKesson Health Solutions and Laura Coughlin, VP of InterQual Development, raised concerns that providing criteria for medical necessity determinations to the public at no cost could breach confidentiality under intellectual property law and that the complexity of such information could create consumer confusion.
  • Jonas Goldenberg, Director of Clinical Issues and Continuing Education at NASW, recommended more stringent criteria for clinicians participating in review panels and advocated that services should be automatically continued pending the outcome of an appeals process.
  • Sarah Gordon Chiaramida, VP of Legal Affairs at MAHP, expressed concerns that requiring diagnosis and treatment codes on adverse determination notices would be confusing and may breach privacy protections by revealing protected health information to third parties. She further voiced concerns that the amendments around increased availability of translation services would be too costly and administratively burdensome for the health plans.
  • Clare McGorrian, Senior Staff Attorney and Director of the Commercial Insurance Appeals Program at HLA provided testimony on behalf of both HLA and HCFA. She advocated that medical necessity criteria should be determined by providers with more clearly defined clinical expertise and recommended that adverse determination notices more prominently display deadlines for action, especially for expedited appeals and continued coverage for ongoing treatment .
  • David Matteodo, Executive Director of MABHS, suggested that providers reviewing appeals be required to be licensed in Massachusetts.

The Health Policy Commission is accepting written testimony and comments from the public until 12 noon on Tuesday, December 24, 2013.  For details on how to submit testimony electronically or via mail, see the Hearing Notice.
 -Alyssa Vangeli

 

December 18, 2013

The Statewide Quality Advisory Committee (SQAC)  met this week for its final 2013 meeting. The group looked at an overview of the current Standard Quality Measure Set (SQMS), which includes 128 measures, 93 of which are mandated and 35 or which were recommended for inclusion by the SQAC after a measure nomination process. Seventy of the measures look at ambulatory care, 51 are for hospital care, and 7 look at care in post-acute settings (skilled nursing facilities and home health). Looking at the priority areas that are covered by SQMS measures, 20% of them are care coordination measures, 16% are chronic disease measures, 12% are preventive care measures, 9% are pediatric measures, 9% are behavioral health measures, 6% maternal and neonatal health care measures, 27% are other and 0% are patient-centered care measures. There was a lot of attention paid to patient-centered care measures during 2013 SQAC measures, with presentations on Patient-Reported Outcome Measures (PROMS) and patient confidence measures, as well as nominations for the inclusion of patient confidence and shared decision-making measures in the SQMS. While those measures were not chosen for inclusion, the SQAC will continue to look at them and, as CHIA Executive Director Boros said, will consider making stronger statements about their importance even if they are not included in the set. Based on the group’s discussion of domains and measure types that are under-represented in the SQMS, the next steps as outlined by Boros are for CHIA staff to:

  • Develop a straw model for reporting on a specific population;
  • Characterize existing SQMS measures as looking at overuse or unnecessary use of care, for those that do so, and propose other overuse measures that could be nominated for inclusion in the SQMS;
  • Start looking at measures relating to outpatient specialist care.

The next SQAC meeting is Monday, February 10, 3-5 at CHIA, 2 Boylston Street, 5th floor. Sometime following that meeting, there will be a solicitation process for proposed measures for the measure set. -Deb Wachenheim

December 17, 2013

UPDATE: An FAQ and an update from the Health Connector (Tuesday 12/17, 2 pm):

In accordance with Acting Gov. Galvin’s request to release all non-emergency employees today due to inclement weather, the Health Connector call center is closing at 2 p.m. today (Tuesday 12/17). The lines will re-open tomorrow at 7 a.m.

Question. What happens to an individual who is unable to get their application through online for January 1st coverage?

 Answer. Applying online is the fastest way to get coverage for January 1.  If you encounter any technical difficulties creating an account, call 1-877-MA ENROLL (877-623-6765) to complete your application. The Health Connector Customer Service Center has more than doubled its staff since October and is now offering applicants the opportunity to schedule an appointment with a Customer Service Representative who will call the applicant back within the applicant's choice of four blocks of time during a day that the applicant chooses.

