MassHealth Members Excluded from Participation in Managed Care

(A) MassHealth Managed Care Provider. The following MassHealth members are excluded from participation with a MassHealth managed care provider. (1) a member who has Medicare; (2) a member who has access to other health insurance that meets the basic-benefit level as defined in 130 CMR 501.001: Definition of Terms; (3) a member who is 65 years of age or older; (4) a member who is not eligible for benefits under Title XIX or XXI of the Social Security Act; (5) a member who is only eligible for benefits under Title XIX or XXI of the Social Security Act through Title XXI during the period from conception to the end of pregnancy; (6) a member in a nursing facility, chronic disease or rehabilitation hospital, intermediate care facility for individuals with intellectual disabilities (ICF/ID), or a state psychiatric hospital for other than a short-term rehabilitative stay; (7) a member who is eligible for emergency Medicaid benefits pursuant to Section 1903(v) of the Social Security Act; (8) a member who is eligible for Children’s Medical Security Plan (CMSP); (9) a member who is eligible through the Emergency Aid to the Elderly, Disabled and Children (EAEDC) Program; (10) a member who is receiving hospice care through MassHealth on a fee-for-service basis, or who is terminally ill as documented by a medical prognosis of a life expectancy of six months or less; and (11) a member who has presumptive eligibility. (B) SCO Plan. The following MassHealth members, 65 years of age and older, who are enrolled in Medicare Parts A and B and are eligible for Medicare Part D are excluded from participating in a SCO Plan. (1) a member who has access to other health insurance, with the exception of Medicare, that meets the basic-benefit level as defined in 130 CMR 501.001: Basic-benefit Level (BBL); (2) a member who does not live in the designated service area of a SCO Plan; (3) a member in an ICF/ID; (4) a member who is not eligible for MassHealth Standard; (5) a member who has presumptive eligibility; (6) a member who is enrolled in a home- and community-based services waiver, except the Home- and Community-Based Services Waiver–Frail Elder as described at 130 CMR 519.007(B): Home- and Community-Based Services Waiver–Frail Elder; (7) a member who is eligible through the Emergency Aid to the Elderly, Disabled and Children (EAEDC) Program; (8) a member who is a refugee described at 130 CMR 522.002: Refugee Resettlement Program; (9) a member who is not eligible for benefits under Title XIX or XXI of the Social Security Act; (10) a member who is only eligible for benefits under Title XIX or XXI of the Social Security Act through Title XXI during the period from conception to the end of pregnancy; (11) a member who is eligible for emergency Medicaid benefits pursuant to Section 1903(v) of the Social Security Act; and (12) a member who is subject to a six-month deductible period under 130 CMR 520.028: Eligibility for a Deductible. (C) One Care Plan. The following MassHealth members who are 21 through 64 years old at time of enrollment and who are enrolled in Medicare Parts A and B and are eligible for Medicare Part D are excluded from participation in a One Care Plan. (1) a member who has other health insurance, with the exception of Medicare, that meets the basic-benefit level as defined in 130 CMR 501.001: Basic-benefit Level (BBL); (2) a member who does not live in the designated service area of a One Care Plan; (3) a member in an ICF/ID; (4) a member who is not eligible for MassHealth Standard or CommonHealth; (5) a member who has presumptive eligibility; (6) a member who is enrolled in a home- and community-based services waiver; (7) a member who is eligible through the Emergency Aid to the Elderly, Disabled and Children (EAEDC) Program; (8) a member who is a refugee described at 130 CMR 522.002: Refugee Resettlement Program; (9) a member who is not eligible for benefits under Title XIX or XXI of the Social Security Act; (10) a member who is only eligible for benefits under Title XIX or XXI of the Social Security Act through Title XXI during the period from conception to the end of pregnancy; (11) a member who is eligible for emergency Medicaid benefits pursuant to Section 1903(v) of the Social Security Act; and (12) a member who is subject to a six-month deductible period under 130 CMR 520.028: Eligibility for a Deductible. 508.003 Enrollment with a MassHealth Managed Care Provider (A) Member Selection. (1) In accordance with 130 CMR 508.004 through 508.006, members required or permitted to select a MassHealth managed care provider may select any MassHealth managed care provider from the MassHealth agency’s list of MassHealth managed care providers for the member’s coverage type in the member’s service area, if the provider is able to accept new members. (2) A member who seeks to enroll with a managed care provider outside of the member's service area must submit a request in writing to the MassHealth agency on forms provided by the MassHealth agency. The MassHealth agency may grant such a request if they determine that: (a) The out-of-area MassHealth managed care provider is in a service area contiguous to the member’s service area; or (b) The MassHealth agency determines either of the following: 1. the member seeks a specific provider who is in the network of the out-of-area MassHealth managed care provider, such requested provider is not in the network of a MassHealth managed care provider in the member’s service area, and the travel time or distance to such requested provider is equal to or less than the travel time to, as determined by the MassHealth agency, a comparable provider in the network of a MassHealth managed care