MassHealth Enrollment Guide Your Choices Starting JULY 2021 LEARN about health plans COMPARE health plans ENROLL in a health plan COMMONWEALTH OF MASSACHUSETTS | Executive Office of Health and Human Services We are here to help We speak your language If you need an interpreter or translation help, please call the MassHealth Customer Service Center. Questions? www.mass.gov/masshealth MassHealth Customer Service Center (800) 841-2900 TTY: (800) 497-4648 for people who are deaf, hard of hearing, or speech disabled. Monday–Friday 8:00 a.m.–5:00 p.m. Hello and welcome MassHealth is the Medicaid program in Massachusetts. We have health plans to choose from so you can get the health care you need. Please read this guide to learn about the plans and choose the one that’s best for you. This guide will help you... Learn Learn about the health plans available in your area and how to choose a provider. Compare Compare health plans in your area and choose the one that’s right for you. Enroll Enroll in a health plan or change to a different health plan. Let’s enroll in a health plan. i Is this guide for you? Certain members in the MassHealth program will need to enroll in a health plan. Use this guide if you ■ Are under 65 ■ Do not have other insurance (including Medicare) ■ Live in the community (for example, not in a nursing facility), and ■ Are in MassHealth Standard, CommonHealth, CarePlus, or Family Assistance. For information about MassHealth coverage, visit www.mass.gov/masshealth. Members described below are not eligible for the health plan options described in this guide. For information about MassHealth coverage, visit www.mass.gov/masshealth. Do not use this guide if you ■ Are over 65 ■ Have other insurance (including Medicare) ■ Do not reside in the community (for example, members who reside in a nursing facility) ■ Are enrolled in Senior Care Options (SCO), Program of All-Inclusive Care for the Elderly (PACE), or One Care ■ Are a member who is eligible solely for » MassHealth Limited » Children’s Medical Security Plan (CMSP), or » Health Safety Net (HSN) ii Contents Learn About Health Plan Options 2–5 Accountable Care Organizations (ACOs) 2 Accountable Care Partnership Plans 2 Primary Care ACOs 3 Managed Care Organizations (MCOs) 3 Primary Care Clinician (PCC) Plan 4 Community Partners 4 Choosing a Primary Care Provider 4 Which Providers Can You See? 5 Compare Health Plans 6–29 Compare Available Health Plans 6 Accountable Care Partnership Plans 7 Primary Care ACO Plans 24 Managed Care Organizations 27 Primary Care Clinician Plan 29 Enroll in or Change a Health Plan 30–33 Enrolling in a Health Plan 30 Changing Your Health Plan 31 Using Your Member ID Cards 33 More Information 34–42 Rights and Responsibilities 34 Understanding Your Costs 35 Grievances, Appeals, and Fair Hearings 35 My Ombudsman 35 Service Areas 36 1 Learn About Health Plan Options Accountable Care Accountable Care Organizations (ACOs) Partnership Plans ACOs are groups of doctors, hospitals, In this type of ACO, a group of PCPs work with and other health care providers who come just one managed care organization to create together to give coordinated, high-quality a full network that includes PCPs, specialists, care to MassHealth members. This way, behavioral health providers, and hospitals. MassHealth members get the right care at PCPs plan and coordinate care to meet your the right time. When an ACO succeeds in health care needs. delivering high-quality care and spending In this kind of health plan, you health care dollars wisely, MassHealth will reward the ACO. ■ Must live in the service areas covered by the ACO There are two types of ACOs you can enroll ■ Must use the plan’s network of providers in: Accountable Care Partnership Plans or Primary Care ACOs. In both, ACOs are led by ■ Choose a PCP in the ACO, or one will be providers, not just administrators. Primary assigned to you Care Providers (PCPs) are at the center of ■ Can change your PCP at any time within the care network. Providers work with you the ACO directly and know your needs, and they will ■ May get the services of a behavioral health have a much bigger part in working with you or long-term services and supports (LTSS) to make decisions about care in an ACO than Community Partner (see page 4) in other types of health plans. ■ Will have a Plan Selection Period and a On the following pages, we describe the two Fixed Enrollment Period every year different types of ACOs as well as managed care organizations (MCOs) and the Primary Care Clinician (PCC) Plan. You can choose any of the options available in your service area. Key Term Primary Care Provider (PCP) A health care provider you choose to give you routine care and refer you to a specialist when necessary. (See page 4 for more information.) 