One Care Plans

(A) Enrollment Requirements. To voluntarily enroll in a One Care Plan, a MassHealth Standard or MassHealth CommonHealth member must meet all of the following criteria. (1) be 21 through 64 years old at the time of enrollment. If a member is enrolled in a One Care Plan and turns 65 years old and is eligible for MassHealth Standard or MassHealth CommonHealth, they may elect to remain in the One Care Plan beyond 65 years old.; (2) be eligible for MassHealth Standard as described in 130 CMR 519.001(B)(1) or 130 CMR 505.001(A)(1) or MassHealth CommonHealth as described in 130 CMR 519.001(B)(5) or 130 CMR 505.001(A)(2); (3) be enrolled in Medicare Parts A and B, be eligible for Medicare Part D, and have no other health insurance that meets the basic-benefit level as defined in 130 CMR 501.001: Basic- Level Benefit (BLB); (4) live in a designated service area of a One Care Plan; and (5) not be subject to any of the exclusions defined in 130 CMR 508.002(C). (B) Selection Procedure. The MassHealth agency will notify members of the availability of a One Care Plan in their service area and of the procedures for enrollment. An eligible member may voluntarily enroll in any One Care Plan in the member’s service area. A service area is the specific geographical area of Massachusetts in which a One Care Plan agrees to serve in its contracts with the MassHealth agency and the Centers for Medicare & Medicaid Services. Service area listings may be obtained from the MassHealth agency or its designee. The list of One Care Plans that the MassHealth agency will make available to members will include those One Care Plans that contract with the MassHealth agency and provide services within the member’s service area. (C) Obtaining Services When Enrolled in a One Care Plan. When a member is enrolled in a One Care Plan in accordance with the requirements under 130 CMR 508.007, the One Care Plan will authorize, arrange, integrate, and coordinate the provision of all covered services for the member. Upon enrollment, the One Care Plan is required to provide evidence of its coverage, the range of available covered services, what to do for emergency conditions and urgent care needs, and how to obtain access to specialty, behavioral health, and long-term services and supports. (D) Disenrollment from a One Care Plan. Disenrollment requests will be effective the first day of the month following the month the request is received by the MassHealth agency or its designee. (E) Discharge or Transfer. The MassHealth agency may discharge or transfer a member from a One Care Plan for good cause, including but not limited to cases where the One Care Plan demonstrates to the MassHealth agency’s satisfaction a pattern of noncompliant or disruptive behavior by the member. In each case, notice to the member of the discharge or transfer will state the justification for the discharge or transfer. (F) Other Programs. A member may not be enrolled in a One Care Plan and concurrently participate or be enrolled in any of the following programs or plans: (1) programs described at 130 CMR 519.007: Individuals Who Would Be Institutionalized; (2) Medicare demonstration program or Medicare Advantage plan, except for a Medicare Advantage Special Needs Plan for Dual Eligibles contracted as a One Care Plan; (3) any Medicare Demonstrations wherein concurrent participation in a One Care Plan is prohibited; (4) Employer Group Waiver Plans or other employer-sponsored plans; or (5) plans receiving a retiree drug subsidy. (G) Copayments. Members who are enrolled in a One Care Plan must make copayments in accordance with the One Care Plan’s MassHealth copayment policy. Those One Care Plan copayment policies must (1) be approved by MassHealth; and (2) be consistent with applicable copayment requirements set forth in 130 CMR 450.000, 130 CMR 506.000, and 130 CMR 520.000.