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Commonwealth Care

State-subsidized health insurance is available to adult residents of Massachusetts (US citizens, nationals, and legal aliens) who are uninsured and meet income guidelines (up to 300% of the federal poverty level). DME is a covered benefit: co-pays and premiums vary by plan type.

Commonwealth Care is a state-subsidized program created by the Massachusetts 2006 Health Reform Law. It offers comprehensive free or low-cost health insurance to adult residents of Massachusetts (US citizens, nationals, and legal aliens) who are uninsured and meet income guidelines (up to 300% of the federal poverty level). Durable medical equipment is a covered benefit, and co-pays and premiums vary by plan type. MassHealth processes Commonwealth Care applications, but Commonwealth Care is designed and run by a new state agency, the Commonwealth Health Insurance Connector Authority.

Commonwealth Care has no asset tests, and requires no premiums from people who earn at or below 150% of the federal poverty level. For people who earn between 150.1% and 300% of the federal poverty level the lowest cost plans have adult monthly premiums that range from $0 to $116 per month (in 2011). However, not all plans are available in all regions, and some plan premiums are significantly higher.

Currently there are five Managed Care Organizations (MCOs) administering these plans (the same as administer MassHealth), and there are three types of Commonwealth Care plans. To learn more about plan types and costs visit the Health Connector website.

Who is Eligible?

If you are over age 19, a US citizen or legal resident, and earn less than 300% of the federal poverty level, you may qualify for a Commonwealth Care plan.

If you are over-income or otherwise ineligible for Commonwealth Care, see Commonwealth Choice. This program recommends commercial health insurance products that the Connector considers a good value for consumers.

What DME Services are Provided?

All four types of Commonwealth Care plans provide access to:

  • Durable medical equipment
  • Supplies
  • Prosthetics
  • Oxygen and respiratory equipment
  • Orthotics (for people with diabetes only)
  • Podiatry
  • Vision care (eye exams and eye glasses every 24 months)

DME costs vary by plan type:

Plan Type 1 charges no co-pays for these DME services. This plan type is for people whose income is at or under 100% of the federal poverty level.

Plan Type 2 charges no DME co-pay, but requires $10 for eye exam visits, $5 for podiatry visits, and $10 for visits to a specialist. Maximum out-of-pocket expenses per year are $750 for services excluding prescription drugs (which has a separate $500/year maximum out-of-pocket limit). This plan type is for people between 100.1% and 200% of the federal poverty level.

Plan Type 3 charges 10% of the cost of the DME (“coinsurance”), also $10 for podiatry visits, and $20 for eye exams. Maximum out-of-pocket expenses per year are $1500 for services excluding prescription drugs (which has a separate $800/year maximum out-of-pocket limit). This plan type is a choice for people between 200.1% and 300% of the federal poverty level.

How are DME Services Provided?

Commonwealth Care plans are delivered through Managed Care Organizations (MCOs). Carefully review your plan materials, which describe coverage for Durable Medical Equipment (DME) and explain how to request it. If you have questions, contact your plan’s member services representative. The following is a general outline of the typical process for obtaining DME.

First, get a prescription from your doctor’s office for the DME item you need. This prescription may come from either your primary care doctor or a specialist. Depending on the equipment and your managed care organization’s (MCO) requirements, you might need an evaluation from a supplier before your doctor writes the prescription. If your supplier doesn’t carry the equipment, they should refer you to another supplier who does.

If needed, your supplier will evaluate you to determine exactly which equipment suits your needs. In some cases, your doctor may send you directly to a supplier for this evaluation before writing a prescription. Once the supplier assesses your specific requirements, they will coordinate with your doctor regarding the necessary prescription.

Commonwealth Care plans typically have contracted DME suppliers. For example, Lakeview Medical is used by certain plans. If your supplier doesn’t have the equipment in stock, they should refer you to another supplier who does.

After receiving the prescription, the supplier submits a request directly to your MCO for “prior approval.” Usually, the MCO responds to these requests within a few days, according to suppliers. Urgent requests may be processed the same day.

If the request for prior approval is denied, the MCO will mail a denial letter to both you and the prescribing doctor. Often, providing additional documentation or clarification from your doctor can help secure approval.

Appealing Denials

Denials are common and can typically be appealed successfully with the right documentation. If your insurance provider denies your request, file your appeal as soon as possible (federal law allows you up to 180 days from the date of service to appeal a denial). The appeals process for Commonwealth Care plans is the same as for commercial (private) insurance plans. Keep copies of all paperwork, letters, and forms. Also, keep a written log of all phone calls, noting whom you spoke with and what actions were discussed or taken.

Your first step is following your MCO’s internal review (or grievance) procedures. Each MCO and private HMO has a formal internal appeals process, regulated by the state’s Office of Patient Protection (OPP). If your internal appeal is unsuccessful, you can request an external review through OPP. Decisions made during external reviews by OPP are final.

The Kaiser Family Foundation offers a helpful guide explaining how to pursue internal and external reviews of your private or Commonwealth Care insurance claim denial. The guide also explains insurance coverage basics, along with applicable state and federal laws. For details, visit this Kaiser Family Foundation web page.

Frequently asked questions about the external review process are also available at this Office of Patient Protection web page (click on “External Review Process” in the Quick Links and then choose the “External Review Overview”).

Contact:

Commonwealth Care Customer Service Center:
(877) 623-6765 VOICE
(877) 623-7773 TTY
Health Connector website

Health Care For All’s Health Helpline: (800) 272-4232
www.hcfama.org
(This is a non-governmental organization that answers questions about healthcare in Massachusetts)