 Question. Can you clarify to whom the temporary coverage for January 1st applies?

Answer. Our highest priority is to ensure that all of our populations that seek insurance coverage will have access to coverage without gaps or delay. If we are not able to process certain applications we will provide applicants seeking financial assistance with temporary access to coverage for January 1, 2014 until we are able to process them into their final new coverage. Those who have applied for non-subsidized coverage online or by paper MUST select a plan and make a payment by December 23 to enroll in coverage for January 1st.

Customer Service Center Update:

The Health Connector's Customer Service Center (1-877-MA ENROLL (1-877-623-6765) will offer extended hours this weekend.  They will be open on Sunday, December 22, from 9:00am-3:00pm to offer consumers assistance in completing applications or making plan selections.

 

As we mentioned in our blog last Friday, the Health Connector and MassHealth are doing the right thing by extending Commonwealth Care, Medical Security, and Insurance Partnership coverage until March 31st, 2014. Current members of these health insurance programs will need to reapply for help paying for health insurance between now and March 24th, 2014 in order to have health insurance for the rest of 2014. See details below about how to reapply and reenroll for coverage beyond March 2014.

What about the people that are losing health insurance coverage on December 31st or are currently uninsured?

The Health Connector and MassHealth have made a commitment to ensuring that folks are covered on January 1st, 2014. The details of this coverage are still being worked out, but we wanted to let our readers know so that the public is as informed as possible and hopefully to ease some anxiety.

How do folks ensure that they have health insurance coverage on January 1st, 2014?

There are four ways to get health insurance for January 1st:

  1. Apply online at mahealthconnector.org
  2. Apply over-the-phone by calling 877-MA-ENROLL (877-623-6765)
  3. Apply via paper application here for help paying for health insurance or here for health insurance with no subsidy
  4. Apply in-person with a navigator or certified application counselor. See the list of them here. [http://bettermahealthconnector.org/get-help/]

What if I already applied and have not received a notice about my new coverage?

The Health Connector and MassHealth are working furiously to process all of the applications they have received for health insurance coverage for January 1st, 2014. If you filled out a paper application for help paying for health insurance, you will receive a notice within the next couple of weeks regarding your new health insurance coverage that starts January 1st. If you filled out a paper application for private health insurance without help paying for health insurance, you will receive a notice very soon with your plan choices and/or bill for your premium*.

***Important note:  In order to have health insurance coverage for January 1st, 2014, you need to have sent in your completed application and premium payment (if you have to pay a premium) by December 23rd, 2013.***

UPDATE: Here's our summary of what people need to do to keep their coverage:

Affordable Care Act Coverage Transition Guide

For People Wanting to Apply for Immediate Coverage Before December 31st, 2013

  • Fill out a Virtual Gateway or the new application for help paying for health insurance. Make sure to check that you want immediate coverage!

For Current Commonwealth Care members (Over 138% FPL [Federal Poverty Level])

December 14, 2013

The Health Connector and MassHealth just sent out this update on contingency plans for health coverage in light of the ongoing issues with the eligibility IT (note that we have not posted the attachments, at the request of the Health Connector):

Over the last several weeks, the Health Connector, in close collaboration with our colleagues at MassHealth, have been working to ensure that people have coverage in place on January 1. As such, we have outlined several important updates about current health coverage programs and when individuals can expect to receive notification regarding their applications.

Update on Subsidized Health Coverage Programs:

Members in the following programs will have access to benefits through the end of March.

  • Commonwealth Care
  • Medical Security Plan
  • Insurance Partnership Employees

Current Commonwealth Care or Insurance Partnership (IP) members who are not being transitioned to MassHealth, as well as members of the Medical Security Program (MSP) who are enrolled in MSP on or after December 16, will have coverage through March 31, 2014. This means that if a current member in one of these programs has not submitted an application, or has not yet received a determination on their application, they still have through March 24, 2014 to apply, select a plan and pay their first month’s premium without experiencing a gap in coverage. Over the next couple of weeks, members in these programs will receive an official letter informing them of this update about their health insurance.

