MassHealth Troubleshooting and Appeals Guide

TROUBLESHOOTING AND APPEALS Health Access Basic Benefits Training February 4, 2025 Ashley Jones-Pierce Greater Boston Legal Services ajonespierce@gbls.org

TROUBLESHOOTING ELIGIBILITY How do you know if there is a problem? Notice of denial, termination or downgrade. Provider says MassHealth isn t active. Pharmacy is unable to fill prescription. Member should be eligible for a more comprehensive benefit. Medicare premium is being deducted from Social Security check. First Steps: Obtain signed Permission to Share Information (PSI) or Authorized Representative Designation (ARD) form Review any notices/documents Check for appeal or other deadlines Forms available at: https://www.mass.gov/lists/masshealth-member-forms.

PSI OR ARD? PSI: Allows you to obtain information from MassHealth about member s account. You cannot make changes to member s MH account/eligibility. You cannot select a health plan for a member. You can obtain records from MH Privacy Office. ARD: Allows you to fill out MassHealth and Health Connector forms. Allows you to report change of address, income, family size, and other circumstances. Allows you to act on behalf of the member with regards to all other matters involving MassHealth and the Health Connector. Fax to 857-323-8300 Forms are typically processed within 24-48 hours. Copies of member eligibility notices are sent to those with PSIs and ARDs on file.

DETERMINING MASSHEALTH ELIGIBILITY STATUS Review notices: Call Customer Service: MassHealth 800-841-2900 Health Connector 877-623-6765 Phone call requires: Three-way call with client or PSI/ARD on file. Member s Online Account: Provides access to notices received and documents submitted. Appointment with MH Representative (phone or video): https://www.mass.gov/info- details/schedule-an-appointment-with-a-masshealth-representative. In-Person Visit to MEC or Connector Office

WHO SHOULD I CONTACT? MassHealth Enrollment Center: For changes in eligibility (such as income or immigration status). If eligibility related information has been submitted, but has not been timely processed or seems to have been entered erroneously. To separate MH household. To contact by phone: 800-841-2900 or 888-665-9993 This will connect you with MH Customer Service and you will need to ask to be transferred to the MEC. It is sometimes difficult to get transferred to the MEC. Once transferred be sure to confirm you are speaking with a MEC worker. Schedule a phone call or video conference with the MEC: https://www.mass.gov/info-details/schedule- an-appointment-with-a-masshealth-representative.

WHO SHOULD I CONTACT? (CONT) MassHealth Customer Service: 1-800-841-2900 Can provide information about status of a case. Call here to apply for coverage over the phone or choose a health plan. Can provide assistance with premium billing or MH Transportation (PT-1) issues. Cannot make eligibility related changes to a case (but will transfer to MEC). Health Connector Customer Service: 1-877-623-6765 All Health Connector related issues.

ELIGIBILITY DECISIONS One notice for MassHealth, HSN, and CMSP: Each family member may receive a separate notice. Under new procedures, member renewal will happen on the individual level, and members of the same household may have different renewal dates. Members of the same family may be eligible for different coverage types. A separate notice for Health Connector programs Decision is based on: Application and submitted proofs, data matches, and changes reported by member Eligibility decisions come from two computer systems: HIX Notices: These notices use MAGI income MH and Health Connector notices come from HIX. MA-21 Notices: Only MH notices. Most notices for seniors and some for people with disabilities. A member may receive notices from both systems.

HEALTH CONNECTOR NOTICES Approval notice will provide the amount of the tax credit and the earliest coverage date. Approval notice may say that you need special circumstances to enroll now. An approval for unsubsidized coverage is a denial of ConnectorCare.

RESOLVING ELIGIBILITY ISSUES Eligibility decisions are made by a computer. Eligibility workers rely on computer-based information to make correct decisions. Inaccurate data will result in erroneous decisions. Some problems can be solved by providing correct information. Sometimes computer glitches result in erroneous decisions or other issues.

CAN ISSUE BE FIXED WITHOUT AN APPEAL? Missing or erroneous account information can be provided by phone, fax, or online. Apparent system error or data entry issue can often be corrected by contacting MH. (ex. Monthly wage entered as weekly) To avoid gaps in coverage that may leave member with medical debt, an appeal may be needed.

RESOLVING ELIGIBILITY ISSUES (CONT) Health Connector Customer Service (877-MA-ENROLL): If customer service is unable to resolve, contact Health Connector Ombudsman: https://www.mahealthconnector.org/about/contact#contact-ombuds. MassHealth Enrollment Center: Call customer service (800-841-2900) and ask to be transferred to the MEC. Escalate to Service Solution Unit (SSU): When calls to Customer Service/MEC have not resolved more complex issues. Appeal: Appeal rights and procedures are detailed on notices.

SERVICE SOLUTIONS UNIT (SSU) SSU is a unit within MH that offers advocates an escalation protocol to help resolve cases when initial attempts by Customer Service and the MEC have not been successful. Assistance can be requested via secure email using standard SSU template: EHS-DL- ITRequests@MassMail.State.MA.US. Advocate must have PSI or ARD. See, https://www.masslegalservices.org/content/new-masshealth-unit-problem-cases.

