Health Plan Overview
What coverage type does not allow to have a health plan?
Limited, CMSP and HSN
What is a BIN number used for?
Pharmacy can submit claim with the correct coverage or plan
What do you click on in MMIS to save the health plan changes successfully?
Save ALL
What should you do before telling a member a service is covered ?
Confirm coverage and plan
Before processing a health plan enrollment or change, which website or resource should you use to verify a provider's participation with a health plan?
MassHealth Choices
What services are covered under MassHealth Limited, and which members typically qualify for this coverage?
MassHealth Limited generally covers emergency medical services only. It is typically available to individuals who meet MassHealth's financial requirements but do not meet immigration or citizenship requirements for full MassHealth benefits
Who is responsible for submitting a Prior Authorization request?
The prescribing provider
True or False
Members can change health plans at any time during the Fixed Enrollment Period.
False only in Plan Selection Period
True or False: Every covered service requires Prior Authorization.
False
What panel in MMIS shows you the enrollment history?
What are the five health plan types discussed during training?
ACO,MCO,PCC,One Care and SCO
Member has ACOA plan and they have questions about a prescription coverage? Can you assist them?
No because they need to speak with plan as they are primary.
Member has Careplus coverage and wants to enroll into PCC plan. What is the MC code you would use
CPPCC
Member has PCC plan and needs help finding a location for vision services. How would you assist?
Go into provider directory and go under specialists and provide a few providers in their area
A member enrolled with Community Care Cooperative requests a replacement ID card. What should number should refer them too?
1-866-676-9226
(Use the phone number from your HP Matrix)
If a member has other health insurance in addition to MassHealth, what is MassHealth's role in paying claims?
MassHealth is generally the payer of last resort. Other health insurance is billed first, and MassHealth may cover eligible remaining costs.
If a member has Medicare and MassHealth, what should you verify regarding their pharmacy benefits?
Verify whether the member has Medicare Part D prescription coverage or Part C plan, since Medicare generally pays first for prescription drugs.
True or False
Member wants to enroll into behavorial health plan, I can go into MMIS and enroll
False
ACOA/MCO-BH is with plan
ACOB/PCC-BH is with us, they have MBHP
Member has careplus coverage and wants to know if they need a referral or prior authorization for Ambulatory Surgery Services. How would you explain
A referral and a prior authorization would need to be submitted in order to see if service can be covered
After confirming member is eligible for plan, what should you confirm in MMIS before enrolling
Confirm members address is correct because they will get new cards with enrollment
Which benefit coverage types are not assigned a MassHealth ID number?
HSN and Premium Assistance
True or False
Member has Berkshire Fallon plan and they need the BIN,PCN, and group number. I can pull up Pharmacy Facts #236 job aid and provide information
Member needs to refer to plan for information
* Can only give for PCC or ACOB plan
If a member has ACO/MCO plan and just needs to update primary care provider, should you process the change or refer them back to the health plan?
Refer them to their health plan, after you confirmed that new PCP accepts members plan
A member wants to switch health plans during their Fixed Enrollment Period. What must you determine before processing the request?
Have a qualifying Exception