Sample Letter to Enrollees Regarding Coverage Extension:

  • The attached letter [note: not attached]  to Commonwealth Care members will go out this week to 110,000 members who will now have until the end of March to enroll into a new plan.
  • The attached letter [note: not attached] to members in the Insurance Partnership program will go out this week to approximately 1,000 members who are likely eligible for subsidies through the Health Connector, informing them that the IP program ends on December 31 and that MassHealth will make premium assistance payments directly to them during the QHP open enrollment period so that they have until the end of March to enroll in a new plan.
  • Letters to members enrolled in MSP are still under review and a draft will be shared once finalized.

Commonwealth Care members who have submitted an application will receive a letter this week informing them that they will still have access to coverage through March 31, 2014, and that their application for new coverage will be processed over the coming months. MSP members (enrolled through December 16) will have access to continuation coverage. For current Commonwealth Care and MSP members whose applications are successfully processed and who complete all steps to enroll in a Health Connector Plan prior to December 23, new coverage could be effective as early as January 1. Insurance Partnership members who are likely eligible for Health Connector coverage may apply for and enroll in coverage anytime between now and March 24.

Update on Applicants for Subsidized Health Coverage Programs:

Our highest priority is to ensure that all of our populations that seek insurance coverage will have access to coverage without gaps or delay. The Health Connector and MassHealth are working to process applications for subsidized coverage as soon as possible. We are prioritizing applications from individuals who are not currently enrolled in any subsidized health program and therefore do not benefit from the extensions described above. We have created an alternative path to process new applications for subsidized coverage and effectuate enrollment in a Qualified Health Plan with premium tax credits to help pay monthly premiums.

  • Members eligible to enroll in a Health Connector plan with premium tax credits, as determined through this process, will be sent letters explaining their access to subsidies and health plan choices, and are informed to return a plan selection form or call member service to select a plan (similar to the current plan selection process for Commonwealth Care). These individuals will also receive a Frequently Asked Questions document along with this enrollment letter.
  • Members eligible for MassHealth programs, as determined through this process, are enrolled in coverage through MassHealth’s legacy eligibility system, MA-21. MassHealth-eligible members can be enrolled in any coverage type that is available in 2014, including MassHealth CarePlus.

Sample Letter to ConnectorCare Enrollees Regarding Plan Selection:

  • The attached letter [note: not attached] has been mailed to applicants seeking financial assistance indicating that the recipient is eligible for a Connector Care plan type and lists the ConnectorCare plans they can choose from as well as the methods to complete their enrollment (mail, phone, in person, fax). The letter states that a final determination notice will be sent in the mail once the application process is complete. The letter also mentions that if the recipient has questions s/he can reach out to Navigators in addition to Certified Application Counselors or Customer Service for further assistance.

If we are not able to process certain applications through this workaround (e.g., due to data limitations), we plan to provide applicants with temporary access to coverage for 1/1/2014 until we are able to process them into their final new coverage.

Update on Non-Subsidized Health Coverage Programs:

December 13, 2013

With just a few weeks before ACA coverage programs begin, the Connector Board met today to discuss website and coverage issues, vote on final regulations for student plans and the new ConnectorCare subsidized coverage program, and approve customer service and risk adjustment contract extensions.

This was the final meeting under the Connector's programmatic offerings that go back to 2006's Chapter 58. Starting in January, it will be Connector 2.0, the ACA Marketplace. But, as we learned today, lots of legacy infrastructure will linger into the new year for a while longer.  Materials from the meeting are posted here, and our full report just takes one click.

December 12, 2013

Connector Slide: Highest Priority is coverageThe Health Connector held their board meeting this morning. We'll have a more detailed Board summary report up soon, but given the uncertainty about their website and enrollment we wanted to quickly share some of the updates. (Also, see this Herald article posted earlier today for some uninformed speculation, and this Herald banner developing story after the meeting focusing on website IT issues.)