THIRD PARTY LIABILITY ISSUES Examples: Member has MH Standard, but providers say they can t bill. Member was just notified they are no longer eligible for a managed care plan. Cause: Other insurance may be showing on member s record, possibly from a data match. Solution: Contact Third Party Liability (TPL) Unit (888-628-7526) to remove insurance from record if no longer active or in cases of domestic violence.

HEAD OF HOUSEHOLD ISSUES The adult who signs the application for coverage is the Head of Household (HOH) for MassHealth. Only the HOH can report account changes. HOH can authorize another household member with an ARD. Problems can arise if a family separates: Ex: Parent 1 is HOH and Parent 2 moves out and has custody of the kids. To establish a new MH Household, Parent 2 would need to contact the MEC to delink old case and submit a new application. There may be changes in MH eligibility due to changes in household composition. Adult child moves out of household.

PHARMACY COVERAGE ISSUES Member has active MH coverage but is unable to fill prescription: Does drug require prior authorization? Ask prescriber to submit prior authorization request. MH Drug List: https://masshealthdruglist.ehs.state.ma.us/MHDL/. Managed care issues? Check to make sure correct insurance is being billed. Did member recently become eligible for Medicare? Medicare Part D is now primary payer. Ask pharmacy to bill LINET if member does not yet have a Part D plan: https://www.humana.com/member/medicare-linet-pharmacy-resources.

MASSHEALTH DRUG LIST Available at: https://masshealthdruglist.ehs.state.ma.us/MHDL/. Specifies which drugs require prior authorization and the approval criteria. Prior Authorization forms are available on website. Generally, MH will approve prior authorization if prescriber documents failed attempt of preferred drug.

PRIOR AUTHORIZATION ISSUES Sometimes a provider must receive permission from MH before they can provide the member with certain medical services. The provider submits a prior authorization request to MH. Medical consultants will determine whether to approve the request. The member and medical provider are notified of MH s decision. The decision can be appealed.

SERVICES REQUIRING PRIOR AUTHORIZATION Many prescription drugs Many dental services Surgeries Non-emergency transportation (PT-1) Personal Care Attendant (PCA) services Durable medical equipment Private duty nursing Adult day health Adult foster care Advanced imaging services Therapy and medical supplies exceeding service limits

PRIOR AUTHORIZATION CRITERIA Medical Necessity: Under 130 CMR 450.204 medical necessity includes both clinical and cost criteria. Specific criteria in regulations for each service Sub-regulatory guidelines for medical necessity determinations for some services on EOHHS website: https://www.mass.gov/lists/masshealth-guidelines-for-medical-necessity-determination. MassHealth cannot rely on Medicare criteria that is more restrictive. MassHealth contracts with third party administrators to make prior authorization determinations: DentaQuest Dental services (changing to BeneCare in future, date TBD) Optum Long-term services in the community

MASSHEALTH ACTION ON PA REQUEST May defer for more information May approve, deny or modify Member is notified if approved, denied or modified and may be notified of a deferral. Modification can approve less of what was requested. MH will not approve something that was not requested. (Ex: If 30 hours/week of PCA hours is requested, MH cannot approve more than 30 hours.) Generally, an approval is limited to the provider who submitted the request.

WHEN SHOULD YOU FILE AN APPEAL? MassHealth eligibility decision appears to be wrong. Appeal may be needed to receive a correct determination. Appeal may be needed to keep the case open and allow member to continue to receive coverage (aid pending). Appeal may be needed to receive retroactive coverage. Member is being terminated for not returning renewal form or verifications. Appeal in time to receive aid pending appeal. Return the application or verifications. Appeal may be needed to prevent gap in coverage if aid pending deadline is missed. Denial of prior approval for service/treatment/item. MCO denial of medical service.

FILE AN APPEAL BY MAIL OR FAX Complete appeal form included with MH notice. Can be signed by the appellant or someone with authority to act on behalf of appellant (including ARD). Include documentation of authority. Briefly state reason for appeal. https://www.mass.gov/doc/fair-hearing-request-form-2/download. Fax or mail appeal to number/address on form. MassHealth 617-887-8797 Health Connector 617-933-3099 Include a copy of notice if available. Request interpreter or any accommodations needed. Managed care appeals require an internal appeal first.

HOW TO APPEAL BY PHONE Call MassHealth Customer Service 800-841-2900 MassHealth rep will assist in completing fair hearing request over the phone. Request reference number from customer service. Be sure to send copy of notice being appealed to MassHealth Board of Hearings: Fax 617-877-8797. If you don t provide a copy of the notice, you may get a dismissal. MassHealth will send member a copy of completed appeal form.

HOW TO FILE AN APPEAL WITHOUT A NOTICE Write short letter to Board of Hearings explaining what is being appealed. Ex: My coverage was terminated on January 1, 2025, and I did not receive written notice . Must be signed by member or their appeal representative. Include member s name, address, phone number and MH ID or SSN.