provider in the member's service area, or 2. the medical benefit of receiving care from a MassHealth managed care provider in the member's service area is substantially outweighed, as determined by the MassHealth agency, by the medical benefit of receiving care from the out-of-area MassHealth managed care provider requested by the member. (B) Member Assignment to a MassHealth Managed Care Provider. If a member does not choose a MassHealth managed care provider within the time specified by the MassHealth agency in a notice to the member or in other circumstances determined appropriate by the MassHealth agency and consistent with applicable laws, the MassHealth agency assigns the member to an available MassHealth managed care provider. (1) The MassHealth agency assigns a member to a MassHealth managed care provider only if the MassHealth managed care provider is: (a) available for the member's coverage type; (b) in the member's service area as described in 130 CMR 508.004(A)(1), 130 CMR 508.005(A)(1), 508.006(A)(1)(a), 508.006(B)(1)(a), as applicable; (c) physically accessible to the member, if the member is disabled; (d) suitable for the member's age and sex (for example, the member is the appropriate age for a pediatrician); and (e) located in an area to which the member has available and affordable transportation. (2) If the MassHealth agency determines that no MassHealth managed care provider meeting the criteria of 130 CMR 508.003(B)(1) is available in the member's service area: (a) The member may 1. choose not to enroll with a MassHealth managed care provider if such circumstances prevail; or 2. select an available MassHealth managed care provider outside of the member's service area. (b) Any MassHealth Standard or CommonHealth member younger than 21 years old who is not enrolled with a MassHealth managed care provider pursuant to 130 CMR 508.003(B)(2)(a)1. must obtain any behavioral health services through the MassHealth behavioral health contractor. All other services for which the member is eligible may be obtained through any qualified participating MassHealth provider. (c) If, after a determination by the MassHealth agency under 130 CMR 508.003(B)(2), the MassHealth agency determines that a MassHealth managed care provider meeting the criteria of 130 CMR 508.003(B)(1) has become available, the member must enroll with such a provider, unless the member is otherwise enrolled with a MassHealth managed care provider pursuant to 130 CMR 508.003(B)(2)(a)2. (3) Notification. The MassHealth agency will notify a member in writing of the name and applicable contact information of the member's MCO, Accountable Care Partnership Plan, Primary Care ACO, or PCC, and the effective date of the member's enrollment with the MassHealth managed care provider. (C) Member Choice to Transfer or Disenroll from a MassHealth Managed Care Provider. Members enrolled with a MassHealth managed care provider may transfer to another available MassHealth managed care provider by providing the MassHealth agency with an oral or written request as provided in 130 CMR 508.003(C). (1) Members enrolled with an MCO, Accountable Care Partnership Plan, or Primary Care ACO may transfer to another available MassHealth managed care provider for any reason during a plan selection period. (a) For members newly enrolled with an MCO, Accountable Care Partnership Plan, or Primary Care ACO, except for members reenrolled in accordance with 130 CMR 508.003(E), the plan selection period occurs during the first 90 days of the member's enrollment, or notification of the member’s enrollment, whichever is later, with the MCO, Accountable Care Partnership Plan, or Primary Care ACO. (b) For all other members, the plan selection period will be a 90-day period that occurs annually. (c) The MassHealth agency may designate additional plan selection periods at its discretion. (2) Except as set forth in 130 CMR 508.003(C)(3), a member enrolled with an MCO, Accountable Care Partnership Plan, or Primary Care ACO must remain enrolled with the MCO, Accountable Care Partnership Plan, or Primary Care ACO for the fixed enrollment period. For all members, the fixed enrollment period is the period of time when a member is not in a plan selection period. The MassHealth agency will notify members in writing of their disenrollment rights at least annually. (a) Members enrolled in an MCO, Accountable Care Partnership Plan, or Primary Care ACO pursuant to 130 CMR 508.001(B)(1) or who is below one year in age do not have a fixed enrollment period. (b) Members voluntarily enrolled in an MCO, Accountable Care Partnership Plan, or Primary Care ACO pursuant to 130 CMR 508.001(B)(2) through (4) may disenroll from their MCO, Accountable Care Partnership Plan, or Primary Care ACO at any time. Such members may be enrolled with the behavioral health contractor pursuant to 130 CMR 508.001(E). Members voluntarily enrolled in an MCO, Accountable Care Partnership Plan, or Primary Care ACO pursuant to 130 CMR 508.001(B)(2) through (4) may transfer to another MassHealth managed care provider only in accordance with this 130 CMR 508.003(C). (3) During fixed enrollment, a member may only request a transfer out of the member's current MCO, Accountable Care Partnership Plan, or Primary Care ACO for the reasons listed in this 130 CMR 508.003(C)(3). (a) The following reasons defined as cause for disenrollment in 42 CFR 438.56(d)(2): 1. the member moves such that the member’s MCO, Accountable Care Partnership Plan, or Primary Care ACO is not available in the member’s new service area; 2. the MCO, Accountable Care Partnership Plan, or Primary Care ACO does not, because of moral or religious objections, cover the service the member seeks; 3. the member needs related services (for example a cesarean section and a tubal ligation) to be performed at the same time; not all related services are available within the network; and the member's primary care provider or another provider determines that receiving the services separately would subject the member to unnecessary risk; or 4. other reasons, including but not limited to, poor quality of care, lack of access to services covered, or lack of access to providers experienced in dealing with the member's health-care needs. (b) the MCO or Accountable Care Partnership Plan is no longer contracted with the MassHealth agency to cover the member's service area, or a PCP that participates in the member’s Primary Care ACO is not available in the member’s service area; (c) the member adequately demonstrates to the MassHealth agency that the MCO, Accountable Care Partnership Plan, or Primary Care ACO has not provided access to providers that meet the member's health care needs over time, even after member's request for assistance; (d) the member is homeless, the MassHealth agency's records indicate the member is homeless, and the MCO, Accountable Care Partnership Plan, or Primary Care ACO cannot accommodate the geographic needs of the member; (e) the member adequately demonstrates to the MassHealth agency that the MCO, Accountable Care Partnership Plan, or Primary Care ACO substantially violated a material provision of its contract with MassHealth agency; (f) the MassHealth agency imposes a sanction on the MCO, Accountable Care Partnership Plan, or Primary Care ACO that specifically allows for members to disenroll from the MCO, Accountable Care Partnership Plan, or Primary Care ACO without cause; (g) the member adequately demonstrates to the MassHealth agency that the MCO, Accountable Care Partnership Plan, or Primary Care ACO is not meeting the member's language, communication, or other accessibility needs or preferences; (h) the member adequately demonstrates to the MassHealth agency that the member’s key network providers, including PCPs, specialists, or behavioral health providers, leave the MCO, Accountable Care Partnership Plan, or Primary Care ACO network; or (i) the member’s service area is Oak Bluffs or Nantucket. (4) Members enrolled in the PCC Plan may transfer from the PCC Plan to another available MassHealth managed care provider at any time. (5) The MassHealth agency will determine if the requirements needed for a member transfer pursuant to 130 CMR 508.003(C)(1) through (4) have been met within 30 days of MassHealth’s receipt of the request. The MassHealth agency's determination is a ground for appeal in accordance with 130 CMR 610.032(A). (a) If the MassHealth agency fails to make a determination within 30 days of MassHealth’s receipt of the request, the request will be considered approved. (b) The effective date for a member transfer will be within 30 days of MassHealth’s receipt of the request. (D) Other Disenrollment of Member from a MassHealth Managed Care Provider. (1) The MassHealth agency may disenroll a member from an MCO, Accountable Care Partnership Plan, or Primary Care ACO at the MCO’s, Accountable Care Partnership Plan’s, or Primary Care ACO’s request, if the MCO, Accountable Care Partnership Plan, or Primary Care ACO demonstrates to the MassHealth agency's satisfaction that the MCO, Accountable Care Partnership Plan, or Primary Care ACO has made reasonable efforts to provide medically necessary services to the member through available primary care providers or other relevant network providers and, despite such efforts, the continued enrollment of the member with the MCO, Accountable Care Partnership Plan, or Primary Care ACO seriously impairs the MCO's, Accountable Care Partnership Plan’s, or Primary Care ACO’s ability to furnish services to either this particular member or other members. (2) The MassHealth agency may disenroll a member from a PCC's panel or a Primary Care ACO’s Participating PCP’s panel, at the PCC's or PCP’s request, if the PCC or PCP demonstrates to the MassHealth agency's satisfaction that (a) there is a pattern of noncompliant or disruptive behavior by the member that is not the result of the member's special needs; (b) the continued enrollment of the member with the provider seriously impairs the provider's ability to furnish services to either this particular member or other members; or (c) the PCC or PCP is unable to meet the medical needs of the member. (3) If the MassHealth agency approves a request for disenrollment under this 130 CMR 508.003(D)(1), (2)(a), or (2)(b), it will state the good cause basis for disenrollment in a notice to the member in accordance with 130 CMR 610.032(A)(10). (E) Reenrollment. Any member enrolled with a MassHealth managed care provider who loses and then regains managed care eligibility may be automatically reenrolled with the MassHealth managed care provider with which the member was most recently enrolled, if such MassHealth managed care provider is available for the member's coverage type and service area. (1) A member enrolled with an MCO, Accountable Care Partnership Plan, or Primary Care ACO who loses managed care eligibility during a plan selection period will receive a new plan selection period upon regaining eligibility. (2) A member enrolled with an MCO, Accountable Care Partnership Plan, or Primary Care ACO who loses managed care eligibility during the fixed enrollment period will not receive a new plan selection period upon regaining managed care eligibility; provided, however, that if a member's loss of managed care eligibility causes the member to miss part or all of the member's annual plan selection period, the member will receive a new plan selection period upon regaining managed care eligibility.