MassHealth Basics
True or False
Applying for MH automatically considers applicants for the Health Safety Net
True
Where can you select in HIX to see the identity proofing detail?
Select View/Edit Profile under Primary Contact Information
Member has SCO plan and needs assistance with prescriptions. How can you assist ?
Refer to SCO plan, we arent able to provide any additional assistance
How can a member start services of PCA? What coverage does member need to have
When does a member’s MassHealth eligibility start?
The first day of the month of the eligibility determination date, or the first day of the month the application was received for paper applications and renewals.
What is the basic requirement for MassHealth? (3)
Residency must reside in Massachusetts.
Citizenship or immigration status must be verified.
Financials must be financially eligible to qualify
True or False
Member has AA PAC,Aid cat 06 and coverage ended, I should transfer to MEC to complete new application
False
If under 65 then create new HIX app with member,if over 65 transfer to teleapplications. MEC cant do applications
You try to enroll a member into a health plan and receive an “Open Action 03” error. What does this mean, and what should you do?
The member has an unfinished application with DTA. Refer the member to DTA to resolve the open action as we cant enroll
True or False
Member wants to submit complaint against facility, I can create task for escalation
False
You should refer them over to Board of Registration in Medicine (BORIM)
HOH is calling in regards of child, whose information should you verify ?
Your verifying HOH and we know they are authorized to speak on anyone in their account
What changes should a member report and when should i be reported?
Address, phone/email, income, household members,pregnacy, disability status,other insurance within 10 days
You receive an HE03004 error. What should you do next?
Confirm the spelling of the member’s name. The DOB matches the SSN, but the name does not.
Member is under 21, has a TPL and needs extra behavorial health services. What program can they enroll into
CBHI
A member’s Social Security check is still being deducted for their Medicare premium, despite having an MSP effective date more than 30 days ago. How can you assist?
Transfer to buy in unit, they will configure the payment issue as MSP has been active for over 30 days.
If HOH is calling to report household lives out of state, should you put admin closure or update address?
Update address and if admin closure isnt placed, you can add
Can a member have both MassHealth and Medicare? If so, what are these members called?
Yes. They are called dual-eligible members
Member is under 65, has AA MHO,MMIS shows DA as the disability status and the Medicare ID has a C. What type of case is this and can you complete renewal?
Pickle/DAC (Disabled Adult Child)Case-transfer to teleapplications as they cant be on HIX
A member has Aid Category 55, and MMIS displays an “Excluded from Managed Care” error. Should you create a task for enrollment, or take another action?
Do not create a task. The member is currently Fee-for-Service and is not eligible for managed care enrollment. Educate the member about their FFS coverage and how to access care under FFS.
A member calls because their medication is not covered, they have Revere Health Choice plan. How can you assist?
Check the Mass.gov drug list to see if a PA is required. Confirm whether the provider submitted a PA. If not, refer the member to their provider. If a PA was submitted and there’s still an issue, create a task for further review.
An individual has documentation acknowledging their presence in the United States. What status does this describe?
A. Lawful Permanent Resident
B. PRUCOL
C. Undocumented Individual
D. U.S. Citizen
B. PRUCOL
A useful way to screen PRUCOL is to ask whether the person has submitted any application or documentation toward an immigration status, or whether they are working (or have worked) with an immigration attorney
Does CMSP have an income limit, and at what percentage of the FPL will they have to pay a premium?
CMSP has no income limit. Households above 200% of the FPL may have to pay a premium.
A member says: "Everyone who lives in my house needs to go on my MassHealth application, right?"
What is the correct response?
no, The most determining factor is tax dependents and children bind members together in the same application.
anyone living with you that is under 19, anyone in your tax return, spouse, unmarried partner if have children together
A member cannot find their PCP on MH Choices, but the provider tells the member that they accept Mass General. Should you refer the member back to the provider, or can you assist them?
You can assist. Check the Mass General plan website to verify the provider. If you can’t confirm them, let the member know and offer enrollment.
The 25-mile rule does not apply to ACO A/MCO.
A member calls because Medicare is showing in the system and they were removed from their health plan. The member says their Medicare coverage does not start until December. How would you assist the member?
If Medicare will not start within 30 days, submit a task to have the member reinstated into their health plan. Make sure Medicare information has not been added to the HIX application before the coverage is active.
Up to what percentage of the FPL can a pregnant individual or a child under age 1 have and still qualify for MassHealth Standard?
200% FPL