APPEAL TIME LIMITS Must be received by Board of Hearings within 60 days of member s receipt of written notice. Presumption that notice is received within 5 days of mailing. Save envelope for postmark. To continue benefits pending appeal: MassHealth Appeal must be received within 10 days of receipt of notice or before implementation of action, whichever is later. Request aid pending on appeal form. Connector File a timely appeal and request on form. If not notice, MH appeal deadline is 120 days from the action, unless waived by the Director. Time limits are strictly enforced. No regulatory good cause for late appeal. Possible to request a reasonable accommodation under the ADA.

AID PENDING APPEAL For MassHealth Appeals: Appeal must be received within 10 days of receipt of notice or before termination/action is taken to receive aid pending appeal. Call BOH to confirm receipt and aid pending. MH often refers to aid pending as protection . Benefits continue until hearing decision is issued. Recoupment is authorized, but has rarely happened. For Connector Appeals: Request on appeal form. Recoupment is authorized and will happen when federal taxes filed for advance premium tax credits.

PRE-HEARING RESOLUTION (PHR) PHR can be requested on hearing request form. This is a newer option to resolve an appeal and applies only to eligibility-related appeals. If requested, MassHealth will reach out to appellant. If PHR is not possible, appeal will proceed to a hearing. See EOM 23-27 for PHR details: https://www.mass.gov/doc/eligibility-operations- memo-23-27-prehearing-resolution-0/download.

DISMISSAL OF HEARING REQUEST 130 CMR 610.035 Reasons for dismissal include: Appeal not timely Not an appealable action (Ex. Service denied by provider, not MH) Change in state or federal law requiring the action. Appeal filed by someone who did not have the right to appeal on behalf of member. Failure to attend hearing. BOH will normally send a letter giving the member 10 days to contest the dismissal. Dismissal must be contested in writing. BOH may vacate dismissal. A dismissal can be appealed to Superior Court.

HEARING PREPARATION You have a right to a copy of the file. Hearing notice explains how to request it. You may have difficulty obtaining file in time to prepare for hearing. Evidence: Documents and testimony Often helpful to submit documents to BOH and MassHealth/MCO rep in advance. Witnesses: Inform BOH of any witnesses who will provide testimony on your behalf. Witnesses may testify by phone, but you should provide BOH with phone number in advance. You can request a subpoena 130 CMR 610.052

REVIEW CASE FILE PRIOR TO HEARING For eligibility appeals, obtain the record from the MEC. A copy of the file should be mailed to the member before the hearing. In prior authorization appeals, request case file from Optum or managed care plan. The file may be mailed to member after hearing is scheduled, but you should request it earlier. Contact Board of Hearings if unclear how to get file.

HEARING NOTICE Written notice is provided with date, time and location of hearing. MassHealth - Mailed at least 10 days before hearing. Health Connector Mailed at least 15 days before hearing. Rescheduling is possible. If you know of scheduling conflicts in advance, include information with hearing request. Most hearings are now telephonic. Video hearings are available by request. Health Connector hearings are telephonic unless you show good cause for an in-person hearing.

MASSHEALTH FAIR HEARING Conducted by impartial MH Hearing Officer (typically a lawyer) Informal Adversarial Representative of decision-maker will attend: MassHealth, Managed Care Plan, Third-Party Administrator, etc. Medical consultant will attend for appeals relating to service denials or disability determinations. Tape recorded/transcript available.

FAIR HEARING (CONT) Hearing is de novo (130 CMR 610.071(A)(2)) Not limited to the record at the time of the initial decision. Settlements are possible/common: Withdrawal of hearing request is vehicle for settlement. Should be in writing. Make sure there is no gap in coverage before withdrawing. Member may request that record be held open to submit additional information or legal memo.

AFTER YOU WIN A FAIR HEARING If you were not receiving aid pending appeal and have an eligibility denial reversed, what happens next? MassHealth: MH eligibility will go back to the date of decision. Notify providers to re-bill MH for past dates not covered. Reimbursement for out-of-pocket expenses is possible (130 CMR 501.015). Health Connector: Member can choose whether they d like coverage to go back to date of incorrect decision if they pay premiums for past period, OR Coverage can begin the following month with premiums due going forward. Special exemption from tax penalty if gap in coverage during appeal.

IMPLEMENTATION OF DECISION Should be implemented within 30 days of decision (130 CMR 610.086). Contact Hearing Officer/Board of Hearings if not implemented. Advocates have noted delayed implementation with One Care plans.

JUDICIAL REVIEW OF MASSHEALTH DECISION Rehearing Request (optional) Within 14 days of date of decision. 130 CMR 610.091 Judicial Review File within 30 days of receipt of hearing decision or denial of rehearing request. 130 CMR 610.092. Judicial Review of Final Agency Decision: MGL. Ch. 30A, 14 Superior Court Standing Order 1-96: Processing and Hearing of Complaints for Judicial Review of Administrative Agency Proceedings.