The takeaway: Despite major website and data problems, the Connector is setting up work-arounds that will make sure that coverage will remain in place for eligible people after January, and that new applicants can get coverage. Administration and Finance Secretary and Connector Chair Glen Shor declared that more people will be covered in Massachusetts after January 1 than are covered today.

As of yesterday, over 93,000 coverage applications have been started, and 34,690 applications submitted.

Here are the key slides on coverage plans:

Connector Slide: Protecting existing coverage

Connector 12-12-13 slide - Adding New People

Connector 12-12-13 slide - Next Steps

Shor said that there are serious concerns about the consistent underperformance of the IT vendor, and that fundamental solutions will need to be discussed in January.

We'll have more to say as we learn more about the details. But we hear the ongoing frustration of people trying to get through a dysfunctional web eligibility and enrollment system, and are very pleased of the commitment by the state (Connector, MassHealth and others)  to find alternative pathways to coverage, with no delays and no gaps in care.

December 11, 2013

HCFA congratulates Rebekah Gewirtz, who was named yesterday as the head of the Mass Public Health Association.

Rebekah has been a long-time friend and ally of HCFA through her work with the state Association of Social Workers. She's been an active leader in the ACT!! Coalition, and she and HCFA have collaborated on many projects over many years. She'll bring a strong strategic vision and commitment to effective action on public health. We look forward to a continued close partnership with MPHA on our many shared priorities.

Here's the MPHA announcement, from their board chair Steven Bradley:

On behalf of the MPHA Board of Directors, I am very pleased to announce that MPHA has selected a new Executive Director, Rebekah Gewirtz, who will begin on January 2, 2014. Rebekah brings a wealth of experience in state and local policy, community organizing, fundraising, and organizational development. Her skills and leadership will be a tremendous asset to MPHA as we seek to increase our impact on public health in the Commonwealth in the years ahead.

Rebekah is currently the Director of Government Relations and Political Action at the National Association of Social Workers, MA Chapter, where she has served for more than eight years. She has also been an elected alderman in the City of Somerville for eight years. In her role as alderman she has championed public health measures, including acting as a leading proponent and co-sponsor of Somerville's Urban Agriculture ordinance, which was the first of if its kind in Massachusetts.

Rebekah is a true friend of public health, understands the political and policy landscape, and has the leadership drive to advance MPHA.

Rebekah joins MPHA at an exciting and pivotal time for both the organization and the field of public health. MPHA has successfully led major budget and policy initiatives over the last years, including passage of the landmark Prevention and Wellness Trust. But we cannot rest on our laurels. The public health landscape continues to undergo significant changes here in Massachusetts and across the nation - including changes in healthcare financing and new models and partnerships to address the social determinants of health. The MPHA Board is confident that Rebekah has the skills and the passion to lead MPHA in this time of significant change, so that we remain influential and forward thinking.    

 As we look ahead to 2014 and beyond under Rebekah's leadership, we hope that you will continue to support the vision and leadership of MPHA with an end of the year gift.

In her time at NASW MA, Rebekah has served on the senior management team and provided leadership in strategic planning, member growth and retention, and organizational development. She has led passage of key social work priority initiatives including legislation protecting social workers against violence in the workplace, and she has been a leader on the campaigns to close corporate tax loopholes and raise the minimum wage. Rebekah is a graduate of the University of Massachusetts, McCormack Institute of Policy Studies where she earned her Master of Science in Public Affairs degree. She has been recognized as a "Woman to Watch" by Democratic Leadership for the 21st Century and received the 2013 Leadership Award from the Greater Boston Labor Council.

 On behalf of everyone at MPHA, I hope that you will join me in welcoming Rebekah, and I ask that you join us in re-committing to the work to build a healthier and more equitable Massachusetts for all.

 

 

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