2 MassHealth Enrollment Guide | LEARN Primary Care ACOs Managed Care In this type of ACO, a group of PCPs have Organizations (MCOs) LEARN joined together into an ACO to be responsible for your care. The ACO contracts directly MCOs are health plans run by insurance with MassHealth to provide primary care companies that provide care through their and coordinate the full range of services for own provider network which includes PCPs, its enrollees. Primary Care ACOs work with specialists, behavioral health providers, and the MassHealth network of specialists and hospitals. Care coordinators are employed by hospitals and may have certain providers the MCO. in their “referral circle.” This circle gives Please note: PCPs who are part of an ACO will you direct access to other providers. The not be available as PCPs in MCO plans. Massachusetts Behavioral Health Partnership In this kind of plan, you (MBHP) provides behavioral health services. ■ Must live in the service areas covered COMPARE In this kind of plan, you by the MCO ■ Choose a PCP in the ACO, or one will be ■ Must use the MCO network of providers assigned to you ■ Choose a PCP in the MCO, or one will be ■ Can change your PCP at any time within assigned to you the ACO ■ Can change your PCP at any time within ■ May get the services of a behavioral health the MCO or long-term services and supports (LTSS) ■ May get the services of a behavioral health Community Partner (see page 4) or long-term services and supports (LTSS) ■ Will have a Plan Selection Period and a Community Partner (see page 4) Fixed Enrollment Period every year ■ Will have a Plan Selection Period and a Fixed Enrollment Period every year ENROLL Key Terms Network Plan Selection Period A group of doctors, hospitals, and other The time of year when you CAN change health care providers that a health plan your health plan. contracts with to provide medical (See page 31 for more information.) care to you. MORE INFORMATION Fixed Enrollment Period Community Partners The time of year when you CANNOT Community Partners are community- change your health plan, except for based experts that can work with you certain reasons. and your health plan to get and arrange (See page 31 for more information.) behavioral health and LTSS services. (See page 4 for more information.) 3 Primary Care Clinician Choosing a (PCC) Plan Primary Care In the PCC Plan, primary care providers are Provider called primary care clinicians (PCCs). The MassHealth network of PCCs, specialists, It is important to choose a primary care and hospitals delivers services. The provider (PCP) for you or your family. Massachusetts Behavioral Health Partnership (MBHP) provides behavioral health services. Your PCP helps you get the care you need. Please note: PCPs who are part of an ACO will PCPs provide a wide range of health care not be available as PCCs in the PCC Plan. services, such as In the PCC Plan, you ■ Yearly checkups ■ Choose a PCC from the MassHealth list, or ■ Vaccinations one will be assigned to you ■ Sick visits ■ Can change your PCC at any time ■ Health screenings ■ Can change from the PCC Plan to an ACO or MCO at any time Getting to Know Your PCP Please note that Community Partners are not Your PCP gets to know you and your health generally available in the PCC Plan, and care history, habits, and goals. Your PCP may not be as coordinated as it is in the ACO ■ Provides treatment or MCO plans. ■ Helps you manage health issues like asthma, obesity, diabetes, and high Community Partners blood pressure Community Partners are local organizations ■ Refers you to a specialist when needed that help certain MassHealth members with behavioral health (BH) and long-term services Changing Your PCP and supports (LTSS) needs. You can change from one PCP to another You may be eligible to get help from a within your health plan at any time and for Community Partner if you are enrolled in any reason. • an Accountable Care Organization (ACO), • a Managed Care Organization (MCO), or ACOs and MCOs • the Department of Mental Health’s Adult To change your PCP, call your health plan’s Community Clinical Services (ACCS) program. customer service department. Their phone Note: If you are transitioning out of the ACCS number is on the back of your health plan’s program, you may receive help from the member ID card. Community Partners program. A Community Partner helps you make a plan PCC Plan and works with your Primary Care Provider If you are a PCC Plan member and you (PCP) and other providers to meet your needs. would like to change your PCP, call us at To learn more about the program, visit (800) 841-2900 (TTY: (800) 